Every finding on record at The Villas at New Brighton

Based on interview and document review, the facility failed to ensure steroid medication was given in accordance with physician orders for 1 of 3 residents (R1) reviewed. R1 had a history of long-term steroid use and multiple complex medical conditions. R1 had orders from the hospital for prednisone (a steroid medication) which were not correctly transcribed into the care center record (EMR) causing at least one missed dose. This error contributed to R1 developing an adrenal crisis and being hospitalized which constitutes actual harm. However, the facility took corrective actions on 7/24/26 prior to the onsite investigation, so these findings are issued at past non-compliance (PNC). Findings include:R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment along with multiple medical conditions including anemia, high blood pressure, diabetes mellitus, hypothyroidism (condition where thyroid gland doesn't make enough thyroid hormone), and unspecified adrenocortical insufficiency (condition where adrenal glands do not make enough hormones, like cortisol, but the specific underlying cause had not yet been identified). R1's After Discharge Orders, dated 7/21/26, identified R1 was hospitalized on [DATE] and was being discharged to the care center. R1 was listed in stable condition and free of communicable disease. The orders listed R1's medications for the care center which included prednisone 5 milligrams (mg) tablets with a corresponding taper dose schedule including 17.5 mg daily for 14 days, 15 mg daily for 30 days, 12.5 mg daily for 30 days, then 10 mg daily thereafter. A start date was listed as 5/13/26, and the diagnosis attached to the prednisone was, Sarcoidosis [inflammatory disease usually with growth of tiny clumps of immune cells called granulomas, most commonly affecting the lungs, lymph nodes, and skin] of other sites. Each page of the orders was signed by admission director (AD)-A. However, R1's Medication Administration Record (MAR), dated 7/2026, identified R1's consumed medications for the month period which lacked evidence the physician order for prednisone from the hospital (dated 7/21/26) had been provided, given, or refused. The last recorded dose of prednisone for R1 was 12.5 mg given on 7/10/26. R1's progress note, dated 7/21/26, identified R1 was readmitted to the care center from the hospital. R1 was alert and oriented X4 and had edema to both her upper and lower extremities. R1's progress note, dated 7/22/26, identified R1 was evaluated by nurse practitioner (NP)-A at the care center. R1 was hospitalized on [DATE] for abdominal pain, diarrhea, and elevated potassium levels. The hospitalization was complicated by urosepsis. She was discharged back to the care center on 7/21/26. On this evaluation, R1 reported diffuse abdominal pain that was minimal, denied chest pain and was agreeable to meet with nephrology to discuss hemodialysis. NP-A placed some lab testing orders and a taper down of her current antidepressant medication. R1's progress note, dated 7/23/26, identified R1 was evaluated by NP-A again on an urgent basis. R1 had reported low blood pressures and was lethargic with no clear cause. R1 had no increased pain, urine changes or bleeding and had completed treatment for the urosepsis identified while hospitalized prior. R1's diagnoses were reviewed and NP-A identified R1 as appearing to be volume up (fluid) and, Adrenal insufficiency: On prednisone. Possibly contributory. A physical exam recorded R1 as lethargic, pale and mildly diaphoretic with clear lung sounds, no acute rashes on her skin, and having a regular heartrate and rhythm. R1 was sent to the ED for evaluation. R1's Emergency Department Note, dated 7/23/26, identified R1 presented to the emergency department (ED) for evaluation of general malaise. EMS reported R1's blood pressure was 70/40 at the care center and R1 had a history of hospitalization due to sepsis and adrenal crisis. A physical exam was completed which found normal heart rate and rhythm, lung sounds clear bilaterally and no evidence of trauma. The medical decision making (MDM) outlined initial concerns for possible fluid overload given R1's history of heart failure and her presentation was felt to be consistent with recurrent septic shock/sepsis. R1 was admitted to the hospital. However, R1's History & Physical, dated 7/23/26 at 3:18 p.m., identified R1 had an extensive medical history including diabetes, adrenal insufficiency, hypothyroidism, and sarcoidosis (on prolonged steroid taper). R1's blood pressure was low at the care center and brought to the ED. In the ED, the blood pressure was even noted to have systolic pressure in the 50's. R1 had been recently hospitalized (7/10/26 to 7/21/26) for hyperkalemia (elevated potassium) and metabolic acidosis. R1 currently endorses malaise, chills and sweats, and shortness of breath. R1's lab values were listed which included a lactate level (indicative of infection) of 1.5 which was within normal range. The physician recorded a main concern of septic shock versus adrenal crisis versus cardiogenic shock. There was no clear source of sepsis infection but was showing signs of volume overload so IV diuretics were stated. The chart then listed, Addendum . Med rec [reconciliation] was done[,] and it appears there are several med errors that likely contributed to the hypotension and adrenal crisis . Prednisone was not started at the nursing home therefore she has been off steroids for 2 days likely contributing to adrenal insufficiency .R1's progress note, dated 7/24/26, identified the care center nurse contacted the hospital for an update on R1. R1 was in the intensive care unit (ICU) for an admission diagnosis of adrenal crisis. The note added, [Name] RN updated regarding missed dose of prednisone and discussed current med orders. This nurse spoke w/ [R1], notified [patient] of missed dose of prednisone. R1's (Facility) Medication Error Reconciliation Form, dated 7/24/26, identified an error happened on 7/22/26, with handwritten description of the error. R1's prednisone taper, as transcribed from the hospital orders, had been missed in transcription. The report listed a section labeled, Outcome to Resident, with handwritten response, Hospitalization. The provider was notified of the error on 7/24/26, and R1 was transferred to the hospital. The section labeled, Investigation Summary ., identified R1 remained in the hospital and . is doing well, in ICU. Drowsy but [alert and oriented] X4 and stable. Admitting DX [diagnosis] adrenal insufficiency. The report labeled a section, Categories of Medication Errors, and marked this error as, Category C [error occurred that resulted in hospitalization]. The facility determined this error was not reportable as an allegation of neglect to the State agency (SA) as only a single dose had been missed and listed follow-up actions which included changing the process for a triple check of admission orders. The report was signed by the director of nursing (DON), nurse manager, and administrator. R1's subsequent hospital records, dated 7/24/26 to 7/28/26, identified R1's subsequent admission and ongoing care at the hospital, with multiple physician notes recording the adrenal crisis and/or insufficiency being likely related to the omitted prednisone dosing at the care center. These included:R1's Hospitalist Progress Note, dated 7/24/26, identified R1 was evaluated by the provider. The note included, 7/24: with steroids, symptoms seem to have resolved. BP high normal. A primary diagnosis of adrenal crisis was listed which reviewed the workup and history of evaluation thus far. The note included the addendum about the missed medication but now added, After steroids restarted, patient appears to be back to normal. The hospital continued to address R1's multiple other health conditions including edema and poor kidney function. R1's Nephrology Progress Note, dated 7/27/26, identified R1 was evaluated for her chronic kidney disease while hospitalized . R1 admitted to the hospital with significant hypotension in the setting of septic shock/adrenal crisis after stopping home dose of prednisone. R1 also had acute kidney injury and volume overload. The note recorded an impression which included, 5. Shock at admission likely from adrenal crisis from mixed [sic] doses of prednisone. R1's Hospitalist Progress Note, dated 7/28/26, identified R1 remained in the hospital after presenting to the ED from the care center with profound hypotension (low blood pressure) which improved rapidly after IV steroid infusion adding, . her presentation was felt to be most consistent with adrenal crisis related to inadequate outpatient steroid dosing rather than sepsis. R1's infection work-up in the hospital remained unrevealing and IV antibiotics had been discontinued. R1 was also found to have anemia and continued to have work-up completed on other medication conditions including diffuse anasarca (extreme, generalized fluid swelling across body). R1 remained hospitalized at the time of the onsite investigation (exited 7/29/26) and was unable to be interviewed. When interviewed on 7/29/26 at 9:11 a.m., registered nurse (RN)-A explained all medication administrations are completed using the five rights to ensure the correct dose, patient and route. When a patient returns from the hospital, the orders are entered into the EMR by AD-A or a nurse. The orders were then double checked by another nurse for accuracy before being listed as 'active.' RN-A stated they recalled having some education on this process just recently but were unable to recall the exact date of that. If a medication error was discovered, then a form was completed with the error information and the physician was updated. RN-A stated they had not had to fill-out one of those forms for a long time and were unsure where they were located. When interviewed on 7/29/26 at 10:11 a.m., AD-A verified their signature at the bottom of R1's After Discharge Orders (dated 7/21/26) and stated they often entered orders into the care center record before they were double-checked by the nurses. AD-A used the start date listed on the prednisone (5/13/26) to initially enter the prednisone into the facility EMR, however, they forgot to add a field of information which caused the screen to place a red-font warning at the top until it was correct. AD-A then went to the provider to confirm the prednisone dose for R1 and returned to the computer but did not see the red-colored warning. They clicked to save the order; however, it did not save due to the warning which needed to be addressed. The order packet was then placed on the desk for the nurse, who was RN-B, to double check and verify them. AD-A stated they were aware an error had occurred with R1's prednisone as the hospital called the care center when they discovered it had happened and told them. As a result, education had been provided and AD-A stated they were paying more attention to orders and to ensure no warnings were displayed with the saved orders in the EMR. On 7/29/26 at 10:29 a.m., NP-A was interviewed and recalled sending R1 to the ED on 7/23/26. R1 had developed low blood pressure and almost appeared septic aside from the abnormal low heartrate. She had been deep lethargy and appeared really sick. NP-A stated they had seen R1 on 7/22/26 for an examination and she looked fine then. NP-A stated they had received a notification after R1 was admitted to the hospital about the medication error and explained when prednisone was abruptly stopped after being taken, that it could cause a reduction in cardiac output and lead to low blood pressure and low heart rates. Those symptoms were also possible in sepsis but usually only in severe cases. NP-A stated it was hard to imagine a single missed dose of prednisone could cause the rapid change R1 had on 7/23/26, but if it were two or three missed doses, then a change like she demonstrated would be more likely. NP-A then reviewed the hospital H&P (dated 7/23/26) which included the addendum of the missed medication. NP-A stated dictation using words like contributing was the hospital's way of saying the missed medication was the most likely contributor to the event. NP-A stated upon review of that documentation, the missed medication was possibly a pretty significant reason she was hospitalized . NP-A added, It fits the picture. When interviewed on 7/29/26 at 11:05 a.m., RN-B verified they were assigned to R1 on 7/21/26 when she returned from the hospital. RN-B stated R1 arrived back to the care center in the evening hours on 7/21/26 and recalled going through the orders left on the desk by AD-A. RN-B stated they did not recall ever seeing the order for prednisone but had since been told they missed it. RN-B stated they should have used the hospital orders to match against the EMR orders once they had been entered. RN-B acknowledged the medication error and explained, I think it was just an oversight on my part too. RN-B verified they had been provided re-education on the expectations for order checking and expressed aloud, I can't have that happen [again].On 7/29/26 at 11:19 a.m., the director of nursing (DON) was interviewed. DON verified hospital return orders should be entered and then double checked by a nurse in the EMR. They should then be checked on the night shift as a triple check. DON stated R1's orders on 7/21/26 should have passed through three different people at the care center to help catch the error that happened. DON stated R1 remained hospitalized and, to their knowledge, the final diagnosis was adrenal insufficient and adrenal crisis. The hospital contacted the care center about the discovered medication error on 7/24/26. DON stated R1 would have had the 7/21/26 dose from the hospital, and the only dose they could confirm she missed as the 7/22/26 dose. R1 had the change of condition so early on 7/23/26, that she had not yet had her morning medications which is when the prednisone would have been given (if it were transcribed). DON stated they then investigated the situation and verified the medication error had happened but questioned if R1 was ever truly stable when she returned from the hospital on 7/21/26. DON acknowledged the lack of any charting in the progress notes to show R1 as lethargic or unwell until the 7/23/26 change of condition. DON stated they knew prednisone was a medication which was important to take on time as it could cause side effects if abruptly stopped. DON explained that since this incident happened, they had completed several steps to help prevent reoccurrence including education to the nurses and auditing other recent readmissions to ensure their orders were correctly entered and transcribed. They had found no further errors.When interviewed on 7/29/26 at 11:50 a.m., the consulting pharmacist (CP) stated prednisone was an intermediate acting steroid medication but was hard to say from a pharmacist's standpoint if a single missed dose could cause that rapid of decline or not. CP stated they didn't feel missing just a single dose could cause a major clinical change, however, CP added they were unsure of R1's exact clinical background or other medical conditions. Prednisone had a biological half-life (duration of action and tissue effect) of 12 to 36 hours so there would likely still be some, although reduced, medication in the body with just one missed dose. A National Library of Medicine article, titled Prednisone, dated 4/2025, identified the elimination half-life of prednisone was 3 to 4 hours in an adult. The facility Medication and Treatment Orders policy, dated 2/2024, identified orders would be consistent with principles of safe and effective order writing. Medications would be administered only by people licensed and authorized to do so. The policy identified orders for medications would be . transcribed accurately and in a timely manner. However, the policy lacked specific information on how orders would be double-checked or audited. The PNC harm-level finding was corrected on 7/24/26 prior to the onsite investigation exited on 7/29/26. The facility took multiple actions to correct the non-compliance including education to direct care staff, auditing other residents for medication errors, and reviewing their systems to reduce the risk of repeated incidence. A sample of other residents was reviewed as part of the investigation, and no additional errors were identified.

Based on interview and document review, the facility failed to ensure an allegation of potential neglect of healthcare was reported to the State agency (SA) for 1 of 1 resident (R1) reviewed who had a significant medication error resulting in an adrenal crisis and hospitalization. Findings include: R1's After Discharge Orders, dated 7/21/26, identified R1 was hospitalized on [DATE] and was being discharged to the care center. R1 was listed in stable condition and free of communicable disease. The orders listed R1's medications for the care center which included prednisone 5 milligrams (mg) tablets with a corresponding taper dose schedule including 17.5 mg daily for 14 days, 15 mg daily for 30 days, 12.5 mg daily for 30 days, then 10 mg daily thereafter. A start date was listed as 5/13/26, and the diagnosis attached to the prednisone was, Sarcoidosis [inflammatory disease usually with growth of tiny clumps of immune cells called granulomas, most commonly affecting the lungs, lymph nodes, and skin] of other sites.However, R1's Medication Administration Record (MAR), dated 7/2026, identified R1's consumed medications for the month period and lacked evidence the physician order for prednisone from the hospital (dated 7/21/26) had been provided, given, or refused. The last recorded dose of prednisone for R1 was 12.5 mg given on 7/10/26.R1's progress note, dated 7/23/26, identified R1 was evaluated by nurse practitioner (NP)-A on an urgent basis. R1 had reported low blood pressures and was lethargic with no clear cause. R1's diagnoses were reviewed and NP-A identified R1 as appearing to be volume up (fluid) and, Adrenal insufficiency: On prednisone. Possibly contributory. A physical exam recorded R1 as lethargic, pale and mildly diaphoretic with clear lung sounds, no acute rashes on her skin, and having a regular heartrate and rhythm. R1 was sent to the ED for evaluation.R1's (Hospital) History & Physical, dated 7/23/26 at 3:18 p.m., identified R1 had an extensive medical history including diabetes, adrenal insufficiency, hypothyroidism, and sarcoidosis (on prolonged steroid taper). R1's blood pressure was low at the care center and brought to the ED. In the ED, the blood pressure was even noted to have systolic pressure in the 50's. The physician recorded a main concern of septic shock versus adrenal crisis versus cardiogenic shock. There was no clear source of sepsis infection but was showing signs of volume overload so IV diuretics were started. The chart then listed, Addendum . Med rec [reconciliation] was done[,] and it appears there are several med errors that likely contributed to the hypotension and adrenal crisis . Prednisone was not started at the nursing home therefore she has been off steroids for 2 days likely contributing to adrenal insufficiency .SEE F760 FOR ADDITIONAL INFORMATION.R1's (Facility) Medication Error Reconciliation Form, dated 7/24/26, identified an error happened on 7/22/26, with handwritten description of the error. R1's prednisone taper, as transcribed from the hospital orders, had been missed in transcription. The report listed a section labeled, Outcome to Resident, with handwritten response, Hospitalization. The provider was notified of the error on 7/24/26, and R1 was transferred to the hospital. The section labeled, Investigation Summary ., identified R1 remained in the hospital and . is doing well, in ICU. Drowsy but [alert and oriented] X4 and stable. Admitting DX [diagnosis] adrenal insufficiency. The report labeled a section, Categories of Medication Errors, and marked this error as, Category C [error occurred that resulted in hospitalization]. The facility determined this error was not reportable as an allegation of neglect to the State agency (SA) as only a single dose had been missed and listed follow-up actions which included changing the process for a triple check of admission orders. The report was signed by the director of nursing (DON), nurse manager, and administrator.The Centers for Medicare and Medicaid (CMS) Internet Quality Improvement and Evaluation System (iQIES) database was reviewed. There was no evidence that the missed medication had been reported to the SA as an allegation of neglect despite the error causing an adrenal crisis and contributing to her hospitalization. When interviewed on 7/29/26 at 11:19 a.m., the director of nursing (DON) verified R1 sustained a medication error due to her prednisone not being transcribed into the record system (EMR). They had since adjusted their process and reeducated staff on expectations for order entry. DON stated that, for certain, only a single dose had been missed prior to R1 being sent back to the hospital on 7/23/26. DON stated they did elevate this incident to corporate oversight who then determined it was not reportable as it was only a single dose missed and they felt that couldn't have caused the clinical change R1 demonstrated on 7/23/26. As a result, it was not reported to the SA.When interviewed on 7/29/26 at 2:28 p.m., the administrator stated they were out of the office when the incident happened, so questions on reporting it would have gone to the corporate regional consultant. The administrator verified it was not reported to the SA but was unsure of the rationale or insight into the decision-making on how that decision was reached. The administrator stated they believed R1 had been transferred due to a change of condition and not the medication error itself.The facility Abuse Prohibition/Vulnerable Adult Policy, dated 11/2025, identified the definition of neglect as, . the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy directed allegations or suspicions of neglect which cause serious bodily injury would be reported to the SA within 2 hours of learning of the allegation, or within 24 hours if the allegation did not result in serious bodily injury.

Based on observation, interview, and document review, the facility failed to ensure medications were labeled with current and accurate administration instructions to reduce the risk of medication error for 1 of 1 resident (R2) whose medication administration was observed.Findings include: R2's Order Summary Report, signed 6/30/26, identified R2's current physician ordered medications and treatments. This included an order for Propranolol HCL (medication used to treat high blood pressure, chest pain, and tremors) 30 milligrams (mg) orally three times daily. The order had a start date recorded as 2/4/2026. On 7/29/26 at 8:53 a.m., R2's medication administration was observed by registered nurse (RN)-A who prepared the medications from a mobile cart. RN-A handed each medication blister pack to the surveyor for review. The medications included one labeled Propranolol 10 mg tablets with label directions reading, Give three tablets (30 mg) per g-tube four times daily before meals and at bedtime. The label had a dispense date recorded as 12/30/2025 and multiple doses had already been removed from the blister pack prior to this observation. RN-A compared the labeled medication to the Medication Administration Record (MAR) which directed 30 mg three times daily (TID) by mouth. RN-A stated the label was wrong and listed the incorrect route for the medication and incorrect frequency of administration. RN-A verified the dose just removed by them was not the first one taken from the blister pack and stated incorrect labels should be addressed with the pharmacy so a new, accurate one can be applied. RN-A stated an incorrect label could cause a medication error. RN-A then continued to prepare R2's medications and gave them to R2 who was seated outside in her wheelchair. R2 took the cup of prepared medications whole with water. Following, at 9:05 a.m., R2 was interviewed and stated she had never even had a gastronomy tube so was unsure where that direction on the label had come from. R2 stated she'd always taken her medications orally.When interviewed on 7/29/26 at 11:19 a.m., the director of nursing (DON) stated if a label is identified as wrong during the medication pass, the nurse should contact pharmacy and verify the actual provider order in the chart. The pharmacy should then send a new label so the order and label match. DON reiterated, Everything should match. DON verified R2 never had a g-tube and stated she was unsure where that direction on the labeled came from. DON stated the label and order should match to ensure correct instructions are followed and having an incorrect label could cause a medication error. When interviewed on 7/29/26 at 11:50 a.m., the consulting pharmacist (CP) stated if nurses find a label that is inaccurate, they should place a sticker over it that indicates referring to the actual order. CP stated the facility should have those on hand to use. In the meantime, the nurse should follow the actual order in the MAR as that is likely the correct one. CP stated the label and order should match to help reduce discrepancy and the risk of medication error adding that a resident getting an extra dose of Propranolol could cause their heart rate or blood pressure to drop. The facility Medication Administration - General Guidelines policy, dated 5/2022, identified medications would be checked using the five rights method before each administration. This included checking the label and package and comparing them to the MAR. If the MAR and label are different, then the container should be flagged right away and the order changes communicated to the pharmacy so the next supply of medication can be labeled with current instructions. However, the policy did not identify how or what to flag the label with to meet this step.

Based on observation and interview, the facility failed to properly store and label medications for 1 of 3 residents (R3) reviewed and for medications in medication cart 1 located on the respiratory care unit (RCU) . This had the opportunity to affect all ten residents whose medications were stored in the cart.Findings include: During an observation on [DATE] at 2:00 p.m., registered nurse (RN)-A prepared R3's medication including artificial tears eye drops). The eye drop vial (15 milliliters) was in a box that had previously been opened. The box and the bottle lacked R3's name and lacked the date it was opened. During an observation on [DATE] at 2:15 p.m., of the medication cart 1 located on the RCU there were three loose white round tablets that did not contain scoring or marks were sitting in the top drawer in the right, front corner and a bottle of carbamide peroxide 6.5% ear drops that had previously been opened but lacked date opened or resident name was in the top drawer in the left front corner. R3's admission Minimum Data Set (MDS), dated [DATE], indicated he had diagnoses of anoxic brain injury related to ruptured cerebral aneurysm, dysphagia, persistent vegetative state, chronic respiratory failure and received nutrition and hydration via gastric tube (g-tube). R3's order summary signed by the nurse practitioner (NP), dated [DATE], included carboxymethylcellulose sodium ophthalmic solution (lubricant eye drops) one drop in both eyes four times daily. During an interview on [DATE] at 2:28 p.m., RN-A stated the eye drops were known to be for R3 because she always works on this cart but should be labeled with his name and the date they were opened. She stated eye drops were supposed to be discarded after they had been open for 30 days and she was unsure when they were opened. She stated the vials of eye drops and ear drops should only be used for one resident. The ear drops should be labeled with the resident's name and the date they were opened. She stated the three white round tablets were house stock vitamin D that was taken from another medication cart earlier in her shift. She stated the medications should not be in the drawer freely. All house stock medications should be labeled with the date they were opened. During an interview on [DATE], nurse manager (NM)-A stated house stock medications should be labeled with the date opened to establish the expiration date. He stated eye drops and ear drops could not be used for multiple residents due to risk of contamination and infection and should be labeled with the resident's name once they have been used to reduce the chance of being used for more than one resident. During an interview on [DATE] at 11:54 a.m., the director of nursing (DON) stated all house stock medications must be labeled with the date they are opened. She stated eye drops and ear drops cannot be shared among residents due to risk of cross-contamination and should have a resident's name on them. She stated there should never be loose pills in the medication cart. The facility Medication Storage in the Facility policy, dated 5/2022, directed nurses may not transfer medications from one container to another or return partially used medication to the original container. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. It directed ophthalmic medications shall be labeled with date opened and the new expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident.

Based on interview and document review the facility failed to include clinical indications for medication and treatments prescribed for 2 of 4 (R2,R3) residents reviewed for standards of practice.Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated he had end stage renal disease, heart failure, hypertension (high blood pressure), cerebrovascular disease (condition affecting the blood vessels and blood supply to the brain), history of a transient ischemic attack (a temporary blockage of blood flow to the brain), a restrictive cardiomyopathy (a heart disease where the heart becomes rigid) and was on dialysis. R2's order summary signed by the nurse practitioner (NP), dated 6/30/26, indicated he was to receive the following medication but the electronic medical record (EMR) lacked a diagnosis or clinical indication: lanthanum carbonate 500 milligrams (mg) (a medication used to lower phosphate levels in patients with end stage kidney disease) three times daily before meals on Monday, Wednesday and Friday. R3's admission Minimum Data Set (MDS), dated [DATE], indicated he had diagnoses of anoxic brain injury related to ruptured cerebral aneurysm, dysphagia, persistent vegetative state, chronic respiratory failure and received nutrition and hydration via gastric tube (g-tube). R3's order summary signed by the nurse practitioner (NP), dated 6/30/26, indicated he was to receive the following medications via g-tube but the electronic medical record (EMR) lacked a diagnosis or clinical indication: aspirin 81 mg every morning, baclofen 20 mg (muscle relaxant) every six hours, bromocriptine mesylate 2.5 mg (a semisynthetic ergot alkaloid and dopamine D2 receptor agonist) three times daily, cyclobenzaprine 10 mg (muscle relaxant) three times daily, glycopyrrolate 1 mg (anticholinergic medication that reduces bodily secretions and regulates the nervous system) two times daily, levetiracetam 100 mg/ml (anti-seizure medication) two times daily, propranolol 30 mg (a medication for high blood pressure, migraines, and chest pain) three times daily. The orders also included the following treatments but lacked clinical indication: sodium chloride inhalation 3% (liquid medication used to treat conditions that cause thick mucus in the lungs) via nebulizer four times daily, bacitracin 500 units/gram (antibiotic ointment) every day to trach site and carboxymethylcellulose sodium ophthalmic solution (lubricant eye drops) one drop in both eyes four times daily. During an interview on 7/8/26 at 10:56 a.m., the regional nurse consultant (RNC) stated the medications should have a diagnosis or indication attached to the order. During an interview on 7/8/26 at 11:54 a.m., the director of nursing (DON) stated there must be a diagnosis for each medication ordered. She stated the admissions coordinator and health unit coordinators enter the orders into the EMR. During an interview on 7/8/26 at 1:10 p.m., the admissions coordinator stated she entered the orders for new admissions, the nurse on the unit performs a second check and a nurse manager performs a third check. She stated if the orders do not include a diagnosis, she would ask the provider to clarify why the resident is taking the medication. During an interview at 7/8/26 at 1:14 p.m., the HUC stated it was required to enter a diagnosis in the EMR for all medication orders. The facility Medication and Treatment Orders policy, dated 2/2024, directed orders for medications and treatments will be consistent with principles of safe and effective order writing. Orders for medications and treatments will be transcribed accurately and in a timely manner. Order must include clinical condition or symptoms for which the medication is prescribed.

Based on observation and interviews, the facility failed to verify placement of a gastric tube (g-tube) prior to medication administration for 1 of 2 residents (R3) reviewed for medication administration via feeding tube.Findings include: During an observation on 7/7/26 at 2:00 p.m., registered nurse (RN)-A paused R3's tube feeding and used a syringe to flush the g-tube with 30 milliliters (ml) water. She then administered the following medications, mixed with 15 ml water each, via gravity: cyclobenzaprine 10 milligrams (mg), gabapentin 100 mg and propranolol 30 mg. RN-A failed to verify placement of the g-tube prior to procedure. R3's admission Minimum Data Set (MDS), dated [DATE], indicated he had diagnoses of anoxic brain injury related to ruptured cerebral aneurysm dysphagia, persistent vegetative state, chronic respiratory failure and received nutrition and hydration via g-tube. R3's care plan, dated 4/24/26, directed tube feeding per order and nothing by mouth (NPO). R3's signed NP orders, dated 6/30/26, indicated to check g-tube to ensure tube is in correct location prior to administering medications/feeding by aspirating small amount of stomach contents. During an interview on 7/7/26 at 2:15 p.m., RN-A stated it was not necessary to verify placement of R3's g-tube as long as R3 was not vomiting and there was no resistance when she flushed it. She stated it was not necessary to visualize the g-tube site as she assessed it earlier in the morning. During an interview on 7/7/26 at 3:37 p.m., nurse manager (NM)-A stated g-tube medication administration procedure should include checking for residue and checking for the resident's orders. During an interview on 7/8/26 at 10:14 a.m., the nurse practitioner (NP) stated verifying placement of the g-tube prior to medication administration was usually the standard to ensure medications were injected into the stomach. During an interview on 7/8/26 at 11:54 a.m., the director of nursing (DON) stated it was necessary to verify g-tube placement required verification of placement and she expected the nurses to follow care plans and orders to reduce the of the tube clogging and/or not working properly. The facility Administering Medications through an Enteral Tube policy, dated 3/2023, directed to verify placement of feeding tube. When correct tube placement has been verified, flush tubing with at least 30 ml of lukewarm tap water. The facility Confirming Placement of Feeding Tube policy, dated 7/2025, directed check to see if there is a specific provider order to check placement. To confirm placement of an existing feeding tube at the bedside:The exit site of the feeding tube should be marked at the time of initial placement.Use additional methods to test whether the tube is properly positioned:For g-tubes: attach syringe to connector and pull back gently to aspirate a small amount of stomach contents.If above suggests improper tube positioning, do not administer the feeding or the medication.

Based on interview and document review the facility failed to coordinate care with the dialysis center for 1 of 2 residents (R4) reviewed for dialysis. This had the opportunity to affect two of the residents at the facility.Findings include: R4's care plan, dated 8/28/25, directed communication folder to be sent to dialysis with each run. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had diagnoses of end stage renal failure (ESRD), dependent on renal dialysis and diabetes mellitus. R4's signed physician orders, dated 6/30/26, directed to complete dialysis form and send with resident to dialysis with dialysis scheduled for every Tuesday, Thursday, and Saturday. During an interview on 7/7/26 at 1:15 p.m., R4 stated she had just returned from dialysis and was not sent to dialysis with paperwork that morning. She stated the facility did not consistently send her to dialysis with paperwork. During an interview on 7/7/26 at 3:45 p.m., registered nurse (RN)-B stated the facility did not get R4's vital signs prior to her leaving for dialysis on 7/7/26 and did not send her with paperwork. A phone call was not made to the dialysis center. During an interview on 7/7/26 at 4:11 p.m., the health unit coordinator (HUC) stated it was her responsibility to set up appointments and transportation. She also sets up the paperwork for each appointment. She stated R4 did not require paperwork for her dialysis treatments. During an interview on 7/7/26 at 4:24 p.m., nurse manager (NM)-B stated the facility's standard practice was to send paperwork with every resident to all appointments, including dialysis. During an interview on 7/8/26 at 11:13 a.m., the dialysis center RN stated R4 did not usually arrive for her dialysis appointments with paperwork from the facility but should arrive with paperwork, including medication list, weight, vital signs, and any changes to her medical condition. During an interview on 7/8/26 at 11:54 a.m., the director of nursing (DON) stated it was not necessary for the facility to send paperwork to all dialysis appointments. The facility should call the dialysis center if the resident has any issues. She stated she was unsure what the facility policy directed them to do as she had not read it. She stated, That's how it's been everywhere I have worked. During an interview on 7/8/26 at 1:29 p.m., the regional nurse consultant (RNC) stated the facility used a dialysis communication form each time a resident went to dialysis which included their vital signs, weight, changes to their health status and any refusals of care. During an interview 7/8/26 at 1:37 p.m., the administrator stated communication with the dialysis center should occur using the dialysis communication form. The facility Dialysis Center Communication Record form included resident name, pre-treatment vital signs, weight, transfer needs/mobility, injection site, precautions needed, as needed/pain medications administered prior to dialysis and additional information. The document included a section for the dialysis nurse to complete upon return to the facility. The facility Hemodialysis policy, dated 11/22/19, directed residents who require dialysis will receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility staff and dialysis center will have ongoing communication and collaboration regarding dialysis care and services. Documentation should include, but is not limited to, pre and post dialysis assessment/observation, daily check of the access site, evaluation for signs and symptoms of infection and fluid intake amounts for each shift with a 24-hour total if fluid restriction is in place.

Based on observation and interviews, the facility failed to maintain clean technique with the gastric feeding tubing for 1 of 2 residents (R3) reviewed for medication administration via enteral feeding.Findings include: During an observation on 7/7/26 at 2:00 p.m., registered nurse (RN)-A paused R3's tube feeding and placed the open end of the tube in a glove, wrapped the glove around the tubing and pressed into the handle of the feeding pump which was attached to a pole, while she administered R3's medications via a syringe. During an observation on 7/7/26 at 3:40 p.m., R3 was in his reclining wheelchair. The tubing was hanging on the pump connected to the pole and the tubing was open to air. R3's admission Minimum Data Set (MDS), dated [DATE], indicated he had diagnoses of anoxic brain injury related to ruptured cerebral aneurysm dysphagia, persistent vegetative state, chronic respiratory failure and received nutrition and hydration via g-tube. R3's care plan, dated 4/24/26, directed tube feeding per order and nothing by mouth (NPO). During an interview on 7/7/26 at 2:25 p.m., RN-A stated she covered the tubing with a glove to keep it clean, and she did not have a cap for it. During an interview on 7/7/26 at 3:37 p.m., nurse manager (NM)-A stated he would not recommend using a glove to cover the end of the tubing or leaving the tubing open to air for enteral feeding as it could pose a risk for contamination. During an interview on 7/8/26 at 10:14 a.m., nurse practitioner (NP)-A stated the enteral feeding tubing was not a sterile process but should be a clean process. He stated, I would not recommend leaving the tubing open to air or covering with a glove and would prefer to have the tubing covered with the cap. During an interview on 7/8/26 at 11:54 a.m., the director of nursing (DON/infection preventionist stated placing a glove on the end of the tubing or leaving it open to air for the enteral tubing because germs could get into the tubing and there was a potential harm of infection. She stated this was not the practice she would expect. The facility Administering Medications through an Enteral Tube policy, dated 3/23/23, directed to stop the feeding and flush the tubing with 15-30 ml of lukewarm tap water then remove the syringe and clamp the tubing. Place the end of the tubing on a clean gauze pad positioned on the abdomen or chest of the resident.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll during 1 of 1 quarter (Quarter 1) reviewed, to the Centers for Medicare Services (CMS), according to specification established by CMS. This had the potential to affect all 83 residents at the facility. Findings include: Payroll Based Journal (PBJ), [NAME] Report 1705D indicated the facility had excessively low weekend staffing during quarter 1 of fiscal year 2026, which included dates between October 1 to December 31, 2025. The CMS payroll-based journal (PBJ) staffing data report indicated the following: Excessively Low Weekend Staffing Triggered An interview on 4/20/26 at 3:39 p.m., staffing coordinator (SC) stated she was responsible for the nurse staff schedules. SC stated there was at least one RN per shift scheduled and that the weekends are covered. SC stated if there were a call in of staff the charge nurse is responsible to find a replacement. An interview on 4/22/26 at 1:49 p.m., the administrator indicated they found the low staffing on the shift first weekend in 11/25. The administrator stated she submitted the PBJ report once corporate pulls the information and they have reviewed it. The administrator stated there was inaccurate reporting. A request for a facility policy for payroll based journal was requested and not received.

Based on observation, interview, and record review, the facility failed to ensure the facility's walk-in freezer was maintained to ensure water drippings and ice build-up would impact frozen food storage. This had the potential to impact all residents who ate from the kitchen.During an observation of the kitchen on 4/22/26 at 9:21 a.m., the walk-in freezer was observed. Inside the freezer, the ceiling had numerous frozen water drops out into the middle of the walk-in freezer, across from the two fans on the left side of the walk-in freezer. On the floor of the walk-in freezer were three frozen areas approximately 12 inches in diameter. An interview on 4/22/26 at 9:22 am., the culinary director (CD) stated the the walk-in freezer had been like that for a couple of weeks. The CD stated the regional person came out and de iced the walk-in freezer. The CD stated the frozen water on the floor is a safety hazard. The CD was unable to find a work order to get the walk-in freezer de iced. An interview on 4/22/26 at 9:26 a.m., the director of maintenance (DM) stated there had been a work order for the walk-in freezer ice build up 8/5/26, and was de iced. The DM stated on 10/14/25, that he had defrosted the freezer and replaced a door gasket. The DM stated he was not aware of the walk-in freezer build up. The DM stated any staff can place a work order or notify their manager and they will let me know of the issue. DM observed the walk-in freezer and indicated the ceiling was half full with frozen water drops and three frozen water areas on the floor all about 12 inches in diameter and one quarter inch thick. A policy for maintaining equipment was requested, however, was not received.

Based on observation and interview, the facility failed to ensure safe storage of medication on 4 of 6 medications carts reviewed.Findings include: During observation on 4/20/26 at 1:26 p.m., a medication cart on the long term care (LTC) until was unlocked without a nurse in eye site of it.At 1:28 p.m., a nursing assistant (NA) walked by the unlocked medication cartAt 1:29 p.m., a housekeeper and maintenance worker walked past medication cartAt 1:30 p.m., licensed practical nurse (LPN) Care Coordinator (CC)-A walked by cart to unplug a cord from a hallway outletBetween 1:33 p.m. and 1:34 p.m., four residents passed the unlocked medication cart unattendedAt 1:34 p.m., CC-A locked the medication cart During interview on 4/20/26 at 1:34 p.m., CC-A confirmed she locked the unattended medication cart. CC-A confirmed the nurse who was working the medication cart was not monitoring the cart. During interview on 4/20/26 at 1:38 p.m., LPN-A confirmed he left the medication cart unlocked. LPN-A states he is unsure how long it was unlocked, but estimates it to be between 5-10 minutes. During observation on 4/21/26 at 11:53 a.m., a medication cart in the respiratory care unity (RCU) was unlocked with no nurse in eye site. A NA walked past pushing a resident in a wheelchair, a male resident passed the cart in an electric wheelchair unattended by staff, a resident pushing a wheelchair walked past unattended by staff, and two staff members walked past without locking the medication cart.At 12:00 p.m., CC-A walks past the unlocked medication cart.At 12:02 p.m., LPN-B walks up to the cart and locks it. LPN-B stated she just noticed it was unlocked and confirmed she was not in eye site of the cart the whole time it was unlocked.During observation on 4/22/26 at 6:55 a.m., medication cart on LTC unit was unlocked with no nurse in eye site. There was a resident sitting next to the unattended, unlocked medication cart. Staff were at nurses station speaking with backs facing medication cart. At 7:05 a.m., registered nurse (RN)-A returned to the unlocked medication cart. RN-A stated he just received the keys for the medication cart from LPN-C and she was the one who left the medication cart unlocked. RN-A confirmed he and LPN-C handed off medication cart keys at nurses station and had not completed a narcotic reconciliation at time of handing off the medication keys. RN-A walked away from unlocked medication cart to find LPN-C to complete narcotic reconciliation and alert her to leaving the medication cart unlocked. RN-A confirmed he knowingly walked away from the unlocked medication cart so he could show LPN-C. During observation on 4/22/26 at 1:14 p.m., medication cart on RCU was unlocked with no nurse in eye site. Two NA's were next to cart preparing to enter a resident room, RN-A walked past unlocked medication cart pushing a resident, a housekeeping staff walks past the cart, and a resident passes the cart in a wheelchair. At 1:19 p.m., LPN-D returned to the cart and locked it. LPN-D confirmed she left the cart unattended and stated she was only on day 2 of her training and forgot to lock the medication cart. LPN-D stated the nurse training her was currently on break. During interview on 4/22/26 at 1:44 p.m., direct of nursing (DON) confirmed medications carts should be locked any time a nurse is outside of arm's length away. DON stated she has not done any audits of medication carts being locked and was unaware this was an issue. DON confirmed keys to the medication cart should have been handed off at the medication cart and a narcotic reconciliation should be completed at that time. DON confirmed she was aware of the concerns found with the last recertification survey regarding medication storage but had not implemented any monitoring. DON stated locking medication carts was important for safety.A policy regarding medication was requested but was not provided.

Based on observation, interview, and document review, the facility failed to ensure resident rights were maintained for 1 of 2 residents (R71) reviewed for dignity. Findings include: R71's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R71 was cognitively intact, and diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, and quadriplegia. R71 communicated clearly and understood others and was dependent on staff for activities of daily living (ADLs). R71's care plan last reviewed 2/11/26, indicated R71 had an alteration in elimination and required staff assistance with incontinent cares upon rising, before or after meals, at bedtime, and two times overnight. R71 had a self-care deficit and required staff assistance with dressing, personal hygiene, and bathing. R71 preferred showers. R71's care plan further indicated staff were not to get R71 up and into her wheelchair until after 11:00 a.m. per patient preference. During interview on 4/20/26 at 2:50 p.m., R71 stated she had requested several times to get up after 11:00 a.m. but staff consistently get her dressed and transferred to her wheelchair earlier in the mornings. R71 became tearful and stated, makes me feel I'm in the land of misfit toys. During interview on 4/20/26 at 3:03 p.m., R71 stated she remains in the same brief all day from the time staff get her up into her wheelchair in the morning until late afternoon, and when staff change her in the afternoon, urine has soaked through her clothing onto her wheelchair. R71 stated that because her wheelchair was soiled, staff changed her into a hospital gown and placed her into bed until the next morning. R71 stated staff typically changed her again at 8:00 p.m. and 5:00 a.m. R71 stated when she asked the staff for help, they told her they were too busy, so I just stopped asking; I gave up the beginning of this year. R71 started to cry and stated she smelled from urine and felt humiliated. During observation and interview on 4/20/26 at 5:21 p.m., R71 was observed in her bed with a hospital gown on. R71 stated this is what they do; I'll be in here for the rest of the day. R71 stated her clothing and wheelchair were saturated because her brief had not been changed since she got up that morning. R71's wheelchair cushion appeared damp and smelled of urine. During observation on 4/22/26 at 1:24 p.m., R71's hair was oily, clumped together at the roots, stringy, heavy and limp. R71 had a significant amount of large, thick, and oily yellow-white flakes that clung to R71's scalp and hair. A layer of yellow-white flakes were noted on R71's shoulders and the back edges of R71's electric wheelchair. Additionally, R71's hair had a greasy, musky odor. During interview on 4/22/26 at 1:24 p.m., R71 stated staff have used a shampoo shower cap on her hair, but staff had not washed her hair since she moved into the facility on [DATE]. R71 stated she could feel the buildup and was aware of the excessive flaking. R71 stated it's demeaning, and very much a dignity issue; dignity left when I came in here. R71 stated the lack of adequate brief care and showers made it worse and caused her to isolate because I don't want anyone to smell it. R71 stated staff had not followed the care plan for brief changes, and it's done when they care and when they want. R71 further stated, I'm marginalized because I'm in a lower income bracket and so you realize that means a lower standard of care. During observation and interview on 4/23/26 at 10:16 a.m., R71 was dressed and seated in an electric wheelchair, and R71's bed was made. R71 stated two aides got her up at 9:30 a.m., and basically said it's now or never. During interview on 4/23/26 at 11:12 a.m., nursing assistant (NA)-A stated the NAR care guides indicated resident preferences and care needs. NA-A stated R71 needed two staff to assist because R71 required a Hoyer lift, and NA-A and another NA got R71 up between 9:00 a.m. and 10:00 a.m. today. NA-A stated she did not usually work with R71 and did not reference the care guide to see the instructions regarding R71's preferred time request. NA-A further stated she had not noticed that R71's hair was oily. During interview on 4/23/26 at 11:53 a.m., director of nursing (DON) stated staff were expected to provide incontinence care every 2 to 3 hours and as needed, and it was important for residents to be kept clean and dry to prevent skin breakdown and infection, and for resident dignity. DON stated staff were expected to follow the care plan, honor resident preferences, and regular showers was important for the dignity and health of the residents. The facility's Resident Rights Policy, revised 11/2025, indicated it is the practice of this facility to uphold the rights of all residents.

Based on observation, interview, and document review, the facility failed to honor a resident's right to make choices about aspects of care for 1 of 2 residents (R71) reviewed for self-determination. Findings include: R71's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R71 was cognitively intact, and had clear speech, the ability to make self understood, and the ability to understand others. R71's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, and quadriplegia, and R71 was dependent on staff for activities of daily living (ADLs). R71's care plan last reviewed 2/11/26, indicated R71 required assist of two with Hoyer transfer, required assist of one with ADLs, and don't get up pt [patient] into her w/c [wheelchair] until after 11AM per pt preference. During interview on 4/20/26 at 2:50 p.m., R71 stated she had requested several times to get up after 11:00 a.m. but staff consistently get her dressed and transferred to her wheelchair earlier in the mornings. R71 became tearful and stated, makes me feel I'm in the land of misfit toys. During observation and interview on 4/23/26 at 10:16 a.m., R71 was dressed and seated in an electric wheelchair, and R71's bed was made. R71 stated two aides got her up at 9:30 a.m., and basically said it's now or never. During interview on 4/23/26 at 11:12 a.m., nursing assistant (NA)-A stated the NAR care guides indicated resident preferences and care needs. NA-A stated R71 needed two staff to assist because R71 required a Hoyer lift, and NA-A and another NA got R71 up between 9:00 a.m. and 10:00 a.m. today. NA-A stated she did not usually work with R71 and did not reference the care guide to see the instructions regarding R71's preferred time request. During interview on 4/23/26 at 11:53 a.m., director of nursing (DON) stated R71's care plan indicated it was R71's preference to not get up and put into her wheelchair until 11:00 a.m., and DON expected staff to honor the resident's preference. DON stated R71's preference should have been listed on the daily nursing assistant (NAR) guide. R71's section of the NAR guide, dated 4/23/26, indicated Don't get up the pt before 11 AM. The facility's Resident Rights Policy, revised 11/2025, indicated it is the practice of this facility to uphold the rights of all residents.

Based on interview and document review, the facility failed to notify a resident/resident representative Medicare part A coverage would end prior to going on a leave of absence (LOA) for one of one residents (R11) reviewed for therapy services. Findings include: R11's admission Minimum Data Set R11 admitted to the facility 1/12/26, was cognitively intact and had the following diagnoses: coronary artery disease (narrowing of arteries), diabetes mellitus, morbid obesity and debility (a state of physical weakness). During interview on 4/20/26 at 6:36 p.m. R11 stated he had gone home for the Easter holiday on 4/5/26, and returned on 4/7/26. R11 stated he had notified facility staff he was planning to leave on 4/5/26, and would need his medication for two days. R11 stated on 4/5/26, the nurse reviewed his medication instructions and then gave him medications through the morning of 4/7/26. Upon his return he was notified by the Minimum Data Set (MDS) nurse (MDS-A) his leave violated his ability to continue receiving Medicare part A covered services and he was given a Notice of Medicare Non-Coverage (NOMNC) with a therapy services end date of 4/10/26. R11 stated he was not informed prior to leaving his leave of absence (LOA) would result in termination of his Medicare part A covered services. During interview on 4/22/26 at 10:53 a.m., Director of Rehab Services (DRS) stated R11 was discharged from physical therapy (PT) and occupational therapy (OT) services on 4/10/26 after a LOA. DRS stated he was first made aware R11 was to be discharged on 4/8/26, during facility staff morning meeting when he was informed R11 had to discharge from therapy because he had taken a LOA and no longer qualified for Medicare part A coverage. During interview on 4/22/26 at 12:20 p.m., MDS nurse stated she issued R11 the NOMNC notice on 4/8/26 after she learned he had been on LOA 4/5/26 through 4/7/26. MDS-A stated due to taking a LOA R11 no longer meet the criteria for a skilled Medicare stay and therefore needed to be discharged from physical and occupational therapy. MDS-A stated she had been previously instructed if a resident was on skilled services they were not allowed to take a LOA.Review of R11's progress note dated 4/5/26 indicated R11 had requested a LOA from facility staff on 4/4/26, was provided with his medications and was instructed on medication administration. The progress note further indicated the on-call nurse and provider were updated at time of LOA per facility protocol.A policy on denial of medicare coverage was requested but one was not received.

Based on observation, interview, and record review the facility failed to provide activities of daily living (ADLs) for 2 of 2 resident (R62 and R71) who were dependent on staff for assistance with ADLs. Findings include: R71's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R71 was cognitively intact, diagnoses included multiple sclerosis and quadriplegia, and R71 required total assistance with bathing. R71's care plan, last reviewed 2/11/26, indicated R71 had a self-care deficit and patient bathing preference was assist of one staff with showers. R71's Weekly Skin Inspection forms dated 11/14/25 through 4/8/26, indicated R71 received weekly bathing assistance as follows: Bed Baths - 4/8, 4/1, 3/25, 3/19, 3/11, 3/4, 2/25, 2/19, 2/11, 2/4, 1/28, 1/21, 1/14, 1/12, 1/2, 12/26, 12/19, 12/12, 11/28, 11/21 Shower - 11/14, 12/5 Refused - 3/17 During observation on 4/22/26 at 1:24 p.m., R71's hair was oily, clumped together at the roots, stringy, heavy and limp. R71 had a significant amount of large, thick, and oily yellow-white flakes that clung to R71's scalp and hair. A layer of yellow-white flakes was noted on R71's shoulders and the back edges of R71's electric wheelchair. Additionally, R71's hair had a greasy, musky odor. During interview on 4/22/26 at 1:24 p.m., R71 stated she preferred showers but has received weekly bed baths instead, and staff told her that she could not have showers because she was not able to hold herself upright in the shower chair. R71 stated that staff have used a shampoo shower cap on her hair, but staff had not washed her hair since she moved into the facility on [DATE]. R71 stated she could feel the buildup and was aware of the excessive flaking. R71 stated it's demeaning. During interview on 4/23/26 at 11:12 a.m., nursing assistant (NA)-A stated the facility had shower chairs with straps to keep residents upright during showers. During interview on 4/23/26 at 11:53 a.m., director of nursing (DON) stated resident care plans were developed based on orders, assessments, and resident preferences, and staff were expected to honor R71's preference for a shower and use the shower chairs that were available in the facility to help R71 remain seated upright. DON stated R71 should have been given showers with hair-washing as per R71's preference. DON stated regular bathing was important for the dignity and health of the residents. The facility's Activities of Daily Living (ADLs)/Maintain Abilities Policy, dated 3/31/23, indicated it is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. Findings include: R62's significant change minimum data set (MDS) dated [DATE], included R62 had severe cognitive impairment. R62's diagnoses included heart failure, bipolar disorder (a mental health condition with intense, fluctuating mood shifts), and schizophrenia (a severe brain disorder which includes delusions, hallucinations, and lack of motivation). During interview and observation on 4/20/26 at 3:57 p.m., R62 stated she really wanted her toenails cut. R62 stated she needed help with this and needed to see a podiatrist. R62's toenails were growing past the end of her toe, some had some thickening. Facility assessment for weekly skin assessment included an observation for fingernails and toenails. Assessments included the following: 3/10/26: refused assessment 3/27/26: Fingernails and toenails not necessary to be trimmed 4/6/26: Fingernails and toenails not necessary to be trimmed 4/10/26: Fingernails and toenails not necessary to be trimmed 4/17/26: Fingernails and toenails not necessary to be trimmed During interview on 4/22/26 at 7:24 a.m., licensed practical nurse (LPN)-A stated skin and nails are assessed once a week after a resident's bath. Fingernails could be trimmed by a nurse if they are long or the patient is diabetic. LPN-A stated the resident would be referred to podiatry if the toenails were long, thick or otherwise unable to be cared for in house. During interview and observation on 4/22/26 at 9:33 a.m., LPN Care Coordinator (CC)-A stated staff do monitor nails weekly during bath time. CC-A stated she does know that R63 sometimes refuses nail care, but staff should be documenting that she refused on the weekly assessments or in a progress note. CC-A confirmed there were no recent notes about R63 refusing nail care. During observation of R63's toenails, CC-A confirmed the toenails were long and some were thickening. CC-A stated R63's toenail on her big toe was grown at least 1/2 inch past the toenail and others were similar lengths. CC-A stated R63 should have been put on the podiatry rounds list but does not believe she was. During interview on 4/22/26 at 9:42 a.m., health information manager (HIM) stated she was the one who coordinates the residents who see podiatry. HIM confirmed R63 was not on the list to see podiatry. During interview on 4/22/26 at 1:44 p.m., director of nursing (DON) confirmed nails should be assessed on bath days and nail care should be completed as needed. DON stated those who needed could be put on a list to see podiatry. DON stated if proper toenail care was not completed, the resident was at risk for skin damage, ingrown toenails and other health hazards. Facility policy for ADLs dated 3/31/23, included residents who were unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and document review, the facility failed follow up on pharmacist recommendations for 1 of 5 residents (R23) reviewed for monthly pharmacist reviews.Findings include: R23's quarterly minimum data set (MDS) dated [DATE], included R23 was cognitively intact. R23 had diagnoses of heart failure, diabetes mellitus (high blood sugars), depression, respiratory failure, and anemia (deficiency of healthy red blood cells reducing oxygen to the body tissues. Review of R23's electronic medical record (EMR) included progress note from the consultant pharmacist indicating recommendations for the facility on 10/21/25, 11/18/25, 12/15/25, 1/23/26, 2/11/26, 3/19/26, 4/15/26. R23's pharmacy recommendation dated 12/15/25, included a recommendation to review the use of both Omeprazole 40 mg (a proton-pump inhibitor used to treat gastroesophageal reflux disease) and Sucralfate 1 mg (a mucosal protectant used to treat and prevent active duodenal ulcers) in an effort to avoid potentially unnecessary medications. During interview on 4/22/26 at 1:44 p.m., director of nursing (DON) stated she gets the monthly pharmacy recommendations emailed to her and she distributes them appropriately to be addressed. DON confirmed the December pharmacy recommendation for R23 was not addressed. The DON stated it was important to follow up on pharmacy recommendations timely for the resident's health. Facility policy for consultant pharmacist reports dated January 2026, included all recommendations are acted upon and documented by the facility staff and/or the prescriber.

Based on interviews and document reviews, the facility failed to ensure care was delivered in accordance with professional standards and care planning for 1 of 3 residents (R1) reviewed for quality of care. R1 had severe cognitive impairment and frequently crawled out of bed to the floor. This resulted in Psychosocial harm for R1 when staff would drag R1 from the floor to the bed for repositioning without the care planned use of a mechanical lift. A reasonable person concept is applied in determining what the psychosocial outcome would have on a reasonable person in a similar situation to suffer because of the noncompliance. Findings Include: Observation of R1's room on 3/19/26 at 2:40 p.m., was a shared room, where her space was closest to the door with a privacy curtain between her side and her roommate's side. R1's bed was against the wall, lengthwise. There was a hospital bed mattress located on the floor along R1's bed, which was approximately six inches lower than the bed, as the bed was in the lowest position. There was a bedside table against the wall immediately next to the door and an oxygen concentrator located near the foot of the bed. Review of video from R1's room, on 3/9/26 at 7:45 a.m. was approximately 1 minute 30 seconds. R1's bed was in a low position. R1's body was partially on the bed and on the floor. She was lying on her back, face up, at the width of the bed, with her hips and legs on the floor, and her waist, chest, and head on the bed. R1 was dressed in a gown with no undergarments. Nursing assistant (NA)-A was standing at the center of R1's bed, bending over at her waist, grabbing the front of R1's hospital gown with both hands near each armpit dragging R1 from the mattress on the floor onto the bed. NA-A paused when R1 was partially on the bed, facing up from her midback to her head. R1's left hand appeared to be grasping for NA-A's forearm. Then NA-A walked off R1's bed. NA-A and NA-B pushed R1's right leg up and over her left side on to the bed. NA-A then pushed R1's left hip, with the help of NA-B pushing R1's left leg, to rotate R1 into the center of the bed lengthwise in a prone. R1's head was now at the head of the bed and her feet at the bottom of the bed, she was face down, with her left arm tucked under her chest and right arm off to her right side. R1 moans when NA-A pulled R1's left arm out from under R1's chest. R1 was left in the prone position on her bed, exposed from the waist down without undergarments. R1's hospital admission history and physical, dated 2/11/26, indicated R1 was [AGE] years old who had cognitive impairment, limited capacity to understand instructions, was very hard of hearing, and required the use of a translator. R1 had been declining for months due to pain and had not been ambulatory using a wheelchair for mobility. R1 was currently living in an assisted living facility. R1 was evaluated and treated for heart failure and would need placement at a skilled nursing facility. R1's admission Minimum Data Set (MDS), dated [DATE], indicated she had diagnoses of heart failure and respiratory failure, severe cognitive impairment, was Hmong speaking, and was dependent on all cares and transfers. R1 was on hospice. R1's care plan, dated 2/18/26, indicated she was a fall risk and had a goal to be safe and free from falls. Interventions included R1 to use a soft touch call light for assistance, a fall mat at bedside when in bed, keeping the bed in a low position and to monitor R1 for falls determining possible root causes. R1 had an alteration in mobility with a goal to move safely within her environment. Interventions included to assist with movement in bed and in/out of bed, and assistance of two staff with a Hoyer lift and medium sling size. R1's NA guide, undated, indicated she required assistance from two staff and mechanical lift for transfers with medium sling size. Assistance of one staff to turn and reposition R1 every two to three hours, offer a bed pain or check and change her incontinent brief upon rising, before or after meals, at bedtime and as needed. R1 frequently removes incontinent brief, reapply when observed. She was a fall risk with bed in low position and a floor mat beside bed. R1 lies on floor mat occasionally per preference. Hmong speaking with translator phone numbers were listed. A facility staff schedule dated 3/9/26, indicated NA-A and NA-B were both working 6:30 a.m. to 2:30 p.m. on 3/9/26. During an interview on 3/19/26, at 3:33 p.m., family member (FM)-A stated she could hear R1 saying hurt, hurt in Hmong when she watched the video of the transfer on 3/9/26. She stated she felt it was abusive and thought R1 was scared and in pain. FM-A stated the staff were supposed to use the mechanical lift to move her. Following another interview with FM-A on 3/20/26 at 3:15 p.m. she had not been offered a care conference or asked for preference of care. She stated it was not R1's preference or culture to stay on the floor. During an interview on 3/20/26, at 8:35 a.m., NA-B stated R1 frequently crawled off her bed to the mattress on the floor. She was aware R1 was to be transferred with the mechanical lift and two staff but there was no room to bring the mechanical lift into the room and fit it around the large floor mattress. She and NA-A were frequently transferring R1 back to bed in a similar manner, without using a mechanical lift, over the previous weeks. NA-B stated neither she nor NA-A told the nurses, clinical leader or director of nursing (DON) they were not using the mechanical lift to transfer R1 into bed from her floor mattress because it was difficult. During an interview on 3/20/26, at 8:48 a.m., NA-A stated she and NA-B had R1 crawl up on the bed on 3/9/26, then pushed her hip to roll her over and never dragged R1 by her clothing. She stated she was aware R1 was to be transferred with the mechanical lift and two staff. She stated she thought they were doing the right thing and did not talk to a nurse, clinical leader, or DON regarding transferring R1 into bed from her floor mattress. During an interview on 3/20/26, at 9:55 a.m., the nurse practitioner (NP) stated she was informed of an inappropriate transfer but had not seen the video. Transferring R1 with the mechanical lift was the safest manner to avoid orthopedic injuries such as dislocation and muscle strains. During an interview on 3/20/26, at 10:16 a.m., the clinical leader/licensed practical nurse (LPN)-A stated R1 was to be transferred with assistance of two staff and a mechanical lift. She was not made aware of any challenges staff had with transfers. During an interview on 3/20/26, at 12:25 p.m., the administrator stated R1 appeared uncomfortable during the transfer seen on the video from 3/9/26 and none of the staff had previously approached her about challenges with transferring R1 back into her bed. During an interview on 3/20/26, at 1:30 p.m., the DON stated R1 required a mechanical lift and assistance from two staff because she could not stand on her own or bear her own weight. She stated the video demonstrated an improper transfer and R1 should always be transferred with the mechanical lift and two staff. She stated NA-A and NA-B should have asked a manager if they were not sure how to safely transfer R1. The facility Safe Resident Handling policy, dated 11/2025, directed all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's care plan. Manual lifting of all residents who are unable to bear weight will be minimized. Residents identified as totally dependent or extensive assistance, for example, will be transferred by means of lift equipment and/or other resident assistance devices instead of a manual lift. The facility Care Planning, dated 11/2024, directed the care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purpose of providing care or services to the residents. The plan of care will be utilized to provide care for the residents. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Based on interview and record review the facility failed to provide an opportunity for 1 of 3 residents (R1) reviewed for care planning to participate in the development of the plan of care.Findings Include: During an observation on 3/20/26, at 8:30 a.m., R1 was seated at the edge of the floor mattress. Her breakfast tray was positioned to her left side on the floor mattress. R1 was leaning on her left elbow as she reached with a fork, using her right hand to eat the food from her tray. Food was observed falling on to the mattress as she tried to eat. R1's admission Minimum Data Set (MDS), dated [DATE], indicated she had diagnoses of heart failure and respiratory failure, she had severe cognitive impairment, was Hmong speaking, and was dependent for all cares and transfers. R1's care plan, dated 2/18/26, indicated she was a fall risk and had a fall mat at her bedside. She required assistance with cares including eating, bed mobility, and transfers, using two staff and a full body mechanical lift. R1's electronic medical record lacked documentation of a care conference and indicated she was admitted on [DATE]. During an interview on 3/19/26, at 4:30 p.m., the administrator stated conferences were offered within three weeks of admission and then quarterly. During an interview on 3/20/26, at 8:35 a.m., NA-B stated R1 frequently crawled off her bed to the mattress on the floor. Staff only put R1 in her wheelchair when her family would be present so they could watch her. She stated they give R1 bed baths because it would take up to three staff to give her a shower. During an interview on 3/20/26, at 8:48 a.m., NA-A stated R1 was eating her breakfast on the floor mattress because they were serving breakfast trays and there was not time to get R1 back into her bed. She was unsure whether it bothered R1. NA-A stated, some cultures, like Hmong, like to be on the floor. During an interview on 3/20/26, at 10:04 a.m., the social services director (SSD) stated resident preferences are elicited during the initial assessments and a care conference within the first 21 days and then held quarterly. R1 should have had a care conference but did was unable to locate the documentation. She stated it would be located in the forms section of the electronic medical record and mentioned in the progress notes. During an interview on 3/20/26, at 10:16 a.m., the clinical leader/licensed practical nurse (LPN)-A stated care conferences were intended to discuss medications, concerns with cares, comfort, and complaints. She thought care conferences should occur within seven days of admission and quarterly. The floor mattress was intended as a fall prevention intervention when R1 was admitted . She stated R1 seemed comfortable on the floor mattress and liked to sit on it, so she care planned for that. During an interview on 3/20/26, at 1:30 p.m., the DON stated resident preferences were determined by their initial assessments and care conferences. The care conferences are held within five days and after that every quarter. R1 had not had a care conference since she was admitted on [DATE] but should have had one. The DON stated the purpose of the care conference was to ensure the residents were comfortable, happy and the facility was meeting their needs. It gave an opportunity to keep the residents and family informed. During an interview on 3/20/26, at 3:15 p.m., FM-A stated she was never offered a care conference. She was in favor of a mattress on the floor next to R1's bed so she would not get hurt but she was not pleased that R1 was left on the floor mattress for hours, she would prefer for R1 to be offered the toilet or commode, would prefer R1 to have a shower instead of a bed bath, and it was not their culture to eat on the floor. During an interview on 3/20/26, at 3:55 p.m., the administrator stated there had not been a care conference for R1. A facility policy, Resident Rights, dated 11/2025, directed it is the practice of this facility to uphold the rights of all residents. The policy included a link to the Combined Federal and State [NAME] of Rights, dated 12/22/2025, which directed the resident has the right to be informed of, and participate in, their treatment, including: -The right to participate in the development and implementation of their person-centered plan of care, including but not limited to:-The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.-The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.-The right to be informed, in advance, of changes to the plan of care.-The right to receive the services and/or items included in the plan of care.-The right to see the care plan, including the right to sign after significant changes to the plan of care.The facility shall inform the residents of the right to participate in their treatment and shall support the residents in this right. The planning process must: facilitate the inclusion of the resident and/or resident representative, include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing goals of care. A facility policy, Care Planning, dated 11/2024, directed each resident will have a person-centered care plan developed by the interdisciplinary team IDT) for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The IDT, in conjunction with the resident and the resident representative, will develop a comprehensive care plan no later than the 21st day of admission of the resident.

Based on interview and record review the facility failed to follow established infection control practices for 1 of 3 residents (R1) reviewed for hand hygiene when staff failed to perform hand hygiene.Findings Include: During an observation on 3/19/26, at 2:40 p.m., nursing assistant (NA)-C and NA-D performed incontinence cares for R1 in her bed. NA-D assisted with positioning of R1 in her bed as NA-C removed the soiled brief, wiped R1's perineum and buttocks, then discarded the brief and wipes. She failed to remove her gloves and perform hand hygiene. NA-C proceeded to place a clean brief under R1, apply barrier cream to her perineum, fasten the brief, position draw sheet, assist to lift R1 with NA-D, position bedding, clip the call light to the bedding, positioned R1's oxygen tubing in her nostrils, moved the bed back to its original location and positioned the privacy curtain before NA-C removed her soiled gloves and performed hand hygiene. R1's admission Minimum Data Set (MDS), dated [DATE], indicated she had diagnoses of heart failure and respiratory failure, severe cognitive impairment, was frequently incontinent of bowel and bladder, and was dependent on facility staff for all cares and transfers, and was Hmong speaking. R1's care plan, dated 2/18/26, indicated she required assistance with cares including bed mobility, transfers, and incontinent care. R1's NA guide, undated, indicated she required assistance with incontinence care every 2 - 3 hours. A facility grievance/complaint form, dated 3/16/26, indicated LPN-A was aware staff were not changing gloves between changing R1's brief and adjusting her oxygen tubing in her nose. During an interview on 3/19/26, at 2:52 p.m., NA-C stated she should have changed her gloves and performed hand hygiene after performing peri care to prevent infection. During an interview on 3/19/26, at 3:33 p.m., family member (FM)-A stated she had observed staff not changing their gloves after performing peri care on the camera she had set up in R1's room. She stated this was shared with the clinical leader/licensed practical nurse (LPN)-A on 3/16/26. During an interview on 3/20/26, at 10:16 a.m., LPN-A stated gloves should be changed between dirty and clean tasks. Hand hygiene should be performed any time gloves are changed. LPN-A stated she received a grievance regarding R1's cares and staff failing to change their gloves after changing her brief on 3/16/26 and provided verbal education to nursing staff. During an interview on 3/20/26, at 1:30 p.m., the director of nursing (DON) stated gloves should be changed before and after providing care and after changing briefs. Hand hygiene should be performed before and after each care provided to the residents to reduce infection risk. A facility document, Handwashing Policy, dated 11/2019, directed proper hand washing techniques should be used to protect the spread of infection: after changing incontinent products. When conducting a procedure requiring the use of gloves, proper hand washing shall be completed before donning gloves and after removing gloves.

Based on interview, observation, and document review, the facility failed to develop care plans for 2 of 3 residents (R2, R3) reviewed for baths/ showers. R2 and R3 refused baths/showers and their care plans did not include interventions for refusals. Findings include: R2's quarterly MDS dated [DATE] indicated intact cognition, paralysis on one side of the body related to stroke, was fully dependent upon staff assistance for bathing, and identified no refusals of bathing/showering. R2's care plan dated 7/7/23 indicated a self-care deficit related to stroke and left-sided weakness, had a history of refusing ADLs, and starting 7/12/23 required assistance of one staff for bathing/showers. The care plan lacked interventions for refusal of bathing and/or showers. R2's Weekly Skin Assessments dated 1/26/26, 2/2/26, 2/9/26, indicated R2 refused showers. During an interview on 2/20/26 at 3:55 p.m., NA-A stated R2 refused showers frequently, but did not know why. NA-A stated staff should offer another shower time when R2 refused but did not know if alternate times were offered. Further, NA-A stated if residents refused showers, the nurse managers should be notified. During an interview on 2/20/26 at 4:03 p.m., during an interview NA-B stated R2 only allowed certain staff to assist with showers and the care plan should indicate that preference. During an interview on 2/23/26 at 1:56 p.m., LPN-A acknowledged R2 missed baths, had a history of refusing baths, and should have a risk/benefit form in place for refusals of showers, but did not. LPN-A stated when residents refused showers, staff should continue to offer showers at another time or day, but acknowledged the medical record lacked indication staff offered other times. LPN-A stated the care plan lacked interventions for staff to follow for R2's bath refusals but acknowledged care plans should have interventions for staff to try when residents refused baths. R3's quarterly MDS dated [DATE] indicated intact cognition, and diagnoses that included traumatic brain injury, a seizure disorder, heart disease, and lung disease. R3 required supervision or touch assistance with bathing and identified no refusals of bathing/showering. R3's care plan dated 6/4/25, indicated R3 had a self-care deficit related to weakness but was independent with bathing, but lacked indication R3 required supervision or touch assistance with bathing. Weekly Skin Inspections dated 1/13/26, 1/20/26, 1/27/26, and 2/3/26 indicated R3 refused showers. During an interview and observations on 2/20/26 at 5:18 p.m., R3 appeared disheveled, and had body odor. R3 stated he did not bathe weekly because he did not feel physically strong enough some weeks, and staff did not offer to help or ask if he showered. R3 was unsure when he last showered. During an interview on 2/23/26 at 12:24 p.m., RN-A acknowledged R3 had a self-care deficit related to weakness, did not bathe weekly, refused showers four weeks in a row, and had no independent showers documented from 1/13/26 to 2/3/26. RN-A stated she was not aware R3 refused showers but may now need reminders and set-up for showers to ensure he bathed regularly. RN-A acknowledged R3's care plan lacked interventions to promote bathing when R3 refused or when R3 did not perform bathing independently. During an interview on 2/23/26 at 1:56 p.m., LPN-A stated she witnessed R3 perform showers on his own but did not see where they were documented. LPN-A acknowledged R3's Weekly Skin Inspections indicated showers were refused from 1/13/26 to 2/3/26 LPN-A stated if R3 refused showers, staff should provide education to R3 about the risks and benefits of not keeping clean, and the care plan should indicate a risk/benefits discussion for refusals and interventions for staff to try in the case of refusals. During an interview on 2/23/26 at 4:37 p.m., the director of nursing (DON )stated when residents refuse a bath, the expectation was for staff to do a risk/benefit with education to the resident, notify the resident's provider, notify the power of attorney, and try different interventions and approaches. The interventions that were successful should be on the resident's care plan. The DON stated care plans should be updated when changes to care are made. Further, the DON stated she was not aware R2 and R3 missed baths for several weeks and acknowledged neither had interventions in their care plans to address care refusals but should have. The Care Planning policy dated 11/2024 indicated the care plan would be used in developing the residents' daily care routines and utilized by staff for the purpose of providing care to the residents. The care plan is to be modified and updated as the condition and care needs of the residents change.

Based on interview and document review, the facility failed to ensure safe transfers with a full body mechanical lift. This resulted in an immediate jeopardy (IJ) for 1 of 4 residents (R1) who sustained a left femur fracture due to a fall from a lift. The immediate jeopardy (IJ) began on 8/29/25, when R1 fell out of a full mechanical lift sling that was not attached to the lift according to manufacturer instructions resulting in a fall with fracture for R1. The administrator and director of nursing (DON) were notified of the IJ on 9/10/25 at 1:49 p.m. The IJ was removed on 9/2/25, prior to the start of the survey, when the facility implemented immediate corrective action to prevent recurrence, therefore, the IJ was issued at past non-compliance.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses which included colon cancer, fracture of left humerus and hemiplegia.R1's care plan dated 6/10/25, indicated R1 required assistance of total/Hoyer mechanical lift (purple/medium sling or large green sling can be used).An orthopedic trauma provider consultation note from the hospital dated 8/30/25, indicated the history of the present illness included a fall from a Hoyer lift. R1 was found to have an acute left femur fracture that required surgical intervention.A hospitalist progress note dated 8/31/25, included under hospital summary: patient (R1) was at a facility and they were using the Hoyer lift to move [R1] when the lift failed and [R1] fell about 3 feet to the ground. Following the fall, [R1] had significant left hip pain and was brought to the emergency department (ED). In the ED, workup revealed a left subtrochanteric (femur) fracture.A nursing note dated 8/30/25 at 12:03 a.m., indicated at 9:45 p.m., 2 staff members were transferring R1 from his bed to a shower chair with a Hoyer lift. During the transfer, one loop of the sling handle came off the Hoyer hook, R1's right leg slid out of the sling and R1 landed on the floor in a sitting position and ended up on his back. A nursing note dated 8/30/25 at 3:57 p.m., indicated R1 had surgery following a left femur fracture.During an interview on 9/9/2025 at 2:47 p.m., family member (FM) stated she watched the video of when R1 fell out of the sling. She stated it was a horrible thing to watch. The strap on the lower left side did not appear to be attached correctly to the lift and came off during the transfer. FM confirmed R1 had a left femur fracture which required surgery with rod placement.During an interview on 9/9/25 at 4:12 p.m., nursing assistant (NA)-A stated she knew the correct way to hook the sling to the lift and identified the strap needed to be placed into the hook. NA-A stated she was assisting on 8/29/25, to transfer R1 from his bed to a shower chair using a full mechanical lift. She did not notice anything wrong with the straps when she attached them to the lift. During the transfer, one of the straps on the sling somehow came off the hook and R1 fell to the floor. NA-A stated she knew the correct way to hook the sling to the lift. The strap needed to be placed into the hook.During an interview on 9/9/25 at 4:34 p.m., licensed practical nurse (LPN)-B stated she was notified by NA-A about R1 falling from the sling onto the floor. When LPN-A entered the room, R1 was on the floor and saying Ow Ow and don't touch me. LPN-A called 911 to transfer R1 to the hospital for evaluation.During an interview on 9/10/25 at 9:09 a.m., a customer service representative from the manufacturer of the full mechanical lift stated a sling could detach from a lift hook if the person in the sling was over the weight limit, the sling was worn out or if the sling was improperly attached. The weight limit for all slings is 600 pounds. A sling used less than one year should still be in good condition if used and cleaned according to manufactures instructions. During an interview on 9/10/25, following incident video review, the DON confirmed the lower right strap had not been connected to the lift correctly and as a result it came off the hook and R1 fell to the floor. DON stated NA-A and NA-B were not following manufacturer's instructions for proper sling attachment during the transfer. DON confirmed the lower right sling loop was placed at the top of the hook instead of the lower part of the hook. Two attempts were made to contact NA-B with no return phone call.The manufacturer full body sling instruction manual undated, identified the sling was correctly attached to the lift when the loops of the sling were placed at the bottom of the hooks. The manual warnings include: if the sling is not properly applied, personal injury and damage to the sling could occur.The facility mechanical lift competency instructs: Attach the sling to the lift assuring that the loops are secured to the hooks.Review of facility policy titled The facility safe resident handling program policy undated, instructed when residents received care require assistance from facility to move, assistance was provided in a manner that was safe to both the resident and employee. The facility implemented the following actions prior to the survey which were verified through interview and document review and therefore the IJ was issued at past non-compliance:Staff involved in the incident were immediately suspended pending investigation.The lift and sling were put out of use.Education included how to identify what size a sling was, where to find a resident's sling size, how to attach the sling to the lift, and what to do if a resident's care plan did not identify sling size or if the proper sling size was not available. All nursing staff were competency tested on use of the full mechanical lift.Any staff that had not completed the education or competency test would be required to complete both at the start of their next scheduled shift.

Based on observation, interview, and record review the facility failed to provide necessary care, treatment, and services to prevent pressure ulcer development for 1 of 3 residents (R1). This resulted in an immediate jeopardy (IJ) who presented to the emergency room (ER) on 4/3/25 with multiple pressure ulcers and wound infections. R1 remained hospitalized . The IJ began on 4/3/25, when the facility failed to assess, report to the provider, and treat pressure ulcers. R1 was found unresponsive and presented to the hospital emergency roiagnom on [DATE], and it was discovered she had multiple pressure ulcers and wound infections. R1 remained hospitalized . The facility administrator and director of nursing (DON) were notified of the IJ at 4:00 p.m. on 4/15/25. The facility implemented corrective action by 4/9/25, prior to the start of the survey and was issued as past non-compliance. Findings Include: R1's Braden Scale (a tool designed to assess a patient's risk for developing pressure ulcers) dated 2/24/25 at 10:45 a.m. identified sensory perception as slightly limited and responded to verbal commands. Skin was often moist, and linens had to be changed at least once a shift. She was chair fast, unable to bear own weight. Mobility was very limited and made occasional slight changes in body or extremity position. Nutrition was probably inadequate and would take occasional dietary supplements. Required moderate to maximum assistance in moving, frequently slid down in bed/chair, required frequent repositioning with maximum assistance. Spasticity, contractures, or agitation led to almost constant friction. R1's Braden score was 12 and indicated high risk (at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below) for development of a pressure ulcer. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. She required substantial/moderate assistance for roll left/right, sit to lying, and lying to sitting, dependent upon staff for all transfers, toileting and personal hygiene, bathing, and lower body dressing, and used a manual wheelchair for mobility. She was frequently incontinent of bladder and always incontinent of bowel. She had a feeding tube. Active diagnoses included: stroke, aphasia (a language disorder that affects the ability to speak, read, write, and understand what others are saying caused by a stroke, brain injury, or progressive neurological disorders), hemiplegia/hemiparesis (weakness on one side), malnutrition, diabetes mellitus (DM), hypertension (HTN), and respiratory failure. At risk for pressure ulcers and no unhealed pressure ulcers or other ulcers, wounds, or skin problems identified. Skin and ulcer treatments included pressure reducing devices for chair and bed. She was administered insulin 7 out 7 days. R1's hospital physician notes dated 2/28/25 at 8:28 a.m. identified skin/wounds: WOCN (wound, ostomy, and continence nurse) not followed currently. Per chart, large head laceration repaired by trauma team. Per nursing notes: BUE (bilateral upper extremity extremities) bruising, head laceration, preventive Mepilex (a foam dressing used to reduce the risk of skin breakdown) on sacrum, LLE (lower leg extremity) edema leg wrap (wrap not removed due to pain/fracture), two plus pulses present bilaterally. R1's care plan dated 3/1/25, identified she had diabetes mellitus, and staff were directed to monitor/document/report to medical doctor (MD) for signs/symptoms (s/sx) of infection to any open areas: redness, pain, heat, swelling, or pus formation. She had an alternation in mobility related to stroke. Staff were directed to provide a pressure redistribution mattress to bed and cushion to wheelchair. She was at risk for alteration in skin integrity related to limited mobility secondary to stroke. Staff were directed to monitor skin integrity daily during cares. Weekly skin inspections by nurse. Turn and reposition every two to three hours. Document on skin condition and keep MD or physician assistant (PA) informed of changes. R1's goal outcome evaluation for plan of care dated 3/2/25 at 7:49 a.m. completed by hospital registered nurse prior to discharge back to facility. Skin: no new deficits noted. Repositioned carefully as movement caused a lot of discomfort. R1's discharge summary dated 3/2/25 at 2:21 p.m. hospital stay from 2/27/25 through 3/2/25 due to an accident when she fell out of her wheelchair trying to grab an object. Known skin injury: forehead laceration repaired with sutures. Physical exam identified periorbital (around eyes) ecchymosis (bruising) and skin warm and dry. R1's orders/treatment administration record (TAR) identified: -On 11/26/25 at 3:00 p.m. air mattress-monitor working order and replace as needed every shift. Staff signed off all shift from 3/1/25 through 4/2/25, except 4 shifts. -On 12/4/25 at 7:00 a.m. Prosource TF20 ENfit compatible enteral liquid (20 grams of high-quality protein to a feeding tube). Give 1 packet by mouth every day shift for supplement. Staff signed off every morning from 3/3/25 through 4/2/25. -On 3/3/25 at 3:00 p.m. monitor for skin breakdown around the nose and behind the ears caused by oxygen tubing every shift. Staff signed off all three shifts from 3/3/25 through 4/2/25, except for 4 shifts. -On 3/13/25 at 3:00 p.m. enteral feeding: monitor skin around tube feeding site and change dressing if applicable every shift (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., 11 p.m. to 7 a.m.) for monitoring. Staff signed off all three shifts from 3/13/25 through 4/2/25, except for 3 shifts. -On 1/30/25 at 5:30 a.m. weekly skin inspection by licensed nurse. Complete weekly skin inspection in point click care (PCC) in the morning every Thursday. Staff signed every Thursday 3/6/25, 3/13/25, 3/20/25, and 3/27/25. -On 3/28/25 at 11:00 p.m. barrier cream to peri area with brief changes every shift for skin care. Staff signed off all shifts 3/28/25 through 4/2/25, except for 1 time. R1's weekly skin inspection completed from 3/13/25 through 3/27/25, by licensed practical nurse (LPN)-B identified: -On 3/13/25 at 12:30 p.m. instructions: it was the nurse's responsibility to evaluate the resident's skin at minimum once a week to ensure skin integrity. Implement interventions as applicable. Bath type: bed bath. Summary of current skin condition: bruises to the face and both hand [sic] due to a previous fall. On 3/20/25 at 11:32 a.m. identified bath type: shower. Summary of current skin condition: no new skin issues noted. On 3/27/25 at 1:55 p.m. identified bath type: bed bath. Summary of current skin condition: resident had no new skin conditions, skin intact. A and D (an ointment rich in vitamins A and D used for a for skin protection, moisturizes, seals, and speeds up the recovery of damaged skin) applied to redness on bottom. R1's progress notes from 3/2/25 through 4/3/25, identified: -On 3/3/25 at 10:16 a.m. readmission visit by nurse practitioner (NP)-B following a hospitalization after a fall with head strike. R1 was found to have a right frontal subarachnoid hemorrhage (SAH) (bleeding in the space below one of the thin layers that cover and protect your brain), forehead laceration, and humeral (upper arm) neck fracture. Ordered forehead sutures to be removed on 3/6/25 . -On 3/5/25 at 2:07 p.m. had purple bruising on her face and sutures over her right eye . -On 3/5/25 at 8:45 p.m. R1 needs to be encouraged to be up two times daily, once on a.m.'s once on p.m.'s no exceptions every day and evening shift for monitoring since fall. She is weak and has been bed bound. -On 3/6/25 at 11:07 a.m. acute visit for pain made by NP-B . was recently taken off TF due to good oral (PO) intact but not continues to demonstrate problems with dysphagia (trouble with swallowing) . well developed in no acute distress . -On 3/12/25 at 7:49 a.m. follow up visit to assess bolus TF tolerance . tolerating bolus feedings and uninterested in food . -On 3/24/25 at 9:26 a.m. primary provider medical doctor (MD) came to see her and was told she had gone to a doctor's appointment. He did not see her today . past surgery history: percutaneous endoscopic gastrostomy (PEG) tube (a tube placed into the stomach through the abdominal wall most commonly to provide a means of feeding when oral intake is not adequate) was placed on 6/20/23 . -On 3/27/25 at 5:46 p.m. assisted with lunch today. Continued to pocket all food. Very slow to take liquids thru straw. Mighty shake given as she was not swallowing any food. Nurse practitioner (NP) made aware, and dietician notified. - On 3/28/25 at 2:52 p.m. The writer noticed the resident could not seat comfortably and hold her head in the chair. Writer asked the aid to put he back to bed for safety. -On 4/2/25 at 1:09 p.m. Interdisciplinary team (IDT) reported R1 was not eating or drinking anything orally. Nursing informed husband was ok with tube feeding (TF) to provide all nutrition needs. Currently received bolus feed two times a day (bid) but will increase to meet all her needs. -On 4/3/25 at 7:54 a.m. follow up visit made by NP-B for anorexia and resumption of full TF diet . upon visit, R1 was slumped over in her wheelchair not responding, she was slumped so far over she was about to fall headfirst onto the floor. Breathing shallow, blood pressure (BP) 90/50, heart rate (HR) 121, unable to obtain pulse oximeter (ox). Instructed staff to call emergency medical services (EMS) for altered mental status (AMS). Concern for stroke or infection. -On 4/3/25 at 8:42 R1 sent to the emergency room (ER). R1's progress notes lacked documentation of skin assessments. R1's hospital medical records from 4/3/25 through 4/8/25 identified: -On 4/3/25 hospital admission history and physical identified sacral pressure wound. Nursing notified primary team of large necrotic pressure wound to her sacrum with various other lesions to the perineum and surrounding erythema. Area has been cleansed and Mepilex added. Pictures in media lab. WOC consult placed. Clinical impressions: SIRS (systemic inflammatory response syndrome) (an exaggerated defense response of the body to a noxious stressor such as infection, trauma, survey, acute inflammation, ischemia or reperfusion, or malignancy, can be life threatening and affects the entire body) and CVA. Physical exam identified scattered bruising on left arm and small abrasion to nose. -On 4/3/25 at 9:39 a.m. emergency department (ED) provider notes identified admitting diagnoses: systemic inflammatory response syndrome (SIRS) rules out urosepsis, closed fracture of neck of the left humerus from a previous fall, and cerebrovascular accident (CVA) (stroke). -On 4/3/25 at 6:54 p.m. documented by a registered nurse (RN) identified during incontinence care for stool upon transfer, grapefruit-sized blackened pressure wound noted on sacrum alongside redness and areas of open skin on and around perineum. Picture obtained and placed in chart. Gently cleaned area and applied sacral Mepilex for protection. Provider also notified, WOC consult placed to follow-up. -On 4/5/25 at 11:42 p.m. comprehensive stroke evaluation impression: 1. subacute stroke in the setting known as intracranial atherosclerosis and hypotension due to infection. 2. Encephalopathy (brain dysfunction caused by an underlying condition) secondary to burden of prior stroke, acute stroke, and active infection. -On 4/6/25 at 1:39 p.m. GI: PEG fell out, 16 French (Fr) foley in place per patient care order. Skin: bruising to face, bilateral upper extremities, and abdomen. Scabs to chest nose, thigh, and buttocks. Pressure wound to sacrum and left heel Peeling/scaling to bilateral feet. Redness/purulent drainage at PEG insertion site, culture sent. Right ear lobe swollen. Left groin open area. Left ear abrasion. -On 4/7/25 seen by medical doctor (MD)-C presented from nursing home with altered medical status (AMS) for one week, hypotensive, and hypoxia. admitted for encephalopathy workup, found to have sepsis 2/2 proteus (a gram-negative common pathogen responsible for complicated urinary tract infections) bacteremia and sub-acute cardiovascular accident (CVA). Stable but elevated leukocytosis and worsening . urinalysis was consistent with E. Coli (bacteria) urinary tract infection, urine culture with no growth, blood cultures initially showing Proteus. there is some concern that sepsis may be of abdominal origin especially with some erythema (redness) and purulent discharge around the patient's g-tube, which incidentally fell out. G-tube swabbed for culture. nursing notified primary team of large necrotic pressure would to patient's sacrum with various other lesions to the perineum and surround erythema. Area has been cleansed and Meplix added. Picture in media lab. 4/7/25 wound/ostomy/colostomy (WOC) reached out and recommended surgery consult for debridement . Physical exam skin: erythema around g-tube, no purulent drainage. Sacral wound necrotic and softening edges per WOC registered nurse (RN). Left heel pressure wound without skin break. -On 4/7/25 at 8:57 a.m. hospital wound registered nurse (RN)-A consult . left upper quadrant (LUQ) g-tube site: tube replaced on 4/7/25, peritubular (area surround the g-tube) assessment: erosion of epidermis, dermis and superficial scab that extends 0.3 centimeters (cm) from insertion site with serosanguinous (clear liquid mixed with blood) drainage . -On 4/8/25 a computed tomography (CT) (imaging test used to obtain detained internal images of the body) was completed to evaluate the sacral wound and underlying abscess and possible osteomyelitis. Impression: wound overlying the sacrum with extensive subcutaneous fat stranding fluid, and emphysema extending laterally within the subcutaneous fat superficial to the right gluteal maximus musculature, suspicious for tracking abscess. Particularly given the areas of rim enhancement. Additional pressure wounds are visualized overlying the ischium tuberosities (the bone in the lower pelvis that absorbs weight when you sit). Nonconvincing CT evidence of osteomyelitis. -On 4/8/25 at 12:18 p.m. Antimicrobial Stewardship Team note identified she presented to emergency department (ED) on 4/3/25 and initial testing revealed elevated white blood cells (WBC) and absolute neutrophils (AMC) (white blood cells that fight infection), as well as a positive urinalysis (UA) for nitrites and leukocyte esterase (white blood cells that indicate infection and inflammation). A head CT in ED showed a new subacute appearing infarct in the medial left occipital lobe . culture of nares was collected on 4/5/25 and tested positive for methicillin-resistant staphylococcus aureus (MRSA) (a bacterial infection many antibiotics don't work on). g-tube wound was cultures on 4/6/25 and currently growing 1+ pneumoniae (bacteria) and 1+ staphylococcus aureus (S aureus) (gram-positive bacteria). -On 4/8/25 at 2:06 p.m. identified she was initially seen on 4/4/25 by hospital registered nurse/WOC (RN)-A and sacrum and perineum skin issues were identified. Pictures were taken on 4/4/25 of identified pressure injuries of the sacrum/right buttock, and left thigh. On 4/9/25 pictures and measurements were taken of those same areas. Sacrum measured 10 centimeters (cm) x 13 cm x 0.1 cm, right buttock 4 cm x 2 cm x 0.1 cm, left thigh 10 cm x 6 cm x 0.1 cm, no tunneling, peri wound skin (surrounding skin) erythema (redness) blanchable (blood flow noted to the area). Sacrum wound was identified as a pressure injury, unstageable and present upon admission. The wound base of the sacrum wound was 95% eschar (a hardened, dry black or brown dead tissue and usually indicates a more advanced wound) /purple epidermis (outer most layer of skin), 5% dermis (the layer of skin found deep to the epidermis that supports and adds strength and pliability to the skin) and slough (a biproduct of the inflammatory phase and a barrier and delay to wound healing). A photo and measurements were taken on 4/7/25 of the deep tissue pressure injury (DTPI) located on the left heel and present on admission per bedside RN on 4/5/25. Measures were taken on 4/7/25 of left heel DTPI and identified 5 cm x 6.5 cm x 0 cm with a wound base 100% maroon, purple and epidermis. Peri wound dry and scaly, no pain and no drainage. Additionally, on 4/7/25 a left upper gastrostomy tube site was identified with erosion of epidermis, dermis, and superficial scab extended 0.3 cm from insertion site with a small amount of serosanguinous (seen in wounds during the healing phase) drainage. During an interview on 4/10/25 at 11:03 a.m. hospital registered wound nurse (RN)-A stated R1 was admitted to the hospital on 4/3/25 with systemic inflammatory response syndrome (SIRS) and possible stroke. R1 had been hospitalized at the end of February 2025 and discharge on 3/2/25 without any wounds other than surgical at that time. She had seen R1 three times since she was admitted to the hospital on 4/3/25 and again today. The sacral wound was deteriorating with two open areas with tunneling. The sacral wound was unstageable and measured 3.5. centimeters (cm) x 2.5 cm x .1 cm, the right buttock was stage 2 and measured 3.5 cm x 2.5 cm x .1 cm, left posterior thigh was a deep tissue injury and measured 7.5 cm x 4.5 cm x 0, and the left heel was a deep tissue injury and measured 5 cm x 6.5 cm x 0. The sacral had tan serosanguinous drainage with a mild odor. R1's skin damage was already there prior to being admitted to the hospital and was one of the largest wounds she had ever seen as a wound nurse in 8 years. When a deep tissue injury occurred, it took up to 72 hours to show up and sometimes it looked like a discoloration and then opened. The sacrum wound is located midline and when left on her back too long seemed like it was consistent with that position to develop. This sacral wound most likely will not have a chance to heal without surgery to clean out the dead/eschar/necrotic tissue and will 100% affect her morbidity and mortality. Today R1 had tunneling in her sacral wound which meat it had stared to release from inside out and had lots of soupy drainage. During an interview on 4/10/25 at 3:29 p.m. hospital social worker (SW) stated R1 was admitted to the hospital on 4/3/25 and pictures were taken of her skin with numerous skin concerns right away. R1 had reddened areas on her bottom and thigh and a large wound located on the sacrum that measured approximately three inches by three inches with a black necrotic center. Hard to believe the nurse's that provided care for R1 and assessed her skin did not notice some type of skin condition changes especially the large one the sacrum. The sacrum wound required treatment and not something only barrier cream would have taken care of. It was very disturbing to see the extensive damage to her skin. During an interview on 4/11/25 at 9:13 a.m. facility NP-A stated standard nursing care provided by nursing staff were expected to have visibility observed the resident's skin every time during cares and weekly skin assessments for skin breakdown and reported it to the nurse or nurse manager. Right before R1 was admitted to the hospital on 4/3/25 she had received a handwritten note from the floor manager LPN-C indicating R1 had the start of a coccyx injury/pressure ulcer caused by prolong immobility and malnutrition. We have a wound team to assess skin concerns such as this. LPN-C indicated she had alerted the wound team. Standing orders should have been placed until staff nurse told me it was worse or required my assistance. She relied on staff nurses to inform and update her and made her aware of changes. She stated things were getting missed by staff and R1's sacral wound could have been prevented. NP-A verified there was a huge gap of communication among staff regarding R1's skin issues and lacked documentation in her electronic medical record progress notes. NP-A viewed the hospital pictures taken of R1's skin and stated the sacrum wound have developed over several weeks and did not happen overnight. R1's left heel had the start of necrosis, malnourished, and most likely could have developed in a couple of days to a week but not overnight, that was for sure. Her expectation would have been to be notified when there was a change in condition right away or at least within the shift depending on how severe it was. She identified R1's wounds and condition as severe, very disturbing to her, and made her worry about how staff were assessing the resident's skin. R1's wounds could have been prevented if caught earlier and thorough skin assessments had been completed. There was harm done here and she was very worried about R1. During an interview on 4/11/25 at 11:22 a.m. NA-C stated R1 was unable to reposition herself in bed and was incontinent of bowel and bladder. Staff were expected to check and change and reposition her every two hours. On 4/1/25, while providing cares to R1 he noticed a little hole (about the size of top of a pen) in her bottom located on the left side of her buttock. He told the floor manager LPN-C and was told to leave her in bed the wound provider was there, did not see anything on her heels. Unable to identify staff that placed a dressing on her sacral area, no drainage, no odor, no pain. R1 had air mattress on her bed but no pressure relieving cushion on her wheelchair. He usually placed a folded blanket in her wheelchair to take pressure off her bottom. During an interview on 4/11/25 at 11:45 a.m. NA-B stated R1 was not able to reposition herself and always incontinent of bowel and bladder. R1 was dependent upon staff to check and change and reposition her every two to three hours. We were expected to document that each time in the electronic medical record. During cares, she noticed a wound on R1's bottom three weeks prior to her going to the hospital on 4/3/25. The wound on her bottom was dark black and approximately 2 to 3 inches in diameter, opened on one side, surround skin was slightly red without drainage. There was an odor to it, unsure how to explain that. She reported the wound to the nurse on the evening shift. A day later she noticed a dressing over R1's wound on her bottom was falling off and the trained medication aide (TMA) told her to leave it on and she would let the nurse manager know. R1 had a thin cushion in her wheelchair. Husband visited often and pushed her around in the wheelchair. During an interview on 4/11/25 at 12:35 p.m. hospital medical doctor (MD) stated R1 was admitted to the hospital with stroke, septic from blood infection from sacral wound and possible urinary tract infection (UTI). A sacral wound as large as R1's wound has most likely resulted from a pressure injury due to lack of repositioning. He questioned if appropriate care had been given to the resident at the facility and was suspicious of her cares the way she presented when brought to hospital by EMS. R1's prognosis was very poor and most likely will be placed on end of life care and very likely may result in death. The main cause was the sacral wound. There were other concerns of her not really waking up, unsure if it was the infection they were treating. The neurology team was being consulted. After R1 was discharged from the hospital to the facility beginning of March 2025, there were no skin issues identified. During an interview on 4/11/25 at 1:16 p.m. LPN-B stated she completed R1's weekly skin assessments on 3/13/25, 3/20/25, and 3/27/25. She completed the skin assessment when R1 had a shower day and may have sat in a shower chair or while the nursing assistant changed her brief in bed, unsure of the last time she assessed her while she laid in bed. R1 sat in the wheelchair fully dressed and she visualized only the skin not covered by clothing. She was not always able to assess the skin and relied on the NA's and asked them if they saw any skin problems when they checked and changed, repositioned, or transferred her. She cleaned around the gastrostomy tube (G-tube) and placed Neosporin (antibiotic ointment used to reduce the risk of infections) and change the dressing. She was unsure as to what should have been included on the weekly assessments. When she removed the sponge dressing from around R1's G-tube she noted a minimal red bloody drainage dried onto the dressing, possibly for the past three weeks. R1's bottom was red, and ointment was applied but lately that area had opened. Last time she saw R1's bottom was the Tuesday 4/1/25, before she was sent into ER. She thought R1 had been seen by the wound team and the floor nurse manager was aware of it. She had not received any education on skin assessments. During an observation on 4/11/25 at 3:20 p.m. LPN-A walked down to R1's room with surveyor and verified her wheelchair did not have a pressure relieving cushion on it and there was a thin pillow approximately 1/4 inches thick with a cover placed on it located in the seat of her wheelchair. She stated R1 should have had a pressure relieving cushion in her wheelchair to prevent pressure ulcers. She verified R1 wore gripper socks while in her wheelchair and shoes when she went out of facility with her husband. During an interview on 4/14/25 at 2:54 p.m. licensed practical nurse (LPN)-C clinical coordinator stated nursing staff would be expected to have completed a weekly skin assessment on each resident. The weekly skin assessment was usually scheduled on the same day as their bath day while in the shower without clothing on or if in the morning while the resident laid in bed so that the entire body and especially their bottom could be assessed. Nursing staff would be expected to have written up a risk management report, documented in the progress notes including measurements, called the provider and request an order to treat those area that were concerning. During the following morning meeting new skin concerns would have been reviewed, then reviewed by risk management and arranged for resident to be seen weekly by the wound care provider to have followed up. The family should have been notified along with the provider so that interventions could have been identified to help prevent the identified area(s) from getting worse and/or prevention of any new areas. R1 had not had skin issues until the week before she went into the hospital on (since last skin check 3/27/25) so floating her heels while in bed was not required, could have been an intervention but what they were doing was working. Although apparently it was not working after what happened to her skin. She had a wheelchair cushion . we give everyone one when they come in should have been a pressure redistribution cushion looks like a foam cushion or air filled with the little finger things that stick up on it. She had a foam one, not sure. The last weekly skin assessment competed on R1 identified she had redness to her bottom, started treating it with A and D ointment (house barrier cream) with brief changes on 3/28/25. There were no specific details placed in the weekly skin assessment such as size of reddened area or progress notes written. If a resident's bottom had been identified with a new skin problem such as a red area that would have been considered a change in condition and the provider should have been notified. On 3/31/25, she was informed by NA-C R1 had a red area on her bottom. During an observation on 4/14/25 at 3:30 p.m. LPN-C and surveyor entered R1's room together. LPN-C confirmed R1 had a pressure relieving mattress on her bed. Located on the manual wheelchair was a lawn chair cushion approximately 1/4 inch thick with a cover over it. She stated thought R1 had a thicker cushion on her chair unable to identify when she had used it. She looked in R1's closets and stated it would have been a nursing intervention, like a standing order. Usually, a pressure relieving cushion was placed in the resident chair and does not leave the room but may have been sent down to the laundry, not sure. During an interview on 4/15/25 at 4:30 a.m. NA-D stated she had cared for R1 on 3/15/25, 3/21/25, 3/24/25, 4/1/25, and 4/3/25. She completed morning cares, washed her up and NA-C assisted her. There was a wound on R1's bottom with a dressing on it all five days she worked. NA-C informed her he had reported the wound to the floor manager LPN-C. Surrounding skin around dressing (approximately 2 inches by 2 inches) was pink, dry, and intact. On 4/3/35, she had arrived at work and R1 laid in bed with her heels positioned on a pillow. On 4/1/25 or 4/3/25 she was not asked by LPN-A to put R1 back to bed and was most likely feeding residents. During an interview on 4/15/25 at 5:00 a.m. NA-E stated he provided cares to R1 and when he positioned her in bed her heels rested on a pillow. She was at risk for pressure ulcers. During cares he noticed for the first time about one month ago a sore on R1's bottom located on the left side of her buttock unsure of the size, unable to really explain it well, was a dark area on her body located on the left side of her buttocks. He had told the nurse (LPN-D), and she informed him the next time we checked and changed here she wanted to see the sore, treat it, and placed a bandage dressing on it. He stated she was checked and changed at least three times during the night shift and sometimes more often. During an interview on 4/15/25 at 8:46 a.m. facility wound provider/ nurse practitioner (NP)-A stated staff were expected to remove the residents clothing prior to completing a weekly skin assessment so that the entire body could have been viewed. She expected staff to make her aware of any resident skin concerns so that they could have been taken care of appropriately, prevented from getting worse and/or getting them in other areas. NP-A viewed R1's pictures of her wounds and stated those pictures are worrisome and if those areas are left untreated especially when she was a diabetic could have led to a bad outcome such as death. The sacral and heel wounds were from pressure and could have been from a lack of repositioning. R1 also had issues with malnutrition, would have made a wound get worse in a matter of hours or in a short period of time. Would have made it even more important to have reported the wounds to the nurse manager and her to assess it right away. During an interview on 4/15/25 at 11:05 a.m. LPN-D stated staff nurses were expected to complete the weekly skin audits and visualize all resident's skin when completed. The assessment should have included any new and current skin issues/wounds/g-tube sites. The weekly skin assessment was important to avoid pressure sores and infection. She had filled in one night and worked as an NA the end of March 2025. She assisted with check and changes and repositioning R1 every two to three hours. She identified a wound on R1's bottom to the left side sacral area, was the size of a baseball, edges looked ruff/ridged, was open in the middle and along the inside of the outer edge approximately 1/4 inch all the way around was black, and dry without drainage. The left heals had an area the size of a quarter, looked new, slightly discolored, felt soft/boggy, and intact skin. She informed the floor manager LPN-C the next day when she came back to work the evening shift. LPN-C was leaving for the day, and she stopped her, informed her R1 had a wound that needed attention LPN-C stated ok and left the building. The following day she reminded LPN-C again and went to R1's room with her, had NA's transfer her to the bed, removed her clothing so we could assess all her skin. LPN-C stated Oh my God no one had told her about R1's sacral wound, left the room and walked to the treatment cart. LPN-D showed LPN-C R1's left heel and she sounded shocked and disappointed. LPN-D left R1's room, completed the medications passes, and unsure if LPN-D returned. The provider should have been notified for orders to treat her sacral wound. During a follow-up interview on 4/15/25 at 11:56 a.m. hospital wound RN-A stated the surgeon at the hospital deemed that R1 would not be able to tolerate surgery on the infected sacral wound and would most likely be transitioned to Hospice. She would not have identified R1's sacral[TRUNCATED]

Based on observation, interview and document review, the facility failed to implement a process to supervise and monitor R3, who is known to smoke with oxygen on, to ensure he left the oxygen in the facility while he was smoking in the designated smoking patio resulting in risk of injury, burns, or fire which had the potential to cause serious harm, injury, impairment, or death to 1 out of 16 residents (R3) reviewed who smoked. The immediate jeopardy began on 4/4/25 when the failure to monitor and supervise R3's smoking, and was identified on 4/4/25. The administrator, director of nursing, and regional nurse consultant were notified of the immediate jeopardy at 4:10 p.m. on 4/4/25. The immediate jeopardy was removed on 4/4/25, but noncompliance remained at the lower scope and severity level of D - isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 had diagnoses of acute respiratory failure with hypoxia (low blood oxygen), heart failure, asthma, and tobacco use. R3's MDS indicated he was cognitively intact. R3's care plan, dated 1/31/25, indicated R3 smoked at the facility unsafely with his oxygen tank on his scooter. Interventions identified: risk versus benefits completed with the resident, spoke about concerns of safety, and resident signed smoking plan. R3's Resident Safe Smoking Oxygen contract, dated 1/31/25, indicated R3 would remove oxygen tank, leaving it at the nursing station or entrance to smoking patio. Contract indicated nursing staff would assist or R3 had demonstrated independence with removal of the oxygen tank. Further, the contract indicated failure to abide by the contract would result in a smoking privilege review by the interdisciplinary team. R3's chart lacked follow up smoking assessments after the 1/31/25 incident. A progress note, dated 3/29/25, indicated R3 was observed multiple times smoking at unassigned times. On 4/4/25 at 10:00 a.m., family member (FM)-A stated she had observed a resident on a royal blue scooter on several occasions smoking with oxygen on the smoking patio. FM-A shared a photo with the surveyor, taken on 3/26/25, of R3 smoking with his oxygen tank in the front basket of his scooter. FM-A stated they had reported this to the facility social worker. On 4/4/25, at 10:12 a.m., R3 was observed to be smoking on the designated smoking patio with his oxygen on per nasal cannula (NC) at 3 liters (L). R3 stated it was his own oxygen tank, so it did not matter. On 4/4/25, at 10:28 a.m., Fire Marshall-A stated smoking while wearing oxygen posed a risk, as oxygen rich atmosphere can cause an intense fire quickly. On 4/4/25, at 11:06 a.m., RN-A stated there is not a plan to monitor the designated smoking area. On 4/4/25, at 11:44 a.m., R3 stated he has been told of the dangers of smoking with oxygen before but did not believe his personal oxygen tanks would blow up or cause a fire. Therefore, he was not leaving the oxygen in the building. On 4/4/25, R2 stated he had observed a few other residents smoking on a regular basis while wearing oxygen on the smoking patio. On 4/4/25, at 12:29 p.m., the administrator stated R3 had been observed smoking with oxygen on 1/31/25. The administrator stated this was addressed by providing R3 with education on the potential danger and risks of slow leak of oxygen. R3 agreed to leave oxygen in facility while going out to smoke. The administrator stated the designated smoking patio does not have direct supervision by staff but does have video surveillance available to view in the administrator's office. The administrator stated no other staff had access to view the video surveillance. The administrator stated the facility has not attempted to withhold smoking material or exchange smoking material for the oxygen tank. The administrator stated smoking with oxygen posed a potential risk of the oxygen tank exploding or propelling, burns or fires. The administrator stated she would observe the video surveillance when she was in her office, but did not offer a specific frequency. On 4/4/25, at 2:49 p.m., the nurse practitioner stated oxygen always poses a safety risk while smoking. She stated R3 was endangering other people by smoking while wearing oxygen. A facility document Resident Smoking Policy, dated 10/24, directed the facility was committed to providing the highest level of customer care and service while assuring residents' needs were being met in a safe manner. Any resident who did not comply with the policy may lose smoking privilege. The policy lacked direction regarding smoking with the use of oxygen. The immediate jeopardy began on 4/4/25, was removed on 4/4/25, when the facility conducted a smoking assessment for R3, revoked R3's smoking privileges at the facility, revised R3's care plan to indicate his smoking privileges had been revoked, reviewed the smoking policy with R3, notified R3's NP, received an order for nicotine lozenges and placed R3 on every 15 minute safety checks. The deficient practice was corrected on 4/4/25, after the facility provided education to all staff regarding designated smoking areas of the facility, no oxygen allowed on the smoking patio, the nurse assigned to the unit closest to the smoking patio's responsibility to monitor the smoking patio every two hours and document, any resident who used oxygen would be required to exchange their oxygen for their smoking materials with the nurse. The facility also held a quality assessment performance quality improvement (QAPI) meeting on 4/4/25 to review and determine a process to monitor for safe smoking practices. Further, the education instructed the staff to provide education to residents, notify the nurse if residents were non-compliant, document instances of non-compliance, and notify the administrator or nurse on-call. The facility also posted the smoking policy on the door to the smoking patio and a sign indicating no oxygen allowed in that area.

Based on interview and document review, the facility failed to ensure a system was in place to prevent the diversion of medications for 30 of 79 residents (R1, R5, R12, R15, R16, R27, R35, R41, R49, R50, R54, R58, R63, R73, R75, R76, R77, R141, R146, R149, R345, R25, R143, R144, R145, R147, R148, R150, and R151) reviewed for drug diversion and were free from misappropriation of their property when their medications to treat moderate to severe pain and other conditions were taken by a staff member. This resulted in diversion of 111 tablets of oxycodone 5 milligram (mg), 21 tablets of oxycodone 2.5 mg, 28 tablets of oxycodone 10 mg, 1 tablet Aderall, 6 tablets Percocet, and 4 tablets Ambien which resulted in the likelihood of serious harm or adverse event to residents prescribed controlled substances. The IJ began on 1/28/25, when registered nurse (RN)-A identified narcotics were given by trained medication assistant (TMA)-A via a G-Tube (flexible tube inserted in the abdomen and into the stomach) for R12 on a daily medication report. RN-A notified RN-B of the concern that TMA-A had given narcotic medication via the G-tube for a R12. The facility administrator and director of nursing (DON) were notified of the IJ on 2/11/25 at 3:45 p.m., which was identified at the scope and severity of K, pattern. The facility had implemented immediate corrective action on 1/30/25 to prevent recurrence, therefore the IJ was issued at past non-compliance. Findings include: Review of the facility narcotic record indicated TMA-A had signed out medications as removed from narcotic book and the medication cart, however TMA-A did not consistently document in the medication administration record (MAR) as administered. R1's annual Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact, and diagnoses included right-side paralysis following unspecified cerebrovascular disease and seizure disorder. R1's Order Summary Report, printed 2/11/25, indicated a physician order dated 12/17/24 for oxycodone (an opioid medication) 5 milligrams (mg) by mouth (po) every 24 hours as needed (PRN) for moderate to severe pain. R1's record indicated R1's oxycodone dosage was increased on 1/15/25 from 5 mg po every 24 hours PRN to 5 mg every 6 hours PRN with a maximum of 2 doses per day. R1's individual narcotic record indicated 25 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R1's Medication Administration Record (MAR), dated 1/1/25 to 1/31/25, indicated 19 doses of oxycodone were administered. Discrepancy of 6 doses. R5's quarterly MDS, dated [DATE], indicated R5 was cognitively intact, and diagnoses included atrial fibrillation (irregular heartbeat) and heart failure. R5's Order Summary Report, printed 2/11/25, indicated a physician order dated 10/2/24 for oxycodone 5 mg po two times a day (BID) PRN for moderate pain. R5's individual narcotic record indicated 40 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R5's MAR dated 1/1/25 to 1/31/25, indicated 29 doses of oxycodone were administered. Discrepancy of 11 doses. R12's admission MDS, dated [DATE], indicated R12 was cognitively intact, and diagnoses included epilepsy, severe protein-calorie malnutrition, and muscle wasting and atrophy. R12's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/7/25 for oxycodone 5 mg via G-Tube (flexible tube inserted surgically through the abdominal wall into the stomach for delivering nutrition, fluids, and medications when a person is unable to eat/drink orally) every 4 hours PRN for pain. R12's individual narcotic record indicated 34 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25, with 7 doses signed out by TMA-A. However, R12's MAR dated 1/1/25 to 1/31/25, indicated 18 doses of oxycodone were administered, and 6 of the doses were administered by TMA-A. Additionally, R12's medications were ordered via G-tube, which required a nurse to administer R12's medications. TMA performing tasks not within their scope of practice. Discrepancy of 16 doses. R15's admission MDS, dated [DATE], indicated R15 was cognitively intact, and diagnoses included paraplegia (paralysis of all or part of the trunk, legs, and pelvic organs) and cerebral palsy. R15's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/10/25 for oxycodone 5 mg po every 6 hours PRN for pain; amphetamine-dextroamphetamine (Adderall) 5 mg po every morning related to attention and concentration deficit; and Adderall 5 mg po at noon PRN for attention and concentration deficit. R15's individual narcotic record indicated 3 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R15's MAR dated 1/1/25 to 1/31/25, indicated 2 doses of oxycodone were administered. Discrepancy of 1 dose. R15's individual narcotic record indicated 22 doses of Adderall were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R15's MAR dated 1/1/25 to 1/31/25, indicated 21 doses of Adderall were administered. Discrepancy of 1 dose. R16's quarterly MDS, dated [DATE], indicated R16 was cognitively intact, and diagnoses included acute osteomyelitis left femur (thigh bone infection) and intervertebral disc degeneration. R16's Order Summary Report, printed 2/11/25, indicated a physician order dated 9/30/24 for oxycodone 5 mg po every 6 hours PRN for pain. R16's individual narcotic record indicated 46 doses of oxycodone were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R16's MAR dated 1/1/25 to 1/31/25, indicated 33 doses of oxycodone were administered. Discrepancy of 13 doses. R27's admission MDS, dated [DATE], indicated R27 was cognitively intact, and diagnoses included cellulitis (skin infection) of left lower limb, and osteomyelitis of the tibia and fibula (long bones in the lower leg). R27's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 1/21/25 for oxycodone 2.5 mg po every 6 hours PRN for moderate to severe pain; a physician order dated 1/6/25 for Percocet - 1-tab po every 4 hours PRN for moderate pain; a physician order dated 1/7/25 for Ambien 10 mg po every 24 hours PRN for sleep; and a physician order dated 1/14/25 for Oxycontin 10 mg po BID for pain. R27's individual narcotic record indicated 9 doses of oxycodone were signed out of the narcotic log from 1/22/25 through 1/27/25. However, R27's MAR dated 1/1/25 to 1/31/25, indicated 6 doses of oxycodone were administered. Additionally, R27's individual narcotic record indicated 9 doses were sent with patient on 1/28/25. However, the document lacked a nurse's signature. Discrepancy of 12 doses. R27's individual narcotic record indicated 16 doses of Percocet were signed out of the narcotic log from 1/7/25 through 1/17/25. However, R27's MAR dated 1/1/25 to 1/31/25, indicated 10 doses of Percocet were administered. Discrepancy of 6 doses. R27's individual narcotic record indicated 7 doses of Ambien were signed out of the narcotic log from 1/12/25 through 1/27/25. However, R27's MAR dated 1/1/25 to 1/31/25, indicated 6 doses of Ambien were administered. Additionally, R27's individual narcotic record indicated 3 doses were sent with patient. However, the document contained 4 scribble marks and lacked a date. Discrepancy of 4 doses. R27's individual narcotic record indicated 2 doses of Oxycontin 10 mg were marked as sent with ex, error, multiple scribble marks, and distroid [sic]. However, the facility was unable to provide a Record of Disposal for the Oxycontin. Discrepancy of 2 doses. R35's admission MDS, dated [DATE], indicated R35 was cognitively intact, and diagnoses included fracture of right lower leg, osteoporosis, and heart failure. R35's MAR dated 1/1/25 to 1/31/25, indicated a physician order start date 12/31/24 for oxycodone 2.5 mg po every 24 hours PRN for pain, and discontinued date 1/20/25. R35's individual narcotic record indicated 11 doses of oxycodone were signed out of the narcotic log from 1/2/25 through 1/23/25, with 2 doses signed out on 1/23/25 (2 days after medication was discontinued). However, R35's MAR dated 1/1/25 to 1/31/25, indicated 2 doses of oxycodone were administered. Discrepancy of 9 doses. R41's quarterly MDS, dated [DATE], indicated R41 was cognitively intact, and diagnoses included right leg below knee amputation and heart failure. R41's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 1/25/25 for oxycodone 5 mg to 10 mg po every 4 hours PRN for pain. R41's individual narcotic record indicated 7 doses of oxycodone 5 mg were signed out of the narcotic log on 1/28/25. However, R41's MAR dated 1/1/25 to 1/31/25, indicated 6 doses of oxycodone 5 mg were administered on 1/28/25. Additionally, 6 doses of oxycodone 5 mg were signed out of the narcotic log on 1/29/25. However, R41's MAR dated 1/1/25 to 1/31/25, indicated 4 doses were administered on 1/29/25. Discrepancy of 3 doses. R49's admission MDS, dated [DATE], indicated R49 was cognitively intact, and diagnoses included fracture of left fibula and tibia (both long bones in lower leg) and respiratory failure. R49's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/13/25 for oxycodone 5 mg po BID for pain. R49's individual narcotic record indicated 3 doses of oxycodone were signed out of the narcotic log from 1/14/25 through 1/18/25. However, R49's MAR dated 1/1/25 to 1/31/25, indicated 2 doses of oxycodone were administered. Discrepancy of 1 dose. R50's admission MDS, dated [DATE], indicated R50 was cognitively intact, and diagnoses included fracture of right femur (thigh bone) and asthma. R50's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 1/6/25 for oxycodone 5 mg po every 24 hours PRN for pain. R50's individual narcotic record indicated 20 doses of oxycodone were signed out of the narcotic log from 1/8/25 through 1/31/25. However, R50's MAR dated 1/1/25 to 1/31/25, indicated 14 doses of oxycodone were administered. Discrepancy of 6 doses. R54's admission MDS, dated [DATE], indicated R54 had mild cognitive impairment, and diagnoses included acute respiratory failure, osteoporosis, and R54 required tracheostomy care, suctioning, and a feeding tube. R54's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/8/25 for oxycodone 5 mg via PEG-tub every 6 hours PRN for moderate to severe pain. R54's individual narcotic record indicated 6 doses of oxycodone were signed out of the narcotic log from 1/24/25 through 1/25/25. However, R54's MAR dated 1/1/25 to 1/31/25, indicated 4 doses of oxycodone were administered. Discrepancy of 2 doses. R58's quarterly MDS, dated [DATE], indicated R58 was cognitively intact, and diagnoses included heart failure and right leg below knee amputation. R58's Order Summary Report, printed 2/11/25, indicated a physician order dated 7/22/24 for oxycodone 5 mg po PRN for pain. R58's individual narcotic record indicated 35 doses of oxycodone were signed out of the narcotic log from 1/7/25 through 1/23/25. However, R58's MAR dated 1/1/25 to 1/31/25, indicated 27 doses of oxycodone were administered. Discrepancy of 8 doses. R63's significant change MDS, dated [DATE], indicated R63 was cognitively intact, and diagnoses included left side hemiplegia and hemiparesis and rheumatoid arthritis. R63's MAR dated 1/1/25 to 1/31/25 indicated a physician order dated 1/3/25 for oxycodone 10 mg po every 4 hours PRN for moderate to severe pain. R63's individual narcotic record indicated 128 doses of oxycodone 10 mg were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R63's MAR dated 1/1/25 to 1/31/25, indicated 104 doses of oxycodone 10 mg were administered. Discrepancy of 24 doses. R73's quarterly MDS, dated [DATE], indicated R73 was cognitively intact, and diagnoses included multiple fractures of pelvis, lumbar vertebra fracture, and multiple rib fractures. R73's Order Summary Report, printed 2/11/25, indicated a physician order dated 11/6/24 for oxycodone 5 mg po every 8 hours PRN for pain. R73's individual narcotic record indicated 60 doses of oxycodone 5 mg were signed out of the narcotic log from 1/1/25 through 1/31/25. However, R73's MAR dated 1/1/25 to 1/31/25, indicated 50 doses of oxycodone were administered. Discrepancy of 10 doses. R75's admission MDS, dated [DATE], indicated R75 had moderately impaired cognition, and diagnoses included pancreatic cancer and generalized abdominal pain. R75's Order Summary Report, printed 2/11/25, indicated a physician order dated 12/28/24 for oxycodone 5 mg po BID PRN for pain. R75's individual narcotic record indicated 5 doses of oxycodone 5 mg were signed out of the narcotic log from 1/17/25 through 1/20/25. However, R75's MAR dated 1/1/25 to 1/31/25, indicated 3 doses of oxycodone were administered. Discrepancy of 2 doses. R76's admission MDS, dated [DATE], indicated R76 was cognitively intact, and diagnoses included systemic lupus erythematosus (immune system attacks healthy tissues and organs), migraines, and cervicalgia (neck pain). R76's Order Summary Report, printed 2/11/25, indicated a physician order dated 12/24/24 for oxycodone 5 mg - 10 mg po every 6 hours PRN for pain. R76's individual narcotic record indicated 79 tabs of oxycodone 5 mg were signed out of the narcotic log from 1/2/25 through 1/31/25. However, R76's MAR dated 1/1/25 to 1/31/25, indicated 67 tabs oxycodone 5 mg were administered. Discrepancy of 12 doses. R77's quarterly MDS, dated [DATE], indicated R77 had severe cognitive impairment, and diagnoses included nontraumatic intracerebral hemorrhage (ruptured blood vessel causing bleeding in the brain), diabetes, and required a feeding tube. R77's Order Summary Report, printed 2/11/25, indicated a physician order dated 10/24/24 for oxycodone 5 mg via G-tube every 24 hours PRN for moderate pain. R77's individual narcotic record indicated 22 tabs of oxycodone 5 mg were signed out of the narcotic log from 1/1/25 through 1/29/25, with 12 tabs signed out by TMA-A. However, R77's MAR dated 1/1/25 to 1/31/25, indicated 12 tabs oxycodone 5 mg were administered, and 11 of the doses were administered by TMA-A. Additionally, R77's medications were ordered via G-tube, which required a nurse to administer R77's medications. TMA performing tasks not within her scope of practice. Discrepancy of 10 doses. In purple is this the surveyor adding this. R141's admission MDS, dated [DATE], indicated R141 had severe cognitive impairment, and diagnoses included cerebral infarction (stroke), left side hemiplegia, chronic pain, and R141 required a feeding tube. R141's Order Summary Report, printed 2/11/25, indicated a physician order dated 1/22/25 for oxycodone 5 mg via G-tube every 6 hours as needed for severe pain. R141's individual narcotic record indicated 2 tabs of oxycodone 5 mg were signed out of the narcotic log from 1/23/25 through 1/24/25, with 1 tab signed out by TMA-A. However, R141's MAR dated 1/1/25 to 1/31/25, indicated 1 tab oxycodone 5 mg was administered, and the dose was administered by TMA-A. Additionally, R141's medications were ordered via G-tube, which required a nurse to administer R141's medications. TMA performing tasks not within her scope of practice. Discrepancy of 1 dose. R146's discharge MDS, dated [DATE], indicated R146 admitted to the facility on [DATE], and discharged from the facility on 12/13/24. R146's individual narcotic record #42, indicated 15 tabs of oxycodone 5 mg tabs were sent home with patient on 12/13/24, with TMA-A's signature and R146's signature noted. However, facility reported that investigation interview with R146 identified she received 7 tabs of oxycodone. Discrepancy of 8 doses. R146's individual narcotic record #17, indicated 8 tabs of oxycodone 10 mg tabs were destroyed on 11/22/24, with the initials SE and TMA-A's signature noted. Initials in question. However, during facility investigation interview RN-A stated the initials SE were forged because the nurse with the initials SE was out of the country on 11/22/24. discrepancy of 8 doses. R149's quarterly MDS, dated [DATE], indicated R149 was cognitively intact, and diagnoses included heart failure and chronic pain syndrome. R149's MAR dated 1/1/25 to 1/31/25, indicated a physician order dated 11/6/24 for oxycodone 5 mg po BID for pain, and an order dated 1/9/25 for oxycodone 5 mg po for acute one time only on 1/9/25. R149's individual narcotic record indicated 4 doses of oxycodone 5 mg were signed out of the narcotic log on 1/9/25. However, R149's MAR dated 1/1/25 to 1/31/25, indicated 3 doses of oxycodone were administered. Discrepancy of 1 dose. R345's admission MDS, dated [DATE], indicated R345 was cognitively intact, and diagnoses included fracture of sacrum, peritonitis (infection of membrane lining abdominal wall. R345's MAR, dated 1/1/25 to 1/31/25, indicated a physician order dated 1/17/25 for oxycodone 10 mg po every 8 hours PRN for pain. R345's individual narcotic record indicated 4 doses of oxycodone 10 mg were signed out of the narcotic log on 1/18/25, and 3 doses on 1/23/25. However, R63's MAR dated 1/1/25 to 1/31/25, indicated only 3 doses of oxycodone 10 mg were administered on 1/18/25, and 2 doses on 1/23/25. Discrepancy of 2 doses An interview on 2/5/25 at 1:53 p.m. with administrator stated RN-A had identified what she thought might be an issue on 1/29/25. RN-A sent an email to the regional nurse consultant (RN-B) and an investigation was started. TMA-A was suspended 1/29/25. An interview on 2/5/25 at 2:23 p.m., RN-A stated RN-A stated each morning a report was ran for missed medications. She looked in the progress notes to read the documentation about why the medication was missed. RN-A stated the report showed TMA-A repeatedly had given oxycodone. RN-A stated she had first noticed around 1/28/25, when the G-tube medications caught her eye as they were signed out by TMA-A. RN-A discussed oxycodone with R35. However, R35 did not know what oxycodone was for nor did she have any pain. RN-A discussed daily oxycodone use with R77. R77 told RN-A that TMA-A told R77 that she had to have her oxyodone via her G-tube but R77 stated she was to have orally to see how she did with oral medications, as they wanted to remove her G-tube. RN-A stated R77 had gotten her medication via G-tube but was charted given orally by TMA-A. It was not uncommon for TMA-A to request keys to the medication cart and staff handed them over. RN-A stated it was out of the TMA's scope of practice to destroy medications or to administer G-tube medications. Therefore, RN-A emailed RN-B and an audit was completed for all resident receiving oxycodone on the transitional care unit (TCU). RN-A stated the TMA-A was suspended on 1/29/25 at the end of her shift. An interview on 2/10/25 at 12:43 p.m., TMA-A stated she was the staffing coordinator and would fill in as a TMA on the unit. TMA-A stated she had set up medications for the nurses. TMA-A denied giving any G-tube medication to resident. TMA-A stated she was not to sign out medications that she had not given. TMA-A denied she had given residents their discharged medications. TMA-A indicated she counted narcotics with the licensed staff and was not sure why the licensed staff had not signed out when they had counted the narcotics. TMA-A denied documenting other staff initials in the narcotic book or in the MAR. TMA-A stated she had given narcotics to residents without talking with the licensed staff. TMA-A indicated she had been suspended since 1/30/25, then was terminated on 2/10/25. An interview on 2/11/25 at 10:04 a.m. TMA-B stated she did not have anyone set up any medications for her to give to the residents. TMA-B stated TMA's do not give any G-tube medications and no liquid morphine. TMA-B indicated that only the nurses destroy medications when they are discontinued. TMA-B stated TMA's do not sign out any narcotics going home with discharge residents. An interview on 2/11/25 at 10:51 a.m. RN-E stated TMA's do not destroy medications, only licensed staff could do that. RN-E stated TMA's do not sign out narcotics and give to residents who were discharged . RN-E stated she did not have TMA's set up medications then RN-A administered them. RN-E stated TMA's cannot give heparin, insulin, or any G-tube medications. An interview on 2/11/25 at 11:11 a.m. care coordinator (CC)-C stated TMA's could not give insulin, injections, nor G-tube medications. CC-C stated TMA's have to talk to licensed staff before giving any as needed medication to a resident. The the licensed staff needed to evaluate the resident. The facility policy Medication Administration dated 4/2018, indicated The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident ' s medication administration record (MAR) are compared with the medication label. It indicated the person who prepares the dose for administration is the person who administers the dose. The individual who administers the medication dose records the administration on the resident ' s MAR/eMAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. A facility policy Preparation and General Guidelines of Controlled Substances dated 5/2022, indicated Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record). 3) Remaining quantity (Accountability Record). 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record). A facility policy Medication Storage in the Facility, Controlled Substance Storage dated 5/2022, indicated At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. The emergency supply may be verified by assuring that the seal on the supply has not been broken. The facility initiated corrective action prior to the start of survey including; education on 1/30/25, the staff were educated not to give the medication cart keys to anyone until the end of the shift to on coming staff. The medication cart and narcotic lock box keys were change out. TMA's were given education on what the expectations of the TMA's can and cannot do. TMA's cannot give narcotics without discussion with licensed staff and the licensed staff have to document their assessment of the resident. Staff must verify in PCC if narcotic given. Audits completed to make sure they are accurate with documentation of the narcotic medications. 44645

Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respirations, no CPR was initiated, and R1 experienced certain death. The facility implemented corrective action, so the deficient practice was issued at past non-compliance. The IJ began on [DATE], when R1 was found unresponsive with an absence of pulse and respirations, CPR was not initiated, and R1 experienced certain death. The facility administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:00 p.m., which was identified at the scope and severity of an isolated IJ. The IJ was removed on [DATE] when the facility implemented immediate corrective action to prevent recurrence, therefore, the IJ was issued at past non-compliance. Findings include: A Facility Reported Incident (FRI) report was submitted to the State Agency (SA) on [DATE]. The report identified, on [DATE], at 5:50 a.m., R1 was found unresponsive in her room, cool to the touch, and absent of vital signs. R1 was full code (wished CPR); however, CPR was not performed. R1's significant change Minimum Data Set (MDS), dated [DATE], identified R1 was cognitively intact. R1's POLST, dated [DATE], identified R1 wished for attempted resuscitation/CPR [Full code], if she were found with no pulse and/or active breaths. The POLST was signed by R1 and a medical provider. An IDT (interdisciplinary team) Care Conference form, locked [DATE], identified R1 was a Full code and wished to remain as such. A provider visit note, dated [DATE], identified R1 was seen by physician assistant (PA)-A. The note identified R1's Code Status as Full Scope of Treatment. R1's Order Summary Report, active orders as of [DATE], identified an active CPR order. A progress note, entered on [DATE], at 7:23 a.m., identified the following timeline of events: -12:00 a.m., during rounds, R1 slept with no issues. -2:00 a.m., R1 was changed, repositioned, and she interacted with staff normally. -5:40 a.m., the nurse was updated by a nursing assistant after the nursing assistant discovered R1's condition. The nurse responded and found R1 unresponsive. The nurse grabbed the defibrator [sic] with the other nurse to start resuscitations, but it was too late, [R1] had ceased to breath, no pulse no respiration. The administrator, family, and the provider were updated. The note lacked identification R1 was provided CPR or that the AED was utilized. When interviewed on [DATE], at 2:44 p.m., licensed practical nurse (LPN)-A stated when a resident was found unresponsive, she was expected to assess for a pulse and respirations - if absent, she was to first verify their code status. If the code status indicated Full code, she was expected to immediately initiate CPR, send others to grab the crash cart and the defibrillator (AED), page a code blue overhead, and call 911. CPR was stopped only when the paramedics gave the okay. She explained that around 2:00 a.m., R1 slept without concerns. Around 5:40 a.m., a nursing assistant called her into R1's room. Right away, LPN-A approached R1 and found her on her back in the middle of the bed. LPN-A checked R1's pulse, shook her, and called her name; however, R1 lacked a response and was without a pulse or respirations. R1 was not cold but her feet were cooler than the rest of her body. Her body was clammy, her color was faded, and she lacked any stiffness when LPN-A shook her hand. LPN-A stated, It was too late. LPN-A added, I was very confused as this has never happened to me before. I was very shaken and confused. It was scary. LPN-A indicated she left R1's room and sought registered nurse (RN)-A for guidance. Once they returned to R1's room, RN-A assessed R1 and confirmed R1 lacked a pulse or respirations. LPN-A identified the AED was brought into R1's room and opened; however, after they verified R1 was a Full code, the AED was not used as it was too late. LPN-A stated after, she contacted the administrator and was told, It was okay; however, she explained, in hindsight, she learned the administrator thought LPN-A had performed CPR and there was miscommunication during that call as she was just providing the administrator with an update on R1's passing - not looking for guidance on what to do during this situation. LPN-A denied she contacted the DON, the on-call nurse, nor the provider for guidance. She stated she should have contacted the DON as the DON is clinical, whereas the administrator was not. LPN-A stated she failed to follow the facility's policy for timely code status verification and CPR initiation. LPN-A identified she was suspended right away and was since provided education that included paper education, conversations with management, and mock drill participation's in which she has to be the champion. On [DATE] and [DATE], interviews were attempted with NA-D, the nursing assistant who updated LPN-A on R1's unresponsive status; however, these were unsuccessful. During a telephone interview on [DATE], at 9:38 a.m., physician assistant (PA)-A stated the facility updated her that R1 was found unresponsive, and the attempted CPR was unsuccessful. If a Full code resident was found unresponsive, with no pulse or respirations, she identified she expected staff to initiate chest compressions and AED use if the AED advised a shock. In addition, she expected 911 to be called. When she was updated that R1 was not provided with CPR, she wished to reserve any comments related to the lack of CPR, as she was unaware of the event details, especially considering not being initially provided all the facts. She indicated she was present at the facility and observed at least two mock CPR drills. On [DATE], between 10:22 a.m. and 11:35 a.m., the following staff were interviewed respectively: LPN-B at 10:22 a.m., nursing assistant (NA)-A at 10:30 a.m., NA-B at 10:39 a.m., RN-B at 10:49 a.m., NA-C at 10:56 a.m., LPN -C at 11:06 a.m., and LPN-E at 11:35 a.m. The nurses stated if a resident was found unresponsive, they were to assess for a pulse and respirations. If none found, they were to verify the code status and if full code, CPR was to be initiated right away. The nurses were able to identify where the code status identification was located. In addition, all the nurses indicated there were no reasons why CPR would not be initiated if a resident were Full code. All nurses acknowledged they were up to date on their CPR certifications. All the NAs identified if they found a resident unresponsive, they were to update a nurse immediately. All the NAs identified they were not allowed to perform CPR, only to assist in the accompanying code processes such as getting the crash cart and AED. All staff explained they were to use the overhead paging system for a code blue call, the crash cart and AED were to be obtained, and call 911 when a resident's code status warranted Full code action. All staff were able to direct where the crash cart and the AED were located. All staff explained the education they had received, and the mock CPR drills they had participated in. All acknowledged the education and drills were very helpful. When interviewed on [DATE], at 11:18 a.m., LPN-D, identified herself as the long-term care (LTC) coordinator. She explained if a resident were found unresponsive, assessed to be free of pulse or respirations, and identified to be a Full code, she expected staff to yell for help, call a code and initiate CPR. LPN-D identified nurses were responsible for CPR, and she confirmed all nurses were CPR certified. She indicated there were no reasons why CPR would not be initiated for a Full code resident, and the paramedics were the only ones who could stop CPR once initiated. LPN-D confirmed R1 was a Full code. She was aware of CPR not being initiated and she identified she was confused by the whole episode as performing CPR on a Full code resident was nursing 101. She explained, it was her understanding there was a communication breakdown as LPN-A contacted the administrator versus the DON or the on-call nurse, along with confusion as to when LPN-A contacted the administrator. In response to the failed systems, education was provided to all staff and mock CPR drills were initiated daily for each shift. These drills continued and would continue until all nurses participated and demonstrated competency. During an interview on [DATE], at 11:47 a.m., the DON stated if a resident was found unresponsive, and CPR was assessed to be indicated based on a verified Full code status, the licensed staff were to initiate CPR no matter what. The DON explained she was contacted by the administrator on the morning of [DATE]. The administrator informed her that after a phone call with LPN-A, and the administrator had additional time to process the call, the administrator was concerned staff did not perform CPR on R1, despite the administrator's knowledge R1 was Full code. Both she and the administrator presented to the facility on [DATE] and initiated a plan to educate all staff going forward. This included paper education with an associated quiz and mock CPR drills. This education would continue until all the staff were educated and all the nurses demonstrated participation. She stated additional follow ups included LPN-A's suspension, review of licensed staff CPR certification statuses and a whole house review of residents' code status with verification to ensure the POLST, orders, and care plan reflected each other. No concerns were identified with the review and verifications. When interviewed on [DATE], at 12:34 p.m., RN-A explained if a resident were found unresponsive, without a pulse and respirations, he was to check the code status. If the resident were a Full code, he was then to initiate CPR right away. He denied there were any reasons why CPR would be withheld if the resident were Full code. RN-A acknowledged he worked the morning of [DATE] and was approached by LPN-A around 5:40 a.m. He stated LPN-A informed him that R1 was unresponsive and asked him to come and see R1. He denied knowledge R1 had passed until he arrived at her room and assessed her. RN-A explained R1 was absent of a pulse and respirations. This prompted him to direct LPN-A to verify R1's code status and to grab the crash cart. In response, LPN-A informed him she contacted the administrator and the administrator told LPN-A not to do CPR. RN-A confirmed he, nor LPN-A, initiated CPR, or used the AED on R1. After he exited R1's room, he consulted another nurse related to his concerns that R1 was a full code and CPR was not initiated, especially as CPR should have been performed. RN-A and the nurse conferred and felt maybe there were a change in the policy, and they had just not yet been updated. RN-A identified education since this incident which included his participation in three mock CPR drills so far. During a telephone interview on [DATE], at 1:24 p.m., R1's family member (FM)-A identified he never personally reviewed R1's POLST; however, [R1] always said she wanted to be Full code. Based on this, he expected they would have attempted resuscitations when they found her on [DATE]. Further, he expected, after they initiated CPR, they would have transferred her to the hospital so hospital staff could have taken over. During an interview on [DATE], at 1:32 p.m., the administrator confirmed LPN-A contacted her on [DATE] at approximately 5:50 a.m., and told her It was too late, it was too late, related to R1: LPN-A stated this matter of fact and did not sound panicked. The administrator initially understood during this first call that CPR was attempted on R1 and it was unsuccessful; however, during the investigation, it was discovered there were communication failures that started with that first call and continued through a third call. After the administrator was able to process the initial phone call once she woke up more, as the phone call woke her up, she called back to the facility and spoke again to LPN-A. She questioned LPN-A if the AED instructed them not to perform a shock. LPN-A responded to her, Yes, [RN-A] took the AED. After the administrator contacted R1's family, she again called back to the facility and spoke a third time to LPN-A. She questioned LPN-A if they took the AED into R1's room: LPN-A confirmed this. As the administrator continued to feel something was off with the events that occurred, she contacted the DON and instructed the DON they needed to investigate further. She arrived at the facility between 8:00 a.m. and 8:30 a.m. During staff interviews, the administrator discovered LPN-A informed RN-A the administrator directed LPN-A to not perform CPR. After this, the DON took over the remainder of the investigation. The administrator acknowledged an action plan was put into place on [DATE] to mitigate repeat episodes once it was confirmed R1 was not provided with CPR. She expected if CPR was indicated, staff were to perform it. Steps in the correction plan included LPN-A's suspension, prepped, and provided staff education which included paper education and mock CPR drills, along with audits. The administrator confirmed there were no concerns identified with the audits and the drills continued. The IJ that began on [DATE] was removed the same day, when it was verified through staff interviews and document review, the facility performed the following corrective actions all on [DATE]: -The facility implemented a full-on investigation that included staff interviews along with family, provider, coroner, and medical director notifications. -LPN-A was suspended. -A FRI was submitted to the SA. -A full house CPR/POLST audit was conducted that verified POLSTs, orders, and care plans all reflected each other. -All licensed staff CPR certifications were verified and reflected all were current. -The CPR policy was reviewed, and no changes were needed. -All staff training on the Code Blue policy, which included a quiz, was initiated. - All staff participation in mock Code Blue drills were initiated. Drills have continued and will continue until each nurse has been deemed competent in the policy processes. -Audits related to CPR protocols would continue to be completed with five staff weekly for four weeks. A Cardiopulmonary Resuscitation policy, dated ,d+[DATE], directed care would be provided according to the resident and/or the resident's representative identified preferences indicated by the physician orders and within the plan of care. CPR was to be initiated, by certified staff, for a resident who experienced a cardiac or respiratory arrest after code status was verified and an assessment revealed no signs of irreversible death were present. If irreversible signs of death were present, CPR was not to be initiated. The policy defined irreversible signs of death based on the American Heart Association which included rigor mortis (body limb stiffening) and dependent lividity (purplish red discoloration to the skin).

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R1) was free from seclusion when he was taken to his room and put in bed with the lights off and door closed against his wishes. R1 incurred psychosocial harm when he was found crying, reported he was afraid, and was transported to the hospital due to shortness of breath and elevated blood pressure after the event, where he remains. Findings include: A report to the state agency (SA) on 6/18/23 at 6:33 a.m., indicated R1 was restrained and assaulted by facility staff. Staff indicated R1 was sitting in a wheelchair at an unsafe angle and staff put R1 to bed. R1 stated he was forcibly put in bed, was not given his cell phone, the landline in the room did not work, and R1 could not call 911 or assistance. R1 began having difficulty breathing and had elevated blood pressure, and emergency medical services were called. R1 was transported to the hospital, where he remained. R1's Admission/Initial Data Collection assessment dated [DATE] indicated R1's short and long term memory were intact. R1's admission progress note dated 6/16/23 indicated R1 transferred from a wheelchair to bed with assistance of two staff and a gait belt. R1's progress note dated 6/17/23 at 8:40 p.m. (late entry) indicated staff put R1 in bed due to going outside the building and falling. On 6/26/23 at 9:59 a.m., family member (FM)-A stated on 6/17/23 between 4:00 p.m. and 5:00 p.m., R1 called them. R1 reported he was afraid, and wanted to leave the facility because staff made him go to bed when he didn't want to go to bed. R1 told FM-A staff removed his shoes, and put his wheelchair out of reach. On 6/26/23 at 12:18 p.m., nursing assistant (NA)-A stated on 6/17/23, R1 was trying to leave the building between 4:00 p.m. and 5:00 p.m. At the direction of the nurse supervisor, R1 was put into bed. NA-A stated R1 insisted he did not want to go to bed, but staff put R1 in bed anyway. On 6/26/23 at 1:22 p.m., registered nurse (RN)-A stated RN-B found R1 in the entryway on 6/17/23, at dinnertime, and subsequently took R1 to his room. RN-A stated R1 indicated he did not want to go to his room, and did not want to go to bed. RN-A stated R1's shoes were removed, the bed was put in the low position, and the wheelchair was placed near the bed. RN-A further stated he didn't think R1 could get in the wheelchair without assistance. On 6/26/23 at 1:36 p.m., RN-B stated at the beginning of the second shift on 6/17/23, R1 was agitated and was trying to leave the building. RN-B informed R1 he could not be supervised to leave the building. RN-B stated R1 was leaning forward in his wheelchair and appeared as if he might fall forward onto the floor. RN-B stated NA-A helped RN-B reposition R1 in the wheelchair. RN-B stated R1 was not safe to stay in the wheelchair, and R1 was less at risk of falling from the wheelchair or from leaving the building if R1 was in bed. RN-B stated R1 did not want to go to bed, and was combative when staff put R1 in bed. RN-B stated R1 was agitated and put to bed because there was not enough staff to shadow R1 until he could calm down. RN-B further stated, I didn't have no one to spare that night. It was around dinner time. [R1] would have had to ask for help to get back in the [wheel]chair. I didn't want to take a chance of him trying to leave again and didn't know if he was in his right mind to sign AMA [against medical advice] paperwork to leave. On 6/26/23 at 3:17 p.m., FM-B stated family was on the way to see R1 on 6/17/23, when R1 called to report staff had forced him to go to bed against his will, and took R1's shoes and placed them out of reach. FM-B stated when family arrived around 5:00 p.m. R1 was in bed crying, the blinds were drawn, the door was closed, the wheelchair was out of reach, and the room was dark. FM-B stated it was disheartening to see, as FM-B had never before seen R1 cry. FM-B stated R1 was scared and did not want to get off the phone with family until they arrived. FM-B stated R1 was so upset at the way he was treated, and it casued him so much distress, that he was hospitalized , and would not return to the facility because he was so upset at the way he was treated. On 6/27/23 at 9:05 a.m., R1 was interviewed. R1 stated on 6/17/23, he wanted to go outside to wait for his family to come and visit him. R1 stated, Some guy came and grabbed the wheelchair, threw me back in bed, and put the wheelchair on the other end of the room where I couldn't get it. It made me feel helpless. On 6/27/23 at 3:23 p.m., the director of nursing (DON) was interviewed and stated RN-B put R1 in bed to give him a pause to see if R1's behaviors would settle. The DON acknowledged there were no documented alternative interventions. The DON further stated R1 had not fallen outside, but was at risk of falling. The DON stated R1 had the ability to stand briefly and required assist of two staff to transfer. Additionally, the DON stated she did not feel R1 was secluded, but instead was given an opportunity to be in bed to prevent falls and improve behaviors. On 6/28/23 at 10:07 a.m., NA-B was interviewed and stated when residents had behaviors staff were required to redirect residents, were not allowed to force residents to their rooms, and were supposed to allow residents to go outside when they chose, unless there was a reason not to listed in the care plan. NA-B stated, If they [residents] don't want to come back in, we can't drag someone back in. That is abuse. We can't just put them in a room and close a door on them, unless they request it. If the door is closed, and they [the resident] has behaviors we can't check on them. They could get hurt. On 6/28/23 at 10:36 a.m., RN-B stated he talked to the DON and wanted to add information. RN-B stated R1 repeatedly stated he wanted to go home, and after R1 was put to bed, RN-B informed him could get out of bed only after staff had finished passing dinner trays. On 6/28/23 at 10:42 a.m., RN-C (who worked at the hospital where R1 was transferred) stated R1 was alert, oriented, and, Had no behavioral issues whatsoever. The facility Restraints policy dated April 2017 directed, Seclusion, which is defined at the placement of a resident alone in a room, shall not be employed. The facility Abuse Prohibition/Vulnerable Adult plan dated 2/2/23 directed involuntary seclusion is a form of abuse.

Based on interview, observation, and document review, the facility failed to protect 2 of 2 residents (R3, R4) from abuse, when R2 sexually assaulted R3 and R4 while intoxicated. This had the potentially to affect all residents who were residing in the facility at the time of the incident. The immediate jeopardy began on 5/13/22, when R2, while intoxicated, sexually assaulted R4. Following the incident, interventions were not implemented to protect other residents residing in the facility while R2 was intoxicated. R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator, director of nursing (DON) and social services director (SSD) were notified of the immediate jeopardy at 3:27 p.m. on 5/24/22. The immediate jeopardy was removed, and the deficient practice corrected on 5/17/22, prior to the start of survey and was therefore issued at Past Noncompliance. Findings include: Review of facility report number 4 to the State Agency (SA) dated 5/13/22, indicated R2 touched R4's chest and commented on R4's breast. R2 was immediately educated the behavior was inappropriate. Further, report indicated nursing staff were directed to monitor the residents to ensure no further contact between R2 and R4 and indicated both R2 and R4 would be seen by Advanced Care Psychology (ACP) in relation to the incident. Review of facility's 5-day investigation of incident dated 5/16/22, indicated R2 had grabbed R4's chest and stated, I want those boobies and then proceeded to kiss R4 on the forehead. R2 admitted she was intoxicated at the time of the incident and R2 appeared as though R2 did not understand the seriousness of the incident. In addition, report lacked evidence of a protection plan implemented for other residents in the facility to prevent R2 from sexually assaulting another resident who resides in the facility. Review of facility report number 0 to the SA dated 5/15/22, indicated on 5/14/22, R2 was witnessed in bed with R3, kissing her on the mouth. R2 and R3 were immediately separated, and R3 was moved out of the room (on 5/15/22). Review of facility's 5-day investigation, R2 admitted she was intoxicated at the time of the incident. Further report indicated the following were implemented to protect R3 and other residents residing in the facility: R2 was placed on 1-1 staffing indefinitely, police were notified, skin check for R3 was completed and no concerns noted, room change occurred on 5/15/22 and R2 will now always be in a private room, resident and staff interviews completed with no concerns identified, all staff education provided on abuse, alcohol policy and implementing immediate interventions to protect all residents completed on 5/17/22. R3's annual Minimal Data Set (MDS) dated [DATE], indicated R3 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly MDS dated [DATE], indicated R4 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly MDS indicated R2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R2's care plan as of 5/18/22, indicated R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan directed staff to ensure safety and notify doctor, perform head to toe assessment and conduct vital signs, perform a room search and remove any alcohol/substance, and if resident was belligerent and risk to self or others call 9-1-1 and execute the emergency medical service protocol. Further, R2's target behaviors included presenting intoxicated, stumbling, increase in volume, acting silly (overly complementary, giggly and extra touchy) staff were to ensure safety of resident, go through active substance use policy with resident, document behaviors and follow-up. Following the 5/13/22 and 5/14/22 incidents of sexually abuse against residents, R2's care plan was revised on 5/17/22 to indicate R2 exhibited sexual behaviors and was cognitively impaired related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan directed staff to assist R2 to find an appropriate activities, follow substance use protocol, remove resident from others, assess for substance use, and notify administrator, director of nursing, director of social services of all behaviors and the residents involved. However, R2's care plan lacked evidence interventions were implemented prior to 5/17/22, to protect other residents when R2 was noted to have a history and repeated sexual behaviors while intoxicated. Review of R2's progress notes: -On 5/13/22, indicated R2 left the facility, was giddy and smiling more than usual when she returned. R4 was sitting at the front desk, R2 grabbed R4's chest and stated, I want those boobies. -On 5/14/22, indicated R2 was exhibiting intoxicated behaviors with her roommate (R3). R2 was noted lying in R3's bed, kissing her on the mouth. R3 was screaming, I am scared, and trying to push R2 away from her. R2 was asked to go to her own bed and started throwing things around the room. Interview with R2 on 5/19/22, at 10:18 a.m. R2 stated she did not mean anything by it when she touched R4's breasts, only meaning that they were bigger than hers. R2 stated she had gone to buy alcohol and consumed it prior to the incident. R2 stated as far as she could remember, she kissed R3 on the forehead, and was not in bed with her. R2 stated she had not kissed any other residents. In addition, R2 admitted she was intoxicated at the time or the incident. R2 at this time was in her private room and a staff member was outside her door for her 1-1 staffing. On 5/19/22, at 10:30 a.m. R3 was observed laying in her bed. R3 was interviewed regarding the sexual incident that occurred with R2, however R3 was unable to recall incident. On 5/19/22, at 11:04 a.m. R4 was observed in his wheelchair at the front entrance visiting with staff. R4 stated a few days ago R2 was intoxicated and made a sexual comment towards him and touched his breast. R4 reported the sexual incident made him uncomfortable but staff removed R1 right away and no further incidents occurred. On 5/24/22, at 9:13 a.m. licensed practical nurse (LPN)-A was interviewed and stated R2 would leave the facility and buy alcohol and would return to the facility intoxicated. LPN-A stated R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-A stated this had been going on for a while. LPN-A stated R2 was not easily redirectable. LPN-A stated on 5/14/22, she was passing medications when she noted R2 lying in R3's bed. LPN-A stated R3 was saying she was scared and tried to push R2 away from her and R2 was difficult to redirect when she was intoxicated. LPN-stated R2 was throwing objects around the room in response to being redirected. LPN-A stated she put the curtain around R2's bed to separate R2 and R3. LPN-A stated she did not move either resident to a different room, because she didn't have permission at the time. On 5/24/22, at 11:23 a.m. the administrator stated there were interventions in place for R2's sexual behaviors prior to the sexual incidents with R3 and R4, but administrator deferred to the social worker. Administrator stated R2 was assessed and would continue to be 1-1 staffing until additional interventions could be determined and implemented or if R2 discharges the facility. Administrator stated staff were expected to use 1-1 staffing with R2 and if R2 left the building the 1-1 staff would be notified of R2's return to the facility and initiate the 1-1 staffing immediately. In addition, administrator stated following the sexual incident between R2 and R3, R2 was moved to a private room, and education was provided to all staff on 5/17/22 which included abuse, reporting, alcohol policy and protocol. On 5/24/22, at 11:23 a.m. the social worker (SW)-A was interviewed. SW-A stated R2 had cognitive deficits, and short-term memory impairments. SW-A stated R2 is a very affectionate person. SW-A stated the incident with R4 was the first reported incident. SW-A stated they cannot stop cognitively intact residents from hugging and kissing. SW-A stated she can't say if there were any interventions between the incidents with R3 and R4. On 5/24/22, at 12:00 p.m. the director of nursing (DON) stated R2 had a problem with alcoholism. The DON stated R2 hugged and kissed her friends, but recently had started kissing residents she doesn't know, and who are not ok with it. The DON stated after the incident with R4, R2 was placed on increased monitoring, but was unable to state what the increased monitoring was other than to watch for interactions between R2 and R4. The DON stated after the incident with R3, R2 was assessed to deteremine interventions to best protect R2 and other residents when she is intoxicated. R2 was placed on an indefinite 1-1, she was moved into a private room and all staff were trained on both the abuse policy and Active Substance Abuse Protocol. The facility is working with R2 on discharge planning. Observations of R2's 1-1 staffing were conducted at various time on 5/18/22, 5/23/22 and 5/24/22 to determine compliance with no concern. Interview to verify compliance, on 5/19/22, at 9:57 a.m. LPN-D stated following the sexual incident between R2 and R3, R2 was moved to a private room and 1-1 staffing was initiated. LPN-D stated the 1-1 staff were expected to sit outside of R2's door at all times, and when R2 leaves the room the 1-1 staff were expected to follow R2. Further, LPN-D stated in addition, management provided education related to abuse, reporting and the facility's alcohol policy and protocol. On 5/24/22, at 9:13 p.m. LPN-A stated education was provided following the sexual incident with R2 and R3 related to alcohol policy and abuse. LPN-A stated if a resident is identified as being intoxicated staff were expected to report to the DON and administration and continue 1:1 staffing to ensure safety of residents. On 5/24/22, at 10:53 a.m. LPN-B stated education related to abuse, reporting, and the facility's alcohol policy and protocol was provided by management following the sexual incident between R2 and R3. LPN-B stated staff were expected to notify DON and administrator if R2 was suspected to be intoxicated and continue 1:1 staffing to ensure safety. Active Substance Abuse Protocol Education, not dated, directed staff to ensure the resident is safe and notify supervisor and the resident nurse. Further directed staff if a resident appears intoxicated ensure safety, hold medications, conduct initial room and belonging search for contraband and lock in medication room, conduct head to toe assessment, write progress note, notify supervisor/provider/administrator/DON, initiate 24-hour intoxication monitoring which include vitals, level or consciousness and fall prevention. However, protocol lacked evidence to keep other residents in the facility safe while a resident is intoxicated. The facility policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 9/11/20, defined sexual abuse as the non-consensual sexual contact of any type with a resident. The past noncompliance immediate jeopardy began on 5/13/22. The immediate jeopardy was removed and the deficient practice corrected by 5/17/22, after the facility implemented a systemic plan that included the following actions: R2 changed to a private room, R2 was placed on 1-1 staffing indefinitely, all staff education provided on abuse, reporting abuse, alcohol policy (revised and updated), active substance abuse protocol, and implementing immediate interventions following an abuse allegation.

Based on interview, and document review, the facility failed to properly assess and monitor pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers. R1 had been admitted from the hospital with existing pressure ulcers, and the pressure ulcers were not monitored or assessed. This resulted in harm to R1, when a pressure ulcer on his coccyx worsened and he sustained a new pressure ulcer to his ankle. Pressure Ulcer definitions by the National Pressure Injury Advisory Panel: Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin: Intact skin with a localized area of non-blanchable [CONDITION(S)] (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss: 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 [CONDITION(S)] 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. Findings include: R1's Face Sheet printed 8/24/21, indicated R1 was admitted from the hospital on 5/20/21. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and required extensive assistance from two staff for bed mobility and transfers. The MDS further incorrectly indicated R1 had one Stage 1 pressure ulcer and was at risk for pressure ulcers. The MDS lacked further record of Stage 2, Stage 3, or Stage 4 pressure ulcers. R1's Care Area Assessment (CAA) for Pressure Ulcer and Injury dated 5/27/21, indicated R1 was at increased risk of skin breakdown. The CAA further indicated R1 had a Stage 1 pressure ulcer to buttocks which was being treated by Triad creme (a sterile coating applied directly onto the wound or peri-wound as a moisture barrier). The CAA indicated R1 required assistance of two staff with bed mobility and was an extensive assist of two for bed mobility, and since he was always incontinent of bladder and frequently incontinent of bowel, he required extensive assistance with toileting. The CAA indicated R1 was at risk for skin breakdown. R1's care plan last updated 8/9/21, indicated R1 had actual impairment to skin integrity on his buttock and left lower leg, and a lower knee amputation related to pressure ulcers. R1's care plan also indicated R1 could be resistive to repositioning every two hours, and was to be up in chair daily. R1's hospital discharge summary dated 5/20/21, indicated R1 admitted from the hospital to the facility and identified the following existing pressure ulcers on 5/19/21: - Left buttock pressure ulcer Stage 3, measured at 7 centimeters (cm) x 5 cm x 0.3 cm - Right buttock pressure ulcer Stage 2 vs, Stage 3. Two open areas measuring 1.2 cm x 0.5 cm x 0.1 cm and 0.5 cm x 0.7 cm x 0.1 cm - Right isheal tuberosity (sitting bones) Stage 2 vs. Stage 3. This area was not measured - Right buttock with large area of devitalized skin (slough or necrotic tissue). Skin appears intact under this area, will monitor as devitalized skin peels away. On 5/20/21, at 12:52 p.m. a progress note the day of R1's admission, indicated the following pressure ulcers that were not measured, staged or accurately assessed: - Wound to both buttocks. R1's medical record lacked assessment and documentation of the pressure ulcer to R1's isheal tuberosity. On 5/20/21, at 9:28 p.m. a progress note indicated R1's condition upon admission included a skin ulcer on R1's sacrum (tailbone) limited to breakdown of skin. The progress note lacked assessment of the pressure area on R1's sacrum. On 6/9/21, at 4:55 p.m. a Wound Assessment completed by the assistant director of nursing (ADON) indicated R1's coccyx (tailbone) pressure ulcer was a healed Stage 1, with [CONDITION(S)] (redness). No further assessment of the pressure ulcer was completed. R1's medical record lacked assessment and monitoring. On 6/24/21, at 4:17 p.m. a Wound Assessment of R1's coccyx completed by the ADON indicated the pressure ulcer as a healed Stage 1. No further assessment of the pressure ulcer was completed. On 7/6/21, a Skin Observation described R1's skin issues as wound healing buttocks and lower abdomen. The Observation lacked any further assessment. R1's medical record lacked any further assessment or monitoring. On 8/1/21, a Skin Observation described R1's skin issues as shearing to left buttock irregular areas. R1 stated he was not scratching it. The Observation lacked any further assessment. On 8/9/21, at 3:39 p.m. a Wound Assessment to R1's right outer ankle completed by the ADON, indicated the pressure ulcer was unstagable, and measured 3.0 am x 2.5 cm with an unknown depth. R1's medical record lacked documentation of when this pressure ulcer developed, and lacked assessment and monitoring. On 8/11/21, at 4:09 p.m. a Wound Assessment to R1's coccyx was completed by the ADON. The Assessment indicated the pressure ulcer was a Stage 3 and measured 5.0 cm x 4.0 cm with an unknown depth. This documentation indicated R1's coccyx pressure ulcer had worsened, having gone from a healed Stage 1 pressure ulcer, to a Stage 3 pressure ulcer. On 8/13/21 at 4:04 a.m. a progress note indicated R1 requested to be sent to the emergency department (ED) initially at 2:00 a.m. due to ongoing complaints of pain after already receiving pain medication. Ultimately, R1 called the paramedics himself and left the facility via ambulance. R1'a Hospital discharge date d 8/16/21, indicated R1 had the following pressure ulcers: - Sacrum pressure ulcer was staged at unstageable, and measured 3 cm x 2.5 cm x 0.2 cm - Right ankle was staged at unstabeable and measured 2.5 cm x 2.5 cm x 0.5 cm lateral and 1.5 cm x 1.5 cm x 0 cm medial On 8/23/21, 1:19 p.m. the director of nursing (DON) was interviewed and stated there were no other assessments of R1's pressure ulcers except what was in the medical record. The DON stated R1's largest pressure ulcer on his buttocks had healed or was closed upon admission, which was the reason why weekly pressure ulcer documentation did not start. The DON stated after the assessment on 6/9/21, there was a lack of further measurements of the pressure ulcer on R1's buttocks or coccyx area until the assessment on 8/11/21. The DON stated at that time, R1's coccyx was assessed at a Stage 3 pressure ulcer. The DON stated the facility's process was to assess pressure ulcers over a week span, and if a pressure ulcer slowed in healing for over two weeks, they would change the treatment plan. On 8/24/21, at 7:12 a.m. R1 was interviewed and stated he had left the facility due to inadequate care. R1 stated he felt his overall cares, including the lack of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21, at 4:30 p.m. the medical director (MD)-A was interviewed and stated the ADON's pressure ulcer assessment on 6/9/21, as a healed Stage 1 on R1's coccyx was incorrect. MD-A stated she did some staff education some time the end of May or June, when she noticed the ADON was not assessing the pressure ulcers accurately. MD-A stated she noted issues with the R1's pressure ulcer documentation. MD-A stated the redness and the measurements were a little off kilter, and the description of the wound bed was lacking. MD-A stated this was due to staff's lack of knowledge. MD-A stated a pressure ulcer was not healed if there was some excoriation and moisture associated skin damage, they would be staged as a Stage 2, not a Stage 1. MD-A stated she expected nursing staff to do a very thorough assessment on pressure ulcers. The facility policy Skin Protection and Prevention dated 7/7/21, directed our facility applies a process to identify residents with or at risk for developing a pressure injury: Upon admission / readmission, transfer out/in, with significant changes in condition routinely through the MDS Assessment process. the policy further directed the first step in the prevention of pressure ulcers/pressure injuries (PU/PIs) is the identification of the resident at risk. A pressure ulcer/injury can occur wherever pressure has impaired circulation to the tissue. Some factors are modifiable [NAME] others are not.

Based on interview and document review, the facility failed to address alcohol consumption, and implement interventions including monitoring for withdrawal symptoms, physical safety when impaired judgement, medication interactions, notify the physician and offer behavioral health services for alcohol dependency for 1 of 2 resident (R1) whom consumed alcohol unsafely. This resulted in an immediate jeopardy. The IJ began on 7/4/21, at 11:25 a.m. when R1 had returned from an overnight community outing and was suspected of consuming alcohol. R1 was noted to be shaking, had an elevated blood pressure and elevated pulse upon return to the facility with no interventions/monitoring were initiated. The director of nursing (DON) and administrator were notified of the IJ on 7/21/21, at 5:46 p.m. The IJ was removed on 7/22/21, at 2:38 p.m., but noncompliance remained at the lower scope and severity level of D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: R1's Face Sheet dated 7/21/21, indicated R1's diagnoses included acute pancreatitis, [CONDITION(S)], alcohol dependence with withdrawal, and kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, used a wheelchair, and was independent with locomotion. R1's care plan dated 6/21/21, indicated R1 was, resistive to drinking orders. R1's care plan lacked interventions related to alcohol usage. Review of R1's progress notes indicated: - 4/23/21, at 11:45 p.m. indicated R1 was admitted to the facility after an episode of excessive alcohol usage. - 5/8/21, at 2:38 p.m. indicated R1 was observed to have taken alcoholic drinks, however, R1 denied drinking alcohol. R1 was advised to stop drinking alcoholic beverages. - 5/9/21, at 2:27 p.m. indicated R1 was, drunk this shift and a large bottle of vodka was found in her room. R1 was unable to eat breakfast and lunch due to drowsiness and had slept all shift. The on-call physician was notified and orders to withhold [MEDICATION(S)] (medication used to treat opioid dependence) and monitoring for [CONDITION(S)] was received. - 5/13/21, at 12:31 p.m. indicated R1's had signs of alcohol intoxication and an empty alcohol bottle was found in her room. The progress notes further indicated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was educated on the restriction of consuming alcohol. R1's room was searched, and the front desk was to check anything R1 brought in and out of the facility. Searches will continue to ensure R1 was safe. - 5/29/21, at 9:45 a.m. indicated a shipment of fruit punch vodka for R1 was intercepted and the delivery person was informed the facility was alcohol free. The delivery person canceled the order. -6/2/21, at 11:03 p.m. indicated therapy staff noticed R1 was drunk based on her performance. R1 was assessed by a nurse manager, however, the nurse manager was unable to tell if R1 was drunk. The physician was notified and R1's [MEDICATION(S)] (pain medication) was discontinued. R1 slept in her room for the entirety of the shift and refused to eat or drink. - 6/3/21, at 3:09 p.m. indicated R1's room was changed as her current room was accessible to the outside and sneaking in alcohol. The progress notes further indicated R1 had been hospitalized more frequently related to substance abuse and R1 sometimes appeared intoxicated with empty bottles of vodka found in her room. R1 was to be searched upon arrival from the community for forbidden substances. - 6/11/21, at 10:36 p.m. indicated R1 went outside by herself and returned confused and had an unstable gait. R1 seemed drank [sic]. R1's blood pressure was 133/93 and her heart rate was 117. R1's physician was notified. - 6/13/21, at 3:34 p.m. indicated eight one-liter sized empty vodka bottles were found in R1's room. At 7:25 p.m., two additional full bottles of vodka were found in R1's walker after she had left and returned to the building. - 6/27/21, at 3:17 p.m. indicated R1's hands were noted to be shaking occasionally. R1 was asked if the facility should notify the physician, however, R1 stated, I shake sometimes, I am fine. R1's vital signs were recorded and noted to be at R1's baseline. - 6/27/21, at 2:07 p.m. indicated her blood pressure was 144/92 and pulse was 103. R1's baseline blood pressure was 120/70 and pulse was between 60 to 80. - 7/4/21, at 7:38 a.m. indicated R1 left the facility at 7:00 p.m. on 7/3/21, and did not return overnight. Staff attempted to call R1, however, the call did not go through. Report was given to the oncoming nurse. - 7/4/21, at 7:58 a.m. indicated all R1's contacts were notified R1 had not returned to the facility, however, no one had called back. The progress note further indicated the DON was notified and had verbalized she would call the facility back with what needed to be done. - 7/4/21, at 10:23 a.m. indicated a call was placed to the facility administrator. The progress notes further indicated the administrator instructed staff R1 was her own responsible party and an alcoholic. Further, R1 could be drinking with her family or friend. Staff were instructed to allow family additional time to see if they called back. Family still had not contacted the facility at the time the progress note was written. - 7/4/21, at 10:57 a.m. indicated R1 contacted the facility and verbalized she was doing fine. The progress notes further indicated R 1 verbalized she was stuck at family's house unexpectedly overnight and she was fine. - 7/4/21, at 2:08 p.m. indicated R1 returned to the facility at 11:25 a.m. and was noted to be shaking. R1 stated she was okay and she shakes at times, so there was no need to contact the physician. R1's vital signs were recorded. R1's vital signs recorded at on 7/4/21, at 11:33 a.m. indicated her blood pressure was 170/100 and pulse was 114. Although R1 had was noted to be shaking on 6/27/21, and 7/4/21, R1's physician was not notified, chemical dependency services were not offered, and R1 was not monitored for symptoms of alcohol withdrawal. R1's physicians note dated 7/16/21, indicated R1 was hospitalized on the following dates: - 5/4/21, through 5/7/21, with pancreatitis. It was also noted R1 had been drinking at the facility. 5/12/21, through 5/26/21, for pancreatitis, severe metabolic acidosis (condition in which the body was increasingly acidic), and congestive heart failure exacerbation. - 6/8/21, through 6/10/21, for vaginal bleeding and was also noted to be in acute alcohol withdrawal. When interviewed on 7/20/21, at 2:10 p.m. nursing assistant (NA)-A stated she did not know when R3 left or returned to the facility. When interviewed on 7/20/21, at 11:25 a.m. The DON confirmed no interventions referenced on R1's care plan, however, R1's room searches were conducted for alcohol and a room change was completed as there was a hole in R1's screen and it was believed she was getting alcohol through it. The DON stated R1 goes outside and it was believed someone may be delivering her alcohol. The DON believed R1 was offered chemical dependency services at least one time. The DON stated R1 was hospitalized frequently, and the facility had more issues finding R1 intoxicated since her admission on 4/23/21. The DON stated R1 was basically killing herself. When interviewed on 7/20/21, at 11:39 a.m. social worker (SW)-A stated there was, plenty missing from R1's care plan related to alcohol consumption. SW-A stated registered nurse (RN)-A made R1's care plan, however, it was not complete. SW-A stated R1 actively used alcohol and was followed by psychiatry. Review of R1's medical record lacked indication chemical dependency or psychiatry services were offered to R1 since admission to the facility on [DATE]. When interviewed on 7/20/21, at 11:40 a.m. RN-A stated R1's care plan should had included interventions related to alcohol use, but it did not get done. When interviewed on 7/20/21, at 11:41 a.m. licensed practical nurse (LPN)-A stated R1 went out during the evening and was unaware of where R1 would go. When interviewed on 7/20/21, at 2:40 p.m. SW-B stated R1 was not referred to psychiatry or other behavioral health services and R1 was not interested. SW-B stated R1 would leave the facility during the day and return at night, however, was unsure where R1 went. SW-B stated R1 actively consumed alcohol and shook sometimes. SW-B stated she was unsure why R1 shook. When interviewed on 7/20/21, at 3:00 p.m. RN-A stated R1 was not compliant with signing out of the facility and attempted to sneak out. RN-A stated R1 tried to find a way out of the facility almost every day and there was no way to stop her from going out. RN-A stated R1 would verbalize she had a family emergency and had to go. RN-A stated the DON found R1 walking to the liquor store, R1 had left for appointments and not returned to the facility, and sometimes R1 had others pick her up from the facility and would not return. RN-A stated staff had previously found alcohol containers in R1's room and her room which was why room searches were initiated. RN-A stated symptoms of alcohol withdrawal included shakiness, confusion, falls, and change in speech. RN-A stated, I think that is what was missed related to monitoring for alcohol withdrawal for R1. RN-A verified R1 did not have shaking unless she had been drinking. RN-A stated R1 was not referred to psychology as she was not prescribed antidepressant or other psychiatric medications. When interviewed on 7/21/21, at 2:30 p.m. LPN-B stated R1 needed to be checked when she returned to the facility from an outing to ensure she had not acquired alcohol. LPN-B stated she had previously seen R1 intoxicated and R1 was shaky sometimes in the morning. LPN-B stated R1's shaking may be after R1 had been consuming alcohol. LPN-B stated R1 had no diagnoses which would result in tremors. When interviewed on 7/21/21, at 8:45 a.m. nurse practitioner (NP)-A stated R1 actively consumed alcohol which resulted in multiple hospitalization s for pancreatitis. NP-A stated consuming alcohol could impact R1's heart and kidney function. NP-A stated R1 was previously prescribed a medication for alcohol consumption after she was hospitalized on [DATE], however, the medication did not work for the resident. NP-A confirmed there were no other conversations about alcohol cessation for R1. NP-A stated signs and symptoms of alcohol withdrawal included tremors, fever, [CONDITION(S)] (high heart rate), agitation, anxiety, blood pressure spikes (elevation), and sweating. NP-A stated she was not aware of alcohol withdrawal monitoring for R1 individuals with withdrawal can get quite unstable. NP-A stated R1 was supposed to have frequent room checks and was, not supposed to be drinking at all. When interviewed on 7/21/21, at 3:10 p.m. R1's cardiologist, (MD)-A, stated alcohol consumption would affect R1's liver and ability to metabolize cardiac medications she was prescribed. MD-A stated the medications could become ineffective and could lead to death. MD-A stated the facility had not notified him of R1's alcohol consumption. When interviewed on 7/21/21, at 4:50 p.m. the facility medical director stated she did not believe R1 drank consistently in the nursing home, but stated R1, seeks alcohol and would binge drink. Facility policy titled Policy and Procedure for Alcohol And Unauthorized Drugs Villa Healthcare Revised 2/19/19, directed: 1. If a resident is found with possession, use, or distribution of unauthorized drugs or alcohol it will be confiscated by facility staff. 2. The facility staff will conduct an initial room search and will continue to do random room searches if necessary. 3. The resident's physician will be notified and able to make medication changes as appropriate. 4. The facility may notify the police of the quantity or if there are concerns of personal harm or damage to property arising from the use of unauthorized drugs and/or alcohol. 5. If visitors/family members are found with distribution of unauthorized drugs and alcohol, they will be asked to leave the facility and police may be notified. 6. Residents who ignore the policy endanger themselves and others will receive the following consequences: Verbal warning and then written contract. Persistent violation of the policy will result in finding alternative living arrangements. The IJ was removed on 7/22/21, at 2:38 p.m. after it was verified through interview and document review the facility implemented a systemic plan for R1 and other residents whom were identified to have substance use disorders which included: - Care plans were updated to include interventions related to alcohol use on 7/21/21. - Updated risk versus benefits documents were reviewed and signed on 7/21/21. - Psychology services were offered and R1 accepted on 7/21/21. - The consulting pharmacist reviewed resident medications for interactions with alcohol on 7/21/21. - Orders were updated to include monitoring for signs and symptoms of intoxication and alcohol withdrawal. Further, staff were to hold medications and notify the physician when signs and symptoms of intoxication/withdrawals were exhibited by a resident on 7/21/21. - The facility substance abuse policy was updated on 7/22/21, which included a protocol for substance abuse. - Actively working facility staff were educated on the above by 7/22/21. Facility staff who had not received training were notified education was required prior to working their next scheduled shift on 7/22/21.

Based on observation, interview and document review, the facility failed to train staff and consistently implement a communication board for 1 of 1 resident (R40) reviewed who was dependent on an alternative means of communication to communicate care needs, share feelings and socialize. This resulted in harm for R40 who suffered emotional distress, and cried when describing how staff failed to allow her an opportunity to communicate in a meaningful manner. Findings include: On 4/15/19 at 4:50 p.m., R40 requested to be interviewed by the surveyor. Due to R40 requiring assistance with communication, registered nurse (RN)-C was asked who would best be able to help provide a method of alternative communication. RN-C stated the activity staff would be best to help with the interview and requested assistance from an activity life enrichment staff, LE-A. R40 was interviewed on 4/15/19, at 5:59 p.m. with LE-A and surveyor using the ABC/communication letter board and a pointer pen placed in R40's right hand. R40 communicated, Staff do not follow my morning and bedtime routine. Not listen to me, they say I refuse to lay down but I refuse because they do not get me up right away and I do not want to be left in my bed, I want to be up in the hallway. They get mad at me. I cry and they get mad at me. They do not do my range of motion (ROM) and will say I refuse. I will not get my position changed and they say I refuse. Don't understand. I will allow the care but they must get me up and follow my morning and evening routines, which they do not do. R40 started to cry during the conversation on 4/15/19, at 5:59 p.m. and tears were streaming down her face. When R40 stopped crying she was able to communicate that staff do not use the letter board so she can have a conversation. R40 indicated staff just ask yes and no questions. Furthermore, R40 expressed being very upset that she was missing her IPad charger indicating someone is going to loan a charger to her, but clearly indicating she wants her own charger back. R40's had an assessment documented in her record which RN-G had conducted 2/23/19 indicating R40 had moderately impaired cognition. When interviewed by phone on 4/22/19, at 9:00 a.m. RN-G recalled, She is not able to answer, not oriented that day, really lethargic that day, I approached her twice but she was kind of sleepy on that day. RN-G verified she had not used R40's communication board to obtain answers from R40, but stated she would try again today to see if (R40) is able to respond. R40's [DIAGNOSES REDACTED]. R40's occupational therapy (OT) notes written 2/14/18 included: Family member present during session, patient setup for use of overhead sling. Education to family and to life enrichment staff regarding setup and placement of hand for optimal use of letter board. Patient able to communicate needs to family and staff. R40's nursing assistant (NA) care sheet dated 4/17/19 directed: please keep communication board with resident when in w/c (wheel chair) assist with communication when in bed as needed. R40's care plan initiated 6/23/18, indicated R40 had an alteration in sensory/communication r/t (related to)[MEDICAL CONDITION] with [MEDICAL CONDITION]; resident able to answer yes with movement of right foot and answer no with movement of right hand; has full lap tray for communication modalities. The interventions included: allow adequate time to respond. Ask yes and no questions if appropriate. Provide picture/word board, full lap tray to accommodate communication modalities. Repeat as necessary and request feedback, clarification from the resident, to ensure understanding. The communication form hanging on the wall in R40's bedroom included: I can have a conversation and talk. Just not with my voice. I can spell out what I need on my alphabet sheet with a pen/pointer in my right hand and a little help if you hold the page for me. I can shake my head 'No', I can wiggle my toes for 'Yes', before leaving me, ask if I have anything more to say (I'll usually let go of the pen if I'm done). I understand American sign language. R40 was observed on 4/16/19, at 7:30 a.m. while RN-B administered her tube feeding. RN-B did not use the communication board with R40, and RN-B stated she generally works on another wing so had not previously used the communication board with R40. R40 was observed on 4/17/19, at 7:00 a.m. in the hallway and the communication board was not available. At that time, licensed practical nurse (LPN)-D, the nurse responsible for R40's care, stated she did not know where the communication board was. After searching in the bedroom, LPN-A found the communication board on the tall bedroom dresser but the pen was not available. After further searching, the pen was found in the bottom of a personal items bin under other personal items. LPN-D expressed not being familiar with using the communication board or pen and stated she usually used yes and no questions to communicate with R40. LPN-D stated she was not aware R40 would like to have conversations with the nurses regarding care and services using the communication board. During the observation, R40 expressed being happy the communication board and pen were found and communicated using the board, No one on the night shift knows how to use the communication board and that is why the pen and board become lost. Furthermore R40 communicated, Losing the pen happens too often and staff do not take the time to talk to me. When interviewed on 4/18/19 at 7:15 a.m. NA-I indicated floated to this unit to help out and was not familiar with the communication board for R40 and would require training to use the communication board for R40. When interviewed on 4/18/19, at 7:20 a.m. LPN-E verified the night shift staff are not familiar with using the communication board for R40 and would require specific training to use the communication board. When interviewed on 4/18/19, at 7:35 a.m. LPN-F stated she did not use the communication board with R40. When interviewed on 4/18/19, at 7:40 a.m. RN-C stated did not use the communication board with R40 and was not sure about staff training available for use of the communication board. When interviewed on 4/18/19, at 7:45 a.m. NA-B acknowledged not using the communication board with R40, and stated training would be required to use it correctly, because the life enrichment staff were the only ones who used the board. When interviewed on 4/18/18, at 9:30 a.m. NA-A stated nursing staff had not been trained to use the communication board for R40, and described using only yes or no questions to communicate with R40. When interviewed on 4/18/19, at 9:40 a.m. NA-F verified not using the communication board because there had been no training completed on how to use the communication board. NA-F described using only yes or no questions to communicate with R40. When requested, the facility did not have a specific policy for the use of the communication board. When interviewed on 4/18/19, at 7:00 a.m. the director of nursing verified the expectation would be to follow the plan of care, and resident wishes, for communication with R40.

Based on observation, interview and document review, the facility failed to ensure safe operations of full and sit to stand mechanical lifts resulting in a fall during transfer in a lift for 2 of 6 residents (R103, R100) reviewed resulting in injury. The potential for serious harm, impairment, injury or death was identified for 6 of 6 residents (R103, R100, R104, R105, R106, 107) observed during lift transfer where the facility was not following manufacturer's recommendations to prevent serious injury/fall. The immediate jeopardy began on 2/8/19, when unsafe lift practices resulted in a fall and was identified on 3/1/19. The administrator and director of nursing were notified of the immediate jeopardy at 4:46 p.m. on 3/1/19. The immediate jeopardy was removed on 3/1/19, but noncompliance remained at the lower scope and severity level of [NAME] - pattern scope and severity level, which indicated no actual harm with a potential for more than minimal harm that is not immediate jeopardy. Findings include: R103's most recent Minimum Data Set (MDS)) dated 2/12/19, revealed R103 was cognitively intact and required extensive assistance from two staff to transfer. R103's Incident Report dated 2/8/19, was reviewed and revealed R103 fell during transfer using a full mechanical lift. The incident report indicated, Found patient on the floor still attached to (full mechanical lift) sling. The bar that holds the (full mechanical lift) sling was on top of patients left lower leg while she was still inside of the (full mechanical lift) sling. R103 was noted as uninjured during the fall and was treated in the facility. The possible causative factors included (full mechanical lift) malfunction. The 2/12/19 review by the Interdisciplinary Team (IDT) indicated, IDT (interdisciplinary team) reviewed resident fall. Resident was being transferred using a (full mechanical lift) with assist of one nursing assistant and OT (occupational therapy) per (plan of care). The (full mechanical lift) tipped to the side as they were placing the resident on the bed. The resident slid to the floor. The resident stated the lift bumped her ankle when she fell and stated she was experiencing some discomfort to her ankle. ROM (Range of motion) were all WNL (within normal limits) to all extremities. The resident denied any other pain at the time of the incident. The (full mechanical lift) that tipped was immediately pulled out of service. The resident was assisted into bed using a different (full mechanical lift). The MD (physician) was updated and order given for x-ray of the resident's left ankle and report came back with no acute fracture. There was no swelling noted to the ankle. The staff working with the (full mechanical lift) at the time of the incident reported the (full mechanical lift) legs were open and the resident was at the lowest height for putting the resident into bed. Neither staff member were able to say why the (full mechanical lift) had tipped. Maintenance was updated and inspected the lift. The lift was noted to have the legs open up while in the locked position if pushed on hard. Maintenance replaced the brackets that lock the legs in place. A full house audit was completed of all lifts in the facility. The facility does monthly checks on lifts on an ongoing basis as well as PRN (as needed) checks. The resident was continued to be monitored for pain/discomfort and any injury. Reported baseline pain at 3/10 that was well controlled with PRN Tylenol and denied any change in pain r/t (related to) the incident. Provider was notified. Resident continued to work with PT/OT (physical therapy/occupational therapy) and had no noted change in pain or ability to participate in therapy. The review did not indicate if potential causative factors outside of lift malfunction were reviewed for potential contribution to the lift tipping. The review did not indicate the type of lift used or if the owner's manual was reviewed to ensure proper procedures were implemented. There was no indication a re-creation of the incident was attempted (without the resident in the lift). Further investigation documentation included a supervisor's report of employee work-related incident and a witness statement from NA-[NAME] The reports focused on the demographics and condition of certified occupational therapy assistant (COTA)-A and how COTA-A was injured and not on the cause of the tipping of the lift with the resident in it. NA-G wrote the therapist (COTA-A) and I was transferring the resident from the chair to bed. We left her up turned her to the bed and the (full mechanical lift) flipped over. The (full mechanical lift) hit (COTA-A) in the face and the resident hit (COTA-A) also. The resident hit (COTA-A), the bed before landing on the floor. I fell against the wall got up and ran and got the nurse for help. R103's progress notes, dated 2/9/19, revealed Resident was found on the floor with the bar that holds the (full mechanical lift) sling on top of her left lower leg with her still inside of the (full mechanical lift) sling. Also found (COTA-A) on the floor holding a towel below her eye, actively bleeding. Nursing assistant was also present who said that the (full mechanical lift) started wobbling and then tipped over as they were trying to transfer resident onto the bed. On 2/28/19, at 4:00 p.m. NA-G reported about three weeks ago she was helping the COTA-A transfer R103 from wheelchair to bed. NA-G reported typically R103 would pivot transfer but had reported she was not up to it. R103 reported it was with the Invacare Reliant 600. NA-G reported they had hooked up the resident in the slings to the hooks on the lift, opened the legs, got R103 to turn when the full mechanical lift started shaking and hit COTA-A in the face. NA-G reported she was working the controls and base of the mechanical lift and COTA-A was guiding the resident in the sling. NA-G reported she tried to grab the resident but instead the force sent her back to the wall. NA-G reported R103 hit the floor and the lift/machine laid on top of COTA-A and R103's leg. NA-G reported she was told a piece was broken. NA-G reported R103 reported leg pain following the incident. NA-G reported COTA-A was cut near the eye and had to be sent to hospital. On 2/28/19, at 4:22 p.m. R103 reported she was on the full mechanical lift and was almost over her bed when it crashed down on the floor. R103 reported NA-G and COTA-A were helping transfer her. COTA-A was towards the end of her bed guiding her and NA-G was operating the controls and lift. R103 reported she grabbed the side of the bed as she was falling towards the floor. R103 reported the lift went pretty much straight down and it happened really fast. R103 reported, If you ever been in a (full mechanical lift), you are in a sling and this thing is lifting you up and they swing you over to the bed. Well, when they swung to the bed, I don't know if the mechanism wasn't working right or if there was a certain way it fell to the floor. I would say it pretty much went down, straight down. I grabbed on to bed. R103 reported she thought the machine may have been defective. R103 was not sure if the lift was fixed and reported the lift came down onto her ankle and when staff tried to lift it up it fell down again onto her ankle. R103 reported she also had shoulder pain following the incident, which had since resolved. On 2/28/19, at 5:16 p.m. the director of maintenance (DM) reported an incident occurred with an Invacare Reliant 600 with R103 tipping over in it. DM reported, along with the regional maintenance supervisor, he inspected every mechanical lift at the facility and completed needed repairs. DM reported the leg assembly was found to be faulty and replaced and wheel bushings were also replaced. DM reported he completed the work with his regional maintenance supervisor. DM reported the full mechanical lift involved in the incident was taken out of service until it was repaired. DM reported he was trained by his previous supervisor how to inspect and repair full mechanical lifts. DM reported he had no documentation of this training. DM noted prior to 2/8/19, he inspected lifts monthly but did not track each lift by serial number and type or note condition and repairs. On 3/1/19, at 1:26 p.m. COTA-A recounted what happened when the Invacare Reliant 600 tipped over with R103 in it on 2/8/19. COTA-A reported R103 was too exhausted to transfer using a pivot transfer so she requested NA-G's assistance to transfer R103 using a full mechanical lift. COTA-A reported when she went to lower R103 to the bed the lift tipped over and knocked COTA-A down, hitting COTA-A under the eye and prompting COTA-A to visit to the emergency room . COTA-A reported she was supporting R103 and NA-G was at the base and controls of the lift. COTA-A reported she knew the legs of the lift were open. COTA reported the lift tipped forward and to the left. COTA-A reported she was standing to the left of R103 and reported the lift fell on top of her. COTA-A reported NA-G and her were going to swing R103 into bed when the lift tipped. COTA-A reported she could not recall the condition of R103 or how the lift looked following the incident. COTA-A reported there was blood in COTA-A's face so she was attending to her own injury while other staff entered to assist R103. COTA-A reported staff had to lift the mechanical lift off of her and R103. R100's care plan intervention, dated 5/11/18, directed TRANSFER: Requires mechanical aide total dependent lift and assist of 2 for transfers. R100's most recent MDS with a cognitive assessment, dated 10/13/18, revealed R100 was cognitively intact. R100's most recent quarterly MDS, dated [DATE], revealed R100 was totally dependent on two staff for transfers. R100's progress notes, dated 2/28/19, revealed Resident was being transferred with (assist of 2) staff in the (full mechanical lift) when the lift tipped and the resident was lowered to the floor by staff. Resident VS (vital signs) were completed and neuros started. (Temperature) 98.6 (F), (Pulse) 74, (respiration rate per minute) 18, (blood pressure) 130/89, 97% (oxygenation on room air). Resident was assisted off the floor with 4 staff members using a different lift. The lift in question was pulled out of service. NP was updated on incident. Skin assessment started. Pain assessments completed and resident reported pain to low back and tail bone 6/10 (moderate pain). Resident states she hit her lower back and tailbone on the foot pedal of her w/c (wheelchair) NP was updated. Awaiting orders. R100's emergency department evaluation, dated 3/1/19, revealed Patient has hand size area of redness over tailbone, scant area within of stage one/non blanchable skin and Per EMS and nursing report, patient was being transferred with a (full mechanical lift) at long term care facility yesterday when the (full mechanical lift) tipped over and patient was 'lowered to the ground.' Tailbone hit wheel of footrest of wheelchair. Patient was initially complaining of low back pain yesterday. She was evaluated yesterday by the NP at the nursing home who increased her ([MEDICATION NAME]). Today, nursing staff noted the patient had increased pain of her right shoulder (history of chronic right shoulder pain) and she was transferred to Regions (Hospital) for further evaluation. Staff reported that patient was crying out with movement of right shoulder which is abnormal for her. R100 was diagnosed with [REDACTED]. R100 had x-rays of her right posterior shoulder and pelvic x-ray negative for fracture/dislocation. On 2/28/19, at 10:50 a.m. R101 reported her roommate (R100) was having a rough day because the mechanical lift used to transfer her between surfaces, had fallen with R100 in it. R100 was noted to be lying in bed with a wash cloth on her forehead. R100's nurse licensed practical nurse (LPN)-E reported she was transferring R100 from her bed to her wheelchair with a nursing assistant (NA)-D when the lift tipped over with R100 in it. LPN-E reported she did not think R100 hit her head because the lift hit (LPN-E) in the head, which LPN-E thought likely blocked R100 from being hit in the head. LPN-E reported the sling tipped forward and went over R100's face. LPN-E reported she was told later by NA-C that the lift had previously tipped. LPN-E reported she felt the lift was faulty. R100's family member (F)-C walked into the room at this time to visit R100. R100 told him her back hurt and she was having a rough day. During a follow up interview and requested reenactment at 11:10 a.m., LPN-E explained NA-D was guiding the base of the mechanical lift and working the control's behind R100's wheelchair while LPN-E guided R100 in the sling. LPN-E reported the floor was somewhat wet from being mopped. LPN-E reported NA-D told her to position R100 in the wheelchair when it started to tip forward. LPN-E reported she grabbed R100 and NA-D grabbed R100's wheelchair. LPN-E reported she had been told the lift tipped over due to the wheels not being locked, but was not sure if they were or not. LPN-E reported the base legs were opened to fit around the wheelchair. On 2/28/19, at 10:55 a.m. the DM reported he had inspected the lift and there were no mechanical issues with it. DM reported he believed the lift tipped because the legs were not locked. On 2/28/19, at 11:00 a.m. NA-C reported she responded to R100 after the lift tipped over with her in it. NA-C reported R100 was flat on the floor with the sling under her when she entered and the full mechanical lift was already out of the room. NA-C reported sometimes the lift tipped a little but as soon as you adjust it, it's ok and sometimes the lift got caught under the bariatric sized beds. NA-C reported she always locked the wheels unless moving the lift from one place to another. On 2/28/19, at 11:05 a.m. NA-D reported she was transferring R100 with LPN-E. NA-D reported she had told LPN-E that the floor was wet. NA-D reported LPN-E responded by telling her R100 needed to be transferred to her wheelchair as family member (F)-C was visiting. NA-D reported she was operating the base and the controls at the side of the wheelchair while LPN-E was guiding R100 in her sling. NA-D reported the legs were open and the wheels were locked. NA-D reported she believed the lift was likely faulty. On 2/28/19, at 11:15 a.m. the director of nursing (DON) reported she had reported the incident with R100 to the state agency and suspended LPN-E and NA-D during the investigation. DON reported staff would be re-educated. At this time DM reported he decided to take the lift off of the floor to re-inspect and review with the regional maintenance supervisor. On 2/28/19, at 5:16 p.m. DM confirmed the same Invacare Reliant 600 was used during the accident on 2/8/19 and 2/28/19. On 3/1/19, at 12:30 p.m. DON and the regional DON reported R100 was sent to the emergency room for evaluation as she felt her right shoulder popping and had increased pain with movement. DON and regional DON reported they determined the positioning of the sling in relation to the wheelchair was wrong, which may have caused the lift to tip with R100 in it. DON explained LPN-E had explained they approached with the lift from behind the wheelchair while NA-D reported they were approaching the wheelchair from the side. DON reported both were incorrect. DON reported NA-D and LPN-E should have approached with the lift coming from the front of the wheelchair. DON reported on the 2/8/19 incident with R103 the legs were locked open and hard to close. DON reported both staff involved in the 2/8/19 lift, COTA-A and NA-G had reported they used proper technique during the lift with the legs open and at the proper height. DON reported she felt the lift may have gone off balance from a leg getting caught under the bed. DON reported the bed was in a low position. DON and regional DON reported the wheels are supposed to be locked when raising or lowering the lift. DON reported the lift would have been in transit so the wheels would have been unlocked for 2/8/19 incident. On 3/1/19, at 12:58 p.m. DM reported he contacted a representative at Direct Supply and told him about the faulty lift after the incident on 12/8/18, when the Invacare Reliant 600 tipped over with R103 in it. DM reported he had just contacted Invacare for a quote on the cost for Invacare to manage a preventative maintenance program. On 3/1/19, at 12:58 p.m. DM reported he contacted a representative at Direct Supply and told him about the faulty lift after the incident on 12/8/19 when the Invacare Reliant 600 tipped over with R103 in it. DM reported he had contacted Invacare today for a quote on the cost for Invacare to manage a preventative maintenance program. On 3/1/19, at 1:16 p.m. LPN-E was interviewed regarding the incident. At that time she indicated she was making R100's bed when the nursing assistant asked for assistance with the full mechanical lift transfer. The full mechanical lift was backed up to the window, the resident was up in the sling and the wheelchair was positioned back into the hoyer. (At time of interview, LPN -E demonstrated the lift with the use of an office chair.) As the resident was going over the top of the wheelchair the lift started to tilt, they both grabbed the resident to break the fall and lowered R100 to the ground. LPN-E demonstrated how the sling/resident went over the top of the wheelchair. R100 was facing out. When asked to clarify if R100 was lifted over the back of the wheelchair with the full mechanical lift, LPN -E answered, Yes, we did it, and its done like that all the time, sometimes the back of the wheelchair has to be held down. It fell forward. LPN-E added that when they were trying to get R100 unbuckled an unnamed nursing assistant came in and said the lift was no good, but later heard all the lifts were fine. The facility's 5 day investigation received following survey exit and dated 3/6/19, revealed Per P[NAME] (plan of care) resident is assist of 2 with a mechanical lift and assist with ADLs (activities of daily living). Resident is A+Ox3 (alert and oriented) and can alert staff with needs. Our internal investigation included a review of resident's medical record along with staff interviews. On 2/28/2019 resident was being assisted to transfer from her bed to her w/c (wheelchair) using 2 staff members and a (full mechanical) lift. The lift tipped and the staff lowered the resident to the floor. The Unit Manager entered the room immediately after the fall and assisted the staff. The (full mechanical lift) that tipped was immediately removed from service and the resident assessed. The resident was assisted back to bed with assist of 4 staff and a different (full mechanical) lift. The 2 staff members assisting with the (full mechanical) transfer when it tipped, identified as (LPN-E) and (NA-D), were suspended pending investigation. A full skin assessment was completed, and the resident had no noted injury. A pain assessment was completed and the resident c/o (complained of) pain to her lower back and tailbone which she stated hit the foot pedals of her w/c (wheelchair). ROM (range of motion) was WNL (within normal limits) and resident had no c/o pain with movement. The NP was in the facility and assessed the resident after the fall. The resident reported to the (NP-A) that she has been having pain in her tailbone for approximately a year and stated the pain initially increased after the fall but that after laying back down the pain subsided. She reported her current pain was not above her usual level of pain. The (NP-A) wrote new orders to increase the resident's scheduled Tylenol ([MEDICATION NAME], a pain reliever) from 650 mg (milligrams) to 1000 mg TID (three times daily). Staff monitored resident pain and resident had no c/o pain/discomfort overnight. In the morning on 3/1/2019 the resident c/o pain to her right shoulder with movement. The NP was updated and gave orders for resident to be sent to the ED (emergency department) for trauma evaluation. Resident returned to the facility after imaging completed with no new orders. Imaging was negative for any acute fractures.The report continued by stating, Per staff interviews the 2 staff members went in to transfer the resident using the (full mechanical) lift. (NA-D) and (LPN-E) were doing the transfer together. The (LPN-E) stated the (NAR-D) had the (full mechanical lift) behind the w/c and the NAR stated they had the (full mechanical lift) next to the w/c. The (LPN-E) stated she was pulling the resident to position her in the w/c while the (NA-D) was operating the (full mechanical lift). The lift started to tip forward and the (LPN-E) and the (NA-D) lowered the resident to the floor. The Unit Manager walked into the room right after the incident occurred and stated the floors were still wet from being mopped. The 2 staff members were asked to demonstrate how the transfer occurred and it appears the (full mechanical lift) tipped (due to) staff not following proper procedure in how to use the mechanical lift. The (full mechanical lift) was at the side of the w/c when it should've been at the front of the w/c. The (full mechanical lift) legs were also not fully opened. When the (LPN-E) pulled the resident towards the w/c it shifted the weight off balance causing the machine to tip. The floor was also not totally dry which also may have contributed. The facility immediately started education with all staff on proper use of the (full mechanical) lift.The facility was training to lock the lift brakes when ready and in position to either raise the resident or lower them but the manufacturer recommends to not lock the brakes. The training was immediately modified with this change.Both staff members were given a disciplinary action. The resident's lifestyle and abilities have not been affected as evidenced by resident continuing to get up in her w/c and visiting with family and staff. Our internal investigation was unable to substantiate any form of abuse or neglect in relation to this incident. R104's care plan intervention, initiated 9/12/17, directed staff Requires mechanical aide: total assist of two staff and use of (full mechanical lift). R104's care plan problem, last revised 9/17/18, further revealed R104 had moderately impaired cognition. R104 was observed in his room on 3/1/19, at 9:51 a.m. Two nursing assistants, NA-A and NA-H were observed in R104's room assisting him to lift using a full mechanical lift Invacare RPS 450. NA-A and NA-H placed the sling on R104, locked the wheels and opened the legs to the base of the lift. DON, present to observe the transfer in the room asked, are you locked? NA-H and NA-A then moved R104 to the transfer surface with wheels unlocked and locked wheels to lower him down in the sling onto the transfer surface. NA-A and NA-H reported they always opened lift legs when raising and lock the wheels. NA-A demonstrated how they opened the lift with a lever at the base of the lift and locked the back wheels by putting the wheels of the caster down. R105's care plan intervention, last revised 3/1/19, directed staff Transfer: Requires mechanical aid assist of 2. R105's care plan problem, last revised 3/4/19, further revealed R105 was totally dependent on staff for activities of daily living and was unresponsive. R105 was observed in his room on 3/1/19, at 10:41 a.m. being assisted by NA-C and NA-I. NA-C reported she had been trained the day before to lock the wheel brakes when putting sling on, locked when lifting up, unlock to move and lock when going down. NA-C and NA-I used an Invacare RPS 450 full mechanical lift. NA-C reported she had also been trained to ensure the legs of the lift base was open. At 10:44 a.m. NA-C and NA-I were observed in R105's room. R105 was lying in bed. NA-C placed the base legs of the lift under the bed and opened the legs. NA-C and NA-I placed a blue and light blue lined sling under R105 and connected to the hooks of the lift. NA-C then locked the wheel caster and used the mechanical lift to lift R105 up from the bed. When R105 was off the bed, NA-C unlocked the wheels to move across the room to the wheelchair, approaching from the right side of the wheelchair. NA-I was at R105's legs. When R105 was over the wheelchair NA-C locked the wheels and lowered R105 down into the wheelchair. NA-I reported he was trained to make sure legs of the lift are open during transfers. NA-I reported he was trained to have wheels locked when raising and lowering patient for safety. R106's care plan interventions, last revised 1/15/18, directed staff Transfer: (Full mechanical lift) with extensive assist of two. R106's care plan, last revised 2/22/19, revealed R106 had an [MEDICAL CONDITIONS], confusion and impaired cognition. R106 was observed in his room on 3/1/19, at 11:30 a.m. NA-I and NA-H were observed in R106's room. NA-I and NA-H used a full mechanical lift and blue sling with purple lining outside to transfer R106 from bed to his wheelchair. NA-A and NA-H used an Invacare RPS 450 full mechanical lift. NA-A and NA-H positioned the sling under R106. NA-A opened the legs of the base of the full mechanical lift and lowered the hooks of the sling down. NA-A then locked the wheels of the lift while NA-A and NA-H connected the sling to the hooks of the mechanical lift. NA-A then used the control to raise the sling up and R106 off the bed. NA-A then unlocked the wheels and while NA-H guided R106's feet, NA-A steered the lift to position R106 over his wheelchair. NA-A then locked the wheels and lowered NA-A into his wheelchair and unhooked R106's sling from the mechanical lift. R107's care plan interventions, dated 7/24/17 and 8/10/17, directed staff Toilet Transfer: Requires extensive assistance with transferring to the toilet if he is unable to make it to the toilet, he is total dependent (assist of 2) with cleaning up and Transfer assist of two with (sit to stand lift) R107 was observed on 3/1/19, at 11:52 a.m. NA-J and NA-K were observed assisting R107 to stand in a sit to stand lift. NA-J and NA-K opened the legs around the wheelchair and locked the wheels. NA-J and NA-K then placed the back support sling behind R107. NA-J and NA-K unlocked the wheels to adjust the sing then locked the wheels to lift R107 up to a standing position. R107 requested surveyor leave room as NA-J and NA-K were going to clean his bottom and he wanted privacy. Surveyor left room. On 3/1/19, at 12:58 p.m. the education director/registered nurse (RN)-I, director of nursing and administrator were interviewed. RN-I reported she had not read the manufacturer's guidelines and manuals for the lifts used at the facility, including the full lifts Invacare Reliant 600 and Invacare Reliant 450 and the sit to stand lift Invacare RPS 350. RN-I reported she taught the nursing staff to lift residents using a checklist she found in a nursing book. RN-I further reported nursing staff were not required to review the manufacturer's guidelines for the manufacturer lifts prior to using the lift. RN-I reported she was teaching the nursing staff to lock the wheels until ready to move because that is what the nursing textbook guidelines said was safest. RN-I reported she did not read the manufacturer's guidelines because she did not question the nursing textbook checklist. RN-I reported she would now re-educate staff to not lock the wheels to the lifts while raising and lowering the patient as she just reviewed the manufacturer's manual for the lifts and realized the lifts were at a greater risk for tipping while lifting the residents if the wheels were locked. The DON reported she had referenced the manuals at times, but had not read the owners' manuals for the lifts. The administrator reported DM had called the Direct Supply representative after the lift tipped with R103 in it on 2/8/19. The administrator reported staff were not required to read the manufacturer's guidelines for lifts prior to lifting residents in them. A representative from Direct Supply, a vendor of the Invacare Reliant 600 was contacted regarding their knowledge of the incident, dated 2/8/19. The following email, dated 3/4/19, revealed, Direct Supply has now reviewed its records relating to its customer 'New Brighton at Villa', 825 1st Ave NW, New Brighton, MN . However, we have no record of receiving a notification from the facility regarding the tipping of an Invacare Reliant 600 lift during (MONTH) 2019 (the scope of the review was limited to (MONTH) 2019). We have reached out to Invacare, the manufacturer of the Reliant 600 lift, to see if have been engaged directly with our customer regarding this matter. Should Invacare indicate that they were notified of one or both events during which a lift tipped, we will request the contact information for a representative at Invacare that can provide you with further details. A follow up email from Direct Supply, dated 3/4/19, revealed We have no record of receiving any notification in (MONTH) 2019, either. A follow up email from Direct Supply, dated 3/5/19, revealed, As a follow-up, we heard back from Invacare regarding this matter. They said that they did their best to go through their calls to determine if the facility reached out to them directly. They did not find anything related to the facility address. However, they cannot say with absolute certainty that they were not engaged by the facility because they typically associate calls with the product serial number and the name of the person who called. An organizational lift audit, dated 2/8/19, was reviewed. The audit noted all lifts had wheel bushings replaced as a precaution. The Invacare RPA 600 was noted to have Leg assembly was replaced found to be faulty. Three other lifts were noted to be in Poor condition. One Invacare Reliant 450 full lift with serial number 98I was noted Taken out of service as a precaution until wheel bushings can be replaced. Two Invacare RPS 350 sit to stand lifts with serial number O2D 4 and 02D 3 were noted in Poor condition which noted, Taken out of service until leg assembly can be replaced. Another Invacare RPS 350 sit to stand noted leg assembly was replaced found to be faulty The Electric Portable Patient Lift-RPA600-IE owner's manual was reviewed. The manual directed .DO NOT lock the casters of the Patient Lift when lifting an individual. Casters MUST be left unlocked to allow Patient Lift to stabilize during lifting procedures. The owner's manual further guided, WARNING: The legs of the patient lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs to maneuver the patient lift under a bed, close the legs only as long as it takes to position the patient lift over the patient and lift the patient off of the bed surface. When the legs of the patient lift are no longer under the bed, return the legs to the maximum open position . The Invacare 450 RPL 450-I use manual was reviewed. The Manual directed WARNING Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patients and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object. The Invacare 450 RPL 450 manual defined a WARNING as Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. The Invacare RPS 350-I owner's manual directed Warning: Invacare recommends locking the rear swivel casters ONLY when positioning or removing the sling (stand assist or transfer) from around the patient. Invacare does NOT recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants . The manual directed Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. The immediate jeopardy that began on 2/

Based on interview and document review, the facility failed to implement interventions to supervise 1 of 4 residents (R15) who had repeated falls, and failed to monitor and report a change in condition including increased pain following a fall. This resulted in actual harm for R15 who sustained a fracture during a fall on 11/10/18. Findings include: R15's Admission Record dated 12/27/18, indicated [DIAGNOSES REDACTED]. R15's 14 day Minimum Data Set ((MDS) dated [DATE], indicated R15 required extensive physical assistance of two staff with transfers and extensive physical assistance of one with eating. In addition, the MDS indicated R15 had both short and long term memory problems. R15's Care Area Assessment (CAA) dated 10/30/18, indicated a BIMS (cognitive assessment) score of 99, which indicates the resident was unable to complete the interview/assessment. The CAA also indicated R15 required extensive assist with transfers and mobility and further indicated that R15 was not steady and required staff assistance to stabilize when moving from seated to standing position. R15's care plan with a revision date of 11/9/18, indicated R15 was at risk for falls related to history of falls, history of [MEDICAL CONDITIONS] required increased supervision and was to be encouraged to be in common areas with staff present when up in wheelchair. R15's nursing assistant care assignment sheet dated 11/28/18, provided by the director of nursing (DON) on 12/27/18, from the investigation file directed staff to Monitor closely for attempting to self transfer, ambulate as needed. Keep foot pedals off the WC (wheelchair). Encourage to be in common areas (with) w/staff when up in WC . In addition, the care sheet indicated R15 was a High fall risk and was confused. During a review of R15's progress notes (PN) the following was revealed: -10/29/18, indicated another resident had reported to receptionist that R15 had just fallen in the day room. The nurse was called immediately and found R15 was laying on her right side half on top of her foot pedals. R15's head was resting next to the leg of the piano. R15 was assessed and assisted into her wheelchair with four staff assist. R15 was noted with no injuries and had full range of motion (ROM), R15 indicated she had pain but was unable to tell the writer where pain was located. Following the fall R15 was to be encouraged to stay in common areas when up in wheelchair. -11/5/18, indicated R15 was found on the floor at 1:10 p.m. by a recreational therapy (RT) staff. R15 was laying on her back and reported she was trying to stand when she fell . R15 denied hitting on any object during the fall and any pain. R15's vital signs and neurological assessment were normal. -Interdisciplinary team (IDT) PN dated 11/6/18, indicated IDT met to review fall from 11/5/18, when R15 was observed on the floor next to her W/C at the nurse's station. R15 had no injury that was observed and the plan of care (P[NAME]) was updated for staff to encourage R15 to ambulate to dining room for meals with walker with stand by assistance (SBA). In addition, R15's daughter had brought in puzzles and color books and staff was to encourage R15 to use when up in W/C. Also activities department, Will work with resident with these materials as well and staff to encourage resident to ambulate with walker and SBA as needed if noted to be attempting to get out of W/C. -Clinical follow up PN dated 11/6/18, indicated the vital signs were stable, R15 was on frequent 15 minutes checks to prevent falls and R15 was out at nurses station when in wheelchair continuously self-propelling wheelchair throughout the building with many attempts to redirect. In addition, the note indicated R15 had small scratches located on right cheekbone with bruising noted and R15 nodded yes when asked if right cheek bone caused pain and Tylenol was given. -Interdisciplinary Team PN 11/9/18, indicated IDT met to review R15's fall which occurred during the PM shift on 11/6/18. Per nursing report resident was brought into dining area by aides to prepare for dinner. Staff observed resident attempting to stand from w/c, resident fell next to table before staff were able to intervene. Vital signs (VS) and neurological assessment were within normal limits (WNL) and intact respectively. The PN also indicated the, ROOT CAUSE: fall related to (r/t) attempting to self-transfer; impulsive, confusion, poor safety awareness. PLAN: staff to not bring resident in early to dining area to meals, continue to remind resident of risk of falling when attempting to stand from w/c and redirect as needed; continue physical therapy (PT) and occupational therapy (OT). Care plans and care guides updated. -PN dated 11/10/18, indicated patient had unwitnessed fall in the dining room. Patients' wheelchair was near the breakfast table and patient was 15 feet (ft) away on the floor laying in fetal position on right hip. Skin assessment completed no injuries noted. VS WNL, neuro WNL for patient. Staff teaching completed to ensure care plan being followed. During further review of the medical record after the fall on 11/10/18, the following was revealed: -PN dated 11/10/18, at 3:02 p.m. R15's daughter requested an x-ray to right hip and staff did obtain an order for [REDACTED]. -PN dated 11/10/18, at 11:59 p.m. R15 showed facial grimacing and was given Tylenol 650 milligram (mg). Also resident vitals blood pressure (BP) 117/62. Pulse 78. Temperature (Temp) 97.4, O2 saturation 91%. Client ate whole dinner plate. -PN note dated 11/11/18, at 11:32 p.m. indicated R15 was resting/sleeping in bed during the shift and the vital signs were within normal parameters with the exception of the blood pressure which was elevated. The note also indicated R15 had received [MEDICATION NAME] PRN (as needed) two times for pain. -PN note dated 11/13/18, at 3:04 p.m. indicated client showed signs of distress when turned and repositioned. -PN note dated 11/14/18, at 3:12 p.m. indicated under mood and behavior that resident indicated ouch when being transferred from bed to w/c (wheelchair), minimal participation PT (physical therapy) OT (occupational therapy). R15's record lacked evidence of a comprehensive post fall re-assessment despite record of the resident having signs of distress and pain since falling on 11/10/18. Review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. After a review of the (MONTH) (YEAR), MAR, it was revealed R15, had received [MEDICATION NAME] PRN four times in approximately 29 hours from 11/10/18, to 11/11/18, compared to only receiving it two times early during the month. During review of the medical record it was revealed the nurse practitioner (NP) had faxed the same copy of the x-ray results to the facility on [DATE], at 9:41 p.m. with notes on the bottom and had asked Need more information. Is patient having pain? Is she less mobile than previous- or difficulty with ambulation. The fax was filed in the chart and lacked notation to acknowledge the facility staff had addressed the questions to the nurse practitioner. Review of physical therapy notes dated 11/12/18, through 11/14/18, revealed during four sessions in the time frame R15 had demonstrated signs and symptoms of pain and still the NP was not updated: -11/12/18, patient complains of left lower extremity (LE) pain and resist when trying to stand . -11/12/18, Patient was unable to achieve standing due to increased left hip pain. Patient resist and shows severe posterior lean making standing achievable . -11/13/18, Grimacing while moving left leg . -11/14/18, Patient (Pt) demonstrates ability to perform active straight leg raise (SLR) bilateral and has no pain with passive SLR, demonstrates pain and guarding with hip abduction (abd) and resists passive range of motion (ROM) of left (L) hip abduction . -Interdisciplinary Team PN dated 11/14/18, indicated, IDT met to review resident fall that occurred in dining area during breakfast on 11/10/18. Per nursing note and interviews resident was at breakfast table in dining area when she stood up from manual wheelchair and attempted to ambulate with staff or assistive device resulting in resident falling to ground landing on right hip area. VS (vital signs) WNL (within normal limits) for resident, skin assessment negative for impairment. MD and family notified, resident placed on acute charting to monitor. Daughter requested x-ray of right hip, orders obtained by on-call provider, x-ray negative for acute injury fracture. Resident was noted next day to be running low-grade temp, on-call notified and orders obtained for STAT (immediate) CBC (complete blood count) and UA (urinalysis) with UC (urine culture) if indicated; labs returned WNL with no new orders, family notified of results. Resident has history of falls r/t (related to) dementia, impulsiveness and poor safety awareness. DON (director of nursing) educated staff at time of fall for resident to not be left unattended in dining area. Care plans and care guides were reviewed and reflect plan of having staff with resident when in dining area and for staff to bring resident to dining area when ready to be served. On 12/27/18, at 1:20 p.m. the NP-A stated she had sent a fax to the facility on [DATE], at 9:41 p.m. asking for R15's status related to the fall but she never got a response back via fax or telephone. The NP-A stated she assumed due to staff lack of communication, R15 was not experiencing any pain. The NP-A stated when she was in the building again on 11/15/18, one of the staff nurses had informed her R15 had been experiencing pain which was odd because she had not had anything for five days since she had sent the fax. The NP-A stated she would have expected at least a nurse to have responded to her inquiry so she would have address the pain concern sooner. The NP-A also stated on her visit on 11/15/18, she then wrote an order for [REDACTED]. NP-A stated she expected the nurses to either have answered her questions back via fax, as this was a preferred communication way or even calling her would have been just fine to make sure something was being done. The NP further stated she found out later the physician had changed the CT scan from being done on the right to the left because resident was then showing left hip pain. On 12/27/18, at 2:11 p.m. when asked about the NP fax sent on 11/11/18, the director of nursing (DON) stated this was the first time she had seen the fax in the chart as she had completed R15's investigation herself and had not seen it in the chart, during record review. The DON stated she had completed a facility reported incident and added, The aide had left her in the dining room to go help another resident after the meal was done when the fall happened. The DON stated R15's daughter wanted an x-ray done which was negative. When asked about if R15 had noted signs and symptoms of pain, the DON stated the only concern that came up on 11/11/18, was R15 had a low grade temperature and the on-call provider had been notified and had ordered a urine test and a complete blood count level. The DON stated there was no documentation of R15 experiencing pain from 11/11/18, to 11/13/18. The DON further stated staff identified on 11/15/18, the hip pain and R15 did not want to stand anymore which was variable as R15 wanted to be less mobile, and that was when the NP was made aware and ordered the pain medication and the CT scan. When asked about the PN dated 11/13/18, which indicated resident had showed signs of distress when repositioned, the DON stated she was going to follow up with the nurse. The DON verified the CT scan found R15 had, Acute fractures involving the left sacrum, left inferior pubic ramus, and left pubic root and medial acetabulum. -At 2:17 p.m. the DON reviewed the electronic progress notes and verified the medical record lacked documentation of the NP inquiry being addressed. -At 2:21 p.m. the DON stated she had followed up with some of the nurses who had worked on 11/11/18, and the following day and all except one had stated they had not seen the fax, as they would have addressed it. The DON stated she would expect the staff to have followed up with the inquiry and noted the sheet to show it had been seen and addressed. The DON also stated she expected staff to follow the plan of care. The DON stated after 11/6/18, R15 was not supposed to be brought to the dining room early as R15 was impulsive, confused, made poor safety judgement and needed supervision. The DON stated the staff had thought the small scratches located on right cheekbone with bruising noted on 11/6/18, were from the previous fall. The DON further stated she had checked with the nurse who had indicated R15 was in distress on 11/13/18, and the nurse had indicated the distress was just when R15 was repositioned that moment and nothing else was noted after and that did not show R15 was in any pain. On 12/27/18, at 2:40 p.m. the physical therapy assistant (PTA)-A reviewed the therapy notes and verified R15 had been seen by various staff between 11/10/18, through 11/15/18, and per the documentation R15 had demonstrated signs and symptoms of pain during the sessions. The physical therapy assistant stated each time therapy staff observed pain during the session they reported the pain to nursing at the end of the session. Despite the fact the facility had self-reported the incident to the State Agency (SA), disciplined the nursing assistant, audited and educated the staff on following resident's care plans; the facility failed to implement fall interventions as identified in the plan of care, failed to respond timely to the NP inquiry on R15's status which included pain on 11/11/18. In addition, the facility staff failed to adequately communicate among the disciplines on R15's signs and symptoms of pain so R15 would receive timely diagnostic services to identify fractures.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents reviewed, R1, who were administered another residents medication. This resulted in actual harm for R1 when the resident had a decrease in consciousness, drop in blood pressure, and was admitted to the hospital. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated the resident had moderate cognitive impairment, and required extensive assistance with all activities of daily living. A Physician Telephone Order dated 11/1/16, at 10:00 p.m. directed staff to monitor R1's vital signs and do neuro checks every 30 minutes for two hours, and to call the physician at midnight with an update. A Physician Telephone order dated 11/2/16, at 12:30 a.m. directed staff to push fluids and obtain vital signs on R1 every two hours overnight. A Physician Telephone order dated 11/2/16, at 9:40 a.m. directed staff to send R1 to the emergency room for increased sleepiness related to medication intoxication. R1's Progress Note dated 11/2/16, titled IDT (interdisciplinary team) review, indicated the resident was sent to the hospital due to increased sleepiness, decreased blood pressure, and increased congestion. R1's hospital emergency room notes dated 11/2/16, indicated the resident was being admitted for accidental overdose. The resident was given another residents medications, which were [MEDICATION NAME] 400 mg (milligrams), [MEDICATION NAME] 20 mg, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 50 mg, and [MEDICATION NAME] 20 mg. When EMS (emergency medical services) arrived at the facility, the facility stated the resident was found earlier in the morning with vomit on her mouth and pillow. R1 was minimally responsive when EMS arrived at the facility and had been that way in the ambulance during transport to the hospital. R1 was admitted to the hospital for unintentional antipsychotic overdose, and urinary tract infection. The resident discharged from the hospital on [DATE], five days later, to another facility. When interviewed on 11/29/16, at 8:20 a.m. staffing coordinator (SC)-F stated on 11/1/16, the facility called licensed practical nurse (LPN)-H to see if she was able to come in and work to replace a sick call from another nurse. SC-F stated LPN-H agreed to come in for the evening shift, however, she would not be able to come in to start the shift until about 4:30 p.m.- 5:00 p.m. so the day nurse stayed until LPN-H arrived. When interviewed on 11/29/16, at 9:05 a.m. LPN-G stated he was the other nurse on the unit with LPN-H on the evening shift on 11/1/16. LPN-G administered medications on the unit on medication cart 1, and LPN-H administered the medications on the unit on medication cart 2. LPN-G stated LPN-H requested assistance with obtaining resident blood sugars due to starting the shift late as blood sugars and medications were not completed prior to LPN-H arriving. LPN-G stated on 11/1/16, at approximately 8:30 p.m. LPN-H asked for assistance because she felt, something was wrong, with R1. LPN-G stated when assessing R1 the resident was weak, confused, and drooling out of the left side of her mouth. LPN-G stated after assessing the resident LPN-H stated she may have given R1 the wrong medications earlier in the shift. LPN-G called the physician regarding R1's status and received orders to monitor the resident and update the physician at midnight. During interview on 11/29/16, at 9:05 a.m. director of nursing (DON) stated LPN-H was called on 11/1/16, to work the evening shift. DON stated LPN-H was able to come in but was not going to arrive until about 4:30 p.m.- 5:00 p.m. DON stated the day nurse agreed to stay until LPN-H arrived. DON stated LPN-H was passing medications and was also the house supervisor the evening of 11/1/16. DON stated LPN-H had called her on 11/1/16, at home around 6:00 p.m. to discuss a insulin dosing question. During the phone call LPN-H told DON that she was behind in passing medications, treatments, blood sugar checks, and insulin's because she had started the shift late. DON stated she asked LPN-H if there was anything she needed, and LPN-H told her there was nothing specific she needed. During interview on 1/17/17, at 1:45 p.m. LPN-H stated the facility called her on 11/1/16, at 3:08 p.m. to work the evening shift. LPN-H stated she arrived at the facility approximately 4:30 p.m. When she arrived the 4:00 p.m. medications were not completed and there were approximately 8-9 resident blood sugars that needed to be checked prior to supper. LPN-H stated that at approximately 5:30 p.m. she felt so overwhelmed she went to check the schedule to request assistance from the nurse supervisor. However, when she checked the schedule she discovered she was the nurse supervisor. LPN-H stated she had multiple physician orders [REDACTED]. LPN-H stated at approximately 9:30 p.m. on 11/1/16, R1 was laying in bed and, was not herself. LPN-H stated R1 was difficult to arouse, and was drooling. LPN-H stated when observing R1 she realized she may have administered the wrong medication to the resident about one hour prior. LPN-H stated she had been interrupted by so many phone calls, resident requests, starting the shift out behind, and was the house supervisor that she prepared another residents medication and walked into R1's room and administered the wrong medications to R1. The facility policy and procedure procedure titled Medication Administration dated 3/2016, directed staff to check the following when administering medication(s): Right medication, right dose, right dosage form, right route, right resident, right time. The policy further directs staff to explain the procedure to the resident and include the type of medication ordered, the reason, frequency, and route.