Every finding on record at The Villas at St Paul

Based on observation, interview, and document review, the facility failed to provide adequate supervision to prevent elopement for 1 of 1 residents (R37) who was reviewed for elopement. This resulted in Immediate Jeopardy (IJ) for R37 when she left the facility and was found approximately 4.5 miles away at her previous home by neighbors, which placed R37 at likelihood for serious harm or death. The IJ began on 8/30/25, when R37 exited the building without staff awareness. An unknown culinary staff had witnessed R37 outside and informed registered nurse (RN)-A who searched and was unable to find R37. The facility was contacted by family member (FM)-A who informed them R37 was found approximately 4.5 miles away without her walker, by R37's previous neighbors after missing for approximately 2.5 hours. It was unknown how R37 had gotten to her previous home and travel was through a busy metropolitan area with double laned roads and light rail systems. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 6/24/26 at 2:25 p.m. The facility had implemented immediate corrective action, and the immediacy was removed on 8/31/25 to prevent reoccurrence, so the IJ was issued at past non-compliance. Findings include: R37's annual Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of Alzheimer's disease with other signs and symptoms involving cognitive functions and awareness, and surgical repair for hip fracture. It further indicated R37 was ambulatory, used a walker, was independent with mobility, and had a history of a hip fracture. Furthermore, R37 did not have a wander/elopement alarm. R37's cognitive loss/dementia care area assessment (CAA) dated 6/25/26, triggered due to scoring a 7.0 on the brief interview for mental health status (BIMS) assessment, indicative of severe cognitive impairment. Furthermore, R37's CAA stated all possible problem areas, goals, and interventions will be care planned to promote the highest level of cognitive well-being. Social Services will continue to monitor and follow up as needed. R37's Elopement Risk Evaluation dated 3/17/25, indicated R37 was not at risk for elopement. R37 was readmitted to the facility after a hip fracture, was assist of one for transfers and had no exit seeking behaviors. However, R37's care plan for elopement triggers and interventions included remained checked. They included: elopement risk care plan which indicated R37 was at risk for elopement related to signs and symptoms involving cognitive function and awareness with five interventions available. All five of the interventions were checked and were as follows: wander guard in place (placement left wrist exp. 4/11/25), wander guard will be monitored for proper functioning, door alarms will be answered promptly, family will be kept informed, and R37 will be invited to activities and gatherings. R37's Elopement Risk Evaluation dated 5/14/25, indicated R37 had a history of wandering/attempts to leave the building, was ambulatory or able to self-propel wheelchair, had a cognitive deficit, and was taking opioid /psychotropic medications which may cause confusion. It further indicated an elopement risk score of 4 which indicated potential for elopement. It also included an elopement risk care plan which indicated R37 was at risk for elopement related to signs and symptoms involving cognitive function and awareness with five interventions available. All five of the interventions were checked and were as follows: wander guard in place (placement left wrist exp. 4/11/25), wander guard will be monitored for proper functioning, door alarms will be answered promptly, family will be kept informed, and R37 will be invited to activities and gatherings. R37's Elopement Risk Evaluation dated 6/24/25, indicated R37 had a history of wandering/attempts to leave the building, was ambulatory or able to self-propel her wheelchair, and had a cognitive deficit. It further indicated an elopement risk score of 4. A score of 4 or more indicated potential for elopement. It further included an elopement risk care plan which indicated R37 was at risk for elopement related to signs and symptoms involving cognitive function and awareness with door alarms will be answered promptly, family will be kept informed, Wander guard in place (placement left wrist exp. 4/11/25) and wander guard will be monitored for proper functioning, were not checked as interventions. There were also additional considerations which included R37 was at risk for elopement, had a wander guard on, no concerns, and will continue to monitor. R37's fall risk assessment dated [DATE], indicated R37 was a fall risk due to multiple falls in the past 6 months, inability to remember they were in a nursing home, location of room or staff names, minimal difficulty with hearing/vision, loss of balance, use of a walker and daily or more behaviors of wandering, verbal/physical abuse or social inappropriate behaviors. The assessment indicated R37 required 15-minute checks for safety. R37's care conference form dated 6/25/25, indicated R37 scored a 7/15 on her BIMS (severely impaired cognition), was at risk for falls, and continued to need minimal assistance with activities of daily living (ADL). It further indicated, R37 was able to ambulate using her two wheeled walker and her wander guard was discontinued this past quarter. R37 spent time throughout the day walking around the unit and walked up and down the hallways. Attendees included: R37, SW (unknown), and nurse manager (unknown). R37's care plan dated 6/25/25, indicated the following: -R37 was a fall risk related to gait instability, occasional age-related tiredness, cognitive impairment, chronic venous insufficiency, hip fracture, dementia/Alzheimer's disease, hypertension, peripheral vascular disease (PVD), alcohol use, malnutrition, and muscle weakness. It further indicated the following interventions: offer to toilet at night every 2-3 hours and as needed, a sign will be posted inside the room for staff to be cautious and open door slowly as people may be approaching from other side, assist of one with ADLS, soft touch call light in reach, stop sign to door to open door slowly, follow PT/OT (physical therapy/occupational therapy) instructions for mobility function, keep room clean and free of clutter, bed in a low position, call light within reach, and monitor/document on safety.-R37 had an alteration in mobility due to gait instability, hip fracture, cognitive impairment, and PVD. It further indicated the following interventions: PT per physician's order, follow PT instructions, grab bars to bed to aid in bed mobility, was independent with ambulation using a walker, independent with movement in bed. -R37 required supervision when leaving the facility and would follow the leave of absence (LOA) policy, -R37 was at risk for elopement related to signs and symptoms involving cognitive functions and awareness and would be monitored for safety during the evenings. It also included the following interventions: door alarms will be answered promptly, family will be kept informed, and R37 would be invited to activities and gatherings. A review of R37's nursing and physician's orders indicated the following: -On 8/28/23, R37 required monitoring of placement of wander guard to left wrist and to check the wander guard function every shift. This order was discontinued on 3/17/25. -On 5/5/25, R37 required 15-minute checks for safety. This order was discontinued on 8/18/25, 12 days before R37 eloped. R37's nursing progress notes indicated the following: -on 3/23/25 at 4:33 a.m., R37 was up this shift until 3:15 a.m. She was rolling in her wheelchair, up and down the hallway. She was going in other residents' rooms and talking loudly. It further indicated R37 was attempting to get on the elevator and set off the alarm over ten times. The nursing assistant (NA) sat with her from 1:00 a.m. to 3:15 a.m. as able in between responding to call lights. R37's behavior was hard to redirect. -on 3/24/2025 at 10:04 a.m., interdisciplinary team (IDT) met to review a fall where R37 was found on the bathroom floor. R37 was active during the night due to her diagnosis of dementia. She had progressed in therapy and was able to ambulate more independently than previously (up to 50 feet). She would benefit from being offered toileting during the night. Care plan was updated, therapy on going, and no complaints of pain or injury. The provider was updated and family was notified. IDT will review as needed. -4/24/25 Writer spoke with resident's daughter this morning and she stated R37 seemed upset and wanted a ride home. The writer explained this happened occasionally and with her dementia it was ok to let her know you can give her a ride home but can't come until later that day. That was what the writer had told R37 in the past, when R37 had asked her for a ride home. R37 would forget and continue on with her day. -on 5/15/25 at 2:33 p.m., R37 was seen wandering on the first floor on 5/12/25 around 9 p.m. R37 was accompanied back up to 3rd floor. She was unable to explain what she was doing or where she was going. IDT agreed to place her on 15-minute checks. Provider updated. -on 6/1/25 at 10:23 a.m., R37 was going through roommate's drawers. R37 was restless and walked down the hallway several times, easily redirected by staff. -on 8/30/25 at 9:18 p.m., indicated culinary staff (unknown) reported to RN-A that around 5:35 p.m. they saw R37 outside the building. RN-A went outside but was unable to locate her so they returned to the facility and notified the police, administrator, and director of nursing (DON). Then RN-A called the hospital, while another nurse drove around the immediate area to see if they could find her. Once the police arrived (at approximately 7:10 p.m.), RN-A gave them a description of R37 and they left. RN-A called FM-A to notify her, and she stated R37 was at the neighbor's house. She had hitch-hiked to her previous residence but was unable to gain access to the home so she went to the neighbor's. The neighbors then called FM-A who had tried to call the facility several times, but no one answered. R37 refused to return to the facility and wanted to be taken to the hospital so she was taken there for evaluation. The hospital called the facility stating R37 was returning to the facility. Report was given to the oncoming nurse along with a wander guard to be applied to R37's ankle or wrist upon arrival. -on 9/2/25 at 4:54 p.m., indicated follow up call with R37's daughter occurred. The Director of Nursing (DON) explained R37 had Wander guard in placed but it was removed following R37's hip fracture and no longer considered independent with mobility and no attempts at leaving. R37 had a plan to visit previous home, left facility and was able to get there safely. R37 was safe and able to return safely. A new elopement assessment was completed and indicated a high risk for elopement and a Wander guard was placed. R37's after visit summary (AVS) dated 8/30/25, indicated the police were notified at 5:30 p.m. that R37 was missing from the facility. It further indicated had a past medical history of dementia who presented to the emergency department (ED) for evaluation of confusion after R37 somehow got 4.5 miles from the facility to her previous address. She was called in as a missing person at 5:30 p.m. and found by her previous neighbors. Spoke with R37's daughter who stated R37 had Alzheimer's disease and was living in memory care. She had a history of escaping and traveling to her old house. She had been living at the facility for over 2 years and was supposed to have a Wanderguard on, but it had been removed recently as they thought she wasn't as mobile due to a recent admission of a hip fracture. During observation on 6/24/26 at 7:28 a.m., R37 was walking up and down the hallway using her 2 wheeled walker. During interview on 6/23/26 at 10:20 a.m., family member (FM)-A stated on 8/20/25, they had received a call from her previous neighbors, informing them R37 was trying to get into her old house. FM-A called the facility, but no one answered so they called 911. FM-A stated they were very upset because when R37 was admitted , they told them she needed to have a wander guard on. The facility told them since R37 had broken her hip, they didn't think she was mobile enough to elope. FM-A was unaware of how R37 got to her previous residence since she didn't have any money. R37 told them she took the bus, but FM-A didn't believe that, as she would have had to transfer to another bus to get there. She had escaped once before in the middle of the night and was trying to hitchhike. She was swearing and throwing things. All the staff could do was follow behind her. They ended up sending her to the hospital. During interview on 6/24/26 at 7:10 a.m., registered nurse (RN)-A stated on 8/30/26, during dinner, an unknown culinary staff reported she saw R37 downstairs. RN-A immediately searched R37's room, the facility, and the surrounding area. They asked the residents (unknown) who were sitting outside the building, and they stated they saw R37 outside walking down the street. RN-A went back into the facility and called a code pink (missing person). They searched the facility and the immediate area again, but they were unable to locate R37. They called the policy, administrator and the DON. Once the police arrived, they gave them a description. They asked RN-A if they thought R37 may have tried to go home and they stated No, because she was demented. The police left and RN-A called R37's daughter who reported they found her at her previous address. The daughter stated she had hitch-hiked and was trying to break in. RN-A further stated R37 was not wearing a wander guard when she left. She used to have one but then she fell and broke her hip and was immobile for a while. Then she started to get better and that's when it (elopement) happened. When R37 came back that night they put a wander guard on her. RN-A stated residents who are not allowed to leave the floor unsupervised, have a wander guard. If a resident gets on the elevator and the alarm doesn't go off, they are safe to leave the floor. Also, each resident was assessed upon admission whether they were at risk for elopement and the resident's care plan indicated if they required supervision when going on a (LOA). During interview on 6/24/26 at 7:35 a.m., NA-E stated residents who are unable to leave the floor/facility unsupervised wear a wander guard. If the alarm by the elevator goes off, that's how they know the resident can't leave unsupervised. During interview on 6/24/26 at 7:59 a.m., NA-F stated they would know if a resident had a wander guard because it would go off when the resident walked by the elevator. If the alarm goes off, the resident was not supposed to leave the floor/facility unsupervised. If it doesn't go off, the resident is able to leave by themselves. During interview on 6/24/26 at 10:05 a.m., the director of nursing (DON) stated if a resident eloped, staff were expected to search the facility and the surrounding area. If they were unable to locate the resident, they should trigger a code pink (missing person) and then all staff would search for the resident. If the resident was still unable to be located, they would call the police and notify the DON and administrator. Staff should then call family, update the provider, call any contacts, and report it to the state agemcy (SA). The DON further stated R37 wasn't an elopement risk when she eloped on (8/30/25) because she had a status change due to a hip fracture. She used to be mobile and went from being independent to requiring staff assistance with ambulation. Her plan of care changed after she returned from the hospital, and she didn't have any exit seeking behavior. That's when the facility decided to discontinue the wander guard. When she eloped, she had a plan to go to her previous address, was able to remember the address, had intention, and had gotten there safely. The DON was unable to determine how she got there. They did not report it to OHFC because R37 wasn't at risk for elopement due to her declining. The DON also stated they determine if a resident needs a wander guard based on their cognition, elopement risk assessment, therapy assessment, history, level of consciousness (LOC) and a doctor's order. In order to determine whether it's safe to remove a residents wander guard; it's usually prompted by a decline in cognition, mobility, or if they can't exhibit exit seeking behaviors. During interview on 6/24/26 at 1:04 p.m., the nurse practitioner (NP)-A stated at the time of elopement, R37 was physically able to ambulate independently but would not be safe by herself cognitively, out in the community. The NP further stated R37 had exit seeking behaviors intermittently which appeared to increase in March of 2025. During interview on 6/25/26 at 1:08 p.m. the administrator stated they didn't consider R37 to have eloped because she didn't have exit seeking behavior, needed assistance with mobility, and wasn't at risk for elopement. The facility policy regarding elopement dated June of 2023, indicated documentation for residents who were at risk for elopement should:-be assessed upon admission, which may indicate potential to wander or exit the facility-care plan that address the potential to wander or exit facility and the measures taken to prevent wandering/elopement. -all attempts to elope, efforts to locate, notification and results of efforts.-full observation/visualization after and elopement for any injuries or new symptoms or conditions which may have developed.-entries that are time specific to reflect the responsiveness and timeliness of actions taken to locate and assess the resident.-bracelet alarm/device is in place and functioning (per TAR or other form of documentation), if applicable. The past non-compliance immediate jeopardy began on 8/30/25 and was removed on 8/31/25, when the facility implemented a systemic plan to ensure all residents were safe. The following actions were implemented prior to survey: -R37 was assessed for possible injury in the emergency department.-R37's elopement risk assessment was updated and placed a wander guard on R37.-R37's care plan was reviewed/revised. -Facility wide audit to identify residents at risk for elopement to ensure interventions and care plan in place/updated. -Staff were educated staff on resident safety (Response to unsupervised residents outside the facility).-Elopement policy was reviewed/revised.-Facility elopement drills were conducted.

Based on observation, interview, and document review, the facility failed to provide appropriate monitoring of dialysis access site for 1 of 1 resident (R3) reviewed for dialysis care. Findings include:R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had intact cognition and received dialysis. R3's diagnoses included diabetes mellitus and end stage renal disease. R3's Clinical Resident Profile printed 6/24/26, indicated, Special Instructions: Dialysis.Enhanced Barrier precaution (EBP) due to dialysis port upper right chest wall. R3's care plan reviewed 6/23/26, indicated R3 was at risk for complications related to dialysis and instructed staff to monitor central dialysis catheter port site for signs of bleeding every shift. R3's provider orders dated 1/15/26, indicated the following: -Dialysis-Review post dialysis treatment report for updates-Monitor dialysis site for bleeding-Dialysis-vital signs after dialysis R3's provider orders lacked evidence of monitoring for bruit and thrill assessment (Bruit - a swishing sound assessed with a stethoscope; thrill- a gently vibration felt by palpation. Bruit and thrill assessment for blood flow through an arterial/venous-AV fistula). In addition, R3's provider orders lacked evidence of direction to avoid blood pressures taken on the left arm due to the presence of an AV fistula. R3's Dialysis Treatment Details Report (TDR) dated 4/14/26, indicated R3 had dialysis access via a Central Venous Catheter (CVC) in the right chest. R3's after visit summary (AVS) dated 4/15/26, indicated, Surgical Procedure: Left Brachiobasilic AVF (surgically created connection-fistula-between the brachial artery and basilic vein for hemodialysis access). R3's AV fistula was ok to use in dialysis. R3's TDR dated 4/17/26, indicated R3's dialysis access was an AV Fistula located in the left upper arm. R3's AVS dated 5/11/26, indicated, You had your tunneled venous catheter [CVC] removed today. During interview on 6/24/26 at 8:37 a.m., registered nurse (RN)-D stated they assess resident's vital signs and weight prior to leaving for dialysis and will document in the electronic medical record (EMR) which then goes onto the dialysis communication form that was sent to dialysis with the resident. RN-D stated upon return from dialysis, the nurse would review the communication form to see if there were any complications with the dialysis session. RN-D further stated the nurse should look at the dialysis site and monitor for bleeding. RN-D stated R3 had a port in his right chest as an access site and was not aware of any required monitoring for bruit or thrill. RN-D stated was not aware R3 had an AV fistula in his left arm. During observation and interview on 6/24/26 at 8:47 a.m., R3 exposed his right chest area to display no CVC site and pulled up his left sleeve to expose the AV fistula site. RN-B could not explain why she was not aware of the site change, but agreed it was very important to know for accurate post dialysis assessment. During interview on 6/24/26 at 10:46 a.m., RN-B stated the nurse should complete the pre and post dialysis assessment and review the dialysis communication form for any changes or complications. RN-B stated appropriate dialysis site assessment for a resident with an AV fistula would include checking for bruit and thrill and would not perform a blood pressure check on the same arm with an AV fistula. RN-B stated R3's dialysis site assessment should have included bruit and thrill and avoidance of BPs on left arm since the fistula was created approximately two months prior and confirmed the EMR lacked evidence of appropriate monitoring. During interview on 6/25/26 at 12:15 p.m., director of nursing (DON) would expect nurses to know the correct location of a resident's dialysis access site and to accurately assess complications and care for the site according to where and what type of access it was. DON stated nurses should have been assessing R3's AV fistula site appropriately for the last two months since the fistula was created and used for dialysis. Facility policy Hemodialysis dated 11/22/19, indicated, Ongoing assessment/evaluation of the resident's condition and monitoring for complications should occur before and after dialysis treatments [i.e. infection and patency of fistula or graft].patency - feel the access for a thrill, listen with a stethoscope for a bruit.No blood pressures should be taken of the access arm.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R3) received appropriate nutrition assessment and support who was at risk for weight loss and dehydration, and was reviewed for dialysis. Findings include:R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had intact cognition, was independent with eating, received dialysis, and required a therapeutic diet. R3's diagnoses included diabetes mellitus and end stage renal disease. R3's care plan printed 6/24/26, indicated R3 had diabetes, was at risk for hypo and hyper glycemia, and instructed staff to monitor compliance with diet and document any problems. R3's care plan further indicated R3 was at risk for dehydration and instructed staff to, Encourage adequate fluid intake. In addition, the care plan indicated R3 had potential nutritional problem related to protein calorie malnutrition and other diagnoses and instructed staff to, Provide supplements as ordered. R3's Clinical Nutrition Evaluation dated 4/16/26, indicated R3 had a weight loss of 5% or more in the last month or of 10% or more in the last 6 months, and was not on a prescribed weight-loss regimen. Provider order dated 4/24/26, indicated, 1500 ml [milliliter] restriction. Dietary to provide: 1080 ml/day. Dietary was to give 360 ml fluids at breakfast that included 1 Ensure Clear (nutritional supplement), 360 cc at lunch, 360 cc at supper. Nursing was to provide 420 ml fluid and to document oral fluid intake every shift. Provider order dated 4/22/26, indicated, required Ensure Clear daily, provided by culinary at breakfast for unplanned weight loss. R3's treatment administration record (TAR) for June 2026, indicated R3 consumed 100% of Ensure Clear every morning from 6/1/26 through 6/23/26. During observation on 6/23/26 at 11:11 a.m., R3's bedside table and dresser contained 19 unopened, Ensure bottles and one opened and half empty Ensure bottle. One of the unopened bottles had a date on the cap 6/23. During interview on 6/23/26 at 11:15 a.m., culinary services director (CSD) while collecting R3's meal tray stated the nursing assistants (NA) would round after meals take note of dietary and fluid amounts and notify the nurse. CSD, CSD would also go by the nurses' station and let the nurse or nursing assistants know and give them a chance to see the tray. During observation and interview on 6/23/26 at 11:58 a.m., director of nursing (DON) and registered nurse (RN)-B in R3's room and collected all the Ensure bottles. DON and RN-B verified R3 had 19 unopened Ensure bottles stored in his room and stated the culinary staff include an Ensure with R3's breakfast every day. DON could not explain why there were so many unopened Ensure bottles and further verified R3's June TAR indicated R3 had consumed 100% of the Ensure delivered during the month of June. During interview on 6/23/26 at 2:32 p.m., RN-B expected nurses to document intake accurately. During interview on 6/24/26 at 8:47 a.m., R3 stated he did not drink all the Ensure they provide because he was concerned about how it would affect his blood glucose since he had diabetes. R3 confirmed he was capable of opening the Ensure containers and stated he consumed one bottle every couple days or so. During interview on 6/24/26 at 12:58 p.m., registered dietician (RD) stated R3 was at nutritional risk and his intake was closely monitored. RD stated she relied on the documentation in the electronic medical record (EMR) to assist in formulating and modifying resident nutrition plans and orders. RD stated would expect documentation of food, fluid and supplement intake would be accurately documented so that her assessment and nutrition plan of care would be appropriate for the resident. RD stated was not aware of R3's reluctance to consume the Ensure due to the affect on his blood glucose, and that she would have changed to a more diabetic friendly supplement if she had known. During follow up interview on 6/25/26 at 12:14 p.m., DON stated she would expect staff to document R3's intake of nutritional supplement accurately so (RD) would have accurate information for her assessment and any necessary adjustments to R3's nutritional plan of care. Facility policy Assessment of Nutritional Status and Integrated Nutrition in the Comprehensive Care Plan dated 9/2012, indicated the resident would be restored to or maintained at a healthful level of nutritional status. The resident will receive the highest quality nutritional care through.Comprehensive assessment of nutritional status.Individualized care planning.Evaluation of outcome oriented measurements. The policy further indicated residents identified as at nutritional risk would be assessed by the RD for review and recommendations.

Based on observation, interview, and document review, the facility failed to ensure pressure ulcer interventions were in place for 1 of 1 residents (R12) reviewed for pressure ulcers (PU).Findings include:R12's significant change Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition, required substantial/maximal assistance with bed mobility, dependent on staff for toileting, and was always incontinent of bowel and bladder. R12's diagnoses included Alzheimer's disease, diabetes, peripheral vascular disease, and pressure ulcer of sacral region.R12's care plan printed 6/23/26, indicated, R12 had an alteration in skin integrity related to current wounds. R12 had a stage 4 PU on the coccyx (tailbone) stage 4 and unstageable Pressure ulcer on the right outer ankle. R12's care plan interventions for skin integrity included, Pressure air mattress to bed.Low air loss air bed, pressure redistribution. R12's care plan lacked evidence of Prevlon boot 24/7 (heel protector designed to offload heel to continuously relieve pressure) intervention for alteration in skin integrity.R12's provider order dated 2/12/26, indicated, Mattress: Air mattress for wound care. Check function every shift.R12's provider order dated 6/19/26, indicated R12 required wound rounds daily for right lateral malleolus and to use Prevlon boot 24/7.R12's wound round progress note dated 6/10/26, indicated R12 had a stage 4 PU on coccyx and an unstageable PU on right malleolus. Interventions for pressure relief/off-loading included, pressure redistribution mattress, and heel offloading. During observation and interview on 6/22/26 at 1:11 p.m., R12 was lying in bed on her back and stated was not aware of any current open areas (pressure ulcers or wounds) and was not sure if she received wound care. Wound care supplies were observed on R12's nightstand. A pair of Prevlon boots was observed on R12's dresser. R12 did not have a pillow under her legs, therefore, her feet were not offloaded. R12's air mattress controller had a yellow flashing light indicating low pressure.During observation on 6/23/26 at 8:57 a.m., R12 in bed eating breakfast. R12 was not wearing boots and air mattress controller flashing yellow light indicating low pressure.During observation and interview on 6/23/26 at 9:08 a.m., nursing assistant (NA)-B entered R12's room. NA-B stated she was going to perform incontinent care but would wait a while longer since the nurse was not available to do the dressing changes. NA-B removed the boots from the dresser and applied them to R12's feet. NA-B stated she had just removed the boots and that they had been on all night. NA-B adjusted the sheet over R12's feet at the end of the bed just in front of the air mattress controller and did not check the function of the air mattress. NA-B left the room.During interview on 6/23/26 at 9:15 a.m., R12 stated she did not have the boots overnight and that the NA did not just take them off this morning. R12 stated would not refuse the boots and she often did have them on while in bed.During observation on 6/23/26 at 10:25 a.m., NA-C into R12's room to perform incontinent care. R12's brief removed and exposed a dressing on the coccyx with the bottom part not attached to the skin and slightly soiled with bowel movement. NA-C wiped R12's bottom, placed a new brief, adjusted R12' blankets and left the room without checking the function of the air mattress.During observation and interview on 6/23/26 at 11:02 a.m., registered nurse (RN)-B into R12's room to check on wound care supplies. RN-B stated they would wait a while to do wound care since R12 was experiencing pain on her bottom and rated the pain 8 out of 10 on a pain scale. RN-B stated they would provide pain medication and allow time for it to take effect prior to completing wound care. RN-B further stated R12's bottom pain was worse for some reason today. RN-B readjusted the pillow under R12 to provide a slight left tilt. RN-B left the room without addressing the air mattress. During observation on 6/23/26 at 11:06 a.m., licensed practical nurse (LPN)-D into R12's room and administered pain medication. LPN-D did not address the air mattress. During observation on 6/23/26 at 11:15 a.m., RN-B brought additional wound care supplies into R12's room and did not address the air mattress. During observation on 6/23/26 at 11:44 a.m., director of nursing (DON) into R12's room to check on her. DON looked to ensure R12 had the boots on and then left the room. DON did not address the air mattress.During observation on 6/23/26 at 11:47 a.m., DON, administrator, and scheduling coordinator (SC) entered R12's room. All three appeared to adjust the bottom of the bed as if they noticed something wrong with the alignment of the mattress. During the adjustment of foot of the bed, the air mattress controller slid to the one side almost dislodging from the footboard. The administrator placed both hands on the controller and repositioned it to the center of the footboard. The air mattress controller still flashing yellow light indicating low pressure. All three staff left the room and none of them addressed the air mattress malfunction.During interview on 6/23/26 at 11:54 a.m., R12 stated her bottom was more painful today than it had been in a while.During interview on 6/23/26 at 12:42 p.m., LPN-D stated was surprised that R12 was complaining about increased pain and that she normally said she was fine.During observation and interview on 6/23/26 at 12:54 p.m., RN-B and LPN-D went into R12's room. Wound care and dressing change were completed. R12 repositioned in bed, sheet adjusted over her and then they left the room. Neither RN-B nor LPN-D addressed the air mattress malfunction. During interview on 6/23/26 at 2:10 p.m., LPN-D stated PU interventions for R12 included frequent repositioning, boots to offload feet, nutrition support, and air mattress. LPN-D into to R12's room and confirmed the air mattress was indicating low pressure. LPN-D stated the controller was supposed to sound an alarm if it was not working and that staff were supposed to check the function regularly.During interview on 6/23/26 at 2:20 p.m., RN-B stated would expect R12 to have a working air mattress and that staff would check the function at least once per shift.During interview on 6/24/26 at 7:40 a.m., nurse practitioner (NP)-B stated an air mattress was the number one priority for someone with a coccyx PU. NP-B stated would expect R12's air mattress to function properly and that a non-functioning air mattress could cause increased pain.During interview on 6/24/26 at 2:48 p.m., RN-C stated thought he remembered R12's air mattress beeping on the 6/22/26 overnight shift and that the alarm could be silenced. RN-C further stated he thought he had fixed the air mattress but could not provide any further details.During interview on 6/25/26 at 12:02 p.m., DON stated PU prevention interventions should be in place as ordered. DON further stated maintenance had looked at R12's bed and found that it was malfunctioning and had to replace the air mattress.Facility policy Skin Assessment and Wound Management dated 2/2025, directed staff to Implement appropriate preventative skin measures. Examples include, but are not limited to-nutritional interventions, mobility and repositioning plan, pressure redistribution plan.

Based on observation, interview and record review, the facility failed to revise a care plan to reflect accurate status when care needs changed for 1 of 19 residents (R12) in the sample. Findings include:R12's significant change Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition, required substantial/maximal assistance with bed mobility, dependent on staff for toileting, and was always incontinent of bowel and bladder. R12's diagnoses included Alzheimer's disease, diverticulitis of large intestine (a painful digestive condition causing bulging pouches in the wall of the large intestine which become inflamed and infected), enterocolitis due to clostridium difficile (C-diff-a highly contagious bacterial infection in the large intestine causing severe watery diarrhea and colon inflammation), and pressure ulcer of sacral region. R12's care plan printed 6/23/26, indicated, Resident has a current infection r/t [related to] C-Diff (infection) , was on Vancomycin (antibiotic medication), and required isolation precautions per protocol. R12's care plan lacked evidence of Prevlon boot 24/7 (heel protector designed to offload heel to continuously relieve pressure) intervention for alteration in skin integrity. R12's progress note dated 6/5/26 at 8:41 a.m., indicated R12 completed antibiotics for C-diff and had no more loose stools. Furthermore, contact precautions removed and placed on EBP [enhanced barrier precautions] due to wounds. Care plan reviewed and updated. R12's provider order dated 6/19/27, indicated R12 required wound rounds daily for right lateral malleolus and to use Prevlon boot 24/7. R12's treatment administration record (TAR) indicated, Staff to follow: Contact Precautions due to CDIFF every shift with a start date 4/16/26. With the exception of one shift, the task had been signed off three times a day (every shift) for the entire month of June. During observation on 6/22/26 at 1:11 p.m., R12's room had signage for EBP and PPE (personal protective equipment). A pair of Prevlon boots was observed on R12's dresser. During interview on 6/23/26 at 2:20 p.m., registered nurse (RN)-B stated R12 had previously had C-diff and was on contact precautions for that, but since that resolved she was just on EBP currently for her wounds. RN-B stated the orders, and care plan should have been updated to accurately reflect R12's status. RN-B stated it was the responsibility of either nurse manager or the DON (who was also the infection preventionist) to make those changes. RN-B could not explain why R12's orders and care plan showed contact precautions were required. During interview on 6/24/26 at 2:48 p.m., RN-C stated R12 had wounds currently and gown was required for wound care. RN-C stated R12 did not have C-diff any longer and could not explain why the order for contact precautions was still active and why he had been signing off in the TAR that contact precautions were being followed. RN-C was not sure what was on R12's care plan and stated would have to look at it. During interview on 6/25/26 at 12:02 p.m., director of nursing (DON) stated expectation for resident orders and care plans to be updated to reflect accurate resident status. DON stated R12 should be on EBP and no longer on contact isolation precautions. Facility policy Care Planning dated 11/2024, indicated, The care plan is to be modified and updated as the condition and care needs of the resident change.

Based on observation, interview and document review, the facility failed to develop a care plan which included resident goals and desired outcomes, care and services provided to attain the highest practicable level of wellbeing, and action taken by the facility to educate the resident regarding alternatives and consequences for 1 of 1 resident (R56) who refused medications.Findings include: R56's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, was independent with bed mobility and wheelchair mobility and, required supervision or touching assistance for lower body dressing. Diagnoses included non-Alzheimer's dementia, hypertension, and adult failure to thrive. R56 took high-risk medications including a diuretic (reduces amount of fluid from the body) and had no rejection of care.R56's self-care deficit care plan dated 4/3/24, identified he refused to wear his ted hose (compression stockings) and he was able to put them on himself and chooses to do so. The care plan did not address refusal of diuretic medication.R56's diuretic care plan dated 1/20/26, identified a goal to be free of dehydration. Staff were directed to administer medication as ordered, encourage adequate fluid intake, monitor labs and monitor for dehydration and to report suspected symptoms to the provider. The care plan did not address refusal of diuretic medication.R56's physician order dated 8/21/25, identified furosemide oral tablet (a diuretic medication which helps reduce the amount of fluid in the body) give one tablet by mouth one time a day for edema.R56's Medication Administration Record (MAR) dated 4/1/26 through 4/30/26, identified furosemide was refused 11 out of 30 days.R56's MAR dated 5/1/26 through 5/31/26, identified furosemide was refused 23 out of 31 days.R56's MAR dated 6/1/26 through 6/22/26, identified furosemide was refused 18 out of 22 days.R56's weight and blood pressure from 4/1/26 through 6/23/26 remained at baseline.R56's Risk vs Benefits Form dated 4/29/26, identified R56 refused medications at times and was occasionally noncompliant with cares. R56 was at increased risk of worsening health condition, unmanaged symptoms, hospitalization, falls, infection, safety/wellbeing due to refusal of medication and intermittent care. The Risk vs Benefits form was not included in the care plan and did not identify goals and desired outcomes related to diuretic medication, alternatives to a diuretic; or specific consequences such as fluid retention, swelling in the legs, feet or abdomen, elevated blood pressure and headaches. A care plan was triggered; however, goals and interventions were not. Therefore, R56's care plan had not identified focus areas, goals and interventions related to refusal of medications.R56's nurse practitioner (NP) note dated 6/11/26, identified no swelling or edema noted in lower limbs.During an observation and interview on 6/22/26 at 1:00 p.m., R56 was seated in his wheelchair. Both lower legs had hard red skin with edema. R56's socks were creating an indentation on his lower legs. R56 said it was painful, and he had it for 5 days. He said staff were not doing anything and he could not remember who he told.During an observation and interview on 6/22/26 at 1:05 p.m., the day shift nursing assistant (NA)-A entered R56's room to assist him to the bathroom. At 1:10 p.m., NA-A exited the room. NA-A stated she worked at the facility regularly and was not sure if she had noticed his legs swollen before today but would update the nurse.During an interview on 6/23/26 at 9:40 a.m., licensed practical nurse (LPN)-A stated R56 would refuse medications, and staff would discuss risks and benefits of refusal such as it could affect his health. LPN-A did not state specifically the side effects of refusing a diuretic. LPN-A worked with R56 routinely and had not noticed edema. With a change in condition staff would document the assessment and update the provider. The nurse care coordinator would update the care plans if needed.During an interview on 6/23/26 at 3:58 p.m., R56 stated he took his diuretic today. R56 said historically he was informed of the risks of not taking his diuretic but not specifically about the leg swelling like he had currently. When R56 was asked why he refused his diuretic, he stated he did not like medications. He also said he was compromising and would at least take the diuretic now. He said nursing advised him to start elevating his legs today which he said he was trying to do.During an interview on 6/24/26 at 7:55 a.m., the LPN care coordinator (LPN)-B stated if a resident refused a medication, they would do a Risk vs Benefit form and review it with the resident. No other forms were provided to the resident, such as specific medication side effects, and details would be documented about the conversations with the resident. She said the provider would discuss alternatives.During an interview on 6/24/26 at 8:04 a.m., LPN care coordinator-C stated if a resident refused a medication, they would do a Risk vs Benefit form and review with the resident. No other forms were provided to the resident such as specific medication side effects and details would be documented about the conversations with the resident. She said the provider would discuss alternatives. Nursing would document everything that was discussed in the medical record. During a follow up interview on 6/24/26 at 8:41 a.m., LPN-A stated they had advised R56 edema was a risk of not taking diuretic medication. She also said everything nursing discusses would be documented in the medical record. During a follow up interview on 6/24/26 at 8:46 a.m., R56 stated no one had discussed alternatives to diuretics with him. He said he did not want to take any more pills and did not know what else he could do. During an interview on 6/24/26 at 10:58 a.m., nurse practitioner (NP)-A stated a diuretic taken sometimes was better than not taking it at all, so that was why the medication had not been discontinued despite frequent refusals. Risks of not taking a diuretic included edema and heart problems. She stated R56's rationale for not taking his diuretic was that he thought it made his symptoms worse. NP-A was not sure if a specific discussion about edema side effects related to refusals was discussed. She stated she would expect the facility to follow their care planning policies and procedures related to medication refusals. During an interview on 6/24/26 at 9:05 a.m., the director of nursing (DON) stated refusals of high-risk medications such as diuretics should be in the care plan with resident goals and interventions.The facility's Refusal of Care procedure dated 11/2025, identified when a resident refused care, treatment, medications, assessments, etc., staff would attempt to reapproach the resident, continued refusals of care would be documented in the progress notes. If a pattern of refusals was identified an interdisciplinary (IDT) would update the care plan accordingly. The facility's Care Planning policy dated 11/2024, identified the care plan was derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care plan was to be modified and updated as the condition and care needs of the resident changed.

Based on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for 2 of 3 residents (R7, R56) reviewed for MDS accuracy. Findings include: R7's quarterly MDS dated [DATE], identified in section K that while a resident a tube feeding was recorded. Diagnoses included diabetes mellitus, and no active diagnoses for nutrition.R7's physician orders dated 3/1/26 through 6/24/26, lacked identification for tube feeding. R7's nutritional assessments dated 3/37/26 and 6/23/26, lacked identification for tube feeding. R7's alteration in nutrition care plan 5/28/25, lacked identification for tube feeding. During an observation on 6/22/26 at 12:01 p.m., R7 had her eyes closed while lying in bed and no tube feeding was observed. During an interview on 6/23/26 at 1:11 p.m., the MDS coordinator reviewed R7's MDS section K and stated the indication for tube feeding must have been a mistake and should have been coded for IV (intravenous) fluids received while in the hospital. The MDS coordinator stated dietary would fill in section K for nutrition, then MDS coordinator would check it for accuracy. The MDS coordinator stated tube feeding would not affect facility reimbursement; however, IV fluids would have. R56's quarterly MDS dated [DATE], identified no rejection of care and cognition was moderately impaired. Diagnoses included Alzheimer's disease with late-onset, hypertension and adult failure to thrive.R56's physician order dated 8/21/25, identified furosemide oral tablet (a diuretic medication which helps reduce the amount of fluid in the body) give one tablet by mouth one time a day for edema.R56's Medication Administration Record (MAR) dated 6/6/26 through 6/12/16, during the 7-day MDS lookback period, identified the medication was refused by the resident 5 out of 7 days.R56's nursing progress notes dated 6/6/26 through 6/12/26, during the 7-day MDS lookback period, identified on 6/12/26 at 9:30 a.m., the doctor was notified of the resident's intermittent refusal of medication.R56's diuretic care plan, lacked identification of refusal of the medications.During an interview on 6/24/26 at 12:04 p.m., the MDS coordinator stated social services (SS)-A filled in the information for section E behaviors on the MDS and she was unaware of what resources SS-A reviewed to gather information about behaviors. The MDS coordinator stated they should follow the indications in the MDS 3.0 RAI Manual.During an interview on 6/24/26 at 12:46 p.m., SS-A stated she would review progress notes and the miscellaneous section in the resident electronic health record (EHR) to check for refusals during the ARD. SS-A reviewed R56's progress notes and stated there was one note in the lookback period that identified refusal of medications so she should have coded it as refused 1 to 3 days. SS-A then reviewed R56's MAR and noticed a medication was refused 5 out of 7 times in the lookback and she should have coded it higher as behavior occurred 4 to 6 days but less than daily. SS-A stated she does not typically review the MAR for medication refusals. During a follow-up email on 6/24/26 at 1:25 p.m., the MDS coordinator identified R56's behavior section was coded incorrectly as he declined medications within the lookback period. The MDS could be modified and corrected following the MDS 3.0 RAI Manual which identified if the resident indicated intention was to decline or refuse, then the resident should be asked about the reasons for rejecting care and about their goals for health care and well-being. If the resident was unable or unwilling to respond to questions about their rejection of care or goals for health care and well-being, then interview the family or significant other to ascertain the resident's health care preferences and goals.Coding Instructions included: Code 0, behavior not exhibited: if rejection of care consistent with goals was not exhibited in the last 7 days. Code 1, behavior of this type occurred 1-3 days: if the resident rejected care consistent with goals 1-3 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Code 2, behavior of this type occurred 4-6 days, but less than daily: if the resident rejected care consistent with goals 4-6 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Code 3, behavior of this type occurred daily: if the resident rejected care consistent with goals daily in the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days.During an interview on 6/25/26 at 9:05 a.m., the director of nursing (DON) stated she expected accuracy of the documentation of the MDS. The MDS Coordinator was responsible for accuracy. An MDS policy was requested but not provided.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R12, R27) were offered and/or provided updated vaccination for pneumococcal disease, in accordance with Centers for Disease Control (CDC). Findings include:Review of current, 2/25/26, CDC Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, adults [AGE] years of age and older who received the PCV13 at any age and the PPSV23 at 65 years or older recommended based on shared clinical decision making, to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. The site further indicated adults [AGE] years of age and older who received PCV13 at any age and PPSV23 while under the age of 65, a single dose of PCV21 or PCV20 should be given at least 5 years after the last pneumococcal vaccine dose. R12's admission Minimum Data Set (MDS) dated [DATE], indicated R12 was over the age of 65 and was not up to date on pneumococcal vaccination and was not offered the pneumococcal vaccination. R12's diagnoses include type 2 diabetes mellitus (DM2), kidney failure, and deep vein thrombosis (DVT). R12's Resident Vaccine Administration Consent Form signed 2/9/26, indicated Vaccine(s) to be given per primary care provider's (PCP) order and CDC guidelines. Furthermore, a pneumococcal vaccine was not indicated and R12 was up to date with the pneumococcal vaccine. R12's Minnesota Immunization Information Connection (MICC) report printed 6/25/26, identified R12 received PCV13 on 2/9/16 and PPSV23 on 3/17/15. R12's MICC lacked evidence of PCV20 or PCV21 administration. R27's admission MDS dated [DATE], indicated R27 was older than 50 and younger than 65. R27's pneumococcal vaccination was up to date. R27's diagnoses included coronary artery disease, thyroid disease, and malnutrition. R27's Resident Vaccine Administration Consent Form signed 3/20/26, indicated vaccine(s) to be given per PCP order and CDC guidelines. Furthermore, R27's pneumococcal vaccine was not indicated and R27 was up to date with the pneumococcal vaccine. R27's MICC report printed 6/25/26, indicated R27 received PPSV23 on 7/30/18, and lacked evidence of PCV20 or PCV21 administration. During interview on 6/25/26 at 11:43 a.m., director of nursing (DON) who was also the Infection Preventionist (IP) stated all residents were assessed upon admission for vaccine status using the MIIC report and a pneumococcal vaccination application and would be offered any recommended vaccines. DON further stated would expect all residents and/or resident representative be offered, educated on, and provided all recommended vaccinations. Facility policy Pneumococcal Policy dated 2/2024, indicated residents would be assessed within 5 days of admission on immunization status and their eligibility to receive the pneumococcal vaccine. Then within 30 days of admission, residents would be offered the vaccine when indicated. The policy further indicted staff to refer to the current CDC recommended adult immunization schedule to determine recommended vaccines.

Based on interview and document review, the facility failed to ensure an elopement was reported to the state agency (SA), within 24 hours for 1 of 1 resident (R37) reviewed for elopement. Findings include: R37's annual Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of Alzheimer's disease with other signs and symptoms involving cognitive functions and awareness, and surgical repair for hip fracture. It further indicated R37 was ambulatory, used a walker, and was independent with mobility. R27's progress note dated 8/30/25 at indicated culinary staff (unknown) reported to RN-A that around 5:35 p.m. they saw R37 outside the building. RN-A went outside but was unable to locate her so they returned to the facility and notified the police, administrator, and director of nursing (DON). Then RN-A called the hospital, while another nurse drove around the immediate area to see if they could find her. Once the police arrived (at approximately 7:10 p.m.), RN-A gave them a description of R37 and they left. RN-A called FM-A, and FM-A stated R37 was at the neighbor's house. R37 had hitch-hiked to her previous residence but was unable to gain access to the home so she went to the neighbor's. The neighbors then called FM-A who had tried to call the facility several times, but no one answered. R37 refused to return to the facility and wanted to be taken to the hospital so she was taken there for evaluation. The hospital called the facility stating R37 was returning to the facility. Report was given to the oncoming nurse along with a wander guard to be applied to R37's ankle or wrist upon arrival. During interview on 6/24/26 at 10:05 a.m., the director of nursing (DON) stated if a resident eloped, staff were expected to search the facility and the surrounding area. If they were unable to locate the resident, they should trigger a code pink (missing person) and then all staff would search for the resident. If the resident was still unable to be located, they would call the police and notify the DON and administrator. Staff should then call family, update the provider, call any contacts, and report it to the SA. DON further stated R37 wasn't an elopement risk when she eloped on (8/30/25) because she had a status change due to a hip fracture. R37 used to be mobile and went from being independent to requiring staff assistance with ambulation. Her plan of care changed after she returned from the hospital, and she didn't have any exit seeking behavior. That's when they decided to discontinue the wander guard. When R37 eloped, she had a plan to go to her previous address, was able to remember the address, had intention, and had gotten there safely. They did not report it to the SA because R37 wasn't at risk for elopement due to her declining in mobility. During interview on 6/25/26 at 1:08 p.m., the administrator stated they have to follow the Minnesota Department of Health's (MDH) guidelines when determining what types of things they report and the timeline for reporting. The administrator statedR37's incident was not reported due to the incident was not considered an elopement. R37 did not have exit seeking behavior, needed assistance with mobility, and wasn't at risk for elopement. R37 had a plan to go to the address, and she made it there safely. The facility policy regarding elopement dated June of 2023, indicated following an elopement, the administrator or designee shall notify the SA, as necessary by state requirements, family/family representative, and the physician.

Based on observation, interview, and document review, the facility failed to ensure medical records contained accurate documentation for 2 of 2 residents (R3, R12) reviewed for medical record accuracy. Findings include:R3R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had intact cognition, was independent with eating, received dialysis, and required a therapeutic diet. R3's diagnoses included diabetes mellitus and end stage renal disease. R3's care plan printed 6/24/26, indicated R3 had diabetes, was at risk for hypo and hyper glycemia, and instructed staff to monitor compliance with diet and document any problems. R3's care plan further indicated R3 was at risk for dehydration and instructed staff to, Encourage adequate fluid intake. In addition, the care plan indicated R3 had potential nutritional problem related to protein calorie malnutrition and other diagnoses and instructed staff to, Provide supplements as ordered.R3's Clinical Nutrition Evaluation dated 4/16/26, indicated R3 had a Loss of 5% or more in the last month or of 10% or more in the last 6 months, and was not on a prescribed weight-loss regimen. Provider order dated 4/24/26, indicated, 1500 ml [milliliter] restriction. Dietary to provide: 1080 ml/day. Dietary to give 360 cc [ml] at breakfast [includes 1 Ensure Clear], 360 cc at lunch, 360 cc at supper. Nursing to provide: 420 ml fluid/day.Document oral fluid intake every shift.Provider order dated 4/22/26, indicated, Other.in the morning for unplanned weight loss Ensure Clear QD [every day] provided by culinary at breakfast.R3's treatment administration record (TAR) for June 2026, indicated R3 consumed 100% of Ensure Clear every morning from 6/1/26 through 6/23/26. During observation on 6/23/26 at 11:11 a.m., R3's bedside table and dresser contained 19 unopened, Ensure bottles and one opened and half empty Ensure bottle. One of the unopened bottles had a date on the cap 6/23. During interview on 6/23/26 at 11:15 a.m., culinary services director (CSD) while collecting R3's meal tray stated the nursing assistants (NA) would round after meals take note of dietary and fluid amounts and notify the nurse. CSD, But I also will swing by the nurse's station and let the nurse or nursing assistant know and give them a chance to see the tray. During observation and interview on 6/23/26 at 11:58 p.m., director of nursing (DON) and registered nurse (RN)-B in R3's room and collected all the Ensure bottles. DON and RN-B verified R3 had 19 unopened Ensure bottles stored in his room and stated the culinary staff include an Ensure with R3's breakfast every day. DON could not explain why there were so many unopened Ensure bottles and further verified R3's June TAR indicated R3 had consumed 100% of the Ensure delivered during the month of June. During interview on 6/23/26 at 2:32 p.m., RN-B stated would expect nurses to document intake accurately. During interview on 6/24/26 at 8:47 a.m., R3 stated he did not drink all the Ensure they provide because he was concerned about how it would affect his blood glucose since he had diabetes. R3 confirmed he was capable of opening the Ensure containers and stated he consumed one bottle every couple days or so. During interview on 6/24/26 at 12:58 p.m., registered dietician (RD) stated R3 was at nutritional risk and his intake was closely monitored. RD stated she relied on the documentation in the electronic medical record (EMR) to assist in formulating and modifying resident nutrition plans and orders. RD stated would expect documentation of food, fluid and supplement intake would be accurately documented so that her assessment and nutrition plan of care would be appropriate for the resident. During follow up interview on 6/25/26 at 12:14 p.m., DON stated would expect staff to document R3's intake of nutritional supplement accurately so (RD) would have accurate information for her assessment and any necessary adjustments to R3's nutritional plan of care. R12R12's significant change MDS dated [DATE], identified R12 had intact cognition, required substantial/maximal assistance with bed mobility, dependent on staff for toileting, and was always incontinent of bowel and bladder. R12's diagnoses included Alzheimer's disease, diverticulitis of large intestine (a painful digestive condition causing bulging pouches in the wall of the large intestine which become inflamed and infected), enterocolitis due to clostridium difficile (C-diff-a highly contagious bacterial infection in the large intestine causing severe watery diarrhea and colon inflammation), and pressure ulcer of sacral region. R12's care plan printed 6/23/26, indicated, Resident has a current infection r/t [related to] C-Diff and was on isolation precautions per protocol. R12's progress note dated 6/5/26 at 8:41 a.m., indicated, Resident completed antibiotics for C-diff. Resident is not having any more loose stools. Provider updated. Contact precautions removed per guidelines. Resident placed on EBP [enhanced barrier precautions] due to wounds. Care plan reviewed and updated.R12's treatment administration record (TAR) indicated, Staff to follow: Contact Precautions due to CDIFF every shift.start date 4/16/26. With the exception of one shift, the task had been signed off three times a day (every shift) for the entire month of June.During observation on 6/22/26 at 1:11 p.m., R12's room had signage for EBP and PPE (personal protective equipment). During interview on 6/23/26 at 2:32 p.m., RN-B stated would expect staff to document cares accurately in the medical record. During interview on 6/24/26 at 2:48 p.m., RN-C stated R12 had wounds currently and gown was required for wound care. RN-C stated R12 did not have C-diff any longer, and could not explain why the order for contact precautions was still active and why he had been signing off in the TAR that contact precautions were being followed. During interview on 6/25/26 at 12:02 p.m., director of nursing (DON) stated expectation for resident orders to be updated to reflect accurate resident status. DON stated R12 should be on EBP and no longer on contact isolation precautions and would expect staff to document accurately in the medical record. A policy on accuracy of documentation was requested but not provided.

Based on interview and document review, the facility failed to ensure that a resident was free from a significant medication error for 1 of 3 residents (R3) reviewed for medication errors. Findings include:R3's diagnoses list dated 3/31/26 included retroperitoneal abscess, acidosis, malnutrition, acute kidney failure, and sepsis.R3's admission Minimum Data Set (MDS) dated [DATE] indicated R3 did not have cognitive impairment R3's hospital Discharge summary dated [DATE] included a diagnosis of hypomagnesemia. R3's magnesium laboratory (lab) result on 3/18/26 was low at 1.3. with instructions to monitor and treat accordingly. Magnesium replacement was ordered. The following order was included in the Start taking these medications list: Magnesium, take 250 milligrams(mg) by mouth daily for hypomagnesemia.R3's provider order dated 3/19/26 instructed Magnesium, take 250 milligrams(mg) by mouth one time a day for hypomagnesemia with a start date of 3/19/26.R3's medication administration record (MAR) for March 2026 indicated R3 did not receive magnesium on 3/19, 3/20, 3/21, 3/22, or 3/23 with a chart code of 9 which indicated see nurse note.R3's nursing note dated 3/19/26 at 2:31 p.m., documented the magnesium was on order.R3's nursing note dated 3/20/26 at 8:22 a.m., documented the magnesium was awaiting medication from pharmacy.R3's nursing note dated 3/21/26 at 8:18 a.m., documented the magnesium was awaiting medication from pharmacy.R3's nursing note dated 3/22/23 at 8:11 a.m., documented the magnesium was awaiting medication from pharmacy.R3's nursing note dated 3/23/26 at 7:48 a.m., documented the magnesium was awaiting medication from pharmacy.R3's nurse practitioner (NP)-B note dated 3/23/26 at 3:41 p.m., included R3's 3/20/26 magnesium lab result was 1.2 and I do not see this was replaced. An order was written to add magnesium to R3's next lab draw on 3/24/26.R3's social services note dated 3/23/26 at 3:46 p.m. identified during a care conference therapy expressed concerns R3 had made little progress in therapy due to complaints of tiredness. The care conference team also expressed concerns related to R3 not eating well due to nausea and dry heaves.R3's social services note dated 3/24/26 at 11:45 a.m., identified R3's family member (FM)-A talked with social services and the nurse manager. FM-A was concerned about R3's lethargy with being difficult to arouse and with R3's lack of eating.R3's MAR for March 2026 indicated R3 received Oxycodone 5mg at 10:21 a.m. for pain rated 8/10. There was no corresponding progress note dated 3/23/26 to identify the medication was administered, nor any recorded symptoms R3 was experiencing, and where the pain was located.R3's electronic MAR (eMAR) note dated 3/24/26 at 12:27 p.m. indicated R3 had received Tylenol 500 mg. The note did not identify any recorded symptoms R3 was experiencing, or where the pain was located.R3's nursing note dated 3/24/26 at 12:31 p.m., identified the facility had received a call from the lab of a critical low lab value of magnesium 1.0 mg/dL (deciliter). The provider was notified, and the facility was waiting to hear back with instructions.R3's telephone encounter NP-C note dated 3/24/26 at 12:44 p.m., identified R3's magnesium level was down to 1.0. R3 was on magnesium supplement 250 mg daily, but nurse at the facility had not started it yet because they only have 400 mg tablets at the facility and the pharmacy has not delivered the 250 mg tablets yet. NP-B suspected R3's nausea, poor intake, and significant weakness could be at least partially related to her low magnesium. R3 also had a temperature of 100 degrees Fahrenheit (F) and body wide pain that was 10/10 in her legs.R3's nursing note dated 3/24/26 at 1:32 p.m., identified R3 was sent to the hospital for a temperature of 100.0 degrees F, lethargy, and critical lab of magnesium 1.0 mL/dL. When emergency personnel arrived R3's blood pressure was 78/53.R3's hospital Discharge summary dated [DATE] indicated R3 had been admitted to the hospital for possible sepsis and had received magnesium supplementation during her stay.During an interview on 3/31/2026 at 3:38 p.m., FM-A stated she was concerned because R3 had been sleeping more, eating less due to nausea, and had new pain in her legs. R3 had chronic back pain as well as abdominal pain from the current illness. A nurse told her they would talk to the provider about making medication changes. FM-A was not informed R3 was not receiving her magnesium supplement.During an interview on 3/31/2026 at 2:31 p.m., licensed practical nurse (LPN)-A stated when a medication was unavailable, it would be charted as 9 with a nursing note explaining why the medication was not administered. LPN-A would look back to see if the medication had been re-ordered. If it had already been re-ordered, he would call the pharmacy to find out when it would be delivered. Over the counter (OTC) medications and supplements were stocked in the facility. Magnesium was an OTC supplement that was stocked in the facility. A nurse needed to confirm the ordered dose could be obtained with the stocked medication or supplement. If the order was different, the nurse would fill out a house stock OTC medication form to request the appropriate dose. The resident's provider should be contacted if the resident missed doses or if the pharmacy could not fill the prescription.During an interview on 4/1/2026 at 9:41 a.m., medical doctor (MD) stated with a magnesium lab result of 1.2, he would have doubled R3's magnesium dose if she was at her baseline or would have sent her to the hospital for intravenous replacement if she had symptoms of low magnesium. Symptoms of low magnesium included weakness, tiredness, and nausea. When the pharmacy cannot provide a medication or supplement, the nurse should reach out to the provider for a new order.On 4/1/2026 at 1:40 p.m., a message was left for NP-B with no return phone call.During an interview on 4/1/2026 at 4:04 p.m., NP-A stated when a resident missed medications, she should be contacted for new orders. NP-A confirmed she had not been contacted about the missing magnesium doses.During an interview on 4/1/2026 at 11:38 a.m., Doctor of Pharmacology (Pharm-D) stated signs and symptoms of low magnesium included leg cramps, fatigue, nausea, and weakness. Due to R3's pain to legs, fatigue, and not eating due to nausea, Pharm-D would consider missing five doses of magnesium a significant medication error. Pharm-D confirmed magnesium had not been sent for R3 because it was an OTC medication that was stocked at the facility. The pharmacy had not received a request for Magnesium 250mg.During an interview on 4/1/2026 at 2:32 a.m., director of nursing (DON) stated magnesium was an OTC supplement stocked in the facility, but the strength was not 250mg. Any OTC medication or supplement could be requested from the pharmacy by filling out the house stock request form and faxing it to the pharmacy. The provider should be contacted if the pharmacy cannot provide the ordered medication. DON further stated a medication error was when a medication was not administered as prescribed. When an error occurred, a nurse should fill out the medication error form if they made the error or would report the error to the nurse manager or DON if a different nurse made the error. DON confirmed she was not notified about the missing magnesium doses for R3 and only discovered the error during review of R3's chart on 4/1/26.The Medication Administration policy dated January 2026 instructed medications are administered in accordance with written orders of the prescriber.

Based on interview and document review, the facility failed to obtain and administrator routine medications according to the physician orders for 1 of 3 (R1) residents reviewed for medication administration.Findings include:R1's diagnoses list dated 2/13/26 included thoracic aortic aneurysm (a dangerous, often silent, weakening and ballooning of the aorta in the chest), neurogenic bowel (loss of normal bowel function due to nerve damage, causing constipation, incontinence, and abdominal pain and bloating), and neuropathic bladder (nerve damage interrupts signals between the brain, spinal cord, and bladder, causing urinary incontinence or retention).R1's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition.R1's provider order dated 2/13/26 instructed Cranberry oral capsule, give 250 milligrams (mg) by mouth one time a day for urinary tract infection prophylaxis (prevent or reduce the risk).R1's medication administration record (MAR) for February 2026 indicated R1 did not receive cranberry on 2/14/26 through 2/18/26, 2/20/26, 2/22/26, and 2/23/26 with a chart code of 9 which indicated see nursing note, for a total of 8 missed doses.R1's nursing notes dated 2/14/26 through 2/23/26 identify the cranberry capsules were on order, med not here, not available. Pharmacy call, waiting for delivery, and awaiting house stock delivery. R1's provider order dated 2/14/25 instructed lactobacillus (probiotic), give one capsule one time a day for diarrhea.R1's MAR for February 2026 and March 2026 indicated R1 did not receive lactobacillus on 2/14/26, 2/16/26, 2/17/26, 2/18/26, 2/20/26 through 2/28/26, and 3/2/26 through 3/8/26 with a chart code of 9 for a total of 20 missed doses.R1's nursing notes dated 2/14/26 through 3/8/26 identify the lactobacillus capsules were on order, awaiting medication from pharmacy pending delivery, awaiting medication from pharmacy, and awaiting delivery.During an interview on 3/31/2026 at 2:31 p.m., licensed practical nurse (LPN)-A stated when a medication was unavailable, it would be charted as 9 with a nursing note explaining why the medication was not administered. LPN-A would look back to see if the medication had been re-ordered. If it had already been re-ordered, he would call the pharmacy to find out when it would be delivered. Over the counter (OTC) medications and supplements were stocked in the facility. A nurse needed to confirm the ordered dose could be obtained with the stocked medication or supplement. If the order was different, the nurse would fill out a house stock OTC medication form to request the appropriate dose. The resident's provider would be contacted if the resident missed doses or if the pharmacy could not fill the prescription.During an interview on 4/1/2026 at 4:04 p.m., nurse practitioner (NP)-A stated when a resident missed medications, she should be contacted for new orders. NP-A confirmed she had not been contacted about the missing cranberry and lactobacillus doses. NP-A did not consider the missing doses a significant medication error but would have wanted to be contacted so the order could be changed or placed on hold.During an interview on 4/1/2026 at 2:32 a.m., director of nursing (DON) stated any OTC medication or supplement could be requested from the pharmacy by filling out the house stock request form and faxing it to the pharmacy. The provider should be contacted if the pharmacy cannot provide the ordered medication. DON further stated a medication error was when a medication was not administered as prescribed. When an error occurred, a nurse should fill out the medication error form if they made the error or would report the error to the nurse manager or DON if a different nurse made the error.The Medication Administration policy dated January 2026 instructed medications are administered in accordance with written orders of the prescriber.

Based on interview and document review the facility failed to identify the indication for the administration of narcotic medications and failed to ensure non-pharmacological interventions were attempted/offered and documented prior to the administration of as needed (PRN) narcotic medications for 1 of 3 residents (R3) reviewed for pain.Findings include:R3's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition.R3's diagnoses list dated 3/31/26 included retroperitoneal abscess (collection of pus behind the abdominal cavity lining), acidosis (excess acid buildup in body fluids), malnutrition, acute kidney failure, and sepsis.R3's care plan dated 3/19/26 included a focus of alteration in comfort related to pain with interventions including but not limited to provide non-medical forms of pain relief such as positioning, rest, massage etcetera.R3's provider order dated 3/18/26 instructed Oxycodone (a narcotic pain relieving medication) Give 5 milligrams (mg) by mouth every six hours as needed for pain with no further indication identified.R3's medication administration record (MAR) for March 2026 identified R3 received Oxycodone the following three times:-3/23/26 at 11:56 a.m. R3 received PRN Oxycodone which was recorded as E [effective]. There was no corresponding progress note dated 3/23/26 to identify the medication was administered, any recorded symptoms R3 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the narcotic being provided.-3/23/26 at 7:37 p.m. R3 received PRN Oxycodone which was recorded as E. There was no corresponding progress note dated 3/23/26 to identify the medication was administered, any recorded symptoms R3 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the narcotic being provided.-3/24/26 at 10:21 a.m. R3 received PRN Oxycodone which was recorded as U [unknown]. There was no corresponding progress note dated 3/23/26 to identify the medication was administered, any recorded symptoms R3 was experiencing or what, if any, non-pharmacological interventions had been attempted or offered prior to the narcotic being provided.During an interview on 3/31/2026 at 2:31 p.m., licensed practical nurse (LPN)-A stated a resident complaining of pain would be assessed for pain location and asked to rate their pain on a scale of 0 (no pain) to 10 (worst pain ever). The resident would be offered a non-pharmacological pain intervention prior to offering PRN pain medication. Non-pharmacological interventions included repositioning, ice, food and beverages. After administering narcotic pain-relieving medication, the nurse should document the time the medication was administered and the resident's stated pain scale rating. The nurse would return to the resident later to assess the effectiveness of the medication and obtain a new pain scale rating. LPN-A stated non-pharmacological interventions were documented once a shift.During an interview on 3/31/2026 at 3:54 p.m., registered nurse (RN)-A stated a resident in pain would be assessed for pain location, characteristics of pain, pain rating on scale of 0-10 then offered a non-pharmacological intervention like repositioning or ice. If the non-pharmaceutical intervention was not effective or the resident refused, a PRN pain medication would be administered based on provider order. After administering a narcotic medication, the nurse should document administration time and the resident's stated pain level. Any non-pharmacological intervention offered should be documented in a progress note.During an interview on 4/1/2026 at 4:04 p.m., nurse practitioner (NP)-A stated non-pharmaceutical pain interventions should be offered prior to PRN medication administration. Non-pharmaceutical pain interventions included repositioning, ice, heat, food, distraction and anything the resident stated helped with pain relief. After non-pharmaceutical pain interventions had been offered and refused or attempted and were not effective, a PRN pain relieving medication could be administered. The nurse should document medication administered, time of administered, location and characteristics of the pain, any non-pharmaceutical interventions attempted and the resident's stated pain rating.During an interview on 4/1/2026 at 2:32 p.m., director of nursing (DON) stated when a resident was having pain, the nurse should assess the resident, ask the resident pain level and location. Based on the information obtained, the nurse should offer non-pharmaceutical interventions. If the non-pharmaceutical intervention was refused or attempted and not effective, the nurse could offer PRN pain medication. The nurse should document the medication administered, time of administration, non-pharmacological interventions offered or attempted, location of pain and resident's stated pain rating. DON confirmed R3's EMR documentation with Oxycodone administration did not identify the location of the pain or any non-pharmaceutical interventions offered or attempted.The Medication Administration policy dated January 2026 instructed when PRN medications are administered the following documentation is provided: date and time of administration, dose, route of administration, complaints or symptoms for which the medication was given, results achieved from giving the dose, and the time results were noted.

Based on observation, interview and record review the facility failed to identify and track a potential infection for 1 of 1 residents (R73) who required treatment for latent tuberculosis (a highly contagious lung disease). Furthermore, the facility failed to ensure transmission-based precautions (TBP) were utilized for 2 of 2 residents (R3, R13) who were on contact isolation precautions. Findings include: R73's quarterly Minimum Data Set (MDS) dated [DATE], indicated R73 had cognitve impairment and diagnoses of chronic lymphocytic leukemia (blood cancer) and high blood pressure. R73's infectious disease after visit summary dated 1/14/25, indicated R73 had been diagnosed with latent TB. While R73 had no symptoms, if left untreated R79 may develop active TB in the future. R73's provider order dated 1/14/25, indicated R73 required rifampin (antibiotic) 600 milligrams (mg) each evening for 4 months for latent TB. A facility document titled Monthly Line Listing InfectionReport for 1/2025- 3/2025 lacked documentation of R73's latent TB infection or antibiotic use. When interviewed on 4/2/25 at 1:09 p.m., the infection preventionist (IP) stated R and R were both on contact precautions for MRSA. Furthermore, IP expected staff to follow the directions on the contact isolation sign posted on R and R 's door. IP stated the interdisciplinary team (IDT) would meet daily and determine if any residents had been started on antibiotics or were admitted with antibiotics. The residents and information were then included on the line listing document and were monitored until the infection cleared and antibiotic was no longer needed. We track when the symptoms, testing, site, and location in the building. The IP verified R73 was not on the Monthly Line Listing report and had not realized R73 and would need to look further into the situation. A follow up interview on 4/3/25 at 11:04 a.m., the IP stated R73 was added to the Monthly Line Listing Infection Report and would be monitored. 49617 R3 R3's prospective payment system (PPS) 5-day assessment Minimum Data Set (MDS) dated [DATE], indicated intact cognition and reported an open lesion on her foot and indicated she was taking an antibiotic during the lookback period. According to the Center for Disease Control (CDC), enhanced barrier precautions (EBP) are an infection control intervention aimed at reducing the transmission of multidrug resistant organisms (MDRO) used during high contact resident care activities. The CDC states contact precautions are put into place to prevent the spread of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment. The CDC recommends using personal protective equipment (PPE), including gown and gloves, for all interactions that may involve contact with the resident or the resident's environment. The CDC indicates donning PPE when entering the room and discarding before exiting the room is done to contain pathogens, or contagious/infectious organisms. R3's care plan dated 1/27/25, indicated she was on EBP related to her incision. The care plan directed staff to follow EBP precautions and don and doff PPE per EBP precautions when providing high contact cares. A provider progress note dated 3/31/25, indicated under the assessment and plan header, MRSA (methicillin resistant Staphylococcus aureus) infection wound culture positive for MRSA and SA (staphylococcus aureus). According to the CDC, MRSA is a type of SA germ that can be resistant to several types of antibiotic treatments and is spread through contact with infected people, wounds, or items that have touched infected skin and are carrying the bacteria. The CDC recommends healthcare providers follow contact precautions when caring for residents with MRSA. R13 R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and reported her diabetic foot ulcer. R13's care plan indicated she was on contact precautions for wound care related to active MRSA in her right foot and abdominal wound. The care plan directed staff to follow indicated infection control precautions per protocol and sign on resident's door. During observation on 4/2/25 at 8:58 a.m., a contact precaution sign was posted on R3 and R13's door. Nursing assistant (NA)-E entered R3 and R13's shared room without donning PPE and asked if they were done with the breakfast tray. R13 pulled her privacy around her wheelchair and NA-E exited the room. Per interview on 4/2/25 at 9:00 a.m., NA-E stated, I would assume they are both on contact precautions. NA-E stated staff should wear PPE for contact cares, or for instances where staff would come into contact with the resident, however, if I was just feeding them or something, I wouldn't need to wear PPE. During observation on 4/2/25 at 11:35 a.m., licensed practical nurse (LPN)-D knocked on R3's door and entered the room without donning PPE. LPN-D approached R3 and touched her shoulder and asked if she was coming to lunch. LPN-D then rubbed her back before exiting the room and performing hand hygiene back. During observation on 4/2/25 at 11:43 a.m., NA-F and social services (SS)-A entered R3's room without donning PPE and approached R3's bedside before exiting the room. During interview on 4/2/25 at 11:43 a.m., LPN-D stated both R3 and R13 were on contact precautions for their wounds. LPN-D expected staff to follow the instructions on the sign posted on their door, which stated gown and gloves at the door, however, if staff were only dropping off a meal tray or asking a question, they would not need to wear PPE. When asked how staff would know when to follow the signage on posted on the door and when it did not apply, LPN-D deferred to RN-A. During interview on 4/2/25 at 11:43 a.m., registered nurse (RN)-A stated staff were expected to follow the contact precautions signage posted on the door, which stated staff should don gown and gloves at the door, but if staff were dropping off a room tray, it would be okay to go without PPE. RN-A stated staff would only need to wear PPE if they were providing direct cares with the resident. When asked to clarify if staff should follow the signage posted on the door, which read, hand hygiene before entry and all staff should d on gown and gloves at the door, or if they should only wear PPE when providing direct cares, RN-A stated staff should follow the signage on the door, however, if they were not providing direct cares, they would not need to don full PPE. LPN-D and RN-A reviewed the contact precautions recommendations on the CDC website which indicated staff should wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens, during the interview and RN-A confirmed staff should always follow the signage on the door. During the interview, RN-A and LPN-D confirmed R3's care plan lacked documentation of correct transmission-based precautions. RN-A stated, I'll change that for her right now. LPN-D verified the deficient practice of not wearing appropriate PPE during the observation and stated NA-F and SS-A should have also worn PPE into the room. A facility policy titled Infection Prevention and Control Program revised 3/13/23, directed staff to use surveillance tools for recognizing the occurrences of infection. Furthermore, infection prevention included identifying possible infections. The policy further directed staff to implement appropriate isolation precautions when necessary.

Based on observation, interview and record review the facility failed to ensure expired food items were removed from service, food items were labeled and dated, and food was stored in a manner to prevent cross contamination. Furthermore, the facility failed to ensure dishwasher temperatures were monitored to ensure proper sanitization. This had the potential to impact all residents who reside in the facility. Findings include: Food storage An observation on [DATE] at 11:43 a.m., the main kitchen was reviewed. A stand-up freezer contained a silver pan with plastic wrap covering it. The plastic wrap was not secured and was loose and lifted off three sides. The plastic wrap had ,d+[DATE] beef roast written on it in black marker. Inside was frozen meat with ice crystals and patches of white frost on it. A stand-up refrigerator was reviewed. Inside contained the following: -a covered, plastic container of cut pineapple with no date. -an opened pack of turkey lunch meat with no date. -two containers of [NAME] cultured sour cream, one opened and one unopened. Both containers had a best by date of [DATE]. On the floor of the dry storage area contained three empty 5 gallon buckets labeled Ecolab liquid laundry chlorine. The buckets had lids, however there were holes in the tops of the lids and small amounts of the contents remained inside. When interviewed on [DATE] at 12:06 p.m., cook (C)-A and C-B verified the above findings. C-B stated any food item that is open should be dated and when new stock is delivered, whoever was putting it away should be looking at the dates and throwing out anything expired. C-A stated the 5-gallon buckets were stored there so they could be cleaned out. C-A acknowledged the buckets still having chemicals inside, and verified should not be stored around the food. On [DATE] at 12:52 p.m., the 4th floor patient refrigeration was reviewed and the following identified: -an unlabeled opened individual bottle of [NAME] 2% milk with approximately ,d+[DATE] of the milk left with a use by date of [DATE]. -a sandwich wrapped in a plastic bag taped to a plastic closed storage container. There was green/gray growth on the sandwich seen through the bag. The tape was dated [DATE]. -three unlabeled and thawed frozen entree meals stored on the top shelf of the refrigerator and not in the freezer. -a loaf of cub foods white sandwich bread with a best by date of [DATE]. -two unlabeled or dated Styrofoam take out containers. -two take-out containers labeled [NAME] ,d+[DATE]. -an unlabeled or dated Wendy's fast-food bag. The freezer had five Ice Brick ice packs piled next to two unlabeled and dated plastic bags tied with unidentified food items inside. When interviewed on /,d+[DATE] at 1:16 p.m., nursing assistant (NA)-A verified the above items in the refrigerator and freezer. NA-A stated families often brought in meals for the residents on this floor and should have the residents name and when it was brought in. NA-A verified ice packs should not be in the freezer with food and there was another freezer in the medication room for those. NA-A further stated kitchen staff were responsible for cleaning of the fridge and to ensure items were thrown out but wasn't sure when the last time that happened was. On [DATE] at 1:55 p.m., the second floor resident refrigerator was reviewed and the following found: -un unlabeled and undated plastic container with clear lid containing what appeared to be a chicken breast with green and gray growths on the chicken. -an unlabeled take-out container from Kitchen Food Correlation dated [DATE]. -5 unlabeled and undated several take out plastic bags with food containers inside. When interviewed on [DATE] at 2:08 p.m., NA-B verified the above findings and further sated when residents want food placed in the refrigerator, the items needed to be labeled and dated. NA-B further stated the kitchen staff monitored for expired items. When interviewed on [DATE] at 2:30 p.m., registered nurse (RN)-A was not sure who reviewed the unit refrigerators and felt it may be activities or housekeeping. RN-A verified resident food items should be labeled with the resident name and date it was brought in. Furthermore, RN-A stated ice packs should not be stored with resident food items as it could cause contamination. When interviewed on [DATE] at 1:36 p.m., the Director of Nursing (DON) expected staff to ensure all food was labeled with the resident name and date it was received. Anything that was open would be thrown out after three days. DON stated it was a group effort between dietary and nursing to remove expired or outdated items from resident refrigerators. DON verified there should be no ice packs stored in freezers as only disposable ones were utilized. Dishwasher An observation on [DATE] at 9:33 a.m., the dishwasher in the main kitchen was observed. On the side of the dishwasher was a sign that directed wash temps to reach 150 degrees Fahrenheit (F) and rinse temps to reach 180 degrees F. Hanging on a clipboard on the wall above the dirty side was a temperature log Dated April, 2025. The log was blank. Dietary Aide (DA)-A was washing pans from breakfast. DA-A was asked to identify wash and rinse temperatures for the next two cycles. DA-A wasn't sure where to look for temperatures for the cycles until shown. Observation of 2 wash/rinse cycles was completed and the first had a wash temp of 150 and a rinse temperature of 173. The second cycle observed had a wash temperature of 153 and a rinse of 175. DA-A verified the temperatures. DA-A was not aware of monitoring temperatures and was not sure what they should be at. DA-A further stated they were not trained about dishwashing temperatures. When interviewed on [DATE] at 9:50 a.m., DA-B stated the dishwasher wash temperature was usually around ,d+[DATE] degrees F, while the rinse temperature generally ran around 184 F. DA-B stated there was no official training for the dishwasher and monitoring temperatures and was just told to the new staff during training. DA-B verified temperatures of a cycle that read 153 F for the wash and 178 for the rinse. DA-B further stated maintenance was completed not long ago to help bring up the temperatures as they had been off. DA-B verified the ,d+[DATE] temperature log was blank and stated the cooks generally did the checks. DA0B was not sure where the ,d+[DATE] log was. When interviewed on [DATE] at 1:57 p.m., the Corporate Dietary Director (CDD) stated when orders arrive, staff were expected to rotate on a first in, first used method and ensure all items checked for expiration and expected any expired items to be tossed at that time. CDD further stated anything stored in the freezer should be in a sealed container or bag. If the item was not, staff should switch it out to ensure that. The CDD acknowledged there had been a breakdown on who was monitoring resident food storage and that was in the process of being worked out. CDD verified the dishwasher utilized high temperatures to sanitize dishes. The dishwasher had not been getting to temperatures a few weeks ago and had received maintenance. CDD further stated DA-B had received education for monitoring temperatures at that time, however education to other staff had not been completed. CDD further stated while ideally temperatures would be taken at each mealtime use, an initial one at the start of the day was expected to be done. During that time, CDD had the temperature log for ,d+[DATE], however it had been misplaced and had not yet been found. A facility policy titled Food Brought into Facility revised ,d+[DATE], directed staff to label resident food with the resident's name and date the item was received. Food must be disposed of properly after 3 days. Furthermore, resident refrigerators may not be used for any other purposes other thatn the storage of resident food and beverage. A facility policy for food storage was requested however was not received.

Based on observation, interview, and document review the facility failed to ensure residents compression stockings were applied correctly for 1 of 1 resident (R20) reviewed for edema. R20's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of spondylosis with myelopathy (cervical region), muscle weakness, and dementia. It further indicated R20 was independent with activities of daily living (ADL) and mobility. R20's physician's order dated 3/31/25, indicated Thrombo-Emobolic Deterrent stockings (TED) on during the day and off at night, every morning and at bedtime. Remove at hour of sleep (HS) and wash and rinse, hang to dry. R20's nursing assistant care sheet (undated), indicated R20 preferred to put TED stocking on himself, staff to check that they are on during the day and off at night. R20's care plan dated 3/25/25, indicated self-care deficit related to increased weakness and failure to thrive with the following interventions: -Independent with dressing -Independent with grooming -Assist of 1 with bathing -Provide assistance with oral cares morning, bedtime, and as needed -Call bell/light within reach at all times, answer promptly. -Hair will be washed by nursing department and cut by beauty shop as needed -Nails will be cut by nursing department -Explain all cares while doing them -Assist with personal hygiene (Specify) -Dressing and personal hygiene preferences (Specify) The care plan lacked any indication R20 wore TED stockings or preferences regarding them. During observation and interview on 3/31/25 at 1:20 p.m., R20 was sitting in his wheelchair in his room and was wearing bilateral TED stockings. Both stockings were rolled down to his ankles and the end of the stockings (where the toes should be), had approximately 4-5 inches of the stocking hanging over. There were indentations in the skin of his ankles where the TED stockings were rolled down. He had a dime sized red area on the top of his right ankle where the stocking was rolled down. R20 stated he put on his own TED stockings. During observation and interview on 4/1/25 at 2:42 p.m., R20 was sitting in his room in his wheelchair. He was wearing bilateral TED stockings and they were rolled down to his ankles. He removed his slippers and the TED stockings were hanging off the ends of his toes approximately 4-5 inches. He also removed his TED stockings and his ankles had indentations in the skin and a red area on the top of his right ankle where the stocking was rolled down. During observation and interview on 4/1/25 at 2:44 p.m., licensed practical nurse (LPN)-A verified R20's TED stockings were not on correctly and nurses and nursing assistants were responsible for applying them. R20 stated he had put on his own TED stockings. During interview on 4/2/25 at 8:39 a.m., LPN-B stated the nurses were responsible for applying residents TED stockings and if the resident prefers to put them on themselves, it was the nurses responsibility to ensure they were on correctly. During interview on 4/2/25 at 9:00 a.m., LPN-C stated nurses were responsible for applying residents TED stockings, but if they wanted to do it themselves, the nurse was still responsible for ensuring they were on correctly, stating That's part of signing it off in the documentation. During interview on 4/3/25 at 12:12 p.m. the director of nursing (DON) stated R20 wore TED stockings per his preference and also prefers to apply them himself. The DON further stated the nurses were responsible for ensuring he was wearing them during the day, they were on correctly, and removed at night. This was important in order to prevent skin breakdown. A facility policy regarding edema in regards to TED stockings was requested but not received.

Upon observation, interview, and record review the facility failed to provide drinks, including water consistent with the resident needs and preferences and sufficient to maintain resident hydration for 5 of 6 residents (R1, R2, R3, R5, and R6) reviewed for hydration. Findings include: R1's Clinical Nutritional assessment dated [DATE] indicated R1's goal was for R1 to remain as nourished and hydrated as possible within the disease process. R1's admission Minimum Data Set, dated [DATE] indicated R1's Brief Inventory of Mental Status (BIM)s score was 00 indicating R1 was severely mentally impaired. R1 required moderate assistance with oral hygiene and eating. He required maximum assistance with dressing and transferring. R1's pertinent diagnose were alcoholic cirrhosis of the liver (severe liver disease caused by excessive alcohol), adult failure to thrive, and cachexia (weight loss of more than 10% in a person not trying to lose weight. R1's care plan dated 3/13/25 indicated staff was to offer fluids and snacks between meals. Upon observation and interview on 3/27/25 at 2:18 p.m. R1 was lying in bed wearing a hospital gown. R1 had two friends visiting him. One of the friends stated R1 never had water when he visited. R1's friend gave him a drink of water out of the cup she was drinking from. R1's mouth was dry, and he did not have fresh water or other liquids in his room to drink. A professional interpreter was called. R1 stated he only received fluids with his meals and with his medications. He would have liked water throughout the day. Upon interview on 3/27/25 at 3:20 p.m. nursing assistant (NA)-A stated he was not certain whether R1 was supposed to have water or not because R1 had an Aspira catheter (an indwelling catheter that removes flood from the abdominal area) in place and R1 was a relatively new resident. R2's physician orders dated 6/27/25 indicated staff was to observe R1 for dehydration, decreased skin turgor (elasticity of the skin), dry mucous membranes, lethargy, fatigue, low urine output, hypotension (low blood pressure) and increased in falls. R2's significant change MDS dated [DATE] indicated R2 BIMs score was a four indicating R2 was cognitively impaired. R2 was totally dependent upon staff for eating, oral cares, toileting, bathing, dressing, hygiene and transferring. R2's significant diagnoses were paranoid schizophrenia (delusions and hallucinations), hyperparathyroidism (thyroid dysfunction when the glands produce too much parathyroid hormone), and bullous pemphigoid (autoimmune skin disorder characterized by large blisters. R2's nutritional assessment dated [DATE] indicated R2's goal was to remain as nourished and hydrated as possible within the disease state process. R2's care plan dated 3/28/25 indicated R2 required staff assistance with drinking liquids and was to have a sippy cup. Upon observation and interview on 3/28/25 at 9:12 a.m. R2 was fully dressed seated in her room in her wheelchair. She did not have water in her room. She stated she got thirst there was water in her bathroom. R3's nursing admission note dated 3/24/25 indicated R3 was able to make his needs known. R3's care plan dated 3/25/25 indicated R3 required staff assistance with dressing and personal hygiene\ R3's admission MDS dated [DATE] was not completed on the date of survey. Upon observation and interview on 3/28/25 at 9:35 a.m. R3 was seated in his wheelchair dressed watching television. He did not have a glass with water or other liquids in his room. He stated he would like water to be available in between meals. R5's admission MDS dated [DATE] indicated R5's BIMs score was a seven indicating R5 was cognitively impaired. R5 required set-up for eating, moderate assistance for oral hygiene, dressing, and transferring. Upon observation and interview on 3/28/25 at 10:09 a.m. R5 was lying on his bed fully dressed. He did not have a glass with water or other liquids in his room. He stated he would like water throughout the day. R6's admission MD dated 11/13/24 indicated R4 had a BIMs score of 15 indicated he was cognitively intact. R6 was independent with eating, oral hygiene, toileting, dressing, and personal hygiene. R6's pertinent diagnoses were right and left leg below the knee amputations, hepatic encephalopathy (loss of brain functions when the liver does not remove toxins) and cirrhosis of the liver. Upon observation and interview on 3/28/25 at 10:21 a.m. R6 was standing outside of his room waiting to speak with surveyor. Upon observation of his room R6 did not have water readily available. He stated when he wanted water between meals and medication passes, he wound find the nurse or the nurses cart, get a glass and fill it in his bathroom. Upon interview on 3/28 at 10:48 a.m. NA-B stated the floor she was working on did not have the reuseable plastic mugs to fill with ice and water for the residents like the other floors had. She stated staff was supposed to fill the small disposable plastic cups the nurses use for their medications on that floor. The cups were four ounces (oz), cups. Upon interview on 3/28/25 at 12:19 a.m. the director of nursing (DON) stated all residents have water readily available. She believed staff were passing water in the morning and if the residents requests more the staff was to provide more. The staff was expected to check each residents room before leaving to ensure they had water. A facility policy titled Monitoring Food and Fluid Consumption dated 9/2012 indicated the facility was to maintain adequate nutritional intake and hydration for all the residents.

Upon observation, interview, and record review the facility failed provide the necessary services of oral hygiene for 5 of 6 residents (R1, R2, R3, R4, R5) reviewed for activity of daily living. Findings include: R1's admission Minimum Data Set, dated [DATE] indicated R1's Brief Inventory of Mental Status (BIM)s score was 00 indicating R1 was severely mentally impaired. R1 required moderate assistance with oral hygiene and eating. He required maximum assistance with dressing and transferring. R1's pertinent diagnose were alcoholic cirrhosis of the liver (severe liver disease caused by excessive alcohol), adult failure to thrive, and cachexia (weight loss of more than 10% in a person not trying to lose weight. R1's care plan dated 3/13/25 indicated R1 was to receive minimum assistant of 1-2 with personal hygiene. Upon observation and interview on 3/27/25 at 2:18 p.m. R1 was lying in bed wearing a hospital gown, two friends were visiting. A plastic basis was observed in his room with an unopened toothbrush wrapped, an unopened box of toothpaste and toothettes (a disposable single use oral care swab with a sponge on one side of the stick used for oral cares. When a toothette was held up to show R1 he stated he did not know what that was. R1 stated he had never been assisted with oral cares at the facility. Upon interview on 3/27/25 at 3:20 p.m. nursing assistant (NA)-A stated he was not certain if the toothettes were to be used with R1 how often, or if he has to use a toothbrush. He stated he had not worked with R1 prior to the day of the survey. He stated orals are to be completed every a.m. and every p.m. R2's significant change MDS dated [DATE] indicated R2 BIMs score was a four indicating R2 was cognitively impaired. R2 was totally dependent upon staff for eating, oral cares, toileting, bathing, dressing, hygiene and transferring. R2's significant diagnoses were paranoid schizophrenia (delusions and hallucinations), hyperparathyroidism (thyroid dysfunction when the glands produce too much parathyroid hormone), and bullous pemphigoid (autoimmune skin disorder characterized by large blisters. R2's care plan dated 3/28/25 indicated R2 had an alteration in dental care related to missing teeth. She was to have oral cares and every and per her request. Upon observation and interview on 3/28/25 at 9:12 a.m. R2 did not have oral care supplies in her room. She stated staff did not assist her with caring for her mouth. R3's nursing admission note dated 3/24/25 indicated R3 was able to make his needs know. R3's care plan dated 3/25/25 indicated R3 required staff assistance with dressing and personal hygiene. The plan did not indicate oral hygiene specifically. R3's admission MDS dated [DATE] was not completed on the date of survey. Upon observation and interview R3 had a plastic basin in his room with an unopened toothbrush wrapped in plastic and an unopened tube of toothpaste. R3 stated he had not brushed his teeth since his admission. He stated he was not certain whether staff was assisting him with that or not. R4's care plan dated 3/6/25 indicated R4 was at risk for dehydration, staff was to education resident, family on the importance of fluid intake. Staff was to observe R4 for dehydration, decreased skin turgor, dry mucous membranes, lethargy, fatigue, low urine output, hypotension (low blood pressure) and increased in falls. R4's annual MDS dated [DATE] indicated a BIMs score was not indicated. R4 was dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, and transferring. R4's pertinent diagnoses were autistic disorder (development disorder that impairs the ability communicate and interact), adjustment disorder with mixed anxiety and depression and drug induced dyskinesia (involuntary repetitive, and abnormal movements). Upon observation and interview on 3/28/25 at 9:35 a.m. R4 was in bed. R4 stated staff was to assist him with brushing his teeth as had mouth issues, however he had oral cares approximately 2-3 times a week. R5's admission MDS dated [DATE] indicated R5's BIMs score was a seven indicating R5 was cognitively impaired. R5 required set-up for eating, moderate assistance for oral hygiene, dressing, and transferring. Upon observation and interview on 3/28/25 at 10:09 a.m. R5 oral supplies were not observed in his room. He stated he was able to brush his own teeth, however needed the equipment to do so. Upon interview on 3/28/25 at 12:19 a.m. the director of nursing (DON) stated if assistance with oral care was on the care plan the staff was to assist them with oral care every morning and evening. A facility policy titled Activities of Daily Living (ADL's) Maintain Abilities Policy indicated: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility would provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. 3. The facility will provide care and services for the following activities of daily living: a. hygiene, bathing, dressing, grooming, and oral care, b. Mobility-transfer and ambulation, including walking, c. Elimination-toileting, d. Dining-eating, including meals and snacks. e. Communication, including speech, language, and other functional communication systems. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and basic life support.

Based on observation, interview and document review, the facility failed to follow infection control guidelines to ensure beard nets were worn by staff who prepared food in the kitchen. This practice had the potential to affect all the residents, staff, and visitors who ate food prepared in the kitchen. Findings include: During an observation on 3/4/25 at 12:41 p.m., cook (CK)-A was observed working in the kitchen where food was being prepared by other staff. CK-A had a full beard, was not wearing a beard net and walked by where the food was being prepared. CK-A stated he worked preparing food on 3/4/25 and 3/5/25, without a beard net because the facility was out of them. CK-A stated he knew he was supposed to wear a beard net to prevent hair from getting into the food. During an interview on 3/4/25 at 12:49 p.m., dietary aide (DA)-A stated the kitchen manager was not in the facility as she left to buy beard covers. During an interview on 3/4/25 at 5:08 p.m., the administrator stated she expected staff to wear a beard cover while preparing food, and if the facility did not have a supply, staff should have communicated the need to her so she could borrow from a sister facility if needed. Review of The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices facility policy dated October 2017, indicated hair nets and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on interview and document review, the facility failed to ensure neglect did not occur when a staff member nursing assistant (NA)-A failed to answer call lights for a resident timely and instructed the resident to not use their call light unless it was an emergency for 1 of 3 residents (R1) reviewed for neglect. Findings include: R1's admission Minimum Data Set (MDS) comprehensive assessment was not completed as R1 was in the facility just over 24 hours. R1's 48-hour care plan was not completed as he had been in the facility just over 24 hours. R1's progress notes dated 2/26/25 at 11:05 p.m., indicated R1 was admitted on [DATE] around 6:30 p.m., and was alert and oriented. R1's progress notes dated 2/27/25 at 9:30 a.m., indicated staff offered R1 psychiatric services due to R1 had fears related to health and his recent amputation. R1's progress note dated 2/27/25 at 5:31 p.m., indicated R1 called 911 to go to the hospital and left the facility at 6:40 p.m. on 2/27/25. During an interview on 3/4/25 at 2:20 p.m., NA-A stated R1 arrived at night, appeared confused, and R1 would try to remove his incontinence brief. When NA-A checked on him, his underwear was down to his knees. NA-A stated he would inquire if R1 needed to use the bathroom and R1 did not understand what he was asking. NA-A indicated, I assumed something was wrong with him cognitively. NA-A stated when R1 activated his call light, R1 wanted his brief changed almost every time and needed to be changed only once. NA-A indicated R1 activated his light when he wanted water, ice, a pain pill, a different blanket, and asked for Ensure twice. NA-A stated he assessed if R1 would continue to use his call light, and further stated, I waited ten minutes to respond and then went back to check on him to see if he really needed something more than a cup of water or ice. The light would keep going off until I responded. I knew it was him, because the roommate was out of the room a lot of the time. If the call light was going off in the other rooms, I looked to see if others needed lights answered first. If someone pulls a bathroom alarm, that's a different light, and I answered those first. I would just check in on him periodically, like every 10 minutes, instead of answering the light. Additionally, NA-A stated, When [R1] needed his wound wrapped, I would say the nurses will get to you when the nurses get to you. I would leave and he would press it [the call light] again. Maybe something could happen in the 5 seconds when I was just there. I have been doing this for a while. It was a behavioral issue. I am experienced. I have been here 3 months. I was a CNA in [another city] for 6 months. I did let him know, unless it was something super important, like an emergency, he needed to ease off the light. I don't think he would remember most things. I did tell him he needed to ease up on the frequency of the call light. Maybe he didn't remember pressing the call light. We really did try to accommodate him. After a time, it was taking away from all the other residents with his confusion. the only thing he really needed was his wound changed. We had others who needed theirs done too. During an interview on 3/4/25 at 3:02 p.m., registered nurse (RN)-A stated R1 used his call light frequently however, expected that as it was R1's first day at the facility and R1 was adjusting to the new environment. RN-A stated it was not acceptable if NA-A made R1 wait for a call light response. We wouldn't know if it was important unless we answered the light. RN-A stated R1 had the right to use his call light and should not have been told to not use it. RN-A stated she was unaware NA-A was not answering R1's light and would have written NA-A up and told the nurse manager if she had known. RN-A stated, In a sense, it is neglect. During an interview on 3/4/25 at 3:09 p.m., RN-B stated he did not know NA-A was not answering R1's call lights, and was also not aware NA-A instructed R1 to not use his call light so frequently. RN-B stated call lights were answered by priority for those with physical needs, medication needs, treatments, and wound cares, however, further acknowledged staff would not know the urgency of the need until they answered the light. RN-B indicated when a resident arrived at night, was elderly, or had cognitive impairment, like R1, the resident may use the call light more. RN-B stated if he had known NA-A told R1 to stop using his light so much, he would have reported the NA to the director of nursing (DON) and would inquire about reporting the NA to the State Agency. During an interview on 3/4/25 at 5:08 p.m., the administrator stated she expected staff to answer call lights within five to 10 minutes and if they were not able to, they should ask for assistance from another staff. The administrator stated she was not aware NA-A told R1 to limit the use of his call light and it did not align with the facility ideals. During an interview on 3/4/25 at 5:21 p.m., DON stated she expected staff to answer call lights within five minutes, every time the resident activated it, and answering it every ten minutes was not acceptable, and stated, If could be an emergency, it could be life and death, and you don't know until you go in the room. Review of facility policy titled The Abuse Prohibition/Vulnerable Adult Plan dated 2/2/2023, indicated neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, mental anguish, or emotional distress.

Based on observation, interview, and document review, the facility failed to protect residents from physical and verbal abuse for 2 of 3 residents (R5, R6) reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R4 hit R5 in the face while he lay in bed and later attacked R5 who fell out of his wheelchair, and verbally abused R6. The IJ began on 4/5/21, at approximately 11:24 p.m. when R4 punched R5 in the face; threatened to kill R6 and attacked R5, who fell out of his wheelchair. After the incident, R5 and R6 left to smoke and R4 was allowed in the smoking area with both R5 and R6 without any staff supervision. R5 was scared and asked R6 to protect him from R4 when R4 then verbally threatened R6 again. The director of nursing (DON), and administrator were notified of the IJ on 4/9/21, at 1:03 p.m. The facility implemented corrective actions and the immediate jeopardy was removed on 4/9/21, at 6:01 p.m. and remained at a lower scope and severity of D level, isolated with no actual harm. Findings include: R5's Face Sheet dated 4/9/21, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition. R5 required extensive assistance with activities of daily living (ADL)'s. Further, R5 had an impairment of his lower extremity and required a wheelchair for mobility. R5 had no behavioral issues identified. R5's care plan had an intervention initiated on 4/9/21, after an altercation with R4 on 4/5/21, that indicated an ADL self-care performance deficient related to above right knee amputation and left below knee amputation. Staff were directed to provide physical assistance. Additionally, staff were to monitor for signs and symptoms of infection for 0.3 centimeters (cm) by 0.3 cm skin tear to R5's the lower left lip, and a 0.5 cm x 0.5 cm skin tear underneath R5's left eye. R5's progress note dated 4/6/21, at 12:30 a.m. indicated R5 had an altercation with his roommate (R4). Roommate (R4) caused a bruise to R5's left eye, chin and side. R5 was assessed for his injuries, and applied ice to the left side of face. R5 then requested to got outside and smoke. R5's Pain Evaluation dated 4/6/21, indicated pain level of four (one was mild and ten was the worst). The pain was new within the last seven days and affected his relationship with others (specified to limit activities with roommate). The pain was constant, aching and was related to being hit in his left eye by his roommate. The evaluation also indicated R5 also had pain and soreness in his left thigh and hip. R6's admission MDS dated [DATE], indicated intact cognition. R6 was independent with ADL's and did not use a device for mobility. The MDS further indicated R6 rejected care four to six days during seven day observation period but less than daily. R6 had no behavioral issues identified. R6's care plan dated 2/15/21, indicated a mood problem related to depression and [CONDITION(S)] and R6 was to remain safe while smoking at the facility. R4's Face Sheet dated 4/9/21, indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R4's admission MDS dated [DATE], indicated intact cognition. R4 had been capable of increased independence with ADLs with rehabilitation. R4 had no behavioral issues identified. R4's care plan dated 4/9/21, indicated a history of substance abuse and behavior problems related to socially inappropriate behavior toward other residents. R4 had a goal to have no injury to self or others. Staff were to monitor for alcohol withdrawals, search room for alcohol every shift, monitor on one to ones; if behaviors escalate call 911, redirect and remind resident if he was attempting to harm others to ensure resident safety. The facility Allegation of Abuse of Another Resident report dated 4/6/21, indicated an incident of physical abuse occurred on 4/5/21. R5 and R4 were roommates and had a physical alteration in their room. R4 thought R5 had stolen his money and went by R5's bed and hit R5 in the left eye. On 4/6/21, R5 was moved to a different floor, education was provided to R4 and R5 by the administrator and DON to avoid common areas. The facility security camera video footage, without audio, was reviewed for the timeframe of 4/5/21, at approximately 10:30 p.m. through the morning of 4/6/21. The footage identified R4 walked independently into the bedroom he shared with R5 at 11:15 p.m. LPN-A entered the room at 11:25 p.m. to answer R5's call light and shortly after R4 left the room and walked towards R6's room. At 11:26 p.m., LPN-A left R5 and R4's room, R4 re-entered the room he shared with R5, and the call light was again turned on. At 11:28 p.m. R5 left R4 and R5's room in his wheelchair and entered the hallway. At 11:29 p.m. R4 charged out of R4 and R5's room past NA-B, who had just entered the area, and struck R5 out of his wheelchair onto the hallway floor before NA-B was able to intervene. LPN-A and NA-A also arrived to intervene and assisted at this time. The security camera footage also indicated at 11:49 p.m. R5 went outside to smoke, he was joined by R6 at 11:56 p.m., and by R4 at 11:57 p.m. Theses residents were unsupervised by staff while outside smoking until 12:03 a.m. when NA-A came out to the smoking area, and R6 went back inside. NA-A continued to supervise R4 and R5 in the smoking area, standing between them until they all went inside at 12:11 a.m. Additional footage showed R4 in the smoking area unsupervised at approximately 1:05 a.m., 1:25 a.m. and 2:00 a.m. The facility Report of Resident Grievance/Complaints dated 4/9/21, indicated R4 went into R6's room and asked if he had stolen his money and if he had, then R4 would kill him. R4 was placed on 15-minute checks. R4's progress note dated 4/7/21, at 11:35 a.m. indicated social services (SS) were informed R4 had been drunk the night before (4/6/21) when the altercation ocurred. R4's room was searched and three empty vodka bottles and one half full bottle of vodka were found. SS called the liquor store to stop delivery to the facility. During observations on 4/8/21, from 8:30 a.m. to 4:30 p.m. R4 was observed to ambulate throughout the facility independently. During an observation on 4/8/21, at 1:30 p.m. R5's left eye appeared swollen and there was a small laceration on his left lip. During an interview on 4/7/21, at 10:54 a.m. licensed practical nurse (LPN)-B stated R4 seemed concerned about money. Further, LPN-B stated R4 would get sharp and snappy at times. During an interview on 4/7/21, at 11:02 a.m. LPN-C stated she had felt bad for R5 as he was helpless and R4 just got on top of R5 and started to beat him up. During an interview on 4/7/21, at 11:21 a.m. R5 stated on the night of 4/5/21, into 4/6/21: --R4 approached him while he lay in bed. R4 stood over R5, yelled about his money and cigarettes, threatened to kill him and punched him in the face. At this time, R5 stated he felt scared R4 was going to kill him and helpless as he only had his arms to defend himself. R5 stated his immediate reaction was to try to kick R4 to defend himself but R5 realized he no longer had legs. --R5 stated shortly after he had been punched by R4, R4 left and went into R6's room; that was when LPN-A arrived. LPN-A approached and did not know what the f**k to do. --R4 came back into the room. R5 asked LPN-A not to leave him alone but she did. R5 stated he was scared and was not sure if R4 was going to kill him when he was left alone. Further, R5 stated he was vulnerable with no legs and was helpless. He was concerned as R4 appeared drunk, got aggressive when he was drank and was not sure of what R4 was capable of doing. --R5 was able to transfer himself into his wheelchair and left the room to get help. R5 went on to state while in the hallway NA-B tried to hold R4 back when R5 was attempting to exit the room. R4 was too strong for NA-B and R4 pushed past NA-B, and was attacked a second time, he knocked me out of my chair. --R5 stated about 20 minutes later, he went to smoke and shortly after R6 joined him. R5 stated while outside he was scared when he saw R4 approach the smoking area and asked R6 to protect him. Once R4 arrived outside, R4 stated a partial apology to R5 for punching him but then started to go off on R6. --While outside, R4 got verbally aggressive towards R6 for protecting R5 and threatened him. --Finally, R5 stated he and R6 were alone and unattended by staff for approximately 20 minutes before NA-A came to the smoking area. Once NA-A came out, R6 told NA-A that R4 threatened him, and R6 went inside. R4, R5 and NA-A remained in the smoking area. During an interview on 4/7/21, at 11:38 a.m. R6 stated R4 woke him up the night of 4/5/21, and accused him of stealing his money. R4 said he was going to kill him. R4 appeared to have been belligerent. Further, R6 stated afterwards he joined R5 outside to smoke. When R5 saw R4 come out to smoke he asked R6 to protect him. R4 asked R5 for his $30 for cigarettes and said he wanted to fight R6, but R6 told R4 he would call the cops. R6 stated he was scared as R4 made death threats to him and had just hit a helpless guy [R5] in a wheelchair. During an interview on 4/7/21, at 1:41 p.m. NA-B stated she arrived to the hallway by R4 and R5's room after R5 had already been hit in the eye by R4. When NA-B arrived R4 had been yelling at R5 for his $30 and R5 was trying to leave the room in his wheelchair. NA-B tried to stand between R4 and R5 but R4 pushed NA-B out of the way and punched R5 out of his wheelchair. NA-B helped get R5 back into his wheelchair while NA-A helped R4. NA-B stated R5 went out to smoke and was not sure if R4 stayed in his room all night. NA-B stated the goal was to separate R4 and R5 for the night. During an interview on 4/7/21, at 2:01 p.m. R4 confirmed he had given R5 a tap or little pop to his head while R5 was in bed. Further, R4 stated, He is a double [CONDITION(S)], if he has a problem, he shouldn't mess with me. Further, R4 stated after he popped R5 in the nose, he went out to smoke; there were a bunch of others outside smoking. R4 reported he had been upset since R5 kept wanting his cigarettes and I'm not his mommy. Lastly, R4 stated it had been growing on him that he had bought $30 worth of cigarettes for R5 and had not been paid back. During an interview on 4/8/21, at 7:57 a.m. NA-A stated she arrived after R5 was on the hallway floor with blood around him and had bled under his left eye and lip. NA-A stated R4 had been ranting and raving about his money therefore NA-A brought R4 to his room. NA-A stated R4 was uptight and wired up but NA-A was able to calm R4 down. Further NA-A confirmed she told R4 it was ok for him to go outside to smoke. NA-A stated she saw R4 smoke other times during that overnight with an unidentified male and an unidentified female resident. Further, NA-A stated R4 might have been drinking which triggered the situation as R4 would not normally ever act this way. During an interview on 4/8/21, at 12:48 p.m. LPN-A stated on the night of 4/5/21, she saw a call light on in R4/R5's room and went to check on it. When LPN-A arrived, R4 was shaking his fist at R5 and was yelling at him about cigarettes and his money. R4 pushed past LPN-A and went into R6's room. R5 reported to LPN-A that R4 had punched him. Further LPN-A stated she could tell R4 just wanted to fight so she left R4 and R5 and went to get help as it was not easy for LPN-A to handle R4 alone. When LPN-A returned R5 was on the hallway floor. LPN-A stated R5 went out to smoke after she completed an assessment. During an interview on 4/9/21, at 8:28 a.m. the DON and administrator stated immediately after the incident they separated R4 and R5. The DON stated she was not made aware of the situation; however, if she had been notified, she would have ensured separation of both residents, increased supervision, called 911, completed a skin and pain assessment on all residents involved, and ensured one to ones on R4 immediately. The facility Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy dated 9/11/20, indicated each resident would be free from verbal or physical abuse. Residents would be protected from abuse and harm while they resided at the facility. If the alleged perpetrator was a facility resident, staff would remove the perpetrator from the situation and another staff member would stay with the alleged perpetrator and wait for further instruction from administration, if possible. The immediate jeopardy that began on 4/5/21, was removed and the deficient practice corrected on 4/9/21, when the facility offered R5 and R6 in house psychology consultation and alternative placement. R4 was placed on one-to-one supervision, moved to a different floor than R5 and R6. Additionally, R4 was offered chemical dependency treatment related to alcohol abuse and in patient chemical dependency support. Staff checked R4's room each shift for alcohol, offered house psychology consolation and provided education on negative affects of consuming alcohol. Further, social services were in the process to find a more appropriate setting for R4. All resident that resided within the facility were interviewed on safety concerns. Further, the residents who were at risk for [CONDITION(S)] which could lead to aggressive behaviors received care plan reviews to ensure appropriate treatment services had been offered, education on chemical/drug use and individualized interventions to address mood and behavior concerns that may arise. Lastly, staff were educated to ensure resident to resident altercations receive immediate interventions to protect all residents. The facility ensured all staff are educated and competent prior to caring for residents. Additionally, the facility will conduct ongoing audits and monitor to ensure continued compliance.

Based on interview and document review the facility failed to ensure the safe use of hot packs and/or rice packs for 1 of 1 residents (R1) who sustained [CONDITION(S)] and required total assistance from staff for activities of daily living. This failure resulted in actual harm when R1 sustained a thermal [CONDITION(S)] to the right hand and required debridement for second degree [CONDITION(S)]. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 had medically complex condition that included [CONDITION(S)] (paralysis from a spinal cord injury which involves the arms, hands trunk, legs and pelvic organs). The MDS also indicated R1 had intact cognition. R1 had rejected cares less than daily (4-6 days in the look-back period). R1 was totally dependent on physical assist of two staff for bed mobility, transfers, dressing, toileting and hygiene. R1 was totally dependent on physical assist of one staff for eating. R1 had functional limitation in range of motion (ROM) in both upper and lower extremities. R1 had frequent pain with an intensity of 5 out of 10, received scheduled pain medication, but had neither received as needed (PRN) pain medications nor non-medication intervention for pain. R1 had a current stage four pressure ulcer and other [CONDITION(S)] other than ulcers, rashes, or cuts and had skin and ulcer treatments in place. R1's care plan dated 3/30/19, indicated R1 had pain due to chronic physical disability of [CONDITION(S)]. R1 had a history of chronic pain and muscle spasms. Nursing was directed to encourage R1 to try different pain relieving methods including heat or cold application. The care plan did not identify where or how the specific heat or cold application should be used. Review of R1's progress notes from 12/1/20 through 12/31/20: -12/17/20, at 11:07 p.m. noted 1545 (3:45 p.m. [R1] requested Tylenol and a hot pack, 650 mg Tylenol administrated PO along with hot pack applied to his neck. Around 2000 (8:00 p.m.) [R1] requested another hot pack and writer offered, resident pain resolved. -12/17/20, at 2:46 a.m. [R1] complained of neck pain, administered standing house order (SHO) Tylenol 650 mg and applied warm pack to his neck. -12/21/20, at 2:22 a.m. complained of neck pain applied warm pack to neck administered Tylenol 650 mg for pain, up in wheelchair with blanket over head to knees, surfing on phone, Foley draining yellow urine, will continue to monitor. -12/22/20, at 12:48 a.m. noted gave heat pack for neck pain, currently sitting in wheelchair with cell phone. -1/3/21, at 10:10 a.m. indicated at approximately 9:20 a.m. the nurse found R1 in his room unresponsive and had blood to the floor from his burn blisters. Vital signs were assessed and R1 was transported to the hospital. R1's incident report dated 12/28/20, at 10:00 a.m. indicated R1 stated he got blisters on his hand from his rice hot pack that was used for his neck. R1 would not say who helped him warm up the rice hot pack. The nurse manager had removed the rice hot pack from R1's room. Review of R1's active physician orders from the electronic medical record revealed the following: -4/19/19, for every shift to offer to put a soft warm blanket around his neck or warm towel around his neck for comfort due to R1's neck getting cold. The order lacked documentation or direction for the use of a hot pack or rice pack. -6/15/20, indicated R1 at times would order a space heater from an online source to use in room. The order directed nursing to check room every shift, re-educate R1 and remove heater in a timely manner. -12/28/20, apply [MEDICATION(S)] on blisters on right hand and cover with kerlix (gauze wrapping), once daily for blister [CONDITION(S)] for two weeks. Additionally, on every shift, staff were to monitor blister [CONDITION(S)] on right hand for signs or symptoms of infection. Facility education sign in sheets dated 6/4/20, 7/21/20, 8/17/20, 10/14/20, 11/24/20, with subject of [R1] educated on space heater or hot pack included only the signatures of administrator and director of nursing (DON). The education sheets lacked any other staff signatures. The sheet did not indicate R1's signature, what R1 had been updated on, nor R1's response to the education or if the administrator and DON provided risk versus benefits to R1. R1's clinical record lacked documentation of the education provided and lacked documentation of R1 response to the education. R1's nurse practitioner (NP)-A progress note on 12/31/20, at 12:56 p.m. indicated R1 was a reliable historian. The note also indicated two days ago nursing reported a blistered area to R1's right hand and the fourth and fifth finger. Nursing found a portable heater in R1's room. Nurse manager suspected patient fell asleep too close to heater. NP ordered wound care. Picture was taken of blistered area and indicated R1 avoided the NP's questions on how the injury occurred. During interview on 1/6/21, at 10:20 a.m. licensed practical nurse (LPN)-A stated R1 was in the hospital. She indicated R1 recently had a blistered area on his right hand from his own microwavable hot pack. LPN-A stated R1 would not have been able to use the microwave to heat up his own hot pack. The only microwave on the unit R1 resided on was in the nurses station and residents could not access the microwave. LPN-A stated did not know any other details about the incident. LPN-A stated they thought they were only supposed to use the facility instant hot packs, but upon review of the supply room with the surveyor no instant hot packs were present in the 3rd floor supply room. During phone interview on 1/6/21, at 11:24 a.m. registered nurse (RN)-D stated had known R1 had blisters on his right hand recently but was unsure what the cause was. RN-D stated R1 would request hot packs for pain on his neck. RN-D stated would use the facility instant hot packs for residents that requested hot packs. During interview on 1/6/21, at 11:52 a.m. nursing assistant (NA)-B stated R1 used to request a microwavable heat pack, but they only used the facility provided ones. During interview 1/6/21, at 11:57 a.m. registered nurse (RN)-E stated the facility only used the instant hot packs. RN-E brought surveyor to the 2nd floor storage room at that time. There were no instant hot packs available, only the instant cold packs in the storage room. RN-E stated normally they had the instant hot packs in stock but did not know why they were not on the shelf today. During interview 1/6/21, at 12:02 p.m. registered nurse (RN)-H stated was not aware of any policy on space heaters or rice packs. RN-H stated the facility would use instant hot packs. During interview on 1/6/21, at 12:05 p.m. registered nurse (RN)-F stated the disposable hot packs (instant ones) were the safest option. During interview on 1/6/21, at 12:16 p.m. registered nurse (RN)-G stated R1 had a history of ordering space heaters online and nursing would remove them. RN-G showed surveyor two white space heaters that were removed from R1's room. RN-G stated one heater was removed a while ago. RN-G stated staff would have had to plug in space heaters and microwave any rice packs as R1 did not have the hand and arm movement to do these tasks fully. R1 also did not have access to a microwave. RN-G stated he was not sure about the rice pack, and took the surveyor on a tour of R1's room and no rice pack was found. During phone interview on 1/6/21, at 12:25 p.m. licensed practical nurse (LPN)-B stated had known R1 recently sustained a burn on his hand. R1 was not sure what the original cause was, but knew a treatment was in place. LPN-B stated R1 had a history of using space heaters and R1 was told not to. LPN-B stated R1 would not have been able to use a space heater independently and would have relied on staff to plug it in and use it. LPN-B was not aware of any rice packs or hot packs R1 would have used. LPN-B stated the only microwave was in the nurses office and residents were not able to access it. During interview on 1/6/21, at 12:39 p.m. director of maintence (DM)-A stated space heaters were not allowed in the facility. DM-A stated was not aware of any space heaters being used recently and was not aware of any education that had been provided. If a space heater was found, DM-A stated then it would be removed from resident room, room assessed for environmental issues and DM-A would put something together for the nurse manager to pass on to staffing. DM-A stated any guidance on hot packs would be clinical and handled by the nursing department. RN-A also stated R1 used to keep electric heaters in his room and the last time RN-A saw a portable heater in R1's room might have been a few weeks ago. RN-A stated R1 was not supposed to have the portable heaters in his room, and after the right hand injury, R1's hot packs were no longer allowed in the room. RN-A was unsure of the facility's policy related to portable heaters or hot packs, and stated did not think they were allowed anymore. During a group interview on 1/6/21, at 1:23 p.m. the DON and administrator stated there was no facility policy for hot packs or space heaters but they were not to be used. DON stated they started house wide staff education on 12/28/20, after R1 reported [CONDITION(S)] on his hand were from the rice hot back. DON did not have any documentation for the education. DON stated R1 had a long history of ordering space heaters online and nursing would remove them. DON did not know how often this occurred and stated would have to look it up. DON stated was unsure how R1 opened the packages. During phone interview on 1/6/21, at 2:21 p.m. medical doctor (MD)-B had access to R1's medical record and reviewed them by phone. MD-B stated was familiar with R1. MD-B stated was under the impression R1 had [CONDITION(S)] on his right hand and it might have been caused from a space heater that R1 was not supposed to have. MD-B stated R1 would have relied on staff to set up hot packs or space heaters. During phone interview on 1/6/21, at 3:17 p.m. emergency department (ED) nurse stated R1 arrived in their hospital ED by ambulance the morning of 1/3/21. ED nurse stated R1 was unresponsive upon arrival. ED nurse stated the emergency medical staff (ambulance transport staff) stated R1's right hand wound was caused by a space heater at the nursing home. ED nurse stated a burn consult had been ordered. During phone interview with medical doctor (MD)-A, on 1/6/21, at 4:45 p.m. MD-A stated had seen R1 for a burn consult while R1 was in the hospital. MD-A stated R1's right hand wounds were consistent with a thermal injury. R1 received debridement (medical removal of dead, damaged, or infected tissue) and treatment to the injured skin. R1's Burn Consult PN from the hospital dated 1/6/21, at 5:35 p.m. indicated R1 was noted to have four wounds consistent with thermal injury of his R [right] hand and fingers. The MD had debrided the wounds. The MD noted superficial partial thickness [CONDITION(S)]. During phone interview on 1/6/21, at 6:00 p.m. nursing assistant (NA)-F stated R1 used to have a space heater and it was removed. NA-A was unsure how long ago this was removed. NA-F stated did not think space heaters were allowed. During interview on 1/7/21, at 11:38 a.m. the administrator and DON stated there was not any other documentation related to the incident other than what was provided in their incident report dated 12/28/20. When asked for education, interviews and/or audits the administrator stated they were working on getting that documentation. Administrator also stated they were able to find a policy for space heaters- and they are not allowed in the facility. They stated they did not have a policy for hot packs. The facility provided the following information: a education sign in sheet of employee name and signatures, however the date was blank and subject of in-service was blank. A separate sheet, undated, was provided that identified: No residents should have a space heater or rice pack in the facility. Residents need to use the hot packs that are ordered by Galtier. If you see a space heater or rice pack you need to remove it immediately and notify the nurse manager or nurse supervisor. The DON and administrator indicated this education was provided to staff after R1 was found with blisters on 12/28/20, however, during staff interviews while on site, staff did not indicate they received this education. A facility policy on Accidents and Incidents was requested and not received.

Based on observation, interview and document review, the facility failed to implement interventions to protect the skin and prevent further breakdown of a facility acquired pressure ulcer for 1 of 3 residents (R65) reviewed for pressure ulcers. The failure of the facility to consistently implement ordered interventions, and reassess the effectiveness of the interventions in a timely manner, resulted in the deterioration of a facility acquired pressure ulcer from a stage II to an unstageable ulcer, which resulted in harm for R65. Findings include: On 6/4/18, at 1:43 p.m. R65 was observed laying in bed. R65 was positioned on his back, and covered by a sheet. Under the sheet, R65 had positioned both heels pulled up towards the buttocks, so his knees were bent and in the air as he appeared to be digging both heels into the mattress. There was a light blue structured walking boot with Velcro straps on the bedside table, and another style of unstructured boot that was smaller, soft, and dark blue, in the corner of the bed on top of the sheet. When questioned what the boots were used for, R65 was confused, asking what boots? After pointing to the boots on the bedside table and bed, R65 was unable to state when they were used, and said they were worn in the winter to help with the cold. During observation on 6/5/18, at 9:32 a.m. R65 was asleep in bed. Again, R65 was positioned laying on his back, with both heels pulled up toward his buttocks, with his knees in the air. R65's heels were pressed into the mattress on the bed, and he had a thin sheet pulled up over himself. R65 did not appear to have boots on either foot, as the outline of the foot and toes could be seen under the sheet. The structured light blue boot was observed on the bedside table. During observation on 6/5/18, at 3:56 p.m. R65 was observed lying in bed under a thin, white knit blanket. R65 was not wearing shoes or boots as the outline of the foot and toes could be seen under the knit blanket. R65 was supine, laying flat on the back, with legs straight and both heels resting on the mattress. During interview on 6/5/18, at 4:23 p.m., registered nurse (RN)-D did not believe R65 had any current skin concerns, but wanted to check the eMR (electronic medical record) to be sure. RN-D said R65 had only been living on the unit for about 2-3 weeks. RN-D looked in the eMR and reported that R65 had a history of [REDACTED]. On 6/6/18, at 7:06 a.m., R65 was observed sitting up in a wheelchair in his room with socks on both feet which were resting on the footrests. At 7:08 a.m. R65 propelled himself in the wheelchair into the hallway. He used both arms to slowly move the wheels little by little, and also moved his feet off the foot pedals, pulling the chair along by digging his heels into the floor and pulling. At that time, licensed practical nurse (LPN)-K greeted R65 and stated, Let's get your boots on. LPN-K stated to nearby staff, (R65) needs to wear (his/her) boots all the time. At 7:10 a.m. R65 again propelled self out of the room in the wheelchair. R65 was now wearing the soft, dark blue boots on both feet. The boots covered the heels and sides of the feet, and did not appear to have any firm support, but rather offered a soft, comfort type cushion. The entire top of the boot was open, exposing the top of the foot, except for a single strap over the foot near the ankle. R65 was observed to wander the hallway in the wheelchair until 7:20 a.m. when staff offered to push R65 to the dining room for breakfast. At 7:47 a.m. R65 moved around the dining room in the wheelchair using his feet to dig into the floor to pull himself, using his arms to push the wheels a little at a time. The soft left boot was observed to have slid off R65's heel and was twisted sideways. After breakfast at 8:58 a.m. on 6/6/18, R65 was observed propelling himself back to his room. The left boot was still twisted and was observed to be sliding off the foot, leaving the left heel unprotected. At 9:01 a.m. staff entered R65's room and removed the boots prior to transferring R65 to the toilet. At 9:09 a.m. staff put the soft boots back on R65's feet before leaving R65 in the wheelchair to watch a movie in the room, per the resident's request. During interview on 6/6/18, at 10:06 a.m. the director of nursing (DON) discussed the measurements of the left heel pressure ulcer. The DON explained that a nurse assessed the wound weekly, and that it could be a nurse manager or a nurse on duty. After assessing, the nurse input the description and measurements, along with pictures of the wound, in the electronic wound tracking system. The DON pulled up current treatments in the electronic wound tracking system and it was noted all current treatments had been initiated on 2/23/18: a high calorie supplement, leaving the wound open to air, keeping heels off the bed, using an ointment, and a low air loss mattress. The DON stated she did not see current treatments for the right wound, but thought the treatment should be the same as the left. The DON reviewed the weekly measurements and said the left heel wound had almost closed in April, but had then started scabbing again. The DON confirmed the most recent wound measurements were from 6/4/18, and measured 10.0 centimeters (cm) x 6.0 cm, which was larger than prior measurements (3.5 cm x 3.0 cm on 6/1/18, 2.0 cm x 2.0 cm on 5/7/18). The DON stated she was concerned about the accuracy of how nursing staff measured the wound. In the pictures, staff held up a flexible ruler next to the skin opening to show the wound size, some staff appeared to measure straight across the wound, while others wrapped the ruler around the ankle to measure. The DON stated she was concerned about the large jump in documented measurements from 6/1/18 (3.5 cm x 3.0 cm ) to 6/4/18 (10.0 cm x 6.0 cm), and would ask nursing staff to re-measure the left heel wound to confirm size. On 6/6/18 at 10:35 a.m., R65 was observed to be supine in bed. The covers were turned down, so R65's legs and feet were visible. R65 was not wearing boots, had a sock on the right foot, but nothing on the left foot. R65's heels rested on the bed. The light blue structured boot was missing from the bedside table, and the soft, dark blue boots were on the floor. LPN-K and LPN-D entered the room and prepared to assess and re-measure the left heel. At 10:38 a.m. LPN-K asked LPN-D why the dark blue boots were on the floor and stated, (R65) needs to wear them at all times. LPN-D did not know why the boots were on the floor, but stated R65 sometimes removed them. The bandage on the left heel was balled up and starting to fall off. LPN-D removed the bandage, and washed the wound. There was a large, dry flap of skin still partially attached on one side, and above the flap was a dark purple/black scab type area. At 10:41 a.m., LPN-D measured the the entire area as 7.0 cm x 5.0 cm, and measured the dark area as 4.5 cm x 2.5 cm. LPN-K stated the wound was categorized as unstageable, because there was no way to know how deep the wound went underneath the dark, scabby tissue. LPN-D applied an adhesive foam dressing to the wound, before getting clean socks for R65, as the wound drainage had left rusty, brown spots on the inside of the sock. Review of the R65's admission record documentation revealed R65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], staff had assessed R65 to be severely cognitively impaired, with a brief interview for mental status (BIMS) score of 3 (indicating severe cognitive impairment). The care area assessment for the most recent annual MDS dated [DATE], indicated R65 was at risk for pressure injury due to dependence on staff for activities of daily living, mood/behaviors, and pain. In addition, R65 was assessed to be reluctant to move or change position due to pain, and staff were to provide off loading and repositioning to prevent pressure. Further the assessment indicated licensed staff were to observe for indications of pressure or skin breakdown. Review of the wound record in the electronic medical record (eMR) revealed R65 currently had two pressure ulcers; one on each heel. The right heel blister was currently categorized as unstageable, was acquired in the facility, and was identified on 5/22/18. The left heel blister was currently categorized as unstageable, also acquired in the facility, and was identified on 2/20/18. Pressure Ulcer Documentation Guidelines provided by the facility, and written by the National Pressure Ulcer Advisory Panel, described an unstageable pressure ulcer as being a wound with full thickness tissue loss in which the base of the ulcer is covered by slough (devitalized tissue that is yellow, tan, gray, green or brown) and/or Eschar (dead tissue that is tan, brown or black) in the wound bed. Until the slough/eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. On 6/6/18 at 11:40 a.m., copies of the current nursing assistant care guide was requested. At 3:28 p.m. the DON provided an undated copy of the nursing assistant care guide, which directed nursing assistants to ensure R65 wore Spenco boots on both feet. Under the special requirements section, there was guidance for R65 to wear Spenco boots at all times to protect R65's heels, and that R65 was being fitted for PRAFO boots (custom fitted supportive boots that keep all pressure off heels). The guidance also indicated staff were to provide wound treatments for the heels, and were to turn and reposition R65 every 2-3 hours while in bed. A progress note written on 6/6/18, at 1:13 p.m. included: (Nurse Practitioner) updated and this writer received orders for PRAFO boots to be ordered; will be here at 3 PM to fit (R65) for the boots today. On 6/7/18, at 7:45 a.m. R65 was observed sleeping in bed under a sheet. R65 was laying on his back, and there appeared to be a pillow under R65's knees, because both knees were bent and slightly elevated. The two soft, dark blue boots were observed on the floor next to the bed, and next to them sat a new pair of PRAFO boots. R65 was not observed to be wearing boots as both heels rested on the mattress. On 6/7/18, at 7:51 a.m., LPN-D stated R65 was supposed to be wearing the soft, dark blue boots when R65 was up, and that they should also be on when R65 was in bed. LPN-D also stated R65 did not like to wear the boots, but that they should be on in bed because R65 always dragged both heels against the mattress in bed, which could cause pressure. LPN-D looked in the room at R65, and confirmed R65 was not currently wearing any protective boots. At 8:02 a.m. nursing assistant (NA)-C stated, (R65) has little booties which (R65) is supposed to wear pretty much all the time. NA-C said this was not a new intervention, but mentioned that R65 was newer to this unit. On 6/7/18, at 8:22 a.m. the DON confirmed R65 got PRAFO boots fitted yesterday. The DON described how R65 liked to take his/her feet off the foot pedals when seated in the wheelchair, and rest heels on the floor, pulling his/her bodyweight along in the wheelchair using the heels. The DON said this was how R65 propelled himself around the unit. The DON said the soft, little dark blue boots would twist and come off while R65 moved around the unit in this manner, but the new PRAFO boots were less likely to fall off. The DON said there was a new order created yesterday, which required R65 to wear the PRAFO boots at all times. Before the PRAFO boots, the order was for R65 to wear the Spenco boots at all times, although the DON said R65 did not always like to wear them. The DON explained that when it came to special order footwear, such as the PRAFO boots, therapy first assessed what was appropriate, and then the physician got involved to approve ordering the special footwear. When asked why the PRAFO boots were just ordered yesterday, the DON replied that when the size of the wound recently got bigger, staff looked at the interventions currently in place, and determined that the interventions obviously were not working. Again the DON described how the soft little boots staff were putting on R65 would not stay in place, and would twist around on R65's feet because the resident was very active and self propelled the wheelchair using the feet. On 6/7/18, at 8:30 a.m. R65 was observed with the new PRAFO boots on, which had a hard plastic piece that curved around and away from the heel, providing space between the heel and the boot to protect the heel from pressure, and ensure the heels were floated off the bed. In a follow-up interview on 6/7/18, at 8:37 a.m. the DON was asked why some of the nursing staff did not seem to be aware of R65's pressure ulcers when asked if R65 had any skin concerns. The DON said R65 had moved onto the unit from another floor on 5/7/18, but explained that all the regular staff on the floor should know about R65's heel ulcers. The DON said that even if staff floated on the unit to fill in, and did not typically work on the unit, the details of R65's care were written on the nursing assistant care guide, so all staff should know what R65 needed. The DON again reviewed the left heel ulcer measurements, and noted that the increase in size had occurred after R65 moved onto the new unit. The DON wondered out loud if the new staff needed time to adjust to R65's cares, and get to know R65 after the move. The DON said that the left heel wound previously looked like it was getting better, but had then gotten bigger. The DON questioned whether there was a communication issue, which could be why staff were not all aware of what was supposed to be happening to protect R65's heels. During interview on 6/7/18, at 10:37 a.m. the physical therapy assistant (PTA) confirmed meeting with R65 the day before at the request of nursing staff. PTA said nursing called, and described the manner in which R65 dug both heels into the ground to pull self along in the wheelchair. PTA remembered working with R65 earlier that winter, and confirmed that R65 was in a wheelchair at that time too, and also self propelled in the chair by using a combination of arms and feet. After being called by nursing yesterday, PTA quickly took a look at R65 before contacting the orthotic company to request fitting R65 with PRAFO boots. PTA said the orthotics company was able to come out quickly to the facility yesterday afternoon to fit R65 with the boots. During interview on 6/7/18, at 11:05 a.m. the administrator provided a new nursing assistant care guide, and explained that it had been updated today. The updated care guide included R65's need to wear PRAFO boots at all times on both feet to protect and float the heels, and to encourage R65 to keep boots on. The guide was also updated with the requirement that R65 be turned and repositioned every 20 minutes while in bed. During interview on 6/7/18, at 12:14 p.m., the registered dietitian (RD) described having a conversation with the unit manager about R65. RD explained being made aware of the skin breakdown yesterday, and as a result, added Pure Protein (protein shake) and Juven (nutrition powder for wound healing) to R65's diet. RD explained R65 was previously taking a high calorie supplement which had some protein, but not as much as what R65 currently needed; hence adding Pure Protein and Juven. RD explained how the nutritional supplements needed by any resident really depended on factors such as a resident's body size, and what was going on with a wound. RD said that R65 needed the extra nutritional supplements added, as R65's needs had increased drastically with the wound breakdown. A progress note written on 6/6/18, at 3:20 p.m., indicated RD followed up with (unit manager) regarding resident's unstageable (pressure ulcer). Per (unit manager), resident with history of pressure ulcers and had a stage II (pressure ulcer) on heel. Resident uses (his/her) heels to pull (his/her) wheelchair and resident drags (his/her) heel against the mattress when in bed. (Unit manager) feels this is what caused resident's heels to open. RD will continue to follow. Review of pertinent orders revealed the following: -2/26/18. Left heel blister measuring 4.5 centimeters (cm) x 4.0 cm noted on 2/20/18. Keep clean and dry, monitor for signs and symptoms of infection, or further signs and symptoms of breakdown. Spenco boots on both feet at all times, keep heels off the bed. - 2/26/18. 120 cubic centimeters (cc) of Hi-Cal (high calorie supplement) three times a day. -2/26/18. Apply Vitamin A and D ointment to both feet and legs twice daily. - 2/26/18. Turn and position resident every 2 hours and as needed. -5/22/18. Order for off load boots for 2/2 heel blisters; therapy updated. -6/6/18. PRAFO boots to be worn at all times to make sure that heels remain offloaded. - 6/6/18. Left heel ulcer: monitor for signs and symptoms of infection, or further signs and symptoms of breakdown. Bilateral float boots on at all times, keep heels off the bed. - 6/6/18. One packet of Juven two times a day for wound healing. - 6/6/18. 60 cc Prostat Sugar Free AWC (advanced wound care) nutritional supplement two times a day for wound healing. On 6/5/18, review of the current care plan in the eMR confirmed R65 had the potential for a pressure ulcers related to dermal (skin) frailty, decreased mobility, inadequate nutrition, and dehydration. The care plan described R65 as having history of prior pressure ulcers that had scabbed over and closed. The care plan noted the fluid filled blister to the left heel on 2/20/18. The care plan did not mention the pressure ulcer on the right heel. Interventions included administering treatments as ordered and monitoring for effectiveness. The care plan directed staff to avoid positioning R65 on the left heel, and to keep heels off the bed at all times with bilateral Spenco boots. Additionally, the care plan required staff to monitor the dressing each shift to ensure it was intact and adhering, and assess and record wound healing weekly, by measuring length, width, and depth where possible. Staff were to report improvement and declines to the Medical Doctor. On 6/6/18 at 11:40 a.m. a copy of the care plan was requested. A portion of the care plan was provided, but failed to include the section about pressure ulcers, so unable to determine when the care plan had been last updated at the time of review on 6/5/18. The most recent physician progress notes [REDACTED]. The note had the following written about pressure ulcers: Left heel wound. (Continue) local cares, use Spenco boots. The most recent nurse practitioner progress note in the chart was for an encounter on 3/23/18, and did not mention anything regarding pressure ulcers. The physician progress notes [REDACTED]. The nurse practitioner progress note from a 3/8/18 encounter noted, Left heel dry skin with old blood under from previous blister, and Continue to protect and relieve pressure. The facility utilized WoundRounds, a computer module for monitoring wounds. The module included a Pressure Ulcer Scale for healing (PUSH) score which, according to the National Pressure Ulcer Advisory Panel, is a scoring system that helps compare the improvement (decreasing PUSH numbers) or deterioration (increasing PUSH numbers) of a wound. The PUSH number was calculated each time the wound was assessed, using data collected such as the wound size, drainage amount, and tissue types. Review of the weekly wound monitoring revealed the following history of the right heel pressure ulcer: -5/22/18: Clinical stage: unstageable (full thickness tissue loss in which the base of the ulcer is covered so the true depth can not be determined.) Tissue type: 100% intact skin. 7.0 cm x 4.0 cm, depth unknown. No drainage. PUSH 11. -6/1/18: Clinical stage: Unstageable. Tissue type: 25% bright pink or red. 6.5 cm x 3.5 cm, depth unknown. No drainage. PUSH 11. -6/4/18: Clinical stage: Unstageable. Tissue type: 100% slough (yellow, devitalized tissue) loosely adherent. 6.5 cm x 3.5 cm, depth unknown. No drainage. PUSH 12. Review of weekly wound monitoring revealed the following history of the left heel pressure ulcer: -2/23/18: Clinical stage: Stage II (Partial thickness loss of dermis). Tissue type: 100% blood filled blister. 4.5 cm x 4.2 cm, with no depth. Moderate serosanguineous drainage (contains serum and blood). PUSH 12. -2/26/18: Clinical stage: Stage II. Tissue type: 100% blood filled blister. 3.5 cm x 4.0 cm, with no depth. Moderate serosanguineous drainage. PUSH 12. -3/5/18: Clinical stage: Stage II. Tissue type: 100% blood filled blister. 3.5 cm x 3.5 cm, with no depth. Moderate serosanguineous drainage. PUSH 12. -3/12/18: Clinical stage: Stage II. Tissue type: 100% blood filled blister. 3.5 cm x 3.5 cm, with no depth. Moderate serosanguineous drainage. PUSH 12. -3/22/18: Clinical stage: Stage II. Tissue type: 50% purple ecchymosis (subcutaneous bleeding), 50% slough loosely adherent. 4.0 cm x 3.5 cm, with no depth. Light serosanguineous drainage. PUSH 13. -3/27/18: Clinical stage: Stage II. Tissue type: % purple ecchymosis (subcutaneous bleeding), 50% slough loosely adherent. 4.0 cm x 3.5 cm, with no depth. Light serosanguineous drainage. PUSH 13. -4/2/18: Clinical stage: Stage II. Tissue type: 20% purple ecchymosis, 30% bright beefy red (often indicative of healthy, healing tissue), 50% slough loosely adherent. 4.0 cm x 3.5 cm, with no depth. Light serosanguineous drainage. PUSH 13. - 4/10/18: Clinical stage: Stage II. Tissue type: 20% purple ecchymosis, 30% bright beefy red, 50% slough loosely adherent. 4.0 cm x 3.5 cm, with no depth. No drainage. PUSH 12. -4/16/18: Clinical stage: Stage II. Tissue type: 20% purple ecchymosis, 30% bright beefy red, 50% slough loosely adherent. 2.0 cm x 3.0 cm, with no depth. No drainage. PUSH 10. -4/23/18: Clinical stage: Stage II. Tissue type: 20% purple ecchymosis, 30% bright beefy red, 50% slough loosely adherent. 2.0 cm x 3.0 cm, with no depth. No drainage. PUSH 10. -5/2/18: Clinical stage: Stage II. Tissue type: 20% purple ecchymosis, 30% bright beefy red, 50% slough loosely adherent. 2.0 cm x 3.0 cm, with no depth. No drainage. PUSH 10 -5/7/18: Clinical stage: Stage II. Tissue type: 20% purple ecchymosis, 30% bright beefy red, 50% slough loosely adherent. 2.0 cm x 2.0 cm, with no depth. No drainage. PUSH 9. -5/16/18: Clinical stage: Unstageable. Tissue type: 45% blood filled blister, 55% purple ecchymosis. 4.0 cm x 5.0 cm, depth unknown. No drainage. PUSH 10. -5/22/18: Clinical stage: Unstageable. Tissue type: 65% deep maroon, 35% slough loosely adherent. 3.5 cm x 3.0 cm, depth unknown. No drainage. PUSH 11. -6/1/18: Clinical stage: Unstageable. Tissue type: 65% deep maroon, 35% slough loosely adherent. 3.5 cm x 3.0 cm, depth unknown. No drainage. PUSH 11. -6/4/18: Clinical stage: Unstageable. Tissue type: 55% slough non-adherent, 45% necrotic (dead) hard adherent. 10.0 cm x 6.0 cm, depth unknown. Moderate serosanguineous drainage. PUSH 16. -6/6/18: Clinical stage: Unstageable. Tissue type: 50% deep maroon, 50% slough loosely adherent. 7.0 cm x 5.0 cm, depth unknown. Moderate serosanguineous drainage. PUSH 15. The Skin Management Guideline, effective 11/28/17, had the following purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. Additionally, per the guideline, a complete, comprehensive evaluation guides the identification of residents at risk, and factors predicting the risk for breakdown; identification of interventions to stabilize, reduce or remove underlying risk factors; evaluate the effectiveness of interventions; modify the interventions as appropriate. The dietitian will be notified upon discovery of a wound, when a wound declines unexpectedly, and if a wound is not showing progress in 2-4 weeks. A therapy evaluation will be requested for positioning and treatment as appropriate upon admission and with a change in condition. Evaluate interventions per risk factors identified and re-evaluate and modify the plan of care based on root cause analysis for new skin alterations. Consult with a physician/nurse practitioner, family and supervisor/designee if the ulcer(s) has not shown progress in two weeks. Consult with the physician/nurse practitioner if the wound is deteriorating or increases in size. Re-evaluate plan of care as appropriate. Post survey, on 6/9/18, at 9:31 a.m. the administrator forwarded information by email that had not been provided during survey. The documentation provided post survey indicated the interdisciplinary team had reviewed R65's status and had updated the resident's care plan to include: 1. Therapy recommended Prafo boots on at all times 2. Interventions were placed in the (point of care) Task list to monitor resident self-removal/displacement of the brace. 3. An air mattress was ordered. 4. Care delivery guides updated to reflect the changes. In addition, the email indicated the interdisciplinary team had completed an action plan on 6/7/18, regarding proper assessment and staging of pressure ulcers, including education with proper positioning, placement, and pictures utilized for WoundRounds. The information provided did not diminish the facility's responsiblity to ensure interventions prescribed should have been implemented, and did not diminish the fact the resident's heel ulcer had increased from a Stage II to an unstageable ulcer.