Every finding on record at The Waterview Pines LLC

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours a day. This had the potential to affect all 67 residents who resided at the facility. This was at past non-compliance do to no RN coverage addressed in the last two quarterly staffing records.Findings include: Review of the facility Staffing Schedules dated 1/1/25 through 6/30/25, revealed there was no RN coverage for the following dates: 1/25/25, 1/26/25, 2/9/25, 3/22/25, 3/23/25, 4/5/25, 4/6/25, 4/19/25, 4/20/25, 5/3/25, 5/4/25, 5/17/25, 5/18/25, 5/26/25, 6/14/25, 6/28/25, and 6/29/25.During an interview on 1/13/26 at 3:43 p.m., the corporate administrator stated the facility had a lot of issues with higher and getting agency staff to work during the first part of the year. The facility was aware there were several days from 1/1/25 through 6/30/25 that did not have RN coverage as required. They daily staffing schedules for 1/1/25 through 6/30/25 were reviewed by the corporate administrator and facility administrator and confirmed there were no RN coverage on the dates listed.Facility staffing policy was requested but not provided.

Based interview and record review the facility failed to ensure psychotropic PRN (as needed) medication orders were timed limited to a duration of 14 days for 1 of 5 residents (R9) who was reviewed for psychotropic medications. Findings include: R9's quarterly Minimum Date Set (MDS) dated [DATE], indicated R9 was cognitively intact with diagnoses of anxiety disorder, major depression, diabetes, and chronic diastolic heart failure. MDS section N. indicated R9 received high risk anti-anxiety medications. R9's facility provided undated Care Plan identified focus areas and interventions to support and monitor R9's behavior and mental health needs related to diagnoses of depression, anxiety, insomnia. Upon entering the facility on 1/12/26 R9's electronic medical record (EMR) orders included the order: alprazolam take 0.5mg every 24 hours as needed (PRN) for increased anxiety. The ordered date was 9/15/20/25. The order did not have a stop date. Pharmacy Consult Recommendations included:-10/22/25: the resident has order for alprazolam 0.5 mg give one tab as needed q 24-hour prn without stop date. Please consider discontinuation or add stop date per CMS regulation. Provider documented response: disagree pt is stable at current dose will reevaluate at next appt. -9/17/25: alprazolam no stop date. Please consider add stop date or discontinuation per CMS SOM. Provider response on 9/23/25 requested follow-up with range mental health who manages med During an interview on 1/15/26 at 11:54 a.m., clinical manager licensed practical nurse (LPN-A) stated R9's alprazolam order needed to have a new script every 14 days. LPN-A stated they did notify the provider to send a new script to the pharmacy every 12 days. They tracked the notification in a calendar but did not enter any orders into the EMR or have record of orders they had requested the provider send to the pharmacy. During an interview on 1/15/26 at 11:58 a.m., the director of nursing stated all PRN psychotropic medications needed to have stop date every 14 days for provider review and reorder if needed. R9 should have had a stop order and a renewal order for their alprazolam. Nurse consultant was present and stated their facility policy allowed nursing to stop PRN medication at 14 days to trigger the provider to reorder the medication. The facility policy Psychotropic Medication Use dated 5/2025, outlined the following instruction for the use of PRN psychotropic use: psychotropic PRN medications are to be used to address acute or intermittent symptoms, or in an emergency and are limited to 14 days. If a provider believes the PRN order should be extended beyond 14 days, the provider must document rationale and duration in the medical record.

Based on observation, interview and document review, the facility failed to review and revise the resident care plan to include chemotherapy, breathing problems and oxygen use for 1 of 3 residents (R31) reviewed for care planning.R31's quarterly minimum data set (MDS), dated [DATE], identified a diagnosis of congestive heart failure (CHF), rectal cancer, and atrial fibrillation.R31's care plan, dated 12/11/25, didn't contain a focus statement for coordination and care of R31's chemotherapy treatments, breathing problems or oxygen use.R31's provider orders, dated 1/12/26, didn't contain orders for oxygen use or the care and keeping of oxygen equipment.R31's Weights and Vitals Summary identified R31 was wearing oxygen via nasal cannula on dates when oxygen saturation levels were recorded starting on 10/29/25 through 1/15/26.R31's provider progress note dated 10/29/25, identified new orders related to CHF: repeat chest x-ray next week, monitor vital signs every shift for two weeks, monitor oxygen saturation every shift daily and as needed for two weeks, if 90 percent or less update provider, oxygen use during the day at two liters per minute (LPM) via nasal cannula while on chemotherapy, make sure oxygen is on at one LPM during the night. A provider progress note from 11/5/26, identified to continue to monitor oxygen use at two LPM via nasal cannula every shift, resident occasionally has nasal cannula not in nostrils.During an observation and interview on 1/12/26 at 3:35 p.m., R31 was observed wearing an oxygen cannula on his nose, the oxygen concentrator was set at one liter per minute (LPM) and R31 stated he wore oxygen daily.During an observation on 1/14/26 at 7:10 a.m., R31 was in bed sleeping, oxygen cannula was on his nose, and the concentrator was running. During an interview on 1/14/26 at 12:23 p.m., licensed practical nurse (LPN)-B stated R3 occasionally wore oxygen.During an interview on 1/14/26 at 2:36 p.m., the director of nursing (DON) stated continuous and as needed (PRN) oxygen should have orders for them. The DON also stated she thought R31 had an order for oxygen because they were working on weaning him down and making sure his saturations stayed in an acceptable range.During an interview on 1/15/26 at 9:23 a.m., physical therapy assistant (PTA)-E confirmed he had been working with R31 since his admission, and R31 had been wearing oxygen when PTA-E was working with him, he thought R31 was currently on one LPM and checked his oxygen saturation levels while working with him. During an observation on 1/15/26 at 9:33 a.m., R31 was wearing oxygen via nasal cannula connected to an oxygen concentrator. During an interview on 1/15/26 at 10:28 a.m., LPN-A who was the clinical manager for R31, stated she would want orders in place if the resident was using oxygen. LPN-A confirmed R31's medical record didn't contain orders for oxygen.

Based on observation, interview and document review, the facility failed to ensure a resident who was unable to perform their own activities of daily living (ADL)s received nail care for 1 of 3 residents (R44) reviewed for ADLs.R44's quarterly minimum data set (MDS), dated [DATE], identified significant cognitive impairment and a diagnosis of late-onset Alzheimer's dementia. The MDS further indicated R44 was dependent in all ADLs. R44's care plan, dated 8/6/25, identified a focus statement for assistance with ADLs related to dementia, osteoarthritis, weakness and falls. Interventions included an assist of one with all ADL tasks including nail care, specifically to trim fingernails and toenails as needed on shower days. The care plan didn't include podiatry care for her toenails, nor did it address behavior or resistance to having nails trimmed. R44's provider orders, dated 8/6/25, identified an order to check fingernails and toenails once a week and provide nail care every Wednesday. Document in nursing note of any behaviors or refusals. R44's electronic medical record (EMR) didn't contain a progress note related to bathing, nail care or refusals of nail care on Wednesday 1/7/26. An assessment, Weekly Skin Inspection dated 1/7/26, identified R44 had a bath or shower and had her finger and toenails trimmed. During an observation and interview on 1/13/26 at 1:39 p.m., family member (FM)-D stated he was having issues with R44's nails not being taken care of, and unbeknownst to him was removed from the podiatry list so her nails didn't get taken care of. FM-D stated he had looked at R44's feet in the first place because she was complaining of foot pain, and he found the great toes each had about one inch overhang from the end of the toe. FM-D also stated he had told the nursing home in writing to put her back on the podiatry list and he had talked to the administrator about it. At 1:49 p.m., FM-D opened R44's hands, as her fingers were pulled in close to her palm, and remarked her fingernails were at least one-quarter inch long, there was brown matter under some of the nails, other nails appeared to be stained. FM-D stated he didn't like to see them like this and thought they needed a trim. During an interview on 1/13/26 at 3:28 p.m., nursing assistant (NA)-E stated they would be responsible for trimming resident nails for non-diabetics only, the diabetics were done by the nurse. During an interview on 1/13/26 at 3:31 p.m., licensed practical nurse (LPN)-C stated R44's toenails were too thick for them to cut, but they could do her fingernails. During an observation and interview on 1/13/26 at 3:35 p.m., LPN-A, who was the clinical nurse manager for R44, stated R44 screamed bloody murder when they tried to trim her nails, and her family was aware of that. LPN-A stated she would expect nail care was done if it was documented as done. LPN-A looked at R44's fingernails and stated they were long and dirty as well. LPN-A stated she would have expected a nursing note and a notice to herself if R44 were refusing. During an interview on 1/13/26 at 3:58 p.m., the director of nursing (DON) stated she expected resident nails to be trim and clean. The DON explained she would have expected the nurse to have made a note if a resident were refusing care.Activities of Daily Living (ADL)s and Maintain Abilities Policy dated 3/31/23, identified a resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure orders were in place for a resident receiving oxygen for 1 of 7 residents (R31). In addition, the facility failed to assess and treat lower extremity edema for 1 of 7 residents (R23) reviewed for quality of care. Findings include: R31: R31's quarterly minimum data set (MDS), dated [DATE], identified a diagnosis of congestive heart failure (CHF), rectal cancer, and atrial fibrillation. R31's care plan, dated 12/11/25, didn't contain a focus statement for breathing or oxygen use. R31's provider orders, dated 1/12/26, didn't contain orders for oxygen use or the care and keeping of oxygen equipment. R31's Weights and Vitals Summary identified R31 was wearing oxygen via nasal cannula on dates when oxygen saturation levels were recorded starting on 10/29/25 through 1/15/26. During an observation and interview on 1/12/26 at 3:35 p.m., R31 was observed wearing an oxygen cannula on his nose, the oxygen concentrator was set at one liter per minute (LPM) and R31 stated he wore oxygen daily. During an observation on 1/14/26 at 7:10 a.m., R31 was in bed sleeping, oxygen cannula was on his nose, and the concentrator was running. During an interview on 1/14/26 at 12:23 p.m., licensed practical nurse (LPN)-B stated R3 occasionally wore oxygen. During an interview on 1/14/26 at 2:36 p.m., the director of nursing (DON) stated continuous and as needed (PRN) oxygen should have orders for them. The DON also stated she thought R31 had an order for oxygen because they were working on weaning him down and making sure his saturations stayed in an acceptable range. During an interview on 1/15/26 at 9:23 a.m., physical therapy assistant (PTA)-E confirmed he had been working with R31 since his admission, and R31 had been wearing oxygen when PTA-E was working with him, he thought R31 was currently on one LPM and checked his oxygen saturation levels while working with him. During an observation on 1/15/26 at 9:33 a.m., R31 was wearing oxygen via nasal cannula connected to an oxygen concentrator. During an interview on 1/15/26 at 10:28 a.m., LPN-A who was the clinical manager for R31, stated she would want orders in place if the resident was using oxygen. LPN-A confirmed R31's medical record didn't contain orders for oxygen. R23: R23's admit Minimum Data Set (MDS) dated [DATE], indicated R23 was moderately cognitively impaired with diagnoses of venous insufficiency, acute respiratory failure, and ischemic cardiomyopathy. R23's undated facility provided Care Plan included focus area: Alteration in skin integrity with interventions: monitor skin during cares, weekly skin inspection by nurse, tubi grips on in a.m. and off in h.s. [bedtime]. R23's Order Summary Report dated as of 1/15/2026, included the following orders:-Tubi grips [material designed to provide compression and reduce swelling] on in a.m., off at H.S. every morning and at bedtime related to acute combined systolic and diastolic congestive heart failure. -Weekly skin inspection by licensed nurse. Complete MHM Weekly Skin In section in PCC every day shift every Thursday.-Orders did not include treatments or lotions for legs. R23's Treatment Administration Record (TAR) for the month of January 2026, had documented entries between 1/1/26 and 1/14/26, were signed off to indicate R23's tubi grips had been put on in the a.m. and removed at bedtime. R23's ordered Weekly Skin Inspection were documented as follows in the electronic medical record (EMR): -11/13/25: Res skin is dry and intact -11/28/25: did not see skin but NA had her dressed and said there was no issues. edema lower legs -12/10/25: BLE edema, no weeping noted from legs, scabs. No other skin issues noted -12/18/25: Edema bilateral lower extremities which are reddened but not weeping at this time. Dry scaly skin on legs. No other skin issues noted. -12/25/25 Edema bilateral lower extremities which are reddened but not weeping at this time. Dry scaly skin on legs. 12/31/25 entry: No new skin issues. Skin is dry warm and intact -1/8/26 no new skin issues skin is dry warm and intact During an interview on 1/12/2026 at 5:23 p.m., R23 was wearing knee high socks and was seated in a recliner with legs elevated. R23 stated they had bad edema in their legs and indicated their family member (FM-A) was the one who took care of their legs. Their legs had been really big and leaking fluid before, but now the fluid was way down and their legs hurt less. R23 stated they didn't really have any treatments for their legs other than a water pill. During an interview on 1/12/26 at 6:00 p.m., both R23 and FM-A were present. R23 stated FM-A cared for their legs not the nurses. FM-A, was not sure what the nurses did, but confirmed they did care for R23's legs during daily visits. FM-A stated R23's legs still had dryness and edema, and scabs (pointed to several scabs on R23's left leg -skin on leg was dry with flakes of skin) but overall R23's legs were much improved. R23 stated she liked to wear their white socks because they were absorbent and comfortable. FM-A stated they had bought the socks for R23 and indicated they were just cotton, not compression socks. During an observation on 1/13/26 at 9:42 a.m., R23 was seated with white knee-high socks on. During an interview on 1/13/26 at 2:15 p.m., R23 was seated with legs elevated wearing white knee-high socks. R23 stated they had kept their socks on from yesterday, nobody had offered to put tubi grip sock for them this a.m. R23 stated they had worn compression tubi things before but could not recall when they had last worn them. No tubi grips were visible in R23's room or bathroom. During an observation on 1/13/26 at 4:14 p.m., R23 was seated in recliner with the same knee-high socks on. During an observation on 1/14/26 at 7:16 a.m., R23 was seated in recliner, feet up, wearing the same knee-high socks. During an observation on 1/14/26 at 8:06 a.m., R23 remained in room with same knee-high socks on. During an observation on 1/14/26 at 11:58 a.m., R23 was being wheeled down the hall wearing the same white knee-high socks. R23 stated they were off to an appointment. During an interview on 1/14/26 at 3:13 p.m., licensed practical nurse (LPN-B) explained when they initialed something in the TAR it meant the task or treatment had been completed. LPN-B stated they had signed off on R23's tubi grips because they thought that R23 had been wearing them, but now they guessed they had not been on. LPN-B stated it was important for R23 to wear tubi grips because it helped prevent deep vein thrombosis (blood clots). During an interview on 1/14/26 at 3:15 p.m., the director of nursing (DON) stated when a task was signed off in the TAR it meant that task was completed. If a task was refused or not completed, they expected charting would reflect that. During an observation on 1/15/2026 at 9:45 a.m., R23 was seated in their recliner wearing their white knee-high socks. NA-D responded to R23's call-light and assisted R23 to the bathroom. During an after-care interview NA-D stated R23 did not wear tubi grips or anything like that. During an interview on 1/15/26 at 9:55 a.m., R23 was wearing white knee-high socks and stated staff had not offered to put any tubi compression things on them that morning. R23 stated their legs were more swollen today because of their appointment yesterday but overall, they felt their legs were much better. R23 indicated the staff didn't do any treatments to their legs, it was FM-A who had been washing and putting some kind of cream on their legs each day when they visited. During an interview on 1/15/26 at 11:44 a.m., clinical manager LPN-A opened R23's chart and stated R23 was not being tracked in wound care because R23 did not have any active wound treatments. Instead R23's leg issues were being tracked in the weekly skin assessments. LPN-A reviewed documented skin assessments and stated they would expect skin assessments to reflect skin changes like new scabs and ideally old scabs and/or other ongoing skin issues. Details were important to determine improvement or worsening skin status. Although R23 did not have orders for lotion application to dry skin, it was expected that NAs would identify and apply lotion to dry skin as part of their routine care of residents. LPN-A confirmed R23 had an order for tubi grips and confirmed charting showed that R23 had been wearing tubi grips each day in January as ordered. It was important for R23 to wear the tubi grips because of the fluid retention R23 had in their lower legs. LPN-A indicated they were not aware R23 had not been wearing their tubi grips and stated they expected staff to document a task as not done if it was not done and communicate to them if it was ongoing so it could be addressed. During an interview on 1/15/26 at 12:05 p.m., the DON stated they expected skin inspection documentation to include descriptive findings of old and healing wounds as well as any new edema, weeping, scabs, or any other area of concern so the information could be used to implement or change treatments accordingly. When tubi grips are ordered, clinical managers should make sure the tubi grips are in the room and being applied as part of their resident monitoring oversight. Nurses are also responsible to ensure TAR orders are followed and should note if a resident is or is not wearing their tubi grips when they go into the resident's rooms and then document accordingly. The facility policy Skin Assessment & Wound Management dated 2/2025, included direction for daily skin inspection with cares, weekly skin inspection by licensed staff, implementation of appropriate preventive measures and referrals, notification and or update to provider, nurse, and family for new or ongoing skin issues as needed, care plan updating as needed, and to provide care and treatments as ordered.

Based on interview and document review the facility failed to monitor fluid intake for a resident on a fluid restriction and on dialysis. This effected 1 of 2 (R8) residents reviewed for dialysis.Findings include: R8's admission Minimum Data Set (MDS) dated [DATE] indicated R8 was cognitively intact. Diagnoses included anemia, coronary artery disease, and end stage renal disease. R8 received hemodialysis while at the facility. R8 care plan dated 12/11/25, indicated risk of complications related to dialysis. Interventions included fluid restriction per order. The care plan also indicated a potential alteration in nutrition related to end stage renal disease on a 1500 milliliter (ml) fluid restriction. R8's Order Summary Report (OSR) dated 12/10/25, indicated a provider order for 1500 ml per 24 hours was entered. 600 ml came from nursing and 900 ml came from dietary Review of R8's Treatment Assessment Report (TAR) from 12/10/25 to 1/14/25 indicated there was a fluid restriction of 1500 ml every 24 hours that needed documented on every shift. The TAR also indicated the following: Not applicable (NA) was entered 27 times in December and 15 times in January for nursing and dietary intakes.An x was entered two times in December and 6 times in January for nursing and dietary intakes.The spot was left blank 3 times in December and one time in January for nursing and dietary intakes During an interview on 1/14/26 at 11:55 a.m., the dialysis center registered nurse (RN)-A stated R8's dry weights (weights after fluid removed during dialysis) were not getting reached. She had low blood pressures which made it difficult to get all the fluid off. There are several reasons that can cause this, but excess fluid intake is one of them. It is important to accurately monitor R8's fluid restriction because of the need to get all fluid off the patient without compromising the patient. During an interview on 1/15/26 at 10:03 a.m., nurse assistant (NA)-A stated all residents on a fluid restriction would be noted on their care plans. The total amount would be separated by how much nursing gave and how much dietary gave. Nursing would enter the total amount of fluid drank each shift when they were eating in their rooms. The nurse assistant was responsible to keep track of the fluid intakes and give them to the nurse to document in the medical record. NA-A did acknowledge R8 was on a 1500 ml fluid restriction. During an interview on 1/15/26 at 10:10 a.m. RN-B stated the aides gathered the fluid intakes for each shift and then gave them to the nurse to enter. The nurse would enter zero of nothing was taken in by nursing or dietary for the shift they were documenting on or enter the exact amount drank if fluid intake occurred. During an interview on 1/15/26 at 10:15 a.m., RN -C stated nursing was responsible for documenting all intakes for the residents in the medical record. There should always be a number entered into each slot on the chart. NA, an x and blank spots were not supposed to be there when a resident was on a fluid restriction. During an interview on 1/15/26 at 10:34 a.m. the director of Nursing (DON) stated all staff should be documenting accurate fluid intakes each shift when a resident is on a fluid restriction. Facility policy Fluid Restriction Guidelines last dated 9/12, indicated fluid intakes would be measured every shift per policy of facility.

Based on observation, interview, and record review the facility failed to ensure portable oxygen tanks were safely transported and/or secured for 1 of 2 residents (R23) reviewed for oxygen safety. Findings include: R23's admit Minimum Data Set (MDS) dated [DATE], indicated R23 was moderately cognitively impaired with diagnoses of venous insufficiency, acute respiratory failure, and ischemic cardiomyopathy. R23's Care Plan included focus area: Alterations in oxygen/gas exchange with oxygen use as ordered. R23's Order Summary Report dated as of 1/15/2026, included the following orders: Check portable oxygen/stroller every shift and fill if needed, and Oxygen Delivery System via 2LPM nasal cannula continuously for diagnosis acute respiratory failure with hypoxia. R23's Treatment Administration Record for the month of January 2026, had documented entries between 1/1/26 and 1/14/26,that indicated staff had checked R23's portable oxygen/stroller every shift and filled if needed. During an interview on 1/12/2026 at 5:23 p.m., R23 was seated in a recliner. R23's oxygen was connected to a large oxygen concentrator in the room. There was a free standing portable green cylinder oxygen tank located to the left of the concentrator sitting upright and directly on the floor. Both R23 and R23's family member (FM-A) stated the oxygen tank had been directly on the floor like that for a long time. Nursing assistant (NA-C) delivered R23's dinner tray and left the room. During an oxygen follow-up interview on 1/12/26 at 5:46 p.m., NA-C looked in R23's room and confirmed there was a free-standing unsecured oxygen tank directly on the floor in R23's room and stated they would need to get the RN because it was not safe to have an oxygen tank sitting in the room like that. Registered nurse (RN-B) entered R23's room, picked up the tank and carried it out of the room. During a follow-up interview on 1/12/26 at 6:30 p.m., RN-B stated they had removed the tank from R23's room and secured it in their oxygen storage area because unsecured oxygen created many safety risks. During an interview on 1/15/26 at 11:30 a.m., the director of nursing stated oxygen tanks should not be carried or left unsecured in the building due to the safety risks associated with oxygen tanks. The DON indicated they expected staff to use a wheeled oxygen tank carrier when they transported oxygen tanks. Staff were also expected to ensure oxygen tanks were secured in appropriate holding devices at all times. The facility policy on safe oxygen storage and handling was requested but not received.

Based on observation, interview and document review the facility failed to perform appropriate hand hygiene while doing a brief change. The facility also failed to utilize appropriate personal protective equipment (PPE) for a resident in enhanced barrier precautions. This affected 2 of 5 resident (R54, R6) reviewed for infection control.Findings include: R6: R6's significant change Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included chronic obstructive pulmonary disease (a progressive lung condition that blocks airflow, making it hard to breath), right foot drop, spinal stenosis lumbar region with neurogenic claudication (nerve compression in the lower back from a narrowed spinal canal, causing symptoms like leg pain, cramping, numbness, or weakness that worsen with standing/walking), heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs), hypertension, and opioid dependence. In addition, R6's MDS identified he was cognitively intact and was dependent on staff for assistance with activities of daily living (ADLs). R6's MDS identified he was frequently incontinent of bowel. R6's care plan dated 12/9/25, identified R6 was on enhanced barrier precautions related to wounds and foley catheter. Interventions included to don and doff personal protective equipment when providing high contact cares. R6's Active Orders as of 1/15/26, identified he had orders for enhanced barrier precautions while providing wound cares and other high contact care activities dated 12/9/25. During an observation on 1/13/26 at 1:25 p.m., nursing assistant (NA)-F entered R6's room, with a non-powered manual sit-to-stand transfer aid (NA-F was not wearing an isolation gown). NA-F closed the curtains, lowered the bed, prepared the bed with a lift sheet, put on gloves put did not put on an isolation gown and positioned R6 to use the transfer aid. After assisting R6 into the bed, NA-F gave R6 the call light, removed gloves, performed hand hygiene and took the transfer aid out of the room. NA-G and NA-F entered the room, both donned gloves, no isolation gowns and proceeded to complete a brief change (incontinent of stool). NA-F called for a nurse to check skin and to complete dressing changes. The director of nursing (DON) entered the room, she had gowned and gloved prior to entering the room. The DON performed the dressing changes, doffed the gown and gloves in the room, washed her hands with soap and water and exited the room. NA-F had removed her gloves after the brief change and washed her hands. NA-F put new gloves on and emptied R6's foley catheter. NA-F removed her gloves and performed hand hygiene before exiting the room. During an interview on 1/13/26 at 1:57 p.m., the DON verified the NAs should have been wearing isolation gowns when they were completing personal cares for R6 related to his foley catheter and wounds. Enhanced Barrier Precautions dated 4/1/24, identified It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy identified staff would wear gowns and gloves during high-contact resident care activities for residents known to be colonized or infected with a multi-drug-resistant organism (MDRO) as well those at increased risk of MDRO acquisition. Examples given were those residents with wounds or indwelling medical devices. High-contact resident cares included transferring, providing hygiene and changing briefs. R54: R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, incontinence of bowel and bladder, and maximal assist to dependent for toileting, hygiene and cares. Diagnoses included non-traumatic brain dysfunction and dementia. During observation on 1/14/26 at 8:38 a.m., nurse assistant (NA)-B entered R54's room to change clothes, do a brief change and get up in chair. NA-B gathered all needed equipment and placed on the bedside table. Hands were washed and clean gloves were placed on hands. The dirty gown was pulled down to the chest level, and the upper body was washed across the shoulders, neck and upper torso. The dirty gown was then completely removed from the resident, and a clean shirt was placed on the resident. Hands were not washed, and gloves were not changed at any time when going from dirty to clean. NA-B then gathered pants and placed them on the resident, pulling just up to the knees, still wearing the same dirty gloves. The brief was removed and peri care performed. Ointment was applied to the buttocks after cleaning. A clean brief was placed under the resident. NA-B removed the right-handed glove and proceeded to complete the brief change, touching the brief and peri area with the ungloved right hand several times. NA-A also came in contact with the dirty linens on the bed with the ungloved right hand. The Glove on the left hand was then removed. Without gloving, NA-B rolled R54 side to side, pulling the pants up the rest of the way, and removed all of the dirty linens under R54 with ungloved hands. New gloves were then put on without washing hands, the lift sling was placed under R54 and R54 was transferred from the bed to the chair. R54 was then taken to the hallway and setup for breakfast. Gloves were removed and hand sanitizer was used at that time. During an interview on 1/14/26 at 10:03 a.m., nurse assistant (NA)-B stated hands should be washed and new gloves put on when going from the dirty part of cares and start of clean part of cares. Gloves should never be removed and cares performed with ungloved hands. NA-B acknowledge she did not change gloves during cares and removed a glove and completed a brief change with an ungloved hand. During an interview on 1/15/26 at 10:03 a.m., the infection preventionist/director of nursing (IP) stated gloves needed to be changed and hands washed anytime they were going from dirty to clean when providing peri care. Example given was when the staff finished brief removal and cleaning of the peri area, hands would need to be washed, and gloves changed before placing the new clean brief on the resident. Facility policy Handwashing Policy last revised 2/24, indicated proper hand-washing techniques would be used to protect the spread of infection. Hand washing would be completed after changing incontinent products or cleaning up after someone who has used the toilet. The policy lacked information about hand hygiene when doing cares and placing clean items on right away.

Based on interview and document review, the facility failed to ensure the past three years of recertification and complaint survey results were available for review. This had the potential to affect all 67 residents residing in the facility, as well as family, visitors and staff.Findings include: On 1/12/26, at 7:27 p.m., a review of the survey binder was completed. Upon review of the survey binder, it was noted that all required recertification surveys, as well as complaint investigation surveys were present, with the exception of the recertification and complaint surveys for the year 2023. During an interview on 1/13/26 at 3:34 p.m., the administrator stated there should be three years of recertification and complaint surveys available for all residents, family and visits to view when wanted. the administrator stated she had just gone through the survey binder a month ago and made sure all needed surveys were in the binder.During an interview on 1/13/26 at 3:48 p.m., the corporate administrator reviewed the survey binder and confirmed all surveys from 2023 were missing and should be in there. A facility policy about the survey binder was requested but not provided.

Based on observations, interviews, and record review the facility failed to promote dignity and respect for 1 of 3 residents (R1) who required assistance with activities of daily living (ADLs) and reported rough and disrespectful care by staff.Findings include: R1's Entry Minimum Data Set (MDS) dated [DATE], identified admission to facility on 9/25/25, from an acute care hospital. R1's care plan (CP) dated 9/26/25, identified he was vulnerable to abuse and instructed staff to monitor for signs of emotional distress, mood or behavior changes and continue to follow the facility's Vulnerable Abuse Reporting policy and directed R1 was independent with activity choices and staff were to respect his choices of preferred room leisure time. CP also indicated R1 had an alteration in mobility related to colon cancer, edema (fluid retention), pain, and malnutrition with a goal he would move safely within his environment; staff were directed to assist with movement in bed and in/out of bed assist of one with front wheeled walker/wheelchair. R1 also had an alteration in mood, behaviors, and psychosocial well-being related to adjustment to facility and current health condition and staff were directed to reapproach R1 when he refused (cares, medications, linen changes to bed) with a soft tone and give him time and options, monitor and document mood state/behaviors upon occurrence, and provide emotional support, validation and comfort measures as needed (PRN). R1's progress notes from 9/26/25, identified: -at 10:32 a.m. R1 refused to allow nursing assistant (NA) and registered nurse (RN) on shift to complete cares and all scheduled medications. Writer went into resident room and spoke with him. He stated, can't you guys just let me sleep for a few more hours and come back. Writer said yes and asked if he had any pain or needed pain medication. He denied pain at that time. -at 7:36 a.m. On Hospice, laid in bed. Not willing to have a full body check due to pain. -at 3:15 p.m. Hydro morphine Hydrocholoride (HCL) 2 milligrams (mg) administered by mouth (po) every 1 hour as needed for low back pain and cancer.-at 6:14 p.m. Follow-up pain scale was 5 out of 10. PRN administration of Hydro morphine was ineffective. Review of the nursing assistant (NA) tasks documentation dated 9/26/25, identified: no behavior charting. During an observation on 10/2/25 at 8:50 a.m., NA-A offered to change his bed; he refused until later and exited the room. During an observation/interview on 10/2/25 at 8:55 a.m. R1 laid in a dark room on bed fully dressed covered with a blanket. R1 stated he was admitted to the facility on [DATE], and the stay had been ok, but the staff would not listen to him, and he was feeling upset about that. R1 had told staff when he was sleeping, he did not want to be bothered. R1 stated one afternoon, right after he was admitted to the facility, a staff NA was ruff with him while she assisted him. The NA moved his legs too fast and almost ripped out his drainage tube. He explained they did not get along or see eye to eye, and she lacked respect for his wishes. R1 stated there was also another female NA in the room when the incident occurred, adding the day it happened NA-A was told he did not want her in his room or taking care of him anymore, then today, she had been assigned to him. This was upsetting for him, and he did not want her in his room or caring for him. There was lack of respect and she refused to listen to what his needs were. He wanted to get back to sleep, not be bothered and would let staff know when he wanted his bed changed. During an interview on 10/2/25 at 9:44 a.m., director of nursing (DON) stated she had gone into R1's room along with NA-A and asked if he wanted to be washed up and dressed for the day and he requested to be left alone and allowed to sleep. She left early that day and was unaware of any concerns R1 may have had or that he did not want NA-A to care for him. During a follow-up interview on 10/3/25 at 11:15 a.m., DON stated she went back yesterday (10/2/25) and realized she had received an email from the floor manager RN-A on 9/26/25 at 3:44 p.m. which indicated MD stopped to see R1, heard him crying due to pain while cares were provided by two staff NAs. MD requested NA-A not be allowed to care for R1. DON stated if she would have been contacted that day she would have removed NA-A from the floor immediately, began an investigation, interviewed all residents she had taken care of, completed skin checks on all cognitively impaired residents, and if signs and symptoms of abuse or neglect were found, reported it within two hours to the state. She would have expected to be contacted by the floor manager RN-A right away. DON added, after she talked with R1 and learned the reason behind the pain was NA-A had moved to his legs too fast, he felt safe, not malicious attempt in any way, it was more of a care concern. DON stated she was unaware NA-A had previous history of discipline action taken with inappropriate behaviors (yelling in hallways, bulling other peers, HIPPA) that could be projected onto residents and mistreated them. Facility untitled document on 10/2/25, identified administrator and director of nursing (DON) were notified of possible rough cares with R1. Writer attempted to speak with R1 around 12:15 p.m. on 10/2/25, he appeared agitated, did not want to speak, was unable to breath and was in pain. R1 was assisted up into wheelchair, brought outside, and communicated he felt better. Interviews with intact cognition residents and skin checks were initiated on all residents. Administrator was notified by Minnesota Department of Health (MDH) surveyor R1 did not want NA-A, who the allegation was against, to care for him. NA-A was immediately given a new assignment and was not removed from the schedule. DON visited with R1, and he did not express any care concerns. Administrator received statements from the two NAs at time of allegation, there were no care concerns noted. During an interview on 10/2/25 at 10:08 a.m. NA-A stated on 9/26/25, around 2:30 p.m. she had entered R1's room along with NA-B and transferred him out of bed. NA-A cleaned up his bed and NA-B assisted R1 with cares and placed clean clothing on him. Together both NAs assisted him back into bed, he complained of pain, indicated the drainage tube had gotten pulled on and hurt. R1 stated out loud, you hurt me and my tube, we did not see anything happen to his tube. R1 repeated my tube hurts now. We were careful and the drainage tube may have rubbed up against something when in bed. No bleeding was noted and no complaints about how he was transferred. MD entered the room as she exited, unsure as to who he was. NA-A's shift was over and did not inform the nurse prior to leaving work that day. Things were going ok since that day; she had worked the following two days (Saturday and Sunday) alone with him, without any other staff in the room with her. She had apologized to R1 on Saturday morning and he did not seem angry, upset, or ask her to leave. The administrator just informed her they would have someone else to take care of R1 the rest of the day, she was not to go in his room and not told why. She was allowed to stay and work with other residents on the floor. During an interview on 10/2/25 at 11:00 a.m. medical doctor (MD) stated on 9/26/25 in the afternoon he had walked into the middle of a situation with R1 and a staff NA-A. R1 stated NA-A pulled on his catheter drain and almost ripped it off. The NA-A stated she was sorry that happened and would report it to the supervisor, R1 appeared teary eyed, visibly upset, obviously something happed that should have not, and needed to be investigated. NA-B interacted great with R1 and informed him she planned on reporting this to the supervisor. Prior to leaving the building he stopped at the front desk office off to the right of the front door and informed a staff that sat behind the desk NA-A was rough with R1 and she informed him she would investigate it. He was a mandated reporter and felt this was a situation that should have had follow up regarding rough handling. During an interview on 10/2/25 at 11:50 a.m. registered nurse (RN)-B stated she was loud at times while in R1's room and he had told her to get out frequently, refused cares and medications. She reapproached him and sometimes it had worked. On 9/26/25, NA-B informed her R1 had been man handled and needed something for pain. R1 was visually upset and teary eyed, stated his drainage tube had been pulled, tube was assessed and intact. While she was in R1's room he stated he did not ever want that lady in there again and pointed to NA-A, was rough handled and his tube hurt. The incident occurred at the end of the day shift, NA-A went home, returned the following day and cared for R1 and other residents. RN-B stated she did not ask R1 if he felt safe or was ok with NA-A caring for him but was aware he had requested no further care by her. During an interview on 10/3/25 at 11:52 a.m., administrator stated they were not aware of the incident with R1 and NA-A until 10/2/25. Administrated indicated both NA-A and NA-B (witness) provided statements, they reviewed NA-A's personnel file and education was provided. We did not suspect abuse. NA-A lifted R1's legs too fast, possibly bumping his drainage tube and increased his pain. Education on professional boundaries and safe handling had been completed with NA-A on 10/2/25.During an interview on 10/2/25 at 2:40 p.m. NA-B stated she cared for R1 frequently and he required total assist of two person with cares. He had cancer and was terminally ill. He did not use his call light, they checked on him at least every two hours, and it was important to be quiet and calm when she entered his room. NA-B stated she arrived at work at 2:30 p.m. on 9/26/25, and received report from NA-A. R1 had not been touched all day and refused cares. NA-A requested assistance to try again. We entered R1's together and room smelled of bowel movement (BM) and urine (noted to be on the bed linens). She sent NA-A out of the room to gather linens. NA-B assisted R1 to stand up while she cleansed his front, back, bottom and placed clean clothing on him. NA-B re-entered the room and changed the linens on his bed. NA-A stood on R1's right side and NA-B stood on his left side, he grabbed under their arms, stood up, pivoted, and sat down on edge of bed. She took ahold of his shoulders and NA-A grabbed his feet. She counted three, two and before she could say one NA-A quickly swung his feet/legs up onto the bed, and was not gentle, adding she gave it all it was worth, not sure what [NA-A] was thinking. (he was a thin person, and legs were light). R1 started to scream and cry and stated his drainage tube got pull and was in pain. She informed NA-A she would finish. NA-A started to pick up dirty lines and was told to leave the room. NA-B reassured R1 and looked at the tube, no bleeding noted. MD was outside R1's door waiting to see him, walked into the room. She informed MD NA-A was a little rough with R1 while she placed his feet/legs onto the bed. MD informed her he did not want NA-A back in the room, the incident reported, and pain medication given now. R1 cried in pain. She walked down to the desk and talked with the nurse on duty requested pain medication to be given per MD. NA-B went down to the office located by the front of the building around 2:45 p.m. where two-unit managers were located. She informed them MD was in R1's room, upset and requested NA-A stay out of his room due to being rough with him and this incident needed to be reported. They responded ok and went back to work. MD came down the hallway and asked NA-B if she had informed the unit managers of the incident and she stated yes, and he thanked her. NA-B stated NA-A was rough with R1 but did not seem to be maliciously done. She had worked with NA-A for 15 years and not seen her treat any other resident that way, felt she was in a hurry and wanted to go home for the day. When R1's legs were grabbed and thrown onto the bed the drainage tube must have been located underneath, was hooked on something, and pulled. During an interview on 10/2/25 at 3:36 p.m., floor manager RN-A stated she had worked on 9/26/25 and heard R1 refused cares throughout the day and at shift change NA-A and NA-B completed R1's cares together. MD came to the office and informed her and another floor manager he did not want NA-A working with R1 anymore without explanation and walked out of the office. NA-B stopped in the office informed her MD did not want NA-A working with R1. RN-A stated she emailed the director of nursing (DON) later that afternoon with the information she had but now sees it would have been beneficial to have asked NA-B more questions. She was made aware he was in pain and resistive to care earlier in the day. Facility policy Combined Federal and State [NAME] of Rights dated 6/18/19, identified the resident has a right to a dignified existence, self-determination, and communication, and access to persons and services inside and outside the facility. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Facility policy Safe Resident Handling dated 3/2020, identified safe patient handling is a key component to reducing hazards of injury to our employees and our residents so that when residents receiving care require assistance from facility employees to move, assistance is provided in a manner that is safe to both the resident and employee. The facility is committed to provide high quality resident care. Facility document undated Professional Boundaries identified the employee-resident relationship was designed to meet the needs of the resident and protects the resident's dignity, autonomy, and privacy and allows for the development of trust. Professional boundaries are the spaces between the employee's power and the resident's vulnerability. Employees should make every effort to respect the power imbalance and ensure resident-centered relationships.

Based on interviews and document review the facility failed to thoroughly investigate an allegation of staff to resident abuse and protect residents during the investigation for 1 of 3 residents (R1) who reported a staff handled their care roughly, causing them pain. Findings include: R1's entry Minimum Data Set (MDS) dated [DATE], identified he was admitted to the facility on [DATE], from an acute care hospital. R1's care plan (CP) dated 9/26/25, identified he was vulnerable to abuse and instructed staff to monitor for signs of emotional distress, mood or behavior changes and continue to follow the facility's Vulnerable Abuse Reporting policy and directed R1 was independent with activity choices and staff were to respect his choices of preferred room leisure time. CP also indicated R1 had an alteration in mobility related to colon cancer, edema (fluid retention), pain, and malnutrition with a goal he would move safely within his environment; staff were directed to assist with movement in bed and in/out of bed assist of one with front wheeled walker/wheelchair. R1 also had an alteration in mood, behaviors, and psychosocial well-being related to adjustment to facility and current health condition and staff were directed to reapproach R1 when he refused (cares, medications, linen changes to bed) with a soft tone and give him time and options, monitor and document mood state/behaviors upon occurrence, and provide emotional support, validation and comfort measures as needed (PRN). During an observation on 10/2/25 at 8:50 a.m., NA-A offered to change his bed; he refused until later and exited the room. During an observation/interview on 10/2/25 at 8:55 a.m., R1 laid in a dark room on bed fully dressed covered with a blanket. R1 stated he was admitted to the facility on [DATE], and the stay had been ok, but the staff would not listen to him, and he was feeling upset about that. R1 had told staff when he was sleeping, he did not want to be bothered. R1 stated one afternoon, right after he was admitted to the facility, a staff NA was ruff with him while she assisted him. The NA moved his legs too fast and almost ripped out his drainage tube. He explained they did not get along or see eye to eye, and she lacked respect for his wishes. R1 stated there was also another female NA in the room when the incident occurred, adding the day it happened NA-A was told he did not want her in his room or taking care of him anymore, then today, she had been assigned to him. This was upsetting for him, and he did not want her in his room or caring for him. There was lack of respect and she refused to listen to what his needs were. He wanted to get back to sleep, not be bothered and would let staff know when he wanted his bed changed. During an interview on 10/2/25 at 9:44 a.m., director of nursing (DON) stated she had gone into R1's room along with NA-A and asked if he wanted to be washed up and dressed for the day and he requested to be left alone and allowed to sleep. She left early that day and was unaware of any concerns R1 may have had or that he did not want NA-A to care for him. During a follow-up interview on 10/3/25 at 11:15 a.m., DON stated she went back yesterday (10/2/25) and realized she had received an email from the floor manager RN-A on 9/26/25 at 3:44 p.m. which indicated MD stopped to see R1, heard him crying due to pain while cares were provided by two staff NAs. MD requested NA-A not be allowed to care for R1. DON stated if she would have been contacted that day she would have removed NA-A from the floor immediately, began an investigation, interviewed all residents she had taken care of, completed skin checks on all cognitively impaired residents, and if signs and symptoms of abuse or neglect were found, reported it within two hours to the state. She would have expected to be contacted by the floor manager RN-A right away. DON added, after she talked with R1 and learned the reason behind the pain was NA-A had moved to his legs too fast, he felt safe, not malicious attempt in any way, it was more of a care concern. DON stated she was unaware NA-A had previous history of discipline action taken with inappropriate behaviors (yelling in hallways, bulling other peers, HIPPA) that could be projected onto residents and mistreated them. During an interview on 10/2/25 at 10:08 a.m., NA-A stated on 9/26/25, around 2:30 p.m. she had entered R1's room along with NA-B and transferred him out of bed. NA-A cleaned up his bed and NA-B assisted R1 with cares and placed clean clothing on him. Together both NAs assisted him back into bed, he complained of pain, indicated the drainage tube had gotten pulled on and hurt. R1 stated out loud, you hurt me and my tube, we did not see anything happen to his tube. R1 repeated my tube hurts now. We were careful and the drainage tube may have rubbed up against something when in bed. No bleeding was noted and no complaints about how he was transferred. MD entered the room as she exited, unsure as to who he was. NA-A's shift was over and did not inform the nurse prior to leaving work that day. Things were going ok since that day; she had worked the following two days (Saturday and Sunday) alone with him, without any other staff in the room with her. She had apologized to R1 on Saturday morning and he did not seem angry, upset, or ask her to leave. The administrator just informed her they would have someone else to take care of R1 the rest of the day, she was not to go in his room and not told why. She was allowed to stay and work with other residents on the floor. During an interview on 10/2/25 at 11:00 a.m., medical doctor (MD) stated on 9/26/25 in the afternoon he had walked into the middle of a situation with R1 and a staff NA-A. R1 stated NA-A pulled on his catheter drain and almost ripped it off. The NA-A stated she was sorry that happened and would report it to the supervisor, R1 appeared teary eyed, visibly upset, obviously something happed that should have not, and needed to be investigated. NA-B interacted great with R1 and informed him she planned on reporting this to the supervisor. Prior to leaving the building he stopped at the front desk office off to the right of the front door and informed a staff that sat behind the desk NA-A was rough with R1 and she informed him she would investigate it. He was a mandated reporter and felt this was a situation that should have had follow up regarding rough handling. During an interview on 10/2/25 at 11:50 a.m., registered nurse (RN)-B stated NA-B informed her R1 had been man handled and needed something for pain. R1 was visually upset and teary eyed, stated his drainage tube had been pulled, tube was assessed and intact. While she was in R1's room he stated he did not ever want that lady in there again and pointed to NA-A, was rough handled and his tube hurt. Whoever came across the situation would have been expected to report it to the DON. MD requested it be reported to upper management and should have adding, if he had gotten hurt or not, it cannot just be dismissed as an incident, whether valid or not and had to be investigated. She would have been expected to report the incident to the DON and administrator right away; she was busy, slipped her mind, and dropped the ball. She had brought this incident up during the employee meeting on 9/29/25, DON and administrator were there. The incident occurred at the end of the day shift, NA-A went home, returned the following day and cared for R1 and other residents. RN-B stated she did not ask R1 if he felt safe or was ok with NA-A caring for him but was aware he had requested no further care by her.During an interview on 10/2/25 at 1:00 p.m., administrator stated RN-B had just informed surveyor she had not reported the incident with R1 (9/26/25) until Monday 9/29/25, did not feel it would have been important due to NA-A would have not rough handled R1. She expected RN-B to have reported this incident immediately. All staff education on safe handling and reporting, resident and staff interviews, skin checks on cognitively impaired residents will be completed today. NA-A was interviewed today, moved to a different wing and allowed to care for other residents as an NA. DON had interviewed R1. During an interview on 10/3/25 at 11:52 a.m., administrator stated they were not aware of the incident with R1 and NA-A until 10/2/25. Administrated indicated both NA-A and NA-B (witness) provided statements, they reviewed NA-A's personnel file and education was provided. We did not suspect abuse. NA-A lifted R1's legs too fast, possibly bumping his drainage tube and increased his pain. Education on professional boundaries and safe handling had been completed with NA-A on 10/2/25.During an interview on 10/2/25 at 2:40 p.m., NA-B stated she cared for R1 frequently and he required total assist of two person with cares. He had cancer and was terminally ill. He did not use his call light, they checked on him at least every two hours, and it was important to be quiet and calm when she entered his room. NA-B stated she arrived at work at 2:30 p.m. on 9/26/25, and received report from NA-A. R1 had not been touched all day and refused cares. NA-A requested assistance to try again. We entered R1's together and room smelled of bowel movement (BM) and urine (noted to be on the bed linens). She sent NA-A out of the room to gather linens. NA-B assisted R1 to stand up while she cleansed his front, back, bottom and placed clean clothing on him. NA-B re-entered the room and changed the linens on his bed. NA-A stood on R1's right side and NA-B stood on his left side, he grabbed under their arms, stood up, pivoted, and sat down on edge of bed. She took ahold of his shoulders and NA-A grabbed his feet. She counted three, two and before she could say one NA-A quickly swung his feet/legs up onto the bed, and was not gentle, adding she gave it all it was worth, not sure what [NA-A] was thinking. (he was a thin person, and legs were light). R1 started to scream and cry and stated his drainage tube got pull and was in pain. She informed NA-A she would finish. NA-A started to pick up dirty lines and was told to leave the room. NA-B reassured R1 and looked at the tube, no bleeding noted. MD was outside R1's door waiting to see him, walked into the room. She informed MD NA-A was a little rough with R1 while she placed his feet/legs onto the bed. MD informed her he did not want NA-A back in the room, the incident reported, and pain medication given now. R1 cried in pain. She walked down to the desk and talked with the nurse on duty requested pain medication to be given per MD. NA-B went down to the office located by the front of the building around 2:45 p.m. where two-unit managers were located. She informed them MD was in R1's room, upset and requested NA-A stay out of his room due to being rough with him and this incident needed to be reported. They responded ok and went back to work. MD came down the hallway and asked NA-B if she had informed the unit managers of the incident and she stated yes, and he thanked her. NA-B stated NA-A was rough with R1 but did not seem to be maliciously done. She had worked with NA-A for 15 years and not seen her treat any other resident that way, felt she was in a hurry and wanted to go home for the day. When R1's legs were grabbed and thrown onto the bed the drainage tube must have been located underneath, was hooked on something, and pulled. During an interview on 10/2/25 at 3:36 p.m., floor manager RN-A stated she had worked on 9/26/25 and heard R1 refused cares throughout the day and at shift change NA-A and NA-B completed R1's cares together. MD came to the office and informed her and another floor manager he did not want NA-A working with R1 anymore without explanation and walked out of the office. NA-B stopped in the office informed her MD did not want NA-A working with R1. RN-A stated she emailed the director of nursing (DON) later that afternoon with the information she had but now sees it would have been beneficial to have asked NA-B more questions. She was made aware he was in pain and resistive to care earlier in the day. She was made aware he was in pain, should have laid eyes on R1, completed a skin assessment and interview with him prior to leaving that day to make sure he was safe. She knew R1 was resistive to care earlier in the day and did not think it was anything that needed to be reported. Facility policy Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, identified investigation will begin immediately in accordance with Federal Law. Staff will take immediate and appropriate actions to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress. The investigation may include interviewing staff, residents, or other witnesses to the incident. Corrective action based on the investigation will be completed (e.g. change of procedure, training, discipline or discharge staff). The facility will provide proper follow up communication related to the incident across all shifts and to practitioners and resident representatives as applicable.

Based on observation, interview and document review the facility failed to develop and implement a procedure to determine appropriate sling types for 3 residents (R1, R2, R3) assessed to require the use of mechanical lift for transfers. This resulted in a fall from a ceiling lift resulting in non-surgical fractures and a head laceration for R1 and observation of the wrong sling size, sling type in their room or being used by staff for R2 and R3. This resulted in immediate jeopardy (IJ) for R1, R2 and R3. The immediate jeopardy began on 8/1/25, when R1 fell while being transferred in a full body mechanical lift and fell out of the lift during transfer, resulting in a serious injury. The facility failed to identify if the staff were correctly using the lift per manufacturer recommendation when the incident occurred and failed to review other residents at risk to ensure proper use of mechanical lifts to prevent future falls. Additional transfer observations identified manufacturer's guidelines were not followed for safe use. The IJ was identified on 8/7/25. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 2:30 p.m. on 8/7/25. The IJ was removed on 8/8/25 at 1:30 p.m., but non-compliance remained at the lower scope and severity level D, which indicated no actual harm with potential for minimal harm that is not immediate jeopardy. Findings include: R1's admission Record indicated she admitted to the facility 6/1/23. R1's diagnosis included dementia with behavioral disturbance, back pain, other chronic pain, and spinal stenosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed no behaviors. The care plan indicted R1 was dependent on staff for transfers and was always incontinent of bowel and bladder. R1's Lift/Mobility Status Form dated 10/7/24, indicated she was unable to bear weight, was unable to follow simple instructions and was not cooperative with transfers. The form indicated use of a ceiling lift with assistance from one staff. R1's care plan dated 6/30/25, identified an alteration in cognition and an alteration in mobility. The care plan directed staff to transfer R1 via celling lift using a toileting sling when using the toilet and a full body split leg sling for all other transfers. R1's Incident Review and Analysis dated 8/1/25, indicated staff was transferring R1 from the bathroom to the bed using a toileting sling when R1 fell out onto the floor and hit her head. R1's Progress note dated 8/1/25, indicated she was lowered to the floor by staff after assisting her from toilet to bed. During transfer R1 let go of the sling and began to slide through the sling. Correct sling, correct brand and care plan followed. R1 had a small laceration to the back of her head and was transported to the emergency department (ED) for evaluation. R1's incident report dated 8/1/25, indicated she was lowered to the floor by staff after assisting from toilet to bed. During transfer R1 let go of the sling and began to slide through the sling. Staff put her arms around R1 and lowered R1 to the floor. Correct sling, size, brand and care plan followed. R1 had small laceration to the back of her head. R1's hospital History and Physical dated 8/4/25, indicated R1 was admitted for fall, trauma, non-surgical fractures and pain control. She was brought the ED for evaluation. She had been lifted on a mechanical lift and fell 3-4 feet, falling on her head onto a hardwood floor. Discharge diagnosis included fracture of left clavicle (collarbone), scalp hematoma (localized collection of blood outside the blood vessels), fracture of one rib and concussion. During interview on 8/6/25 at 5:12 p.m., the director of nursing (DON) stated the Lift/Mobility Status form was completed upon admission, quarterly and with a change of condition. The DON stated after R1 fell they had made sure the proper sized sling had been used. The DON stated if R1 brought her arms inside the sling during the transfer, it could have caused her to fall. During interview on 8/7/25 at 8:44 a.m., the facility's ceiling lift representative (R)-A stated typically when an accident happened during transfer in a lift, something would have been wrong with the way the sling was used or applied. R-A said the toileting slings used with the ceiling lift required the resident to keep their arms outside the sling. R-A said with the toileting sling, size was a much bigger deal because there was more open area. R-A stated if a resident did not have the cognitive or physical ability to keep their arms outside the sling, the toileting sling would not be recommended. R-A said if the sling used during transfer was appropriate for the resident, a fall from the lift should not have happened. During interview on 8/7/25 at 9:00 a.m., nursing assistant (NA)-A stated she had been transferring R1 from the wheelchair to the bed, not from the toilet, and said during the transfer, R1 put her arms through the sling and had been confused and tired. NA-A said R1 had been resting her hands on her legs on her lap. NA-A said she had watched R1 put her arms inside the sling and had told her to keep her arms outside the sling. NA-A said she tried to catch R1 when she fell and they both fell. She said the wheelchair was positioned parallel to the bed with a floor mat between the bed and the chair but said R1 had landed on the floor at the end of the bed. NA-A stated she had used the correct sling size and had used the toileting sling. However, R1's care plan directed the use of a full body sling for transfers when not using the toilet. R2's admission Record indicated he admitted to the facility 1/28/20. R2's diagnosis included hemiplegia and hemiparesis, instability of left ankle, chronic pain and mild dementia. R2's quarterly MDS dated [DATE], identified moderate cognitive impairment and rejection of care behaviors 1 -3 days during the assessment period. The MDS indicated R2 was dependent on staff for transfers. R2's Lift/Mobility Status Form dated 1/30/24, indicated he could bear weight on at least one leg, was cooperative with transfers and was able to follow simple instructions. Lift to be utilized indicated a manual sit/stand lift. R2's care plan dated 8/4/25, identified an alteration in cognition with noted impairments in short term memory and an alteration in mobility related to weakness and lack of coordination. The care plan directed staff to transfer R2 using a ceiling lift and size small toileting sling or mechanical lift using a size small full body split leg sling. During observation on 8/6/25 at 4:00 p.m., R2 had a sling laying on top of his bed. The sling was yellow with black edges and was labeled size medium. During observation on 8/6/25 at 4:57 a.m., with the administrator present, R2 was observed to have a size small sling on his bed. R2 stated they just switched it. R2 said the one used previously that day had been the wrong size and said earlier he had slid through the sling and using his hands demonstrated approximately 6 -8 inches from the floor. During interview on 8/6/258 at 5:05 p.m., the administrator said R2 had been transferred earlier with the ceiling lift and the sling adjusted. The administrator said there was no concern with the lift hook up or sling size per R2. The administrator stated there had been no follow up with staff to verify if the appropriate sling had been used but said the care plan had been followed. During interview on 8/7/25 at 3:22 p.m., family member (FM)-A stated she was present when R2 slipped through the toileting sling. FM-A said she was not sure what happened but said R2 was about a foot above the bed and he slipped through and landed on his butt and back on the bed. FM-A said she thought the slings were one size fits all and said staff had used a larger sling before. R2 was present and said, I fell out the bottom, that's why they brought me a new one, referring to the sling. R3's admission Record indicated she admitted to the facility 4/16/23. R3's diagnosis included dementia, anxiety, right above knee amputation and chronic pain. R3's quarterly MDS dated [DATE], identified a memory problem and indicated she displayed physical, verbal and rejection of care behaviors 1-3 days during the assessment period. The MDS indicated R3 was dependent on staff for transfers. R3's Mobility/Lift Status Form dated 1/8/25, identified an amputation and indicated she could not bear weight and was not cooperative with transfers. The form identified the use of a ceiling lift. During observation on 8/6/25 at 4:13 p.m., NA-C and NA-D prepared to transfer R3. R3 was lying in bed and had a toileting sling underneath her. NA-C and NA-D switched the sling for a full body sling as directed in the care plan. NA-C stated the sling underneath R3 was not the correct sling. NA-D said the staff on the previous shift had used the wrong sling to transfer R3. During interview on 8/7/25 at 10:43 a.m., registered nurse (RN)-A stated slings were assessed on admission, quarterly and with a change of condition. RN-A stated sling size and type were based on height and weight of the resident and said sling type was based on whether the resident was continent or not. RN-A said a toileting sling would not be used if there were physical limitations such as an amputation or if the resident was agitated or displayed behaviors and could go through the sling. RN-A said the toileting sling was appropriate for R1 even though R1's Lift form indicated she was unable to follow simple instructions and was not cooperative with transfers, because R1 still used the toilet. Facility Policy [NAME] Patient Handling dated 3/2020, indicated safe patient handling is a key component to providing employees a safe work environment, while providing high quality resident care. Specifically, mechanical lift equipment and/or other approved patient moving aides/devices should be used in all circumstances when liftin/moving residents except when manual assistance is deemed absolutely necessary. All resident care will be provided in a safe, appropriate and timely manner in accordance with the residents plan of care. The immediate jeopardy began on 8/1/25. The immediate jeopardy was removed 8/8/25, after the facility implemented a systemic plan that included the following actions: - Developed and implemented a system to determine appropriate sling size/use based on resident need and manufacturer's guidelines for R1, R2, and R3.-Assessed all residents who required the use of an assistive device to ensure correct sling was in use.-Ensured staff were educated to that process and where to find information regarding accurate sling per resident.- Developed a procedure related to assessment of resident sling use.-Educated staff responsible for transferring residents to the above policies, procedures, and changes made prior to the beginning of their next shift.

Based on interview and document review the facility failed to report an allegation of neglect of care related to a fall from a mechanical lift to the state agency (SA) for 1 of 3 residents reviewed for use of mechanical lifts.R1's admission Record indicated she admitted to the facility 6/1/23. R1's diagnosis included dementia with behavioral disturbance, back pain, other chronic pain, and spinal stenosis. R1's care plan dated 6/30/25, identified an alteration in cognition and an alteration in mobility. The care plan directed staff to transfer R1 via celling lift using a toileting sling when using the toilet and a full body split leg sling for all other transfers. R1's Incident Review and Analysis dated 8/1/25, indicated Staff was transferring R1 from the bathroom to the bed using a toileting sling and R1 fell out onto the floor and hit her head. During interview with the administrator and DON on 8/6/25 at 4:46 p.m., the administrator stated R1 was in a toileting sling and she fell through because she placed her arms inside the sling. The administrator stated the incident had not been reported to the SA because the care plan had been followed during the transfer. During interview on 8/7/25 at 8:44 a.m., the facility's ceiling lift representative (R)-A stated typically when an accident happened during transfer in a lift, something would have been wrong with the way the sling was used or applied. R-A said the toileting slings used with the ceiling lift required the resident to keep their arms outside the sling. R-A said with the toileting sling, size was a much bigger deal because there was more open area. R-A stated if a resident did not have the cognitive or physical ability to keep their arms outside the sling, the toileting sling would not be recommended. R-A said if the sling used during transfer was appropriate for the resident, a fall from the lift should not have happened.During interview on 8/7/25 at 9:00 a.m., nursing assistant (NA)-A stated she had been transferring R1 from the wheelchair to the bed, not from the toilet, and said during the transfer, R1 put her arms through the sling and had been confused and tired. NA-A said R1 had been resting her hands on her legs on her lap. NA-A said she had watched R1 put her arms inside the sling and had told her to keep her arms outside the sling. NA-A said she tried to catch R1 when she fell and they both fell. She said the wheelchair was positioned parallel to the bed with a floor mat between the bed and the chair but said R1 had landed on the floor at the end of the bed. NA-A said she had used the correct sling size and had used the toileting sling. However, R1's care plan directed the use of a full body sling for transfers when not using the toilet.Facility policy Abuse Prohibition/Vulnerable Adult dated 4/2025, indicated all staff are responsible for reporting situation that is considered abuse or neglect, defined as the facility failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Suspected abuse shall be reported to the SA no later than two hours after forming the suspicion of abuse.

Based on interview and document review the facility failed to thoroughly investigate a fall from a lift resulting in significant injury for 1 of 3 residents (R1) reviewed for neglect of care.R1's admission Record indicated she admitted to the facility 6/1/23. R1's diagnosis included dementia with behavioral disturbance, back pain, other chronic pain, and spinal stenosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed no behaviors. The care plan indicted R1 was dependent on staff for transfers and was always incontinent of bowel and bladder.R1's Lift/Mobility Status Form dated 10/7/24, indicated she was unable to bear weight, was unable to follow simple instructions and was not cooperative with transfers. The form indicated use of a ceiling lift with assistance from one staff.R1's care plan dated 6/30/25, identified an alteration in cognition and an alteration in mobility. The care plan directed staff to transfer R1 via celling lift using a toileting sling when using the toilet and a full body split leg sling for all other transfers. R1's Incident Review and Analysis dated 8/1/25, indicated Staff was transferring R1 from the bathroom to the bed using a toileting sling and R1 fell out onto the floor and hit her head. R1's Progress note dated 8/1/25, indicated she was lowered to the floor by staff after assisting her from toilet to bed. During transfer R1 let go of the sling and began to slide through the sling. Correct sling, correct brand and care plan followed. R1 had a small laceration to the back of her head and was transported to the emergency department (ED) for evaluation.R1's incident report dated 8/1/25, indicated she was lowered to the floor by staff after assisting from toilet to bed. During transfer R1 let go of the sling and began to slide through the sling. Staff put her arms around R1 and lowered R1 to the floor. Correct sling, size, brand and care plan followed. R1 had small laceration to the back of her head.R1's hospital History and Physical dated 8/4/25, indicated R1 was admitted for fall, trauma, non-surgical fractures and pain control. She was brought the ED for evaluation. She had been lifted on a mechanical lift and fell 3-4 feet, falling on her head onto a hardwood floor. Discharge diagnosis included fracture of left clavicle (collarbone), scalp hematoma (localized collection of blood outside the blood vessels), fracture of one rib and concussion. An untitled, undated facility investigation provided by the administrator indicated on 8/1/25, R1 was lowered to the floor by staff. Nursing assistant (NA) stated R1 was placed in the sling correctly, hooked to the ceiling lift, legs were crossed. As the NA lifted R1 she noticed R1's bottom was slipping down. The NA grabbed R1 around the waist. R1 had put her arms inside the sling which resulted in her sliding down in the sling further. R1's feet were still in the sling but NA lowered her to the floor. The director of nursing (DON) confirmed the care plan was followed, appropriate way to transfer, correct sling, correct brand and size and lift was in working condition. NA demonstrated how the transfer was performed from start to finish including action taken when R1 began sliding down. The investigation did not include an interview with the NA who had performed the transfer.During interview with the administrator and DON on 8/6/25 at 4:46 p.m., the administrator stated R1 was in a toileting sling and she fell through because she placed her arms inside the sling. The DON stated based on the interview with the NA, R1 had let go of the sling and put her arms inside of it resulting in the fall. The DON stated she had talked to the NA after the incident and said she and the administrator had made a follow up call with the NA but had not documented either conversation. The DON further stated the NA had completed a return demonstration of how to properly use the lift which also had not been documented.During interview on 8/7/25 at 8:44 a.m., the facility's ceiling lift representative (R)-A stated typically when an accident happened during transfer in a lift, something would have been wrong with the way the sling was used or applied. R-A said the toileting slings used with the ceiling lift required the resident to keep their arms outside the sling. R-A said with the toileting sling, size was a much bigger deal because there was more open area. R-A stated if a resident did not have the cognitive or physical ability to keep their arms outside the sling, the toileting sling would not be recommended. R-A said if the sling used during transfer was appropriate for the resident, a fall from the lift should not have happened.During interview on 8/7/25 at 9:00 a.m., nursing assistant (NA)-A stated she had been transferring R1 from the wheelchair to the bed, not from the toilet, and said during the transfer, R1 put her arms through the sling and had been confused and tired. NA-A said R1 had been resting her hands on her legs on her lap. NA-A said she had watched R1 put her arms inside the sling and had told her to keep her arms outside the sling. NA-A said she tried to catch R1 when she fell and they both fell. She said the wheelchair was positioned parallel to the bed with a floor mat between the bed and the chair but said R1 had landed on the floor at the end of the bed. NA-A said she had used the correct sling size and had used the toileting sling. However, R1's care plan directed the use of a full body sling for transfers when not using the toilet.Facility policy Abuse Prohibition/Vulnerable Adult dated 4/2025, indicated investigation shall begin immediately. Staff will take immediate action to prevent further abuse/neglect while the investigation is in process. Investigation may include interviews with staff, residents or other witnesses to the event. Corrective action based on the investigation will be completed (e,g,, change of procedure, training, discipline or discharge of staff, etc.)

Based on interview and document review, the facility failed to ensure voiced concerns about the provision of care were acted upon timely and resolved to help potentially prevent occurrences for 3 of 3 residents (R1, R4, R6) reviewed who had voiced concerns about care from a staff member. Findings include: A facility-reported Vulnerable Adult Maltreatment Report (i.e,, FRI) dated, 7/16/25, identified R1 reported being handled roughly by a nursing assistant (NA) the night prior. The report identified NA-A as the alleged perpetrator and outlined they had been terminated from the care center. The report continued and identified another resident (R6) had reported concerns about how NA-A had transferred them and, again, that NA-A was rough with cares.R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment but demonstrated no delusional thinking. On 7/24/25 at 11:27 a.m., R1 was interviewed and recalled the incident from the week prior. R1 expressed it involved a male staff member who she felt was rough when doing cares. R1 stated she was sleeping at night and then suddenly, Next thing I knew, I was against the wall. R1 stated the male staff member just rolled her over without waking her up which caused her to be startled and have some pain. R1 stated being moved by him without warning was upsetting adding aloud, It was too hard [how he moved her]. R1 stated she reported this concern to someone at the care center but was unsure whom.R1's Aeris History & Physical, dated 7/14/25, identified R1 was evaluated by the medical doctor (MD) who outlined, Patient' neurostatus [sic] has not changed but she does claim there was some roughness with her last night . claims that somebody beat her up at this time but it is vague . gave to social service director [ ] and they are going to investigate. No reported injury noted last evening but she does have palpatory tenderness . will do an x-ray at this time.When interviewed on 7/24/25 at 12:13 p.m., NA-B stated they had worked at the campus through their agency for approximately three or four months. NA-B stated they were aware R1 had reported someone had rough handled her, and verified they had worked the shift with NA-A on the date of the alleged incident. NA-B stated they had never physically seen NA-A be intentionally abusive to any residents, however, had reported some concerns prior about his care to other staff members. NA-B stated the resident's had reported concerns that NA-A would move too fast with cares and, as a result, NA-B had told NA-A he needed to slow down while providing care. At 12:52 p.m., a follow-up interview was completed with NA-B. NA-B explained they had first heard residents' concerns being expressed about NA-A as soon as I came here and started working several months prior. NA-B reiterated the comments by the residents started at the same time and expressed they felt it was already being addressed from appearances. NA-B stated several residents had complained about NA-A and his provided care and named R4. NA-B stated residents' comments were often about NA-A moving too fast and explained there had also been one incident where a resident who used a mechanical lift was left suspended up while NA-A left the room to get incontinence products which NA-B attributed to a lack of organization with cares and a need for additional training. NA-B stated NA-A could be not easy to talk to and help improve his cares as he seemed to take is sometimes personally. NA-B stated they felt the management was aware of these concerns, including from months' prior, as the charge nurse who often worked as aware of the concerns, too. NA-B stated multiple nurses who had worked with NA-A also, Say the same thing. NA-B reiterated the employee all of these concerns had been reported and/or observed with was NA-A. R4's quarterly Minimum Data Set (MDS), dated [DATE], identified R4 had moderate cognitive impairment but demonstrated no delusional thinking. On 7/24/25 at 2:20 p.m., R4 was interviewed about his services in the nursing home and responded aloud, Not great. R4 was questioned if he had any concerns about the care provided by NA-A he could recall to which R4 responded aloud, [NA-A] I had trouble with. R4 explained NA-A had never physically hurt him but rather just comes on strong and did not always explain cares or what he wanted adding, It's a demand thing by him. R4 added, I don't like that. R4 stated he had told the staff at the desk about these concerns but was dismissed with a boys will be boys response. R6 was discharged from the care center at the time of survey and unavailable for interview. During the abbreviated survey, a telephone interview was attempted with NA-A; however, they were unable to be reached. When interviewed on 7/24/25 at 1:43 p.m., licensed practical nurse (LPN)-A verified they routinely worked the overnight shift and had worked with NA-A. LPN-A stated they had never observed or had anyone report concerns about NA-A's care on the night shift prior adding, He was one of the nicest guys there ever was. The facility-provided WVP (Waterview Pines) Grievances listing, dated 1/1/25 to 7/25/25, identified all filed grievances along with each' respective incident number, category, resident involved, date reported and resolution date. The listing identified R4 had filed a grievance in April 2025 related to call light response; however, the listing outlined no grievances were filed for R1, R4, R5 related to provision of care concerns. The provided listing lacked employee name details. During the abbreviated survey, no evidence was provided to demonstrate the facility' had acted upon the concerns expressed by residents to NA-B until 7/7/25 when a FRI for R4 was submitted; despite other staff hearing concerns from the residents about NA-A's provided care for several months prior. On 7/24/25 at 3:14 p.m., the administrator, director of nursing (DON), and social worker (SW)-A were interviewed, and SW-A verified they helped address and manage grievances for the resident population. The administrator stated they were aware of the two situations which had a VA filed (i.e., R4, R1) about them and upon completing an investigation into those learned of R6 having concerns about NA-A's provided care. The administrator stated none of the staff had raised concerns about NA-A's care prior to those events adding, Nobody has brought up any concerns. The administrator stated they had an all staff meeting recently, too, and nothing was voiced or raised about the NA's care. The administrator and DON both verified they were unaware of an incident involving a resident being left suspended in the air in a mechanical lift until now with the administrator adding, This is news to me. The administrator and DON both expressed they would have immediately followed up on that concern if it had been reported to them. The management team all acknowledged they had not been told of the concerns as heard by the floor staff and were unaware of any concerns until 7/7/25, when the first FRI for R4 was submitted. The DON and administrator both acknowledged having completed no formal audits of NA-A's care including after 7/7/25, when the FRI was reported. The team all expressed a formal grievance would have likely been completed months prior if they had been told of the concerns with NA-A's care; and the administrator stated they would have acted upon it earlier (prior to 7/7/25) had the information reached them adding, I absolutely would have [followed up]. The administrator stated no formal grievances were filed on the FRI(s) as they were reportable to the State agency; however, the administrator expressed it was important to ensure concerns were addressed and resolved timely so it doesn't happen to the next person, adding further, Little concerns can turn into something big if it's not addressed. Further, the administrator stated they felt having the new management at the care center and more frequent all staff meetings would help ensure concerns get reported more timely to them from the floor staff. A facility' provided Complaint and Grievance Policy, dated 9/2023, identified any resident could file a grievance and forms were readily available within the care center adding, Any complaints, regardless of how they are received by the facility, will be investigated per the policy. The policy continued, A grievance form should be completed when a complaint has been give to any employee of the facility. This includes when a grievance has been resolved right away to show documentation that it was addressed and resolved to the satisfaction of the person submitting the concern. The policy directed an investigation would then be completed and a summary, either verbally or in-writing, would be provided to the complainant.

Based on observation, interview and document review, the facility failed to ensure there was a sufficient number of staff to ensure all resident cares were completed timely for 9 of 9 anonymous reporters (AR-8, AR-1, AR-2, AR-3, AR-3, AR-4, AR-5, AR-6, and AR-7) interviewed. Also for family members, (FM)-L with concerns of resident (R32) being left soiled for extended periods of time, and nail care not being provided and environment being left soiled with stool, FM-K for long call light times, and FM-C for having to provide care themselves to ensure bedtime cares would be completed. In addition, residents R29 and R7 for long call light wait times, resulting in urinary incontinence for R7, R32 who was not assisted with morning cares until 2:30 in the afternoon, R4 for lack of nail care, R8 who was receiving end of life cares, but not repositioned and provided comfort cares timely, and R1 who did not receive pain medications timely due to inadequate staffing. In addition six residents (R1, R5, R21, R22, R31, and R37) who expressed ongoing concerns with not enough staff and significant wait times for cares. This had the potential to affect all 53 residents who resided in the facility. Findings include: Staff and Family Interviews: During an interview on [DATE] at 1:42 p.m., an anonymous reporter (AR)-8 stated they had concerns about the agency staff working at the facility without enough training, citing examples of residents being triple-briefed (layering incontinence products) and not actually being changed like they should be. Mainly the agency staff work afternoons and overnights. The reporter stated they had talked with the director of nursing (DON) and scheduler about their concerns and were told just to be nice. The reporter also stated they were short for this afternoon on the Meadows unit, so they would have to mandate someone after 8:30 p.m., someone would have to float between the two units, and tomorrow's schedule was the same. During an interview on [DATE] at 5:08 p.m., R29 stated they thought the facility was short staffed on weekends and reported they had witnessed very long call light times. R29 stated they had never been at risk; staff just took longer to answer lights and spent less time with them especially on nights and weekends. During an interview on [DATE] at 5:42 p.m., family member (FM)-L stated they had recently filed a grievance, and they had never done that before because they knew the staff really tried hard. On [DATE], FM-L stated they had found R32 half out of bed with a diaper full, and a scratch along their diaper line which was raw and bleeding. At that time FM-L felt the facility didn't have enough staff working. FM-L stated they filed a second grievance last week because R32's bedrails had BM on them when they arrived for a visit. Staff explained R32 had messed themselves but was now in the dining room. FM-L found R32 seated in the dining room with a staff member ready to eat. When FM-L approached R32, they smelled BM and noted there was BM under R32's fingernails. At FM-L's request staff took R32 to the shower room. When staff removed R32's diaper, R32 was still dirty, it took staff a half hour to clean R32 up. FM-L stated they did not have enough staff to take care of the residents. They stated they were at the facility daily, and R32 did get good care, but when R32 was yelling for help, there was not enough staff to hear and help R32. Maybe they need to have a staff that rounds and answers call lights. FM-L also stated they help other residents when they visit when they can. During an interview on [DATE] at 5:59 p.m., FM-K stated the staff here are overworked. They work so hard, it makes you want to help them. They are good about getting to you when you ask, but it can be a long wait. They just really need more staff here. During an interview on [DATE] at 06:02 p.m., nursing aide (NA)-C stated the agency staff were not getting the training and education that core staff did. NA-C explained when they worked with agency staff it was harder to get their tasks done because a lot of their time was spent providing direction and explanation to the agency staff. During an interview on [DATE] at 6:17 p.m., FM-C stated they came to the facility two to three times per day, one of those times was at bedtime, because the facility didn't have enough staff and they wanted to make sure their resident was comfortable and tucked-in for the night. FM-C stated they were hopeful things would improve once the regular staff got back from vacation. During an interview on [DATE] at 7:07 p.m., AR-1 stated they had 32 residents to care for that evening with only two NAs, but a third NA was called in to work from 6 p.m. to 9 p.m. because state survey was in the building and it was presumed would leave by 9 p.m. The reporter stated they tried to get their work done, but it was killing them, and management wanted the showers, activities of daily living (ADLs), feeding at meals, turning, and repositioning all done but it was too much. The reporter stated they had many conversations with management about the workload and the agency staff who came in. The reporter also stated the agency staff didn't know anything and were not being trained. They were brought in at the start of the shift and put on the floor. The reporter and the other regular NAs would have to try and help the agency staff and still do their own work. Some of the things the reporter stated they couldn't get done were showers and sometimes call lights. During an interview on [DATE] at 12:25 p.m., AR-2 stated sometimes there is only one NA scheduled on Meadows in the morning until 9:00 a.m. NAs must get all the residents up and ready for breakfast and lunch. Between meals some residents transferred back to bed and all residents needed toileting and repositioning between meals and throughout the day. They also usually had three showers to work into the day shift. The reporter stated it was especially difficult to get residents that required two staff for transfers and cares up because each NA had their own resident load they were responsible for. Staff don't get breaks, they have to eat while they are working. Staff usually worked through breaks so call lights got answered, but if they did, they might get in trouble for extra time. When they took their break, they would also get in trouble when call lights weren't answered while they were on break. For the most part they were able to get check and changes done but it was quick. We have to be task oriented and there was not time to support the social parts for residents. During an interview on [DATE] at 12:27 p.m., AR-3 stated they didn't feel they could get their work done during a shift. They used to have four aids on this hall and now they had two or three. Gardens used to have three aids and now cut down to two. AR-3 added they only had two aids again today so they would stay until 7 p.m. They tried their best not to skip showers but if there were more than two to be done in a shift, they may not get them done. Weekends were the worst. She had talked with management, and they said, what can they do. The reporter added agency staff were not helpful. During an interview on [DATE] at 12:32 p.m., AR-4 stated some days they could get their work done during their shift but that meant they didn't take any breaks. The reporter stated they busted their butt to make sure things got done because they don't want to leave work feeling like they couldn't get their work done. The reporter stated they had talked with management about how busy their shift was and had been clocking in early to try and get a jump-start on the day but they were told not to do that anymore. During an interview on [DATE] at 3:45 p.m., R7 stated they experienced some very long call light waits. R7 stated about two weeks ago they had put their call light on to go to the bathroom, and they waited so long they ended up having an accident in their pants because they couldn't hold it any longer. When staff did respond they felt so guilty and apologized, said they couldn't get to my room faster. The staff felt so guilty that it happened, they said they couldn't get in faster. R7 stated they had waited a really long time and it had been very embarrassing for them not being able to go to the bathroom on their own and having to go in their pants. During an interview on [DATE] at 10:23 a.m., AR-5 stated they could get their work done depending on who they were working with and whether they were short-staffed. The reporter also stated they tried to reposition residents every two to three hours, but it depended on when they could get to them. The reporter shared they worried about coming to work and being the only NA there because it had happened to other people and they didn't know what they would do in that scenario. AR-5 adds there used to be more aids on both the halls, four on one and three on the other, but now they regularly only had two aides and sometimes even one. During an interview on [DATE] at 10:35 a.m., AR-6 reporter stated they felt they could get their work done, but some days when they were short-staffed, they did the best they could. The reporter wasn't comfortable saying there were things they couldn't get done. During an interview on [DATE] at 12:27 p.m., AR-7 stated they wished they had more staffing. They were usually responsible for 10 to 11 residents. NA-A stated there were things they wished they could get done like fingernails and shaving, but staff had to cut corners on one day and hope that they could do those things the next. Self-Determination and Activities of Daily Living: See also F561 and F677 R32: R32's careplan last reviewed [DATE], identified R32 preferred to dine in the main dining room and instructed staff to encourage resident to attend meals in the dining room where he could visit with others. Further, R32's care plan identified R32 required assistance with ADLS and preferred to get ready by 8:00 a.m. During an interview on [DATE] at 2:01 p.m., R32 was shirtless in bed with a blanket covering the waist down. R32 stated, they tell me every day they don't have enough people so here I am with just a blanket on. R32 indicated they needed help to get dressed and get out of bed so they were not able go to the dining room on their own. R32 preferred to be dressed for breakfast, but instead stated they felt like a fool in bed with just their pajama pants and blanket on. On [DATE] at 2:20 p.m., NA-E knocked on the door, entered R32's room and told R32 they would be back shortly with another NA to get them (R32) up for the day. After NA-E exited the room, R32 stated they would like to be dressed and out and about so they could visit with people, but instead they were stuck in bed. During an interview on [DATE] at 2:30 p.m., NA-E confirmed they were just now getting to R32 to get them up for the first time that day. NA-E explained when they didn't have the staff, they could only do what they could do. R32 was also a two-person transfer, so they had to find another staff who was also getting their residents up to assist them with R32's transfer. At times we are staffed so low we can't get our residents taken care of as they should be. During an interview on [DATE] at 4:42 p.m., R32 stated, they didn't get me up until noon today. During an interview on [DATE] at 10:30 a.m., R32 stated, here I am sitting in bed again still. During an interview at [DATE] at 12:25 p.m., NA-E stated R32 liked to go to the dining room for breakfast and they would like to get R32 up for breakfast, but because R32 was a two person transfer, it was not always possible to do on days when only one NA was scheduled until 9:30 a.m. on the Meadows unit. During an interview on [DATE] at 12:43 p.m., registered nurse RN-A stated if a resident wants to be up and dressed in the morning for breakfast then that preference should be honored. If a resident wanted to be up and dressed and instead was left in bed with just a shirt on, that would be a dignity issue. During an interview on [DATE] at 2:42 p.m., the DON stated if it was a resident's preference to have a shirt on in bed, or to be up and dressed to have breakfast in the dining room, they would expect those preferences were met. The DON stated they knew R32 preferred to be up and out in the main area tooling around with his wife. The facility policy Activities of Daily Living (ADLs)/Maintain Abilities Policy dated [DATE], read Intent: it is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments understand the principles of quality of life and honor and support these principles for each resident; and that care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. R4: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4's diagnoses included traumatic brain dysfunction, diabetes mellitus, hemiplegia/hemiparesis (a symptom that causes partial or total paralysis on one side of the body/muscle weakness or partial paralysis on one side of the body), and traumatic brain injury (TBI). R4's quarterly MDS identified R4 was severely cognitively impaired, sometimes understood and sometimes understands, had unclear speech, and was dependent on staff for ADLs. R4's care plan dated [DATE], identified R4 had a self care deficit with dressing, grooming, and bathing related to weakness and TBI. Interventions included nursing assistant to perform nail care for hands and feet on bath day. Weekly skin care assessments dated [DATE], [DATE], and [DATE], documented fingernails and toenails not addressed. Weekly skin care assessment dated [DATE], documented fingernails and toenails not necessary. On [DATE], R4 was lying in bed his left hand was in a fist and the fingernails on both hands were approximately ,d+[DATE] inch in length. On [DATE] at 2:04 p.m., licensed practical nurse (LPN)-A looked at R4's hand and stated the nails needed to be cut, she also observed a brown substance under some of the fingernails, and stated the nails were about a ,d+[DATE] in length. On [DATE] at11:06 a.m., the DON stated nail care should be completed by the nursing assistants on their shower day, unless the resident is diabetic then the nail care should be completed by the licensed nurse. The DON stated this should be documented on the weekly skin assessment form. The weekly skin assessments were requested but not provided. Quality of Care: See also F684. R8: R8's provider orders dated [DATE], identified hospice care through Essentia East Range Hospice with orders to call hospice first for changes in condition, need for additional services, medications, supplies, questions, concerns, and notification of death. R8's care plan dated [DATE], identified risk for skin breakdown related to impaired mobility, decrease in range of motion to both upper and lower extremities, and need for mechanical lift. Interventions included repositioning every three hours during the day and on rounds at night as needed. R8's care plan also identified hospice care related to end-stage disease process with interventions to maintain communication with hospice and keep them informed of resident's condition, or changes in condition, as needed. Review of R8's progress notes didn't contain a progress note regarding her change in condition or notification of hospice. During an interview and observation on [DATE] at 4:24 p.m., FM-A stated she had been there for about an hour and a half, and FM-B had been there prior to that. FM-A and B explained they and their siblings spent most of every day at the facility to make sure R8 was taken care of. They stated the last time R8 had been repositioned was about 1:30 p.m. FM-A explained R8 had not been responsive today and hadn't taken in food or fluids. R8 was positioned in the bed on her left side with her left arm tucked under her body. During an observation on [DATE] at 4:59 p.m., NA-D went into R8's room, looked at her and then went to her neighbor and asked if she was ready to go to dinner. NA-D then left the room with R8's neighbor. At 5:08 p.m., NA-D walked past R8's room and to elsewhere in the building. There were no other staff present in the hall. During an interview on [DATE] at 5:25 p.m., NA-B stated they reposition residents every two hours. NA-B didn't recall when it was last done for R8 because he had been busy getting residents to dinner. NA-B explained he just takes care of the people on his sheet and R8 was not on his sheet, and right now there were call lights on for people who needed help going to the bathroom. NA-B stated he went around helping where he saw help was needed and didn't get report on when R8 was last repositioned because she wasn't on his list, adding there were only two people working on this hall and it was dinner time. During an interview on [DATE] at 5:29 p.m., RN-B stated they were short on the floor, so she was going to go join them in the dining room to feed the residents and then left the area. During an observation on [DATE] at 5:33 p.m., RN-B and NA-B came back to R8's room and proceeded to reposition her. R8 had two red areas on her right buttock, RN-B looked at the areas and applied barrier cream. During an interview on [DATE] at 3:20 p.m., hospice nurse (HN)-A stated they got a call from the facility regarding R8 at 6:45 p.m. on [DATE], and then made a visit to the facility to see R8 at 7:15 p.m. HN-A stated they assessed R8, showed RN-B how to crush the pain medication in a very small amount of water to be given buccally (into the inside of the cheek), and instructed on pain management. The facility notified hospice at 0345 that R8 had died . HN-A stated they wished they had known R8 was making changes that day so that hospice could have provided support to the family and the facility. During an interview on [DATE] at 9:10 a.m., the DON stated R8 had varying abilities to swallow but would agree R8 had a change in condition on [DATE] and hospice should have been updated. The DON also stated it didn't meet her expectations for a resident to go four hours without repositioning with risks including skin breakdown and pressure injuries. R1: R1's annual MDS dated [DATE], identified R1 was cognitively intact with the diagnoses of cancer, hypertension, GERD, arthritis, anxiety, and depression. Section E- Behavior did not identify R1 as having any behavior symptoms that negatively impacted self or others. Section N - Medications indicated R1 received high risk medications in the classes of antidepressant, anticoagulant, diuretic, opioid, and hypoglycemic. Section V - Care Area Assessment Summary section V0200 did not identify pain as a care area triggered to be addressed in the care plan. R1's careplan last reviewed on [DATE], focus area Alteration in comfort denoted the goal for R1 to have adequate relief from pain and instructed pain medication as ordered. R1's Medication Administration recorded provided by the facility showed the following medications had been administered to R1 on [DATE] at 11:12 a.m.: -Gabapentin Oral Capsule 100 MG (Gabapentin). -Celexa 10 mg give 10 mg by mouth in the morning related to anxiety -furosemide Tablet give 20 mg by mouth in the morning - chronic atrial fibrillation, unspecified (I48.20); essential (primary) hypertension (I10) -digoxin Tablet give 62.5 mcg by mouth in the morning related to unspecified atrial fibrillation (I48.91) Hold if APICAL pulse is 60 bpm. -tramadol HCl Oral tablet 50 mg give 50 mg by mouth every morning and at bedtime for Pain -Potassium tablet give 20 mEq by mouth in the morning related to hypokalemia (E87.6) administer with or after meals with full glass ,d+[DATE] oz water or juice R1' [DATE] Treatment Administration record identified to monitor for pain every shift. R1's pain levels were documented as follows: -[DATE] night shift pain level: 4 -[DATE] days shift pain level: 5 -[DATE] day shift pain level: 4 -[DATE] day shift pain level: N/A -All other pain assessments on day/eve/night shifts between the dates of [DATE] and ,d+[DATE] had documented pain level: 0. Assessments were not time stamped to identify the time pain assessments were completed. During an interview on [DATE] at 1:08 p.m., LPN-A stated they usually passed medications for about 30 residents and often they also did the dressing changes too. They had a cart nurse a couple times a week, but the facility was trying to eliminate that position. LPN-A stated today they didn't finish their morning medication pass until 11:15 a.m., and then they had to start the afternoon medication pass at 11:30 a.m. LPN-A stated they worked dressing changes in between pill passes and indicated they hardly ever got a lunch break, maybe 10 minutes. LPN-A also frequently had to stay after their shift was over to get their work done. LPN-A stated there was not enough staff and their two nursing aids were constantly running. How can you toilet twenty-two plus people every two hours and get lights and pass meals, and help in the dining too? Even the agency staff tell us we don't have enough staff. During an interview on [DATE] at 1:31 p.m., R1 stated they had to wait and wait for their medications on [DATE]. They had their call light on, and they didn't get their medications until after 11:00 a.m. Someone had died , and staff were trying to do something with that, but nobody came in to tell me that was why they were not answering my call light. During an interview on [DATE] at 1:10 p.m., RN-A explained the window of time for morning medications was 5:30 a.m. to 10:00 a.m. If something was scheduled at 5:30 a.m., they had until 10:00 a.m. to give it unless the medication was time specified or had special instructions. Morning medications should be given by 10:00 a.m. Administration after 10:00 would be considered outside of the acceptable time frame. Administering morning medications late after 11:00 a.m. was not acceptable. RN-A confirmed the facility did have a death the morning of [DATE] and went on to say a death at the facility should not impact the care of other residents or their ability to get their medications. Staff should be responding to resident call lights, if R1 waited two hours, that is not acceptable. Usually, the Meadows unit is staffed with two nursing aids on the weekend. During an interview on [DATE] at 9:30 a.m., R1 stated they usually got their morning medications between 9:00 - 9:30 a.m., however on [DATE], they didn't get their mediation until after 11 a.m. and nobody went into their room. R1 reported staff were having a problem with a resident that died . R1 reported that morning they had tried everything to get someone in their room, they banged on their bedside table, put their call light on, turned the TV up, and yelled. R1 reported they had been so worked up and anxious because their pain was so bad, they had called a family member because they didn't know what else to do. R1 reported their leg, neck and back pain had been a nine out of ten. R1 pointed to their left leg and explained they had broken that leg in two places and even though it was healed, they still needed to take a heavy pill [opioid: Tramadol HCL] to reduce the leg pain. R1 stated on weekends they had one nurse and usually just one nurse aide in the morning, so nobody was really around. R1 stated it was upsetting when their medications were late because they had heart medication and pain medications they needed in the morning. During an interview on [DATE] at 3:06 p.m., the DON opened R1's EMR and explained when a medication is ordered every morning and bedtime it falls into the open med pass so it can be given in the facility window for med pass. Nurses should prioritize resident medication administration by who is getting up first, etcetera. The DON reviewed R1's mediation and confirmed R1 had received their morning medication after 11:00 a.m. on [DATE]. The DON stated pain was a priority, but since they were not present on [DATE] they could not speak to what had occurred. The DON stated absolutely if they had a fall or an emergent situation, they expected that event to take priority over medication administration. The DON stated the facility was staffed to care for their residents and to take care of emergencies. It was unfortunate that R1 was waiting and upset and in pain while staff addressed the death of a resident on [DATE], however the DON felt it was an isolated incident, as they were not aware of this being an ongoing issue. The DON stated it was okay for medications to be given outside of the designated administration window if something else was pressing. Facility Assessment: The Facility assessment dated [DATE], identified a need for nurse (RN/LPN) to resident ratio of 1:25 to 1:30 for day and evening shift and 1:59 for overnight shift. The assessment also identified a need for NA to resident ratio of 1:10 to 1:12 for day shift, 1:10 to 1:14 for evening shift, and 1:25 for overnight shift or 2.8 to 3.2 hours per resident days. Review of facility-submitted schedules, daily posted staffing, and payroll data for the time period of [DATE] to [DATE] revealed hours of care (calculated with the actual number of NA hours worked and the daily resident census) ranging from 1.6 to 2.2 hours per resident per day. On ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], [DATE] the actual total NA hours worked was eight or more hours less than the total NA hours on the posted facility staffing. Of note, on Sunday [DATE] the actual NA hours worked was 20 hours more than the posted facility staffing, despite one NA working the Garden unit alone from a little before 7:30 a.m. until about 9 a.m. Surveyor: [NAME]-[NAME], Tr Resident Council: Six residents (R1, R5, R21, R22, R31, and R37) and the ombudsman attended a meeting with resident council members on [DATE] at 1:31 p.m. The residents agreed that staffing was an issue that came up at all their resident meetings. They stated call light response times was a big issue. Discussion included: -Multiple members expressed most staff worked really hard, and they just couldn't do it all. -One of the residents stated call lights were good now because the survey team was in the building. -Another resident shared sometimes when they put their call light on staff would turn it off and say they would be right back but then they never came back. Then staff got mad if you turned it back on again after waiting an hour for someone one to help. Other residents confirmed their call light had been turned off and forgot too. -Others shared of call light waits as long as one to three hours and one resident shared they had had an accident in their pant because staff didn't answer their call light in time. -Members stated that administration had come to some of their meetings in the past and they had talked to them about concerns. One of the old administrators said the facility was monitoring call light logs, but residents stated they didn't really know what that meant. Members indicated when it came to staffing, the facility response had not really been much. They hadn't really had a good reply about staffing concerns. Members were not sure if administration was made aware of the concerns they discussed. The members indicated they knew how to file a grievance as an individual, but they were not sure about resident council filing a collective grievance. Administration Interviews: During an interview on [DATE] at 3:49 p.m., the administrator, the associate administrator, the DON, and the regional nurse consultant were all present. The administrator stated some of the things they took into consideration for staffing were metrics based on hours per patient day (PPD) and accounting for the level of care and the number of residents in house. The administrators, DON and nurse managers met every weekday morning to review the staffing plan and provide feedback based on what else was going on in the building. They also made rounds and checked in with the staff. The associate administrator stated they gave staff empathy when they were short-staffed and would look at the numbers on each of the wings and made sure they were within that. The administrator stated in addition to staffing ratios and calculations, they also looked at resident needs and what equipment was needed to support staffing levels. Unit meetings and Labor Management Committee were opportunities for staff input on staffing. The DON stated within the past month there were concerns with shifts in census within the building so they had changed work assignments around based on staff input to balance workload. When asked if the facility was adequately staffed to continue caring for residents in the event of a death or emergency, the administrator stated emergencies and events like deaths were planned for in their staffing ratios. Daily staffing plans factored in unexpected events and included an on-call staff that could come in to assist with an emergency or something the on-site staff could not handle. The administrator also indicated there may be some variances on other priority items during an unplanned event, but they believed the staffing ratios supported the care that was being provided. When asked how agency staff were trained and oriented, the administrator stated they had agency staff come in a half-hour prior to the start of their shift and complete the competencies and emergency preparedness information, to get acquainted to the units and introduce them to other staff. When they receive complaints regarding agency staff, they follow up with the staff to better understand what the issues were so they could help. 47263

Based on observation, interview and document review, the facility failed to ensure orders for respiratory care were implemented for 1 of 1 (R23) resident reviewed for respiratory care. Findings include: On 11/17/24 at 5:29 p.m., R23 was in her room lying in bed wearing oxygen per nasal cannula at 2 liters per minute. R23's oxygen was humidified and the bottle was dated 10/16/24. R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had diagnoses which included centrilobular emphysema (a form of chronic lung disease), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pulmonary fibrosis (a condition in which the lungs become scarred over time. Symptoms include shortness of breath, a dry cough), atherosclerosis of aorta (a condition where plaque builds up in the walls of the aorta), morbid obesity with alveolar hypoventilation (insufficient ventilation), and chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). R23's order summary dated 11/20/24, included orders to Fill concentrator bubbler every evening shift dated 10/24/22. The orders did not include changing the concentrator bubbler. R23's electronic medical record (EMR) did not include evidence of oxygen bubbler being changed on any schedule. On 11/19/24 at 11:34 a.m., regisetered nurse (RN)-A reviewed R23's EMR and verified there was not any documentation for changing the oxygen bubbler. RN-A stated she would expect the oxygen bubbler to be changed monthly per the policy and should be changed regularly for infection control purposes. RN-A verified the date on the oxygen bubbler as 10/16/24. On 11/20/24 at 10:53 a.m., the director of nursing (DON) stated she would expect oxygen bubblers to be changed per the policy for infection control purposes. Policies on respiratory care practices were requested but not provided.

Based on observation, interview, and document review the facility failed to to ensure timely repositioning and coordination of care for a hospice patient with a change in condition for 1 of 5 (R8) residents; to ensure provider orders for weight monitoring were followed for 1 of 5 (R26) residents; to ensure dressing changes were completed as ordered for 1 of 5 (R40) residents; to ensure placement of ankle-foot orthosis (AFO) for 1 of 5 (R32) residents; and to ensure timely delivery of medications for 1 of 5 (R1) residents reviewed for quality of care. Findings include: R8: R8's significant change in condition Minimum Data Set (MDS) dated [DATE], identified moderately intact cognition and diagnoses of dementia and congestive heart failure. R8 was dependent on staff for eating, bed mobility and toileting. R8's provider orders dated [DATE], identified hospice care through Essentia East Range Hospice with orders to call hospice first for changes in condition, need for additional services, medications, supplies, questions, concerns, and notification of death. R8's care plan dated [DATE], identified risk for skin breakdown related to impaired mobility, decrease in range of motion to both upper and lower extremities, and need for mechanical lift. Interventions included repositioning every three hours during the day and on rounds at night as needed. R8's care plan also identified hospice care related to end-stage disease process with interventions to maintain communication with hospice and keep them informed of resident's condition, or changes in condition, as needed. Review of R8's progress notes didn't contain a progress note regarding her change in condition or notification of hospice. During an interview and observation on [DATE] at 4:24 p.m., family member (FM)-A stated she had been there for about an hour and a half, and FM-B had been there prior to that. FM-A and B explained they and their siblings spent most of every day at the facility to make sure R8 was taken care of. They stated the last time R8 had been repositioned was about 1:30 p.m. FM-A explained R8 had not been responsive today and hadn't taken in food or fluids. R8 was positioned in the bed on her left side with her left arm tucked under her body. During an observation on [DATE] at 4:59 p.m., nursing assistant (NA)-D went into R8's room, looked at her and then went to her neighbor and asked if she was ready to go to dinner. NA-D then left the room with R8's neighbor. At 5:08 p.m., NA-D walked past R8's room and to elsewhere in the building. There were no other staff present in the hall. During an observation and interview on [DATE] at 05:10 p.m., registered nurse (RN)-B entered R8's room with three whole pills in a cup and a glass of water. RN-B stated she was not sure the last time R8 was repositioned because her shift started at 2 p.m. today. RN-B donned gloves and approached R8's bedside with the medication. FM-A became upset and asked why RN-B would be giving R8 whole pills when she was supposed to have crushed meds in applesauce. RN-B was not able to explain adequately to calm FM-A regarding the medications and what her plan was. RN-B left the unit at 5:19 p.m. to find someone to help. At 5:20 p.m., NA-D returned to the hall and answered another resident's call light. During an interview on [DATE] at 5:25 p.m., NA-B stated they reposition residents every two hours. NA-B didn't recall when it was last done for R8 because he had been busy getting residents to dinner. NA-B explained he just takes care of the people on his sheet and R8 was not on his sheet, and right now there were call lights on for people who needed help going to the bathroom. NA-B stated he went around helping where he saw help was needed and didn't get report on when R8 was last repositioned because she wasn't on his list, adding there were only two people working on this hall and it was dinner time. During an interview on [DATE] at 5:29 p.m., RN-B stated they were short on the floor, so she was going to go join them in the dining room to feed the residents and then left the area. During an observation on [DATE] at 5:33 p.m., RN-B and NA-B came back to R8's room and proceeded to reposition her. R8 had two red areas on her right buttock, RN-B looked at the areas and applied barrier cream. During an interview on [DATE] at 3:20 p.m., hospice nurse (HN)-A stated they got a call from the facility regarding R8 at 6:45 p.m. on [DATE], and then made a visit to the facility to see R8 at 7:15 p.m. HN-A stated they assessed R8, showed RN-B how to crush the pain medication in a very small amount of water to be given buccally (into the inside of the cheek), and instructed on pain management. The facility notified hospice at 0345 that R8 had died . HN-A stated they wished they had known R8 was making changes that day so that hospice could have provided support to the family and the facility. During an interview on [DATE] at 9:10 a.m., the director of nursing (DON) stated R8 had varying abilities to swallow but would agree R8 had a change in condition on [DATE] and hospice should have been updated. The DON also stated it didn't meet her expectations for a resident to go four hours without repositioning with risks including skin breakdown and pressure injuries. R26: R26's quarterly MDS dated [DATE], identified moderately impaired cognition and diagnoses of congestive heart failure (CHF) and chronic kidney disease. R26's provider orders dated [DATE], identified weekly weight monitoring, to notify cardiology of an increase of five pounds in one week, and furosemide (a medication used to treat excess fluid) daily. R26's care plan didn't address CHF or weight monitoring. Review of R26's medical record revealed the following lapses in weekly weight monitoring: -,d+[DATE] to [DATE] -,d+[DATE] to [DATE] -,d+[DATE] to [DATE] -,d+[DATE] to [DATE] -,d+[DATE] to [DATE] During an interview on [DATE] at 12:44 p.m., the DON stated the lapses in weekly weights do not meet her expectations. The risks of not monitoring weights for R26 would be fluid overload. R40: R40's admission MDS dated [DATE], identified intact cognition and diagnosis of acquired absence of the left leg with an above-the-knee amputation (AKA). R40's MDS also identified the presence of surgical wounds. R40's provider orders dated [DATE], identified daily wound care to left AKA surgical wound including moistening gauze with betadine, wringing it out and leaving the gauze moist, fluffing it, and applying it over the suture line. Cover all with an abdominal pad and secure with tape. R40's care plan dated [DATE], identified daily wound care to surgical site, to observe for and report changes, and weekly skin inspections by a licensed nurse. R40's treatment administration record (TAR) for [DATE] did not have any initials on Sunday [DATE] dressing change. During an observation and interview on [DATE] at 6:06 p.m., R40 was observed to have an abdominal pad taped to the left AKA site. The dressing was soiled with yellowish drainage the length of the dressing and about five centimeters wide. R40 stated no one had changed her dressing today. During an interview on [DATE] at 1:08 p.m., licensed practical nurse (LPN)-B stated she worked day shift [DATE] and didn't have time to do the dressing change during her regular shift but had stayed late to get it done and must not have signed it off. LPN-B further stated the dressing change took some time because R40 needed to have pain medication prior to the dressing change, and the nurses had to remove every other staple with each dressing change. Facility records revealed LPN-B clocked out for the day at 3:01 p.m. During an interview on [DATE] at 12:38 p.m., the DON stated she would expect a dressing to be changed daily if that was what was ordered and confirmed the dressing change was not checked off for [DATE]. The DON stated R40 was often non-compliant with repositioning, stayed up in her wheelchair too long, and the wound had opened up at the suture line so R40 was scheduled for another procedure to revise the wound. 47263 R32: R32's quarterly MDS dated [DATE], Section C - Cognitive Patterns did not include a completed Brief Interview for Mental status. R32's quarterly MDS dated [DATE], identified R32 had significant cognitive impairment. Diagnoses included neurological disorders, heart failure and non-Alzheimer's dementia with depression and anxiety. Section GG identified R32 required maximal assistance to total dependence for ADL's and was dependent for transfers. R32's careplan last reviewed [DATE], identified R32 was a hoyer transfer of two and included the following instruction: -AFO brace to the left foot/ankle - on in the a.m. and off in the p.m. -Resting splint on Left hand - on during the day and off at bedtime. During an interview on [DATE] at 2:01 p.m., R32 was shirtless in bed with a blanket covering the waist down. R32 did not have a splint or their left hand. During an observation on [DATE] at 12:50 p.m., R32 was seated in dining at a table with peers. R32's left arm was resting across their abdomen, R32 did not have a hand splint on. During an observation on [DATE] at 8:56 a.m., R32 was seated in dining room eating breakfast. R32's was not wearing a hand splint and their left arm/hand was resting in their lap. During an observation on [DATE] at 1:06 p.m., R32 did not have a hand splint on, R32's wheelchair did not have a side tray on it. R32's left arm was draped across R32's lap. During an interview on [DATE] at 12:43 p.m., RN-A reviewed R32's care plan and confirmed R32 was care planed for a left-hand splint however the hand splint was not ordered nor was it included in R32's tasks. There was however the use of a half arm tray included in R32's tasks. RN-A confirmed they could not find any documentation that R32 had been refusing to wear the hand splint or use the half arm tray. RN-A confirmed R32 should be wearing the hand splint and added it to R32's task list. During an interview on [DATE] at 2:42 p.m., the DON stated they had helped R32 get up in the morning and sometimes he refused the hand splint and other times he put it on. The DON confirmed the hand splint was in R32's care plan, but not the orders, and confirmed they were not able to find documentation of R32's refusal to wear the hand splint. The DON left the interview room and returned with R32's Kardex. The DON pointed out the section of the Kardex which listed the splint instructions for the NAs to follow. The DON stated normally staff would document when a splint was on or off and refusals to wear. If a resident continued to refuse, then follow-up would be done and then if a resident continued to refuse it would be evaluated for discontinuation. RN-A had added R32's hand splint to the tasks earlier that day so NA's now had a place to document the splint. R1: R1's annual MDS dated [DATE], identified R1 was cognitively intact with the diagnoses of cancer, hypertension, GERD, arthritis, anxiety, and depression. Section E- Behavior did not identify R1 as having any behavior symptoms that negatively impacted self or others. Section N - Medications indicated R1 received high risk medications in the classes of antidepressant, anticoagulant, diuretic, opioid, and hypoglycemic. Section V - Care Area Assessment Summary section V0200 did not identify pain as a care area triggered to be addressed in the care plan. R1's careplan last reviewed on [DATE], focus area Alteration in comfort denoted the goal for R1 to have adequate relief from pain and instructed pain medication as ordered. R1's Medication Administration recorded provided by the facility showed the following medications had been administered to R1 on [DATE] at 11:12 a.m.: -Gabapentin Oral Capsule 100 milligrams (mg) -Celexa 10 mg give 10 mg by mouth in the morning related to anxiety -furosemide Tablet give 20 mg by mouth in the morning - chronic atrial fibrillation, unspecified (I48.20); essential (primary) hypertension (I10) -digoxin Tablet give 62.5 mcg by mouth in the morning related to unspecified atrial fibrillation (I48.91) Hold if APICAL pulse is 60 bpm. -tramadol HCl Oral tablet 50 mg give 50 mg by mouth every morning and at bedtime for Pain -Potassium tablet give 20 mEq by mouth in the morning related to hypokalemia (E87.6) administer with or after meals with full glass ,d+[DATE]oz water or juice R1' [DATE] Treatment Administration record identified to monitor for pain every shift. R1's pain levels were documented as follows: -[DATE] night shift pain level: 4 -[DATE] days shift pain level: 5 -[DATE] day shift pain level: 4 -[DATE] day shift pain level: N/A -All other pain assessments on day/eve/night shifts between the dates of [DATE] and ,d+[DATE] had documented pain level: 0. Assessments were not time stamped to identify the time pain assessments were completed. During an interview on [DATE] at 1:08 p.m., LPN-A stated they usually passed medications for about 30 residents and often they also did the dressing changes too. They had a cart nurse a couple times a week, but the facility was trying to eliminate that position. LPN-A stated today they didn't finish their morning medication pass until 11:15 a.m., and then they had to start the afternoon medication pass at 11:30 a.m. LPN-A stated they worked dressing changes in between pill passes and indicated they hardly ever got a lunch break, maybe 10 minutes. LPN-A also frequently had to stay after their shift was over to get their work done. LPN-A stated there was not enough staff and their two nursing aids were constantly running. How can you toilet twenty-two plus people every two hours and get lights and pass meals, and help in the dining too? Even the agency staff tell us we don't have enough staff. During an interview on [DATE] at 1:31 p.m., R1 stated they had to wait and wait for their medications on [DATE]. They had their call light on, and they didn't get their medications until after 11:00 a.m. Someone had died , and staff were trying to do something with that, but nobody came in to tell me that was why they were not answering my call light. During an interview on [DATE] at 1:10 p.m., RN-A explained the window of time for morning medications was 5:30 a.m. to 10:00 a.m. If something was scheduled at 5:30 a.m., they had until 10:00 a.m. to give it unless the medication was time specified or had special instructions. Morning medications should be given by 10:00 a.m. Administration after 10:00 would be considered outside of the acceptable time frame. Administering morning medications late after 11:00 a.m. was not acceptable. RN-A confirmed the facility did have a death the morning of [DATE] and went on to say a death at the facility should not impact the care of other residents or their ability to get their medications. Staff should be responding to resident call lights, if R1 waited two hours, that is not acceptable. Usually, the Meadows unit is staffed with two nursing aids on the weekend. During an interview on [DATE] at 9:30 a.m., R1 stated they usually got their morning medications between 9:00 - 9:30 a.m., however on [DATE], they didn't get their mediation until after 11 a.m. and nobody went into their room. R1 reported staff were having a problem with a resident that died . R1 reported that morning they had tried everything to get someone in their room, they banged on their bedside table, put their call light on, turned the TV up, and yelled. R1 reported they had been so worked up and anxious because their pain was so bad, they had called a family member because they didn't know what else to do. R1 reported their leg, neck and back pain had been a nine out of ten. R1 pointed to their left leg and explained they had broken that leg in two places and even though it was healed, they still needed to take a heavy pill [opioid: Tramadol HCL] to reduce the leg pain. R1 stated on weekends they had one nurse and usually just one nurse aide in the morning, so nobody was really around. R1 stated it was upsetting when their medications were late because they had heart medication and pain medications they needed in the morning. During an interview on [DATE] at 3:06 p.m., the DON opened R1's EMR and explained when a medication is ordered every morning and bedtime it falls into the open med pass so it can be given in the facility window for med pass. Nurses should prioritize resident medication administration by who is getting up first, etcetera. The DON reviewed R1's mediation and confirmed R1 had received their morning medication after 11:00 a.m. on [DATE]. The DON stated pain was a priority, but since they were not present on [DATE] they could not speak to what had occurred. The DON stated absolutely if they had a fall or an emergent situation, they expected that event to take priority over medication administration. The DON stated the facility was staffed to care for their residents and to take care of emergencies. It was unfortunate that R1 was waiting and upset and in pain while staff addressed the death of a resident on [DATE], however the DON felt it was an isolated incident, as they were not aware of this being an ongoing issue. The DON stated it was okay for medications to be given outside of the designated administration window if something else was pressing.

Based on observation, interview, and document review, the facility failed to ensure residents were supervised by nursing staff or trained feeding staff during dining for 1 of 1 (R20) resident reviewed for dining. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], identified R20's diagnoses included, dementia, multiple sclerosis (a disease in which the immune system eats away the protective covering of nerves), depression, and dysphagia (difficulty swallowing). R20's MDS identified R20 was severely cognitively impaired and required partial to moderate assistance with eating. On 11/18/24 at 6:24 p.m., one resident (R20) remained in the dining room with one dietary staff clearing tables. R20 remained at her table eating and drinking. -at 6:35 p.m., R20 remained alone in the dining room drinking beverages. -at 6:40 p.m., the dietary manager asked R20 if she wanted a ride to her room, shortly after that a nursing assistant entered the dining room and said she would take R20 to her room. On 11/19/24 at 11:49 a.m., registered nurse (RN)-A verified nursing staff should be in the dining room at all times when residents were eating for safety. On 11/20/24 at 10:51 a.m., the director of nursing (DON) verified nursing staff should be in the dining room during meals in the event someone choked. Dining Room Supervision dated 8/26/20, identified the following A nursing assistant or other designated, trained personnel will be assigned to the dining room at all meals. They will assist the residents in food preparation such as cutting, arranging food, andopening condiments and with feeding.

Based on observation, interview and document review the facility failed to dispose of an expired bottle of half and half that was still available for residents to use. This had the ability to effect every resident who used half and half during meals. Findings included: On [DATE] at 1:24 p.m., an opened bottle of [NAME] half and half dairy product was noted in the refrigerator of the dinning hall dinette room. Hand written on the bottle was an open date of [DATE]. The manufacture's expiration date was [DATE]. During an interview on [DATE] at 1:30 p.m., culinary aide (CA)-A looked at the bottle and confirmed [DATE], was the dated the bottle was first opened. CA-A also acknowledged [DATE], was the manufacturer's expiration date on the bottle of half and half. CA-A stated dairy products like half and half are only good for 5 days after they are opened so this bottle of half and half should have been thrown away on [DATE], but for sure on [DATE], when the manufacturer says the dairy product is expired. she did not know why the dairy product was still accessible for residents to use. During an interview on [DATE] at 11:48 a.m.,the culinary director (CD) stated all dairy products are good for 5 days after being open. Dairy product should then be disposed of at that time, or the manufacturer's recommended expiration date. During an interview on [DATE] at 2:06 p.m., the infection preventionist (IP) stated the longer dairy products are used past the expiration date increased the risk of bacteria and food born illness occurring in residents. Facility policy Food Receiving and Storage , last revised 2017, lacked information related to monitoring of foods and liquids for expiration dates.

Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when she eloped from the facility, and was found outside after an indeterminable amount of time. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 3/10/24 at 11:00 a.m. when dietary aide (DA)-A discovered R1 outside of the facility on the sidewalk, approximately 30 feet from the door. Weather Underground identified the temperature in Virginia, MN was 19 degrees Fahrenheit (F) at 10:53 a.m. The administrator and director of nursing (DON) were informed of the IJ on 3/20/24 at 4:10 p.m. The facility had implemented corrective action on 3/14/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's face sheet dated 3/19/24 indicated R1 had diagnoses of schizophrenia, borderline personality disorder and bipolar disorder. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had delusions, and severe cognitive impairment. The MDS also identified R1 wandered which placed her at significant risk of getting to a potentially dangerous situation. R1's Elopement Risk assessment dated [DATE] indicated R1 had a history of wandering or attempts to leave the building, and was able to self-propel her wheelchair. The assessment also identified R1 exhibited pacing or agitated behavior, and had been asking to go home. R1's family had voiced concerns she may have a tendency to wander or elope, and she was taking medications which may cause confusion. R1's care plan dated 11/23/23 indicated R1 was at risk for elopement due to her cognitive deficit and utilized a Code Alert wander management system (used to trigger alarms to alert staff when a resident wearing a Code Alert bracelet is near a door). Interventions indicated to monitor the Code Alert for proper functioning, and door alarms would be answered promptly. On 3/11/24, an Incident Review and Analysis form indicated R1 had an elopement on 3/10/24 at approximately 11:00 a.m., when a culinary staff member saw R1 on the sidewalk on 12th Avenue, self-propelling in her wheelchair toward 8th Street. The staff member walked with R1 to the back door near the kitchen, and brought her back to her unit. R1 did not recall how she got out of the building or where she was going. The report indicated cognitive function and awareness may have contributed to the incident. On 3/11/24 at 1:33 p.m., a progress note indicated R1's Code Alert was functioning properly at the time of the incident. Facility internal investigation notes indicated the staff working on 3/10/24 did not hear an alarm sound. Investigation notes indicated two nursing assistants (NAs) were on break at the time of the elopement. On 3/19/24 at 1:34 p.m., licensed practical nurse (LPN)-B stated she did not recall hearing an alarm on 3/10/24. On 3/19/24 at 2:27 p.m., nursing assistant (NA)-C stated she did not recall hearing an alarm on 3/10/24. On 3/20/24 at 8:14 a.m., DA-A stated on 3/10/24 at approximately 11:00 a.m. she was returning to the facility from her break, and she saw R1 on the sidewalk. DA-A stated she assisted R1 back into the building. DA-A stated the Code Alert alarm did go off when she brought R1 back into the building. On 3/20/24 at 8:18 a.m., the director of nursing (DON) stated she was called and informed R1 had eloped out of the facility. The DON stated at the time, she thought R1 had only went through the door, and did not realize R1 had left the facility. On 3/20/24 at 9:01 a.m., the director of maintenance (DM)-A stated he checked the Code Alert door systems weekly. DM-A stated there had been no failures with the system, or with the alarms sounding. DM-A stated the facility Code Alert system was older, and did not track the time an alarm goes off, or when it was reset. DM-A stated in order for a resident to leave the facility wearing a Code Alert braclet, someone had to manually reset the alarm to stop if from sounding. On 3/20/24 at 9:24 a.m., LPN-A stated she did not realize R1 was missing at the time. LPN-A stated when she found out R1 had eloped from the facilty, she called the DON and informed her of the elopement. On 3/20/24 at 9:47 a.m., the Code Alert company representative stated the door alarms will sound indefinitely until the alarms have been manually reset. On 3/20/24 at 12:06 p.m., the DON stated she could not understand how this would have happened because either the door alarm did not sound, or a staff person shut the alarm off and was afraid to tell her. The DON stated some residents wore the Code Alert bracelet on their person, while others residents had the bracelet attached to their wheelchair. The DON stated the night shift nurse was responsible for checking the function of the Code Alert bracelets every night. The DON stated this was done either by bringing the device to a door to hear the alarm, or by bringing a test box to the bracelet, where a green light indicated the bracelet was working. The DON stated all facility staff have the ability de-activate the Code Alert system on the door by punching in a code. This incuded dietary staff, housekeeping staff, maintianence staff, activiy staff and all nursing staff. On 3/20/24 at 12:28 p.m., cook (C)-A stated she assisted R1 to return to her wing of the nursing home after D-A brought her inside on 3/10/24. C-A stated R1 was wearing sweatpants, a t-shirt, a fleece top, and a ball cap as she re-entered the building. C-A stated the alarm sounded as R1 re-entered the building. On 3/20/24 at 2:02 p.m., NA-A stated R1 was last seen inside the facility around 9:30 a.m., when he redirected her back to her wing of the facility. On 3/20/24 at 2:11 p.m., NA-B stated she did not hear an alarm on 3/10/24. On 3/20/24 at 2:18 p.m., therapy recreation aide (TR)-A stated she did not hear an alarm on 3/10/24. The facility Elopement Policy dated 6/23, directed to assure each resident is assessed on an ongoing basis and has appropriate safety precautions in place. The past noncompliance immediate jeopardy began on 3/10/24. The immediate jeopardy was removed and the deficient practice was corrected by 3/14/24, after the facility implemented a systemic plan that included the following actions: Elopement policy and Code Alert Wander Management system education, audits of all Code Alert Wander Management sensors in use, and audits of elopement risk assessments. The facility consulted with a contractor to extend the time with the magnetic locking system for the doors, and is waiting for permission from the State Fire Marshal. Audits have been conducted on all exit door alarms, and on all resident personal Code Alert alarm devices. Verification of corrective action was confirmed by observation, interview, and document review on 3/19/24 and 3/20/24.

Based on interview, and document review, the facility failed to provide a proper fitting transfer sling which resulted in a fall from the overhead mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R1, when she slid through ceiling lift sling and fell and sustained a hip fracture and swelling to the top of her head. The immediate jeopardy (IJ) began on 11/22/22, at 4:10 p.m. when R1 had a fall from the ceiling lift. The fall resulted in R1 incurring a fractured hip and swelling to the top of her head. The administrator, the director of nursing (DON), the regional director of operations (DOO)-A and the nurse consultant (RN)-C were notified of the IJ on 12/6/22, at 3:36 p.m. The IJ was removed on 12/7/22, at 10:50 a.m. but non-compliance remained at the lower scope and severity of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Diagnosis Report printed on 12/8/22, indicated R1's diagnoses included Alzheimer's disease, depression, osteoarthritis, weakness and pain. R1's care plan dated 8/6/19, indicated R1 was limited in ability to independently complete activities of daily living (ADLs) related to dementia. R1 required the total assistance of one staff for all ADLs. The care plan directed R1 transferred with the ceiling lift using a small full sit-on sling and the assistance of one staff. If the ceiling lift was unavailable, R1 was to be transferred with the floor mechanical lift using the small full body split-leg sling with the assistance of two staff. It was okay for R1's daughter to be the second assist. On 12/2/22, at 1:25 p.m. R1's family member (FM)-A reported to the surveyor on 11/22/22, R1 fell out of the ceiling lift during a transfer. R1 received a hip fracture from the fall. FM-A stated she was wondering if the fall had been reported because the only way to fall out of a ceiling lift was when a resident was not hooked up correctly. A facility incident report dated 11/22/22, indicated on 11/22/22, at 4:10 p.m. R1 fell out of a transfer sling. R1 was unable to tell what happened. R1 had swelling to the top of her scalp. R1 was not sent to the hospital. R1 was being transferred from the bed to the recliner using a small full split-leg (sit-on) sling with the assistance of one staff. R1 fell through the sling and onto the floor. Immediate interventions were R1's sling was changed to a full sling. An x-ray report dated 11/23/22, indicated the reason for the x-ray was pain post-fall. The report indicated R1 had an acute comminuted (the bone was broken or crushed into three or more pieces) intertrochanter right femur fracture. During an interview on 12/5/22, at 10:46 a.m. with the administrator, DON, director of operations (COO)-A and RN-C, the DON stated immediately after the fall RN-A inspected R1's sling and found the sling used was the correct size. The DON stated R1 had a change in condition, did not have core strength and slid out of the sling. The DON stated RN-A had watched R1 transfer that morning by a different nursing assistant (NA) and R1 did fine in the sling. The sling was still hanging from the ceiling lift and was connected correctly. The DON stated it was not staff error. During an interview on 12/5/22, at 1:35 p.m. NA-A stated she was using the split-leg sling when transferring R1, and she connected the sling with the gray straps. NA-A stated she had never had a problem before. NA-A stated R1's care plan directed what size of sling to use. NA-A stated she did not look at the sling size and assumed it was the correct size. NA-A stated R1 had a shower and it was possible someone else brought the incorrect sling into R1's room. NA-A stated she was not sure but it was a possibility. NA-A stated R1 slid out of the bottom of the sling. NA-A tried to stop R1 from falling but it happened so fast. NA-A stated NA-B was in the room but did not help hook up the lift sling. NA-A stated R1 was transferred with the ceiling lift and one assist. NA-B was behind the chair to push the chair under R1. NA-A stated NA-B did not have a chance to put chair under R1 because R1 fell so quickly. NA-A stated NA-B left the room to get RN-A, and RN-A was in R1's room within five minutes. NA-A stated the sling material was shiny and slippery, and R1's hands were on her chest. NA-A stated after the fall, leadership did not observe her providing transfers to any other resident. On 12/5/22, at 2:49 p.m. NA-A stated the only way a resident could slip out of a sling was if the sling was positioned incorrectly or if the sling was the wrong size. During an interview on 12/5/22, at 2:40 p.m. NA-B stated she was on the other side of R1's bed and about to leave the room. NA-B stated NA-A was transferring R1 with the ceiling lift as NA-B was going out the door. NA-B heard NA-A yell. When NA-B turned around R1 was falling from the lift sling and NA-A was trying to catch R1. The sling was the full body sling of which had an open bottom. NA-B stated the sling appeared to be hooked up properly. During an interview with RN-A on 12/5/22, at 2:20 p.m. RN-A stated upon entering R1's room after the fall from the ceiling lift, R1 was on the floor on her left side parallel to bed. A small sized split-leg sling was used during the fall, and was attached at all four points of the lift. RN-A assessed R1 who stated R1 winced with leg movement. After the fall from the lift, RN-A changed R1's sling from the small sized split-leg sling to the full-body sling. RN-A stated she checked the sling condition after the fall, and it was in good condition. RN-A further stated R1 sustained a right hip fracture from the fall. On 12/6/22, at 8:10 a.m. RN-A was interviewed again and stated R1 could have become limp and slid through the sling. RN-A stated therefore, R1's lift sling was changed to the full body sling with no opening. On 12/6/22, 8:51 a.m. the DON and RN-C were interviewed. When questioned, the DON stated a resident could fall from a mechanical lift if the sling was not the appropriate size, or if the staff were not utilizing the lift or the sling correctly, or if the lift malfunctioned. The DON stated R1 was using a split-leg sling when she slid through the bottom of the sling. The straps were crossed and R1's legs should have gotten caught in the crossed straps. During an interview on 12/6/22, 10:15 a.m. with the Guldman's ceiling lift manufacturer chief operating officer (COO)-B, the COO-B stated residents do not fall from a lift sling if the sling is applied properly and the caregiver had been trained. If a resident slid out the bottom opening of a sling, the sling was not applied correctly. COO-B stated if a resident had poor core strength and slid out of a sling, then the sling was too big for the resident. The facility's Safe Lifting and Movement of Residents policy dated 7/17, directed the nursing staff and the rehabilitation staff would assess the residents need for transfer assistance on an ongoing basis. The resident would be assessed for preference, mobility, size, weight bearing ability, cognitive status, cooperation, and rehabilitation goals. The facility's Abuse Prohibition Vulnerable Adult policy dated 4/11/22, included the purpose of the policy implementation was to prevent injuries. The policy further directed avoidable accidents described as an accident of which occurred because the facility failed to evaluate or analyze the hazards and risks and eliminate them if possible. If not possible, identify and implement measures to reduce the hazards or risks as much as possible. The IJ was removed on 12/7/22, at 10:50 a.m. when the facility verbally educated all nurses and nursing assistants on the need to use the appropriate size and type of sling as identified on the resident's care plan and competencies were redone in regard to ceiling lifts and use and on how to utilize the slings. Staff that did not receive the verbal training would be notified and removed from the schedule until education could be completed. Any newly hired nurses and nursing assistants would receive ceiling lift and sling education and competency completed before their first working shift. All residents that use ceiling lifts were assessed to ensure they were care planned for the appropriate ceiling lift sling as directed in the sling style and size guide in the manufactures lift manual. All residents that require a ceiling lift for transfers would be assessed by the RN managers or DON on admission or when a significant change was identified to ensure the resident was care planned for the appropriate sling. The Safe Lifting and Movement policy was reviewed and remained current.

Based on interview and document review, the facility failed to test employees for COVID-19 according to county transmission rate, and outbreak status as directed by Centers for Disease Control (CDC). The facility did not have a system to track employee testing, and as a result 4 of 7 nursing assistants not up to date with vaccine status (NA)-A, NA-F, NA-E and NA-G) were reviewed and not testing according to the county transmission rate. In addition, the facility did not implement outbreak testing when NA-N tested positive for COVID-19 on 6/25/22. This deficient practice resulted in an immediate jeopardy (IJ) situation for all 58 residents residing in the facility during a COVID-19 outbreak with 16 residents (R7, R9, R19, R21, R29, R31, R32, R33, R34, R37, R38, R39, R44. R45, R46, R208) who contracted COVID-19, and (R209) who was hospitalized with COVID-19. The IJ began on 6/25/22, when nursing assistant (NA)-N tested positive for COVID-19 but the facility did not begin outbreak testing until 7/6/22, did not ensure all staff were testing, and did not track testing. The IJ was removed on 9/2/22, at 10:38 a.m. but noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance Interim Infection Prevention and Control (IPC) Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 2/2/22, nursing homes must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and health care personnel (HCP) to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. In nursing homes, HCP who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: -In nursing homes located in counties with substantial to high community transmission, these HCP should have a [CONDITION(S)] test twice a week. -If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). Per recommendations above, these facilities should prioritize resources to test symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents or HCP. On 8/30/22, at 11:27 a.m. the infection preventionist (IP) nurse stated the county in which the facility was located had been in high community transmission rates for all of June, July and August 2022. The facility required all not up-to-date employees to test two times per week. During routine testing a not up-to-date staff tested positive for COVID-19 on 6/25/22, and six others tested positive between 6/25/22, and 7/5/22. The IP stated the facility's COVID-19 outbreak started on 7/6/22 and six residents tested positive on 7/6/22. The IP stated all employees were trained to perform self testing using the Binax Rapid Testing, complete a sign in sheet and individual testing form that identified the results of the test. The IP nurse tried to check who had tested on each required test date at least weekly, but did not have a tracking system to ensure these were consistently completed and, as a result, would not be able to know if not up-to-date employees who were asymptomatic but still COVID-19 positive were working. The IP stated she was unable to track the employee testing on a daily basis to see if an not up-to-date employee had tested . She indicated this information was important to stop the spread of COVID-19. Review of seven not up-to-date employee individual COVID-19 test results for June and July, who had tested positive during the facility identified COVID-19 outbreak beginning 7/6/22, indicated the following: -NA-A was unvaccinated and had worked 12 of 30 days in June 2022. NA-A had not tested the week of 6/26/22, despite having worked three shifts during the week: 6/27/222, 6/29/22, and 6/30/22. NA-A had worked 7/1/22, 7/2/22, 7/3/22, 7/4/22 and 7/5/22. NA-A tested negative on 7/2/22, with a rapid antigen test, however reported symptoms of fatigue and fever and tested positive on 7/5/22. -NA-F was not up-to-date on vaccinations and had worked 12 of 30 days in June 2022. NA-F had not tested any of the two tests required the week of 6/19/22 or one of the two tests required the week of 6/26/22, prior to the shifts she worked on 6/26/22, 6/28/22 and 6/29/22. NA-F had worked 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/5/22, and 7/6/22, however had not tested on any days in July before testing positive on 7/7/22. No exhibited symptoms had been recorded at the time of NA-F's positive test result. -NA-E was not up-to-date on vaccinations and had worked 16 of 30 days in June 2022. NA-E had tested on [DATE], however no other required two times a week COVID-19 testing had been documented, despite having worked three to four times per week in June 2022. NA-E worked 7/1/22, 7/2/22, 7/3/22, and 7/4/22, however, only tested on [DATE], with a positive result with reported symptoms of fatigue, fever, chills, congestion and headache. NA-E had not tested the required two times per week prior to working her July shifts. NA-E worked 17 of 30 days in August. -NA-G was not up-to-date on vaccinations and had worked 5 of 30 days in June 2022. NA-G had worked 6/25/22, and 6/26/22, however had not completed the required COVID-19 testing two times weekly for the week of 6/26/22. No required testing results were recorded for NA-G for the entire month of June. NA-G had tested prior to each of the July shifts she worked until testing positive on 7/13/22, with reported symptoms of congestion, dizzy, headache and a cough. Review of five not up-to-date employees for the required two times per week testing requirement for August from 8/1/22, through 8/30/22, indicated the following: -NA-B was not up-to-date and had worked 7 of 30 days in August 2022. NA-B did not have any COVID-19 test results documented the month of August 2022. -NA-C was not up-to-date and had worked 14 of 30 days in August 2022. NA-C had tested on e of two required COVID-19 tests the week of 8/1/22, two of the required two tests for week of 8/7/22, one of the two required tests the week of 8/14/22, and had not tested either of the two required tests the week of 8/21/22. -Auxiliary staff (AS)-F was not up-to-date and worked in common areas of the facility during the work week. AS-F had tested on e of the two required COVID-19 tests the week of 8/1/22, one of the two required tests the week of 8/7/22, two of two required tests the week of 8/14/22, and one of the required two tests the week of 8/21/22. Residents medical records, who had tested positive for COVID-19 during the facility's identified COVID-19 outbreak beginning 7/6/22, identified the following: -R209's undated Admission Report and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R209's progress notes (PN) dated 7/5/22, indicated R209 tested positive for COVID-19 on 7/5/22, and exhibited symptoms of increase confusion, not feeling well, lethargy and headache. R209 was sent to the emergency room and admitted to the hospital on 7/5/22. PN dated 7/7/22, indicated R209 had returned to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -R9's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's PN dated 7/12/22, indicated R9 tested positive for COVID-19 on 7/12/22 and had symptoms of diarrhea. R9's PN 7/13/22, indicated R9 developed additional symptoms of lethargy and treatment with Paxlovid (an oral antiviral medication) two times (BID) per day for five days was initiated. -R7's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's PN dated 7/6/22, indicated R7 tested positive for COVID-19 on 7/6/22. R7's PN dated 7/7/22 indicated treatment with Paxlovid two times per day for five days was initiated and a PN dated 7/9/22, indicated R7 exhibited symptoms of not feeling well. -R19's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's PN dated 7/8/22, indicated R19 tested positive for COVID-19 on 7/8/22 and R19 appeared flushed and fatigued. PN dated 7/12/22, indicated R19 was tired and sleeping a lot. -R21's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's PN dated 7/6/22, indicated R21 tested positive for COVID-19 on 7/6/22. PN dated 7/9/22, indicated confusion and PN dated 7/10/22, indicated R21 developed symptoms of fatigue and congestion. -R29's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -R31's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's PN dated 7/21/22, indicated R31 tested positive for COVID-19 on 7/21/22. R31's PN dated 7/22/22, indicated R31 developed symptoms of a non productive cough and treatment with Paxlovid BID for five days was initiated. -R32's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's PN dated 7/6/22, indicated R32 tested positive for COVID-19 on 7/6/22. R32's PN dated 7/9/22, indicated R32 developed symptoms of wheezing and not feeling well. -R33's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's PN dated 7/7/22, indicated R33 developed symptoms of cough and head congestion. -R34's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's PN dated 7/8/22, indicated R34 tested positive for COVID-19 on 7/8/22, and developed symptoms of nasal drainage and treatment with Paxlovid BID for five days was initiated. -R37's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R37's PN dated 7/6/22, indicated R37 tested positive for COVID-19 on 7/6/22. R37's PN dated 7/9/22, indicated R37 developed symptoms of wheezing and not feeling well. -R38's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's PN dated 7/12/22, indicated R38 tested positive for COVID-19 on 7/19/22, and had not exhibited any symptoms of COVID-19. -R39's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's PN dated 7/6/22, indicated R39 tested positive for COVID-19 on 7/6/22. PN dated 7/10/22 indicated R39 exhibited symptoms of a cough. -R44's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R44's PN dated 7/8/22, indicated R44 tested positive for COVID-19 on 7/8/22, and developed symptoms of low energy, coughing and congestion. -R45's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's PN dated 7/27/22, indicated R45 tested positive for COVID-29 on 7/27/22, and developed symptoms of lethargy. -R46's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's PN dated 7/8/22, indicated R46 had refused testing for COVID-19, however, developed symptoms of flush and fatigue and was placed in droplet precautions as a result of symptoms. -R208's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R208's PN dated 7/8/22, indicated R208 tested positive for COVID-19 on 7/8/22. R208's PN dated 7/9/22, identified R208 developed symptoms of congestion and PN dated 7/10/22, indicated R208 also developed fatigue. During joint interview with the director of nursing (DON), administrator and nurse consultant (NC) on 8/31/22, at 11:50 a.m. the DON stated the only requirement for not up-to-date employees was to test two times per week. All employees had to wear the same personal protective equipment (PPE) of surgical mask covering nose and mouth and eye protection when in patient care areas, regardless of vaccination status. The facility tracked testing using the testing log signature sheets which included the dates the employees tested and their assertion they completed the required test. The administrator stated they had identified a problem yesterday, 8/30/22, during the health department survey with employees testing. They were just starting to work on a process. The DON also stated if she had known an employee worked without performing the required test they would not have been allowed to work. All of the not up-to-date employees had been granted exemptions from having to receive the COVID-19 vaccination series. None of the employees were refusing to test for COVID-19. Although the first staff person tested positive for COVID-19 on 6/25/22, with six other staff testing positive between 6/25/22, until 7/5/22, the facility did not begin outbreak testings until 7/6/22, at which time six residents tested positive. In addition to the late determination of outbreak status, the facility did not ensure compliance with the required COVID-19 testing and tracking of employees based on the county positivity rate and during the facility outbreak. This system failure continued through the month of August 2022 until the health department survey. For the outbreak period, the last employee positive was 7/19/22, and the last positive resident was 7/26/22; the facility considered the outbreak to be done on 8/2/22. However, staff did test positive on 8/8/22 and 8/24/22. According to CDC guidance, if additional cases are identified, testing should continue on affected unit(s) or facility-wide every 3-7 days in addition to room restriction and full PPE use for care of residents who are not up to date with all recommended COVID-19 vaccine doses, until there are no new cases for 14 days. As a result of the failed test tracking system staff who were COVID-19 positive could have been working with residents. The facility's policy COVID-19 Testing Policy with revision date 3/11/22, indicated in an effort to reduce COVID-19 transmission throughout the facility, the facility would test residents and staff based on parameters and frequency set forth by the Department of Health, Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention. A new facility onset of COVID-19 infection in any staff or resident would trigger an outbreak investigation. All health care workers, regardless of vaccination status, should be tested for COVID-19 when working in a facility experiencing an outbreak. Routine testing of employees whose vaccination status was not up to date, should be based on the extent of the virus in the community. Employees whose vaccination status was up to date would not have to be routinely tested . If the level of COVID-19 community transmission was high, minimum testing frequency of staff who were not up to date with COVID-19 vaccination would be two times per week. The facility must demonstrate compliance with the testing requirements, among which included the facility's procedures for addressing residents and staff that refused testing or are unable to be tested and how the facility would address those cases. The IJ which began on 6/25/22, was removed on 9/2/22, at 10:38 a.m. when it could be verified through observation, interview and document review the facility had tested all their employees to ensure all employees had a verified negative COVID-19 test result prior to the start of their shift. Administration had trained all employees on COVID-19 test requirements. Policies were reviewed and revised to reflect protocols for testing procedures and tracking to ensure all staff were tested for COVID-19 in a manner consistent with current standards of practice for conducting and tracking COVID-19 tests; Education was provided to all staff on current and updated COVID protocols for staff and would continue for continued outbreak testing; and completion of testing and training would be tracked, analyzed, and acted on to ensure compliance with routine and outbreak testing.

Based on interview and document review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents (R1) who received incorrect [MEDICATION(S)] (anticoagulant/blood thinner) dosing. This deficient practice resulted in an immediate jeopardy (IJ) situation for R1, who required hospitalization with a critical INR (internationalized normalized ratio - a laboratory measurement of how long it takes blood to form a clot), and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The immediate jeopardy began on 6/20/22, when the pharmacy delivered bubble pack medication cards for [MEDICATION(S)] packaged for two milligram (mg) tablets that actually contained 5 mg tablets. The error was discovered on 6/27/22, when registered nurse (RN)-B noted the [MEDICATION(S)] tablets in the bubble pack medication card did not match the description typed on the [MEDICATION(S)] card. The IJ that began on 6/20/22, was corrected on 6/29/22 when the facility implemented interventions to prevent reoccurrence. The administrator, director of nursing (DON) and corporate administrator were notified of the IJ past noncompliance on 7/6/22, at 3:41 p.m., as a result of the immediate corrective action taken by the facility. Findings include: R1's Admission Record printed on 7/7/22, indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's [MEDICATION(S)] use was related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, required supervision with activities of daily living, and had a recent surgery involving tendons/ligaments/or muscles. The MDS also indicated R1 received anticoagulant medication. Review of R1's care plan, initiated on 6/20/22, indicated R1 was on anticoagulant therapy (medications that help prevent existing blood clots from growing larger and prevent the formation of new blood clots by increasing the amount of time it takes a blood clot to form). One of R1's goals was to be free of adverse reactions related to anticoagulant use. Interventions included labs as ordered and to report abnormal labs to the physician, to monitor/document/report as needed signs and symptoms of anticoagulant therapy. Signs and symptoms included blood tinged or frank blood in the urine, black tarry stools, dark or bright red blood in stools, sudden changes in mental status, or sudden changes in vital signs. R1's Order Summary Report printed on 7/7/22, included orders for [MEDICATION(S)] (a trade name for [MEDICATION(S)]; used to treat and prevent blood clots) 5 mg, give one tablet by mouth in the evening every Monday, Wednesday, Friday, and Sunday. [MEDICATION(S)] 6 mg, give one tablet by mouth at bedtime every Tuesday, Thursday, and Saturday. According to the facility's investigative report dated 7/1/22, R1 had received the following doses of [MEDICATION(S)]: 6/20/22, 12.5 mg 6/21/22, 15 mg 6/22/22, 12.5 mg 6/23/22, 15 mg 6/24/22, 12.5 mg 6/25/22, 15 mg 6/26/22, 12.5 mg According to R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6/20/22, 5 mg 6/21/22, 6 mg 6/22/22, 5 mg 6/23/22, 6 mg 6/24/22, 5 mg 6/25/22, 6 mg 6/26/22, 5 mg R1's laboratory test dated 6/28/22, for INR resulted in a critical lab value of 10.8. An INR range of 2.0 to 3.0 is an effective therapeutic range for people taking [MEDICATION(S)]. Review of R1's progress notes revealed the following: -6/28/22, at 2:43 p.m. INR was greater than 10.8 today. Review of why it was so high showed last night a nurse discovered that them (sp) [MEDICATION(S)] tabs, from the pharmacy/bubble pack had 5 mg tabs (peach) and should have been 2 mg (violet) tabs. R1 received too much [MEDICATION(S)]. Essentia [MEDICATION(S)] clinic called and was updated. New orders were to give Vitamin K [medication used for [MEDICATION(S)] overdose] stat and check a HGB [hemoglobin]. HG was 8.3 [healthy range for women is 11.6 to 15 grams per deciliter]. Hold [MEDICATION(S)] 6/28/22 and 6/29/22 and recheck INR 6/30/22. Stop Aspirin. -6/28/22, at 2:51 p.m. Spoke to R1 this morning about the [MEDICATION(S)] dosing and that we are holding the [MEDICATION(S)] today and tomorrow and she did not receive any last night after the nurse updated this writer. R1 reported she felt weak and was having a harder time with transfers and just different (weaker) today. No blood noted in nose, urination, bowel. Drew blood today x 2 and R1 stopped bleeding immediately from her antecubital areas. No therapy today. Will continue to monitor. -6/28/22, at 5:27 p.m. R1 was in her recliner and states she was feeling very faint like, lightheaded and there was something not right. Yesterday she was doing therapy and transferring and today totally weak especially when standing/transferring. BP sitting 120/60, BP standing 60/40. When she stood she became very lightheaded and stated: I'm going to faint. She sat down and was extremely weak. Call made to physician assistant (PA) to update. Order received to send to the emergency room (ER). 911 was called and ambulance arrived for transport. -6/28/22, at 9:48 p.m. R 1 was admitted to the hospital and received a blood transfusion at the ER. R1's hospital discharge summary dated 6/30/22, indicated R1 was admitted from the facility with dizziness, weakness, and melena (dark sticky feces) related secondary to unintentional [MEDICATION(S)] overdose. R1's course in the emergency room indicated she had a computerized tomography scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) of abdomen and pelvis without clear gastrointestinal (GI) bleed, she did receive two units of packed red blood cells (PRBC) for [CONDITION(S)]. R1's facility discharge summary dated 6/30/22, indicated R1 had a referral placed to general surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . An endoscopy can be used to look for a bleeding source). R1 was discharged home on 6/30/22. On 7/5/22, at 3:42 p.m. nurse consultant (NC)-A stated the pharmacy put five mg [MEDICATION(S)] tablets in the medication bubble packets that were labeled as two mg [MEDICATION(S)] tablets. NC-A stated the error was not discovered until RN-B found the error on 6/27/22, after R1 had received the wrong dose seven times. On 7/5/22, at 3:51 p.m. the director of nursing (DON) stated R1 was symptomatic from the medication error and was transferred to the ER for blood transfusion. The DON stated they were unsure of the source of R1's bleeding and she would need follow up to determine the cause of her low HG. On 7/5/22, at 3:58 p.m. licensed practical nurse (LPN)-A stated her had been educated on dosing for [MEDICATION(S)] by the facility and would be a lot more careful and would make sure the pill color matched the pill in the medication bubble pack. On 7/6/22, at 9:02 a.m. an attempt was made to communicate with R1 and family member (FM)-F, but there was no response. On 7/6/22, at 9:18 a.m. medical director (MD)-C stated he would expect the medication coming from the pharmacy to be correct in the package. MD-C stated a double dose of [MEDICATION(S)] would case a higher INR and a high INR would make the resident at risk for spontaneous bleeding. MD-C further stated usually a GI bleed would not be fatal. MD-C stated he would have expected the facility to have notified the residents provider as soon as the medication error was discovered on 6/27/22. On 7/6/22, at 9:35 a.m. pharmacy manager (PM)-E verified there was a break down in the pharmacy's filling process when the [MEDICATION(S)] pills were filled and 5 mg tablets were placed in a medication bubble pack labeled as 2 mg tablets. On 7/6/22, at 9:54 a.m. RN-A stated she received a message from RN-B on 6/27/22, at 7:55 p.m. who stated the [MEDICATION(S)] pill color did not match the description of the pill color did not match the pill in the medication bubble pack. RN-A told RN-B not to give the medication and to put the card on her desk. RN-A did not realized the medication had been given for the previous six days. RN-A stated had she known that she would have had RN-B call a provider when the error was discovered. RN-A knew R1 was due for an INR lab draw on 6/28/22. RN-A stated she arrived at work at 8:30 a.m. on 6/28/22, and started her investigation. However, RN-A did not notify the administrator until 9:40 a.m. for reporting purposes. On 7/6/22, at 10:31 a.m. RN-B stated she noticed the [MEDICATION(S)] pill was peach and should have been purple. When she punched the pill out into a medication cup she also noted there was a five on the pill. RN-B stated she called her manager and talked to her about it. Her manager told her to not give the dose and to put the medication back in the bubble pack and put it on her desk. RN-B was told to watch R1 for signs of bleeding. She was not told to call a provider about the error. On 7/6/22, at 11:07 a.m. the DON verified R1's provider should have been notified immediately upon discovering the medication error. The DON stated the education for nursing staff and the TMA was started on 6/29/22, in person with staff who were working and by phone for staff who were not working. The policy titled Administering Medications dated 4/2019, directed staff to contact the resident's provider if a dosage was believed to be inappropriate, excessive, or if suspected of adverse consequences. The staff were directed to check the medication label three times to verify the right resident, right medication, right dosage, right time, and right route of medication before giving the medication. The past noncompliance immediate jeopardy began on 6/20/22, when the first incorrect dose of [MEDICATION(S)] was given. The immediate jeopardy was removed on 6/29/22, when the facility implemented the following corrective actions: -Re-education of nursing staff on 6/29/22, on the six rights of medication administration on 6/29/22. A 6/29/22, nurse education sheet listed each staff name with a signature behind. Interviews with nursing staff on 7/6/22, verified knowledge of the correct process of checking the [MEDICATION(S)] chart, how to check the descriptions of pills and checking the dosage. -All current resident's [MEDICATION(S)] bubble packs were reviewed to ensure they were correctly packaged by the pharmacy -Added descriptions/pictures of [MEDICATION(S)] (color, printed mg) to each medication cart and on the bulletin board in the nurse's station on 6/29/22, as observed on 7/5/22, and 7/6/22. -On 6/29/22, the facility contacted the pharmacy about the error and about their new process going forward of checking the pill description and dosage. -They discussed at QAPI and with the medical director who was present at the QAPI meeting

Based on interview and document review, the facility failed to ensure the care plan was followed to ensure the call light was available for 1 of 1 residents (R1) reviewed for accidents. This resulted in harm for R1, who fell and sustained a fracture. Findings include: R1's Face Sheet indicated [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 was severely cognitively impaired, required extensive assistance with transfers and toileting, and was frequently incontinent of bowel and bladder. R1's Fall Risk Assessment started [DATE], and completed [DATE], indicated R1 had intermittent confusion, impaired mobility, history of 3 or more falls in the past 3 months, and balance problems. A decision was made to initiate the plan of care. R1's care plan dated [DATE], directed to keep call light within reach at all times. A review of the facility's Internal Investigation Report Form dated [DATE], indicated that at 12:45 a.m. R1 was found laying on the floor in her room. R1's call light was on the recliner, and not within her reach. R1 was interviewed immediately, and stated, I was trying to get to the bathroom. When asked why she didn't ask for help R1 stated, I couldn't find my call light and hollered for help. I stood up and fell , hit head on floor. When interviewed on [DATE], at 2:30 p.m. nursing assistant (NA)-A stated, Oh .I know better than that, I must have forgot. Progress notes dated [DATE], indicated R1 complained of right ankle pain immediately following the fall. The MD was called, and ordered to monitor the resident. Progress notes dated [DATE], indicated R1's MD was making rounds, noted R1's blood pressure (BP) was low, and ordered her to be sent to the ER. An x-ray report dated [DATE], indicated R1 sustained a mildly displaced [MEDICAL CONDITION] fibula. The facility's investigation summary submitted to the State Agency (SA) on [DATE], indicated on [DATE], NA-E heard a thump at 12:45 a.m. and went running into R1's room, where R1 was on the floor. R1 said she had to go to the bathroom, and could not find the call light. R1's call light was still clipped on the recliner where she had been sitting prior to going to bed that evening. R1 stated she had tried to get up herself and fell . R1 said she hit her head and her ankle hurt. ER was called, the MD reviewed her medications, and told the facility to monitor R1. Later in the day, R1 did not have any complaints of dizziness, but complained of pain in her ankle. On [DATE], R1's MD made rounds, noted her BP was lower than normal, and she had some [MEDICAL CONDITION](rapid heartbeat). MD ordered R1 to be sent to ER, where R1 was found to have a [MEDICAL CONDITION] tibia. A hospital note dated [DATE], indicated R1 was noted to have cardiac issues, a mass on her liver and kidney, and [MEDICAL CONDITION]. A progress noted dated [DATE], indicated R1 returned to the facility. R1 died on [DATE]. On [DATE], at 1:15 p.m. the director of nursing (DON) was interviewed. The DON stated when she hires staff, she makes sure they are educated on placing call lights within residents' reach. The DON stated she reeducated all staff on the importance of having call lights in place following R1's fall. On [DATE], at 2:36 p.m. NA-A was interviewed. NA-A stated she had learned to make sure call lights were in place in nursing assistant training and in orientation at the facility. The night R1 fell , NA-A stated she got R1 ready for bed. NA-A stated she was familiar with R1's routine. NA-A stated she had assumed she had put R1's call light by her bed, on her side rail. NA-A stated R1 would use her call light appropriately on the afternoon shift. NA-A's Competency Checklist indicated NA-A was oriented on call lights on [DATE]. The Competency Checklist also indicated NA-felt comfortable with call lights on [DATE]. On [DATE], at 3:33 p.m. NA-B was interviewed. NA-B stated she worked the afternoon shift, and R1 was able to use the call light. NA-B stated on afternoon shift, R1 was not incontinent, because she put her light on to go to the bathroom. NA-B stated R1 needed assist of one to transfer because she had weakness. NA-B stated R1 wore an incontinent brief at night. NA-B stated R1 always rang to go to the toilet on afternoon shift. On [DATE], at 3:38 p.m. NA-C was interviewed. NA-C stated R1 came to her unit following her hospitalization on [DATE]. NA-C stated R1 went on Hospice care, and died a few days later. On [DATE], at 4:02 p.m. NA-E was interviewed. NA-E stated he was the NA working the night R1 fell . NA-E stated R1 used the call light consistently, and she would ring ,[DATE] times at night to go to the bathroom. NA-E stated R1 was never incontinent at night, she would always ring for staff, and they would take her to the bathroom. NA-E stated the night R1 fell , he heard a noise and went into her room, and she was on the floor. NA-E stated he saw the call light was clipped to the recliner, so he knew she didn't have it available. NA-E stated R1 told him she had to go to the bathroom, so she got up because she didn't have the call light. NA-E stated R1 had been incontinent of urine on the floor. NA-E stated he believed R1 would not have fallen if she would have had the call light available. A policy on following the care plan was requested but not provided.

Based on observation, interview, and document review, the facility failed to ensure pressure ulcers were identified and assessments were completed to prevent the development of and worsening of pressure ulcers for 2 of 3 residents (R13, R152) reviewed for pressure ulcers. This resulted in actual harm for R13 due to development of a pressure ulcer to the right leg. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 1: Nonblanchable [DIAGNOSES REDACTED]: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage 2: Partial Thickness Skin Loss: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) and/or eschar (dark, dead tissue) may be visible. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). R13's Face Sheet printed 5/25/17, indicated [DIAGNOSES REDACTED]. R13's admission Minimum Data Set ((MDS) dated [DATE], lacked identification of risk for pressure ulcers and presence of current unhealed pressure ulcers. need to see if identified history of The MDS also indicated R13 required extensive assistance of 2 staff for bed mobility and transfers, and had daily vocal complaints of pain. R13's quarterly MDS dated [DATE], indicated R13 had a severe cognitive deficit, required extensive assistance of 2 staff for bed mobility and total assistance of 2 staff for transfers. The MDS further indicated R13 was at risk for pressure ulcers, had no pressure ulcers, no healed pressure ulcers, and had no pressure ulcers on the previous assessment. The MDS also indicated interventions included a pressure device for chair and bed, but did not identify a turning and repositioning program. R13's Care Area Assessment (CAA) dated 12/22/16, indicated R13 was at increased risk for skin breakdown related to decreased mobility due to a recent right femur fracture, and incontinence of bowel and bladder. R13's care plan initiated 12/22/16, and edited 5/23/17, indicated R13 had a history of [REDACTED]. R13's care plan approaches started 12/22/16, directed staff to keep clean and dry as possible, provide incontinence care after each incontinent episode, and report any signs of skin breakdown. The care plan approaches started 1/5/17, and edited 5/23/17, directed resident to be repositioned side to side only when in bed and encourage use of wedge for side lying. Care plan approaches started 1/11/17, and edited 4/20/17, directed the use of an alternating air-flow mattress with side bolsters, and treatment to pressure ulcers per orders. Care plan approaches dated 1/19/17, directed the resident to be out of bed and up for meals only and special events per family requests. Care plan approaches dated 1/26/17, directed the use of blue heel lift boots to be worn on both feet at all times except during cares for skin inspection. The care plan further directed no pressure to be placed on the right leg while in bed or wheelchair. Care plan approaches dated 3/8/17, included a foot cradle to the bed to keep blanket weight off R13's feet, and a ROHO (pressure prevention cushion with individual air cells) cushion in the wheelchair. R13's care plan further indicated R13 had increased nutrient needs related to impaired skin integrity and directed R13 to receive 4 ounces of Ensure Plus (oral supplement) four times daily to aid in wound healing. R13's care plan lacked direction for a repositioning program. R13's Kardex/nursing assistant (NA) Care Plan Reference Sheet initiated 12/13/16, indicated R13 required extensive assist of one staff for turning in bed, and total assist of two staff for moving R13 up in bed, and to check and change R13 every two hours for incontinence. Additions to the Kardex on 12/16/16, included bilateral heel lift boots on at all times except during cares. Changes dated 1/5/17, included reposition R13 side to side only in bed. Changes dated 1/19/17, included to get R13 up in wheelchair only for meals and special events per family requests. Changes dated 1/30/17, included a wedge for positioning. Changes dated 4/20/17, included an alternating air-flow mattress with bolster sides. Undated changes included identification of a Stage III pressure ulcer on R13's right lower leg, and directed staff to place no pressure to the area. It also identified a ROHO cushion in wheelchair, and a foot cradle on bed to keep pressure off R13's feet from blankets. R13's Kardex lacked direction for repositioning times. R13's facility pre-screening for admitted d 12/12/16, indicated R13's general skin condition was fragile and bruised, but indicated there were no wounds or pressure ulcer care, or repositioning program. The pre-screening form indicated R13 had a knee immobilizer, and was weight bearing as tolerated with pivoting transfers. R13's hospital Discharge Summary dated 12/13/16, indicated R13 had been admitted to the hospital on [DATE], with a right femur fracture, was given a trial of an immobilizer with limited weight bearing and tolerated it well with minimal breakthrough pain medications. Surgery to repair the fracture had been considered, but due to R13's high morbidity risk and progressive decline, surgery was not performed. R13's hospital Discharge Summary did not identify any areas of skin breakdown or pressure ulcers. R13's Interagency Referral (IAR) dated 12/13/16, included directions for [MEDICATION NAME] (menthol-zinc oxide used to treat or prevent minor skin irritations, moisture barrier) ointment to be applied with morning and nighttime cares, and three times daily as needed. The IAR indicated R13 had bruising of leg. The IAR also directed to transfer R13 with a lift, but R13 could bear touch down weight for transfers to chair only. The IAR further indicated R13 had constant, aching pain of the right leg. R13's IAR lacked documentation of any pressure ulcers. R13's Head-to-Toe Skin assessment dated [DATE], indicated R13 had an area measuring 1.0 x 1.1 centimeters (cm), but lacked any description of the area. A progress note dated 12/13/16, at 10:08 p.m. indicated an unidentified treatment was applied to irritated skin on the buttocks. R13's admission Observation Report dated 12/13/16, at 5:17 p.m. indicated R13 required assistance of two staff for bed mobility, had pain expressed with non-verbal sounds, and vocal complaints of pain of the right arm and leg. The admission note for the Observation Report dated 12/13/16, indicated R13 used a hoyer lift for transfers, could have behaviors related to not wanting to move in fear of creating more pain for herself, and had no [MEDICAL CONDITION] noted to either leg. The admission note did not identify any skin integrity concerns. R13's physician orders [REDACTED]. This was discontinued on 12/13/16. R13's progress notes dated 12/14/16, at 9:48 p.m. indicated R13 had two superficial open areas on the buttocks; one in the buttock slit measured 1.3 centimeters (cm) x 0.5 cm, and the second on the left buttock that measured 1.6 cm x 1.5 cm. The progress note indicated [MEDICATION NAME] was applied and the areas would be monitored. R13's nurse practitioner (NP) progress notes dated 12/16/16, at 7:00 a.m. indicated R13 had been admitted with a fractured right femur and used an immobilizer. The note further indicated R13 had pain with movement of the right leg, but was receiving both scheduled pain medication, and medication for breakthrough pain. The note also indicated R13 had good circulation, motion, sensitivity (CMS) and warmth in the right leg. The progress note indicated R13's skin had no observed [MEDICAL CONDITION] or open areas. On 12/16/16, at 10:00 p.m. a Skin Integrity Event-Pressure Sore/Stasis Ulcer form indicated R13 had a Stage II pressure ulcer on the right heel. The Skin Integrity Event (SIE) form lacked description of the pressure ulcer or interventions in place for the identified pressure ulcer. R13's progress notes dated 12/21/16, indicated a pressure ulcer on the right inner heel was identified on 12/16/16. The area was described as an intact blister measuring 2.2 cm x 2.5 cm. The right heel was further described as being boggy, and the outer ankle was dark in color. R13's care plan was updated on 12/21/16, to include blue boots to be worn, and heels to be floated off surfaces. Further progress notes on 12/21/17, indicated there was no fluid noted in the right heel blister, and R13 was at increased risk of skin breakdown according to a Braden assessment (tool used to assist in identifying risk of skin breakdown) score of 15 dated 12/21/16. R13's progress notes indicated R13 was to be repositioned every 2 hours and as necessary, and could be resistive to movement due to fear of falling. R13's medical record indicated R13's right heel pressure ulcer was not measured again, after this date, though it was periodically observed. R13's Skin Risk Assessment (SRA) with Braden dated 12/21/16, indicated R13 had one Stage II pressure ulcer that was not present on admission, but was identified on 12/16/16. The SRA indicated interventions included heel protectors, pressure reducing devices for chair and bed, pressure ulcer care, but lacked a turning and repositioning program. R13's SRA lacked identification of previously identified open areas in the 12/14/16, progress notes. R13's interdisciplinary team (IDT) progress note dated 12/21/16, indicated R13 had a fracture and wore an immobilizer on the right leg, which limited R13's mobility of the right leg. The IDT note indicated interventions initiated were determined to be appropriate. R13's progress notes dated 12/23/16, indicated a message had been left with the clinic regarding use of the immobilizer, and when or if it could be removed for R13 to receive a bath. Progress notes lacked a response from the clinic or follow up by the facility regarding the immobilizer until 1/13/17 (30 days following hospital return). R13's medical record lacked documentation of monitoring of the right heel pressure ulcer and skin until 1/4/17, when a Stage II coccyx pressure ulcer was identified. R13's coccyx pressure ulcer area measured 3.4 cm x 3.1 cm and had an area of dark tissue that measured 1.5 cm x 1.7 cm. The progress notes indicated R13 was totally dependent on two staff for repositioning, wore a right leg immobilizer at all times, and was incontinent of bowel and bladder. R13's care plan was updated at that time to be repositioned side to side only in bed, and a Tissue Tolerance assessment (tool to assist in identifying a resident's tissue perfusion and tolerance to persistent pressure to determine the proper positioning time for the individual resident) was initiated. R13's progress notes dated 1/5/17, indicated the IDT met and determined the dietician would review R13's intake and nutritional needs, the SRA and Tissue Tolerance would be initiated. The dietician note dated 1/5/17, indicated an order for [REDACTED]. R13's SRA with Braden and related progress note dated 1/6/17, indicated R13's Braden score remained at 15, indicating R13 was at risk for skin breakdown with the same risk factors previously identified. The progress note indicated R13's Stage II right inner heel pressure ulcer was healing, dry, and the skin had a tan discoloration. The note identified scar tissue from old wounds on both buttocks, and R13 reported she had wounds on her buttocks in the past. New interventions included an alternating air-flow mattress initiated that day, Ensure Plus (nutritional supplement) had been started, and a Tissue Tolerance was completed indicating resident tolerated being in one position for two hours without redness, bogginess, or warmth to any bony prominences. R13's SRA indicated R13 had two Stage II pressure ulcers, one was present on admission, though the previous assessment verified no pressure ulcers were present on admission, but was identified as being present on the prior assessment. R13's NP progress note dated 1/10/17, indicated R13 was seen for a skin check. NP documentation indicated R13 had a Stage II pressure ulcer on the coccyx which had worsened, and R13 was at high risk for pressure ulcers due to being bed and chair ridden because of a [MEDICAL CONDITION]. R13's NP progress note indicated the coccyx pressure ulcer had a thick layer of slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucous-like) and eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges) covering the wound bed. The pressure ulcer measured about 1.5 cm x 1.5 cm, and was unstageable at that time. The NP spoke with a wound care NP and determined the pressure ulcer would need to be surgically debrided to heal, but the facility could try mechanical [MEDICATION NAME] with [MEDICATION NAME] (honey-based ointment to assist with wound healing). Nursing progress notes dated 1/10/17, indicated the NP assessed the right inner heel pressure ulcer, which was continuing to heal, had no fluid, and had a semi-hard tissue covering it. The NP directed to leave the heel ulcer open to air, and ordered [MEDICATION NAME] gel to coccyx pressure ulcer and cover with Mepiliex (foam dressing to assist with management of drainage and prevent maceration of wounds) to be changed every 3 days, and reassess in one week. Physician orders [REDACTED]. R13's physician orders [REDACTED]. R13's progress notes dated 1/12/17, indicated the NP would contact the physician assistant who worked with R13 in the hospital regarding the immobilizer. R13's progress notes dated 1/13/17, indicated the NP received direction from the orthopedic NP that R13 could be out of the immobilizer if comfortable in bed, but have it on if she were to be getting up, and during transfers until 6-8 weeks post hospitalization , and off in the wheelchair if she was comfortable. The note also indicated R13 may have a bath or shower. R13's physician orders [REDACTED]. Physician orders [REDACTED]. R13's progress notes and new SIE dated 1/16/17, indicated R13's right leg immobilizer was not removed until 1/16/17, and when the immobilizer was removed, an unstageable pressure ulcer was noted on R13's lower right leg above the ankle. The pressure ulccer measured 9.2 cm x 2.7 cm covered with eschar, and an area parallel with intact skin separating the two areas measuring 4.2 cm x 1.5 cm also covered with eschar. The surrounding tissue had [DIAGNOSES REDACTED] (red inflammation). R13 did not have any complaints of pain to the area. A [MEDICATION NAME] border pad was applied after R13 showered. R13's progress notes dated 1/17/17, indicated NP approved leaving the immobilizer off but directed staff to support R13's right leg during transfers. R13's progress notes further indicated the IDT met and indicated R13 had a femur fracture with previous orders to wear the immobilizer at all times and was at high risk for skin breakdown. A new SRA was to be done and the dietician was to be updated. R13's progress notes dated 1/17/17, indicated NP assessed resident skin ulcers and ordered a leg/ankle X-ray to rule out osteo[DIAGNOSES REDACTED] (infection in the bone) and start [MEDICATION NAME] (antibiotic) 300 mg three times daily for 10 days for [MEDICAL CONDITION] (skin/tissue infection). R13's progress note further indicated R13 was to have an appointment with general surgery for [REDACTED]. Further progress notes on 1/17/17, indicated the coccyx ulcer measured 2.0 cm x 1.5 cm with 100% slough and dark tissue in the center. R13's right heel pressure ulcer continued to have thin dry skin, but was not measured. R13's Infection Control-Infection Report (IC-IR) initiated 1/17/17, indicated R13 had an infection of the skin of the right lower leg, treated with an antibiotic and [MEDICATION NAME] (used to decrease risk of infection of the bowel with ,[MEDICAL CONDITION]. difficele from antibiotic use). R13's IC-IR indicated R13's X-ray reports dated 1/18/17, indicated there was no evidence of osteo[DIAGNOSES REDACTED]. R13's SRA with Braden dated 1/18/17, indicated R13 had two Stage II pressure ulcers and one unstageable pressure ulcer covered with eschar. R13's Braden score continued to be 15, indicating R13 was at risk for skin breakdown. Interventions at this time included a repositioning program. R13's related progress note dated 1/18/17, indicated R13's immobilizer was discontinued recently, as R13 did not stand at any time, and was transferred with the use of a lift while staff supported the right leg. R13's progress note indicated R13 was scheduled to see general surgery for [REDACTED]. Interventions at that time included blue lift boots to feet at all times, repositioned side-to-side only while in bed to off-load coccyx, alternating air-flow mattress, Ensure Plus supplement, and a multivitamin. A tissue tolerance was to be completed in bed and wheelchair. The wheelchair tissue tolerance was completed after R13 was out at an appointment for greater than 2 hours. The tissue tolerance determined R13 tolerated repositioning every 2 hours, so this plan of care would be continued, but due to coccyx pressure ulcer, R13's plan of care was changed to be up in wheelchair only for meals and special events per family requests. R13's Operative Procedure Progress Note dated 1/19/17, indicated R13 had a debridement of the right lower extremity pressure ulcer and the coccyx pressure ulcer under general anesthesia. The brief post-op note indicated the coccyx pressure ulcer measured 2 cm x 1 cm x 0.5 cm, and the right lower leg pressure ulcre was down to the tendon and measured 8 cm x 3 cm x 0.5 cm. R13's Operative Report dated 1/19/17, indicated general endotrachial tube anesthesia was administered in the operating room. The coccyx pressure ulcer was debrided to viable tissue. The right lower extremity pressure ulcer eschar was debrided, and necrotic (dead tissue) was found underneath. The necrotic tissue was debrided and involved tissue down to the tendons. R13 tolerated the procedure well, and was discharged back to the facility the same day. R13's progress notes dated 1/201/7, indicated new treatment orders were received from surgeon for coccyx and right lower leg pressure ulcers. The treatment to the coccyx pressure ulcer was changed to wet to dry dressing daily, and if increased drainage let the NP know and it could be increased to twice daily. The treatment to the right lower leg pressure ulcer was changed to hydrogel dressing daily, keep wound beds moist. R13's Braden Scale dated 1/22/17, indicated R13 remained at high risk for pressure ulcers. R13's progress note dated 1/23/17, indicated R13 tolerated lying on right side for two hours without redness, increased warmth or bogginess to bony prominences. Further progress notes dated 1/23/17, indicated R13's right lower leg pressure ulcer measured 9.4 cm x 2.7 cm with exposed tendon and 10% slough. The note also identified a water blister measuring 2 cm x 1.9 cm located 8.5 cm superior to the pressure ulcer. R13's progress notes dated 1/26/17, indicated R13 had been at high risk for pressure ulcers related to her immobility so would continue restorative therapy for strengthening to allow her to move more freely and independently. R13's progress notes dated 1/26/17, indicated orders were received to apply [MEDICATION NAME] to right heel ulcer daily. R13's NP progress note dated 1/27/17, indicated R13 was finishing the antibiotic treatment, and the NP viewed R13's coccyx and indicated it was healing, had red beefy base with minimal slough The NP was unable to view the leg pressure ulcers due to dressing just being changed, but documented there were no signs of infection. The [MEDICATION NAME] was discontinued on this date. R13's progress notes dated 1/27/17, indicated R13 had a follow up appointment with the surgeon, had no change in treatment and received directives to keep pressure off debridement site and coccyx as much as possible. R13's progress notes dated 1/31/17, indicated NP assessed pressure ulcers and the following findings were documented: Right heel pressure ulcer was resolved and no longer required the [MEDICATION NAME] treatment. Coccyx surgical wound measured 1.8 cm x 2.2 cm x 0.3 cm with 50% slough. Right lower extremity: Upper surgical wound measured 5 cm x 2.3 cm x 0.4 cm with 25% slough and 75% granulation (red healing) tissue with the tendon still exposed. Lower pressure ulcer measured 3.9 cm x 2.7 cm x 0.7 cm with 75% slough and 25% granulation tissue noted. R13's progress notes dated 2/2/17, and 2/9/17, indicated R13 had a follow-up appointments with the surgeon and had no changes in treatment. Care of the pressure ulcers was released to the NP unless there were concerns. R13's NP progress notes dated 2/14/17, indicated all wounds show improvement, but the tendon exposed in the upper right leg pressure ulcer was developing a brown spot. General surgery was notified and expressed concern that it may be getting too dry, so dressing changes were to be changed to twice daily. NP progress note indicated coccyx pressure ulcer was a Stage II and the right leg pressure ulcer was a Stage III. R13's Braden Scales dated 2/7/17, 2/15/17, and 2/21/17, continue to indicate R13 was at high risk for pressure ulcers. R13's progress notes dated 2/16/17, indicated the coccyx pressure ulcer measured 1.5 cm x 1.4 cm x 0.2 cm with 10% slough and 90% granulation tissue, the upper right lower leg pressure ulcer measured 5.0 cm x 2.6 cm x 0.4 cm with 25% slough and 75% granulation tissue and the tendon exposed, and the lower right lower leg pressure ulcer measured 3.7 cm x 2.5 cm x 1.0 cm and was 90% slough and 10% granulation tissue. R13's progress notes dated 2/20/17, indicated the coccyx pressure ulcer measured 1.9 cm x 1.3 cm x 0.3 cm with 10% slough and 90% granulation tissue, the upper right lower leg pressure ulcer measured 5.0 cm x 2.5 cm x 0.4 cm with 10% slough and 90% granulation tissue with the tendon still visible, and the lower right lower leg pressure ulcer measured 3.2 cm x 2.5 cm x 0.6 cm and was 90% slough and 10 % granulation tissue. R13's NP progress notes dated 2/28/17, indicated the pressure ulcers had been making good progress with healing. Hydrogel dressings were being used to leg wounds twice daily and wet to dry packing was used daily on the coccyx, and R13 tolerated dressing changes well. NP documented the right leg wound continued to have healthy granulation tissue filling in the wound from the base up. NP documented the tendon was slightly brown and the surgery and wound care NP was aware. Coccyx pressure ukcer was healing with healthy tissue in the base. NP made no changes in treatment orders. Progress notes dated 3/4/17, indicated R13's right ankle tendon appeared darker brown to a larger area of the tendon. A new fluid-filled blister was identified on the posterior side of the pressure ulcer nearer the heel and measured 3.5 cm x 1.5 cm. The blister was intact. Staff were to be informed to avoid pressure to the ankle and use extreme caution when caring for resident. R13's progress notes dated 3/5/17, indicated the tendon in the right lower leg wound changed from dark brown to a dark yellow with a slight pearly shine. Progress notes further indicated R13's coccyx pressure ulcer had a moderate amount of serosanguinous (yellow fluid with small amounts of blood) drainage, with a small amount of teal colored drainage and fluorescent yellow colored drainage on dressing. Dressings were changed as ordered. R13's progress notes dated 3/6/17, indicated physical therapy (PT) screened R13 for PT intervention for pressure ulcers Stage III and Stage IV. It was determined PT was not indicated at that time. Quarterly nursing progress note dated 3/8/17, indicated R13 did not attempt to move in bed without staff assistance, Braden score was 14 indicating R13 remained at risk for skin breakdown, and was incontinent of bowel and bladder. R13's quarterly progress note indicated R13 had a Stage II pressure ulcer of the coccyx and Stage III pressure ulcer of the right lower leg. Interventions included heel lift boot at all times, reposition side-to-side in bed with use of a wedge, up only for meals and family request, off-load right leg pressure ulcer from surfaces at all times, foot cradle to keep heavy blankets off feet, alternating air flow mattress to bed and a ROHO cushion in wheelchair. R13's IDT progress notes dated 3/9/17, indicated R13's Stage II pressure ulcer on the coccyx and right lower leg pressure ulcers were improving, though the tendon in R13's upper right lower leg was more exposed. R13 was scheduled with plastic surgery for [REDACTED]. R13's NP progress notes dated 3/14/17, indicated coccyx pressure ulcer improved, and right lower leg pressure ulcer continued to slowly improve, but had a newer fluid filled blister below the lower right lower leg pressure ulcer. R13's NP note indicated R13 was scheduled for a consult regarding a possible graft over the tendon exposed in the right lower leg pressure ulcer. Dietary had reviewed and recommended zinc and vitamin C for wound healing. R13's plan of care was continued. R13's progress notes dated 3/15/17, indicated R13 was referred to plastic surgery. R13's plastic surgery note dated 3/20/17, indicated all wounds were improving, and had the potential to heal. An [MEDICATION NAME] AG dressing (helps to maintain a moist wound healing environment and control the bacteria to help prevent infection) was ordered. R13's progress notes dated 3/21/17, indicated R13's coccyx pressure ulcer measured 1.0 cm x 2.3 cm x 0.1 cm with 5% slough and 95% granulation. R13's upper right lower pressure ulcer measured 4.3 cm x 2.4 cm x 0.3 cm with 30% slough and 70% granulation tissue with the exposed tendon measuring 2.7 cm x 1.2 cm. R13's lower right lower leg pressure ulcer measured 2.7 cm x 2.2 cm x 0.4 cm and was 10% slough and 90% granulation. IDT progress notes dated 4/6/17, indicated R13's pressure ulcers were improving with the current treatment, and interventions included pressure relief, Ensure four times daily, multivitamin, and alternating air flow bed. R13's progress note dated 4/19/17, indicated R13's coccyx pressure ulcer measured 0.5 cm x 0.2 cm x 0.2 cm with 100% granulation tissue. R13's upper right lower pressure ulcer measured 3.6 cm x 2.0 cm x 0.3 cm with 100% granulation tissue noted and a white in the center measuring 2.4 cm x 0.7 cm. R13's lower right lower leg pressure ulcer measured 2.2 cm x 1.4 cm x 0.2 cm with 100% granulation tissue. R13's progress note dated 4/25/17, indicated plastic surgery was contacted and R13's treatment to the right lower extremity back to hydrogel gauze twice daily. Pictures of R13's wounds were sent to plastic surgeon, as follow-up appointment would be canceled if wounds were improved. R13's progress notes dated 5/8/17, indicated R13's coccyx pressure ulcer had healed. Treatment was changed to [MEDICATION NAME]. R13's upper right lower leg pressure ulcer measured 3.3 cm x 1.8 cm x 0.1 cm with 100% granulation. R13's lower right lower pressure ulcer measured 1.7 cm x 1.0 cm x 0.1 cm with 100% granulation tissue. R13's progress notes indicated pressure ulcers were monitored and assessed routinely from 1/4/17 through 5/23/17. A Changes in Resident Care Plan communication form dated 1/30/17, directed the use of wedge for repositioning, and a communication form dated 3/21/17, directed the use of blue heel lift boots bot feet at all times except with cares for inspection and to continue to use a pillow under the right knee to elevate leg. The changes in Resident Care Plan form indicated the communication is passed through shift report three times. On 5/22/17, at 10:55 a.m. registered nurse (RN)-B verified R13 currently had pressure ulcers on the coccyx and right lower extremity that were acquired in the facility following admission. On 5/23/17, at 8:01 a.m. R13 was observed to be lying in bed, positioned with positioning device under the left side. R13 was gotten up for breakfast at 9:00 a.m. R13 had blue lift boots on both feet, had a ROHO cushion in the wheelchair, and an alternating air mattress on the bed. R13 was transferred with a lift and the assist of 2 staff back to bed at 10:29 a.m. after eating breakfast. Nursing assistant (NA)-A explained R13's positioning devices with the wedge, blue boots, and pillow so there is no pressure on her pressure ulcers. NA-A stated R13 was repositioned every 2 hours. On 5/23/17, at 10:35 a.m. director of nursing (DON) explained R13 had her scheduled pain medication but was still painful when the blue boot was removed for the dressing change. R13 was to receive another pain medication that was ordered for breakthrough pain and they would wait at least 15 minutes for the dressing change. On 5/23/17, at 10:58 a.m. RN-B and DON were observed during R13's dressing changes to co

Based on observation, interview, and document review, the facility failed to ensure assessments were completed to minimize the risk of falls for one of one resident (R1) reviewed for falls out of sling while using mechanical lift equipment. R1 was harmed when R1 fell from the use of a sling that was not compatible with the lift equipment and broke her arm. The facility failed to comprehensively assess the resident's mechanical lift, sling type, and sling size. The failure for the facility to identify the need for resident assessments before using lift equipment placed all 26 residents who use lift equipment at risk for immediate jeopardy (IJ). The IJ began on 04/1/2017 at 1:00 p.m. when R1 fell from the mechanical lift equipment resulting in a fractured humerus. The resident was not assessed for the mechanical lift, sling type, or the sling size. The administrator and a clinical nurse manger were notified of the IJ on 04/12/2017 at 1:50 p.m. The IJ was removed on 04/14/2017 at 11:59 a.m. However, noncompliance remained at the lower scope and severity level of actual harm that is not immediate jeopardy. Findings include: R1's medical record was reviewed. R1 was admitted to the facility on [DATE], with muscle weakness, dementia with behavioral disturbances, restlessness and agitation. R1's care plan dated 2/2/2017, indicated R1 was at risk of falls related to severe cognitive impairment impaired safety awareness and anxiety medication. In addition, the care plan dated 2/2/2017, indicated the use of a sling/mechanical lift. R1 required assistance of two staff for transfers with a mechanical lift with a sling. R1's medical record did not include a comprehensive assessment for the use of a mechanical lift, sling type, and sling size. The incident report dated 4/1/2017, indicated NA-A had R1 in a full body mechanical lift sling transfer alone from wheelchair to the bed. R1 began flaying arms and slid out of the bottom of the sling landing on the left side and hitting head, R1 was lying between the legs of the mechanical lift on the floor. NA-A indicated she had the sling on correctly. NA-A indicated she couldn't find anyone to assist her so she transfer R1. Nursing progress note dated 4/1/2017 at 5:21 p.m. indicated R1 slid out of a full body sling onto the floor during a transfer and hit the left side of her head where the staples were located from a previous fall out of bed. The resident was lying on the left side between the legs of the mechanical sling lift. The nurse assessed R1 by completing neurological checks and obtaining vitals signs. The resident was sent to the hospital for an assessment. R1's hospital discharge summary to the facility dated 4/1/2017 indicated R1 had a closed fracture of the proximal end of the right humerus. R1's discharge orders included treatment for [REDACTED]. R1 was to rest her arm with a sling keeping it immobile as needed. NA-A was observed to transfer R1 on 4/11/2017 at 1:30 p.m. from the wheelchair to her bed. NA-A used a sling made for a ceiling lift to transfer R1 with the mechanical sling lift. NA-A confirmed the sling used during the observation was the sling used when R1 fell on [DATE]. This was brought to the administrator's attention. Staff were not aware that slings and mechanical lift equipment could not be interchanged. The facility immediately began to assess how the sling and mechanical lift equipment was being used. An interview on 4/11/2017 at 11:10 a.m. NA-A stated R1 was sitting in the hallway getting agitated and complaining of a headache. R1 wanted to go to bed. NA-A said attempts were made to find someone to help transfer R1 by going down the hall and looking for help. NA-A couldn't find another staff and moved R1 into her room and started to transfer R1 by herself. The mechanic sling lift equipment was in the residents room. NA-A applied the sling that staff had previously used and placed it under and around R1. NA-A than hooked the sling to the mechanical lift located in R1's room. NA-A stated the sling was applied correctly, but R1 started to flail her arms, kick and suddenly slid out of the bottom of the sling. NA-A wasn't sure how R1 fell out of the sling, but insisted R1 fell out of the bottom of the sling. During an interview on 4/11/2017 at 1:28 p.m. the administrator said NA-A told her she knew she should not transfer R1 by herself, but R1 was getting agitated, and complained of a headache. NA-A said she couldn't find anyone to help him/he so she transfer R1 by herself and R1 fell out of the bottom of the sling. During an interview on 4/11/2017 at 2:46 p.m. the director of nurses (DON) said she was not aware of the possibility of falling out of the sling. The DON said there was no assessment tool and they have not followed the manufacturer guidelines to assess residents for the use of the mechanical lift, sling type, or sling size. The DON stated the last training for staff on using mechanical lift equipment was 3/27/2013. During an interview on 4/11/2017 at 3:50 p.m. registered nurse (RN)-E said she does complete a sling assessment. RN-E stated the assessment consists of watching a resident transfer with a mechanic sling lift by looking at the resident to be sure the resident's arm fit inside of the sling. RN-E said the facility does not have an assessment tool. RN-E stated she is usually the second person for the transfer when the assessment is completed. RN-E said they don't have a specific tool or policy that addresses when or how to do the assessment. RN-E said R1 did not have an assessment for the use of the mechanical sling lift. The facility policy titled mechanical lifts dated 3/27/2013 indicated resident must have two staff for transfers using the mechanical sling lift. All staff must be trained on using the equipment. The policy did not include information to ensure the proper sling was used with the proper mechanical sling lift. The manufacturers guidelines revised 11/01/2012, indicated to use only manufactured slings and accessories designed for use with the mechanical sling lift. It also indicated to be sure to use the proper size sling using the sling sizing chart. To double check, lay a sling across the residents chest. If it's the proper size sling, you will note two to eight inches of extra material extended past the side of each arm. In addition, the manual instructions indicated to always use the correct style of sling for the resident, the most common is the divided leg sling. The manufacturer provided a guide to help develop a facility procedure and education for staff. The manufacturer also recommend a copy of the education sheet is kept in the employee file. The immediate jeopardy that began on 4/1/17 was removed and the administrative staff were notified on 4/14/2017 after the verification that the facility assessed all residents who use any mechanical lift for the type of mechanical lift, type of sling and size of sling in accordance with the manufacturing instructions for the mechanical lift equipment, the facility removed all mechanical lifts out of use and removed them from the unit until correct slings were obtained, revised the facility policy on mechanical lifts, and trained all staff on the mechanical lift equipment, sling type, and sling size by written instruction that included demonstration and return demonstration by the staff. Noncompliance remained at the lower scope and severity level of isolated actual harm that is not immediate jeopardy.