Every finding on record at Thorne Crest Retirement Center

Based on observation, interview, and record review the facility failed to comprehensively assess and evaluate care plan interventions for effectiveness, and develop individualized repositioning program to prevent pressure ulcer development and/or deterioration for 2 of 3 residents (R1, R2) reviewed for pressure ulcers.Findings include:Stage 2 pressure ulcer: partial-thickness loss of skin that presents as a shallow, open wound with a red or pink wound bed without exposure of fat or deeper tissues.Deep tissue injury: affects the deeper layers of tissue beneath the skin including muscles, subcutaneous fat, and sometimes bone which disrupt blood flow and oxygen delivery to the tissue.Braden Scale for Predicting Pressure Sore Risk is a standardized tool to assess the risk of developing pressure injuries. The scale evaluates six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each category is scored from 1-4, except friction/shear which is scored 1-3. Scores are categorized as 19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, and 9 or less very high risk.R1R1's face sheet dated 5/19/26, identified diagnoses of unspecified fracture of lower end of left femur (upper leg bone), subsequent encounter for closed fracture with routine healing, hypertension, obesity, and chronic peripheral venous insufficiency (not enough blood flow to legs).R1's hospital discharge after visit summary dated 1/9/26, identified a Braden Scale score of 15.R1's facility Braden Scale with Skin Risk Evaluation dated 1/9/26, identified a score of 16. Skin Evaluation Risk included: acute condition, decreased range of motion, cast/brace/splint, limited mobility/bedfast. No ulcers were present on admission. Treatments included pressure-reducing device for chair and bed. R1 was to have an immobilizer on left leg at all times.R1's care plan dated 1/13/26, identified R1 was incontinent of bowel and bladder. R1 was dependent on staff for toileting, staff to offer toileting on wake up, after meals, and at bedtime.R1's care plan dated 1/21/26, identified R1 had potential for impaired skin integrity related to immobility due to femur fracture and urinary incontinence. Interventions included to apply moisture barrier as needed, Braden Scale on admission, every week for four weeks, quarterly, and with any significant change, nursing assistants (NA) to observe skin with morning and evening cares and report any abnormalities to the nurse, maintain good skin hygiene, moisturize dry skin as needed, observe for alteration in skin integrity and report to physician, skin inspected weekly per schedule, pressure reducing mattress on bed and cushion in wheelchair. On 2/9/26, every two-hour repositioning and blue pressure relieving boots to feet at all times for pressure relief were added.Although R1's care plan called for repositioning every two hours, there was no documentation of a comprehensive assessment supporting that interval or demonstrating that R1 could tolerate pressure for two-hour periods without increased risk of skin breakdown.R1's Hospice admission dated 2/3/26, identified R1 admitted to hospice services with decline in condition including 6.61% weight loss in the past 6 months, meal intake decline in the past 6 months typically only eating 0-25% of breakfast and nothing for lunch or supper, bedbound, incontinent of bladder, and sleeping 20-22 hours/day.R1's record identified R1 did not have a Braden Scale with Skin Risk Evaluation completed weekly between 1/9/26 and 2/4/26.R1's facility Braden Scale with Skin Risk Evaluation dated 2/5/26, indicated R1 had developed pressure ulcers since admission. The evaluation identified a score of 14 indicating R1 was at moderate risk for pressure ulcers (even though R1 had developed two pressure ulcers). Skin Evaluation Risk included: chronic incontinence, cognitive impairment, decreased range of motion, muscle wasting, pale skin, cast/brace/splint, limited mobility/bedfast. R1 had one or more unhealed pressure ulcers/injuries, however did not identify how many ulcers R1 had or location. Treatment included pressure-reducing device for chair and bed, turning and repositioning program, pressure ulcer/injury care. Interventions included to elevate edematous (fluid retention)/affected extremities.Review of R1's record did not include a comprehensive assessment of the pressure ulcers that were noted on the Braden Scale Evaluation dated 2/5/26. Although R1's record identified developed pressure areas there was no indication the care plan interventions were evaluated for effectiveness, there was no change identified in the reposition program, and no new additional interventions were developed or implemented to prevent deterioration or new ulcer development.R1's progress note dated 2/7/26, identified R1 refused supper, was incontinent of urine once, and had a bed bath with no new skin issues identified.R1's progress note dated 2/9/26, identified R1 had been in bed all day and not been eating. Hospice registered nurse (HRN)-A and family was present. A deep tissue injury was noted on right heel. The area was closed, discolored and non-blanchable (redness or discoloration on skin does not turn white when gentle pressure applied). Pressure relieving boots applied and an air alternating mattress was ordered. A reddened line that measured 8 centimeters (cm) across R1's lower buttock was blanchable (turns white with gentle pressure applied) and appeared to have been caused by edge of R1's brief being rolled down. A small stage 2 pressure ulcer was noted on R1's coccyx in a V shape. HRN-A was increasing visits to daily due to R1's declining condition.R1's Client Coordination Notes Report from hospice dated 2/9/26, identified R1 was in bed upon visit arrival, minimally responsive with Cheyne-Stokes (abnormal breathing pattern) and 40 second apnea (no breathing). No mottling (blotchy, red, purple, bluish discoloration of skin) noted. Suspected deep tissue injury noted to right heel, HRN-A notified assistant director of nursing (ADON) and director of nursing (DON). Stage 2 pressure sore noted to coccyx, non-blanchable areas noted to upper right and left buttocks. Incontinence brief had been soiled with urine. R1 positioned on left side. Reviewed positioning frequency, floating heels, and pressure injury prevention with nurse and nursing assistant.R1's Client Coordination Notes Report from hospice dated 2/10/26, identified family was present and stated R1 had been repositioned every two hours and that R1 tolerated that well. Light mottling noted to lower extremities.Review of R1's record between 2/5/26 through 2/10/26 revealed no indication of a comprehensive pressure ulcer assessment was completed that would identify measurements, drainage, and pain. Further not evident of a comprehensive analysis that determined causal factors of pressure ulcer development so that appropriate interventions could be developed and implemented that would negate the risk of deterioration and/or new ulcer development.R1's Client Coordination Notes Report from hospice dated 2/11/26, identified HRN-A requested tasks be added for facility aides to reposition R1 every two hours.R1's Skin Issues progress note dated 2/11/26, identified left gluteus pressure ulcer acquired in-house, unknown how long the wound had been present. Measurement was 10.16 cm length by 1.27 cm width with intact surrounding tissue. No drainage, or odor present.R1's physician orders dated 2/11/26, identified pressure ulcer care to coccyx and deep tissue injury to right heel beginning 2/9/26. Blue pressure relieving boots to bilateral feet at all times beginning 2/9/26.During an interview on 5/19/26 at 3:13 p.m., registered nurse (RN)-A stated residents were at risk for pressure injuries if they laid in one position for extended periods or were unable to move by themselves. RN-A would not implement heel protectors unless a resident had boggy heels. If a resident had a pressure ulcer they should go on a more frequent turning and repositioning schedule such as every 2-3 hours. The NA's should just know by word of mouth to reposition residents every 2-3 hours if it was not in the care plan. R1 admitted to facility for therapy and planned to return to community when completed. Therapy was not progressing, and R1 initiated enrolling in hospice for personal reasons. R1 had started to decline around the time he started hospice and could not vocalize his needs as much. RN-A recalled working with R1 the weekend prior to 2/9/26, and R1 had stayed in bed most of the shift. RN-A thought R1 was on a 2-3-hour repositioning plan but was unable to locate when reviewing R1's care plan and Kardex. R1 should have been on a turning/repositioning schedule and heels offloaded prior to developing a deep tissue injury and pressure ulcer.During an interview on 5/20/26 at 8:58 a.m., RN-B stated the Braden Scale is used to determine specific things like a repositioning schedule, need for air mattresses, pressure reducing cushions for chairs. If a resident deteriorated RN-B would complete a Braden, update care plan, add interventions of heel protectors or float heels in bed, turn/reposition every two hours, toilet every 2-3 hours. NA's should automatically float all residents heels when they are in bed. RN-B reviewed R1's care plan, Kardex and Braden Scale; RN-B stated R1 was missing Braden Scale assessments as he should have had one weekly since admission and did not have a turn/reposition program in care plan or Kardex.During a phone interview on 5/20/26 at 12:54 p.m., HRN-A stated staff should reposition residents every two hours and elevate extremities in places with high risk of pressure injuries such as elbows, heels, coccyx. HRN-A recalled finding the deep tissue injury to R1's right heel on 2/9/26, it was not mottling. The deep tissue injury could have been avoidable if R1's heels were elevated.R2R2's face sheet dated 5/20/26, identified diagnoses of unspecified urinary incontinence, and atherosclerotic heart disease of native coronary artery without angina pectoris (plaque in the arteries).R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 had some cognitive issues. R2 required substantial/maximum assistance with toileting and dressing lower body; moderate assistance for sit to stand. R2 was frequently incontinent of bladder and had occasional bowel incontinence. R2 was at risk of developing pressure injuries but did not currently have any. R2 had a pressure relieving device for chair and bed.R2's skin integrity care plan dated 10/6/25, identified R2 had potential for impaired skin integrity related to immobility, lower extremity edema, urinary incontinence and history of falls with skin issues. Interventions included to apply moisture barrier as needed, Braden Skin Risk Evaluation on admission, every week for four weeks, quarterly, and with any significant change, NA's to observe skin with morning and evening cares and report any abnormalities to the nurse, maintain good skin hygiene, moisture dry skin as needed, observe for alteration in skin integrity and report to physician, weekly licensed nurse skin inspection, pressure relieving mattress on bed and cushion in chair.R2's Braden Scale with Skin Risk Evaluation dated 3/11/26, identified a score of 16, which was a mild risk of developing pressure ulcers. Skin risk included chronic incontinence, cognitive impairment, history of refusal of care or treatment, edema, pale skin. R2 did not have unhealed pressure ulcers. Treatment included pressure reducing device for chair and bed, elevate edematous/affected extremities.R2's progress note dated 3/19/26, identified hospice nurse notified ADON of new skin issue of a stage 2 pressure wound to left buttock. Added NA tasks for turning and repositioning every two hours, encourage repositioning out of recliner, sit in other areas and lay in bed at night.R2's record did not identify any documentation of a comprehensive assessment that demonstrated how long R2 could tolerate pressure without increased risk of skin breakdown.R2's physician order dated 3/19/26, identified stage 2 pressure ulcer to left buttock. Cleanse wound with wound wash, apply Mepilex (bordered foam dressing) and change every three days and as needed.R2's Skin Evaluation dated 3/19/26, identified stage 2 pressure ulcer/injury to left gluteal fold acquired in-house. Measurements 1.0 cm by (x) 0.4 cm x 1.5 cm depth. No undermining or tunneling.R2's Skin Evaluation dated 3/25/26, identified stage 2 pressure ulcer/injury to left gluteal fold. Measurements were 1.8 cm x 1.2 cm x 0.4 cm depth. Partial-thickness skin loss with exposed dermis (middle layer of skin).R2's Skin Evaluation dated 4/8/26, identified stage 2 pressure ulcer/injury to left gluteal fold. Measurements were 1.8 cm x 1.2 cm x 0.4 cm.R2's Skin Evaluation dated 4/14/26, identified stage 2 pressure ulcer/injury to left gluteal fold. Measurements were 1.9 cm x 1.3 cm x 0.4 cm.R2's Skin Evaluation dated 4/22/26, identified stage 2 pressure ulcer/injury to left gluteal fold. Measurements were 1.7 cm x 1.5 cm x 0.2 cm.R2's Skin Evaluation dated 5/5/26, identified left gluteal cleft was healed.R2's Kardex dated 5/20/26, identified staff to monitor-turn and reposition-need to encourage to get out of recliner, sit in more areas, lay in bed at night.During an observation on 5/20/26 at 10:16 a.m., staff pointed out where R2 slept in the main living room area. R2 slept on a recliner chair that had a cloth pad on the seat for incontinence and a tie blanket hanging over the arm of the chair. R2 was not in the chair at the time.During an interview on 5/19/26 at 3:08 p.m., NA-A stated all residents are repositioned every 2-3 hours. Bedbound residents would also be repositioned every 2-3 hours.During an interview on 5/20/26 at 8:47 a.m., NA-B stated she would put barrier cream on all incontinent residents to protect their skin. Incontinent residents should be on a two-hour toileting schedule and if bedbound they should also have two-hour turn/reposition schedule. R2 rarely uses her bed to sleep in and prefers the recliner. R2 does not have a pressure relieving device for the recliner chair.During an interview on 5/20/26 at 8:58 a.m., RN-B stated R2 usually slept in the recliner in the front room and the NA's use a pillow to offload her position. RN-B would expect R2 to have a pressure-relieving device in her chair.During a phone interview on 5/20/26 at 12:54 p.m., HRN-A stated she was the nurse who cared for R2 and recommended good peri care and reposition every two hours after she developed her stage 2 pressure ulcer. Turning and repositioning is very important to prevent pressure ulcers from occurring.During an interview on 5/20/26 at 1:28 p.m., assistant director of nursing (ADON) stated the Braden Scale provides a score and tells the risk of skin based off the assessment. Braden Scales are completed on admission, quarterly, annually, or if ADON visually saw a decline in a resident such as not getting out of bed or if the resident was on hospice. Bed bound residents should be repositioned every 2-3 hours. The facility does not do tissue tolerance assessments on residents. Nurses complete weekly skin checks on residents with baths and if reddened skin was reported, ADON would readjust plan of care. Residents would be provided with heel boots if facility noticed they were in bed more, not able to reposition themselves, and not mobile. If staff were also seeing redness that was not blanchable (skin would turn white when pressure applied and return to original color) on heels the facility may put heel boots on the resident. R1 should have been reassessed with a Braden Scale when he began declining as a decline would show signs his skin was at risk. R1's pressure injuries probably would have been avoidable. R2 sleeps in a recliner most of the time and does not have a pressure relieving device in the recliner. Facility does not put pressure relieving devices in recliners because of the risk of residents sliding off them. R2 was on a toileting schedule but would also alert staff when she needed to use the bathroom although she would already be incontinent.During an interview on 5/20/26 at 2:21 p.m., director of nursing (DON) stated the facility does not do tissue tolerance on residents. Braden Scale should be done on admission, quarterly, if a new ulcer appears, or with a change of condition. Braden Scale would kind of tell you if a resident needed to be on a turning/repositioning schedule but if someone had a stage one or two pressure ulcer they would automatically be placed on a two-hour repositioning schedule. NA's look at skin constantly and nurses observe skin weekly with baths and any skin issues would be identified through them. DON stated the facility did not have a policy for tissue tolerance or Braden Scales.The facility Wound Treatment Management dated 2/11/26, identified facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Treatment decisions will be based on: Etiology of the wound:Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage.Surgical.Incidental (i.e. skin tear, medical adhesive related skin injury).Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxis).Characteristics of the wound:Pressure injury stage (or level of tissue destruction if not a pressure injury).Size - including shape, depth, and presence of tunneling and/or undermining.Volume and characteristics of exudate.Presence of pain.Presence of infection or need to address bacterial bioburden.Condition of the tissue in the wound bed.Condition of peri-wound skin.Location of the wound.Goals and preferences of the resident/representative. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include:Lack of progression towards healing.Changes in the characteristics of the wound (see above).Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance in a timely manner, when 15 of 47 residents (R3, R5, R7, R13, R15, R17, R22, R24, R25, R28, R34, R36, R39, R43, R47) reviewed for sufficient staffing, experienced excessively long call light wait times, and/or missed breakfast, or experienced a delay in getting to breakfast or delay in receiving care. This deficient practice had the potential to affect all 47 residents who resided in the facility. Findings include: Refer to F676- Based on observation, interview, and document review, the facility failed to provide assistance to complete personal hygiene care for 1 of 1 resident (R3) reviewed who needed assistance with fingernail care. Refer to F677 – Based on observation, interview and document review, the facility failed to provide timely toileting for 1 of 1 resident (R36) who was dependent upon staff for assistance with activities of daily living (ADL). Refer to F684 – Based on observation, interview, and document review, the facility failed to ensure necessary care and services were provided for 1 of 1 resident (R2) reviewed for non-pressure skin concerns, when staff failed to appropriately assess, treat, and manage bilateral lower-extremity wounds. This included failure to timely notify the provider and obtain and implement wound care orders following a change in skin condition, and failure to ensure wound care was provided as needed. These failures resulted in R2 going multiple days without wound care and placed the resident at risk for worsening skin breakdown, infection, and complications related to delayed treatment. Further, the facility failed to complete and monitor daily weights, monitor blood pressures, and administer medications in accordance with provider-prescribed blood pressure parameters and treatment orders for 1 of 1 resident (R2) reviewed for edema. In addition, the facility failed to follow physician orders for obtaining daily weights and applying elastic compression bandages to legs for 1 of 1 resident (R26), reviewed for edema. MDS/Care plan: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact, no rejection of care, utilized a wheelchair, required substantial/maximal assistance with personal hygiene, upper body dressing, dependent on staff for toileting hygiene and transfers; diagnoses included hemiplegia or hemiparesis, depression, dependence on renal dialysis. R3's care plan dated 1/2/26, mobility needs assist with transfers and bed mobility due immobility related to right side hemiparesis, chronic renal disease, severe malnutrition, and mild cognitive impairment unable to ambulate. R5's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R5 required substantial assistance or was dependent upon staff for most activities of daily living (ADLs), including wheelchair mobility. R5 did not walk. R7's quarterly MDS dated [DATE], indicated no cognitive impairment, utilized a wheelchair, independent with eating, dependent on staff for toileting, dressing, personal hygiene, and transfers. R13's admission MDS dated [DATE], indicated intact cognition, use of wheelchair, partial/moderate assistance with personal hygiene, dependent for toileting hygiene and lower body dressing. R15 quarterly MDS dated [DATE], indicated cognitively intact, utilized a wheelchair, supervision or touching assistance with eating, dependent on staff for toileting, dressing, toilet transfer, and chair/bed-to-chair transfer. R15's care plan dated 12/10/25, at risk for injury related to history of falls, poor balance, unsteady gait d/t (due to) decline in physical function, provide 2 assist transfer at night d/t increased weakness I need assist with ambulation, transfers, and bed mobility due to weakness and cognitive impairment, able to feed myself independently, following staff setup, need cues from staff at times for eating, staff to provide setup assist with feeding, set up tray; pour liquids, cut foods, and apply condiments with each meal, eating: sit at feeder table, supervision and cuing, bring to dining room, staff to sit with resident and provide cueing and assistance as needed. R15's nutrition - amount eaten- document amount ate for all meals dated 1/26/26, failed to indicate R15 ate breakfast. R17's quarterly MDS dated [DATE], indicated severe cognitive impairment, utilized a wheelchair, required supervision or touching assistance with eating, substantial/maximal assistance with transfers. R17's care plan dated 12/29/25, nutritional status at risk for wt (weight) loss due to poor PO (oral) intake, limited to extensive assistance with feeding at all meals, staff to provide total assistance with eating and drinking food and fluids at meals toilet hygiene, toilet every 2-3 hours assist onto toilet upon rising, before/after meals and before bedtime mobility: need assist with ambulation, transfers, and bed mobility due to dementia and weakness. R17's nutrition - amount eaten- document amount ate for all meals dated 1/26/26, failed to indicate R17 ate breakfast. R22's annual MDS dated [DATE], indicated moderately impaired cognition. R24's annual MDS dated [DATE], indicated R24 was cognitively intact, no behaviors, no rejection of care, utilized a walker and wheelchair, required partial/moderate assistance with toileting hygiene, personal hygiene, dressing, toilet transfer, chair to bed transfer, independent with sit to lying and rolling. R24's care plan dated 1/2/26, indicated mobility: minimal assist with transfers and bed mobility due impaired mobility related to Rheumatoid Arthritis, will self-transfer a lot of times without asking for assistance. R25's quarterly MDS dated [DATE], indicated no cognitive impairment, utilized a wheelchair, independent with eating, dependent on staff for toileting, dressing, and transfers. R25's care plan dated 12/19/25, indicated mobility: assist with transfers and bed mobility due limited mobility provide assistance with bed mobility as necessary chair / bed-to-chair transfer- dependent with hoyer lift (mechanical equipment) and 2 assist, every 2-3 hours in chair and in bed. R28's quarterly MDS dated [DATE], indicated R28 had severe cognitive impairment, utilized a wheelchair and walker, independent with eating, required partial/moderate assistance with lying to sitting, sit to stand. R28's care plan dated 11/24/25, falls: at risk for injury due to weakness, poor safety awareness related to cognitive impairment and a history of falls, will self-transfer without waiting for staff assistance. falls intervention: keep w/w (wheeled walker) within reach at all times as patient will self-transfer, ambulate and toilet regardless of if w/w is in reach, evening shift to check at end of shift mobility, need assist with ambulation, transfers, and bed mobility due weakness, tend to self transfer myself without putting on call light d/t (due to) cognitive impairment, eating: independent after set-up R34's quarterly MDS dated [DATE], indicated R34 was rarely/never understood, utilized a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with toileting, dressing, and transfers. R34's care plan dated 12/29/25, dietary dx (diagnosis) w/Parkinson's disease, with altered mental status and dementia.currently eating adequately but am at risk for wt loss as I decline; staff to provide setup assist with feeding, provide verbal cues, set up tray; pour liquids, cut foods, and apply condiments with each meal, encourage consumption of meals and assist as needed. R36's significant change MDS dated [DATE], indicated severe cognitive impairment, clear speech, rarely/never understood, usually understands. R36 was dependent upon staff for activities of daily living (ADLs) or required substantial assistance, did not walk. R36's care plan with revised date of 10/21/25, indicated R36 was incontinent of bladder and bowel and required assistance with toileting due to Alzheimer's disease, put on the toilet at these time frames: 5:00 a.m., upon rising, before/after meals, and HS (bedtime). R36's nutrition - amount eaten- document amount ate for all meals dated 1/26/26, failed to indicate R36 ate breakfast. R39's annual MDS dated [DATE], indicated severe cognitive impairment, utilized a wheelchair, supervision or touching assistance with eating, dependent on toileting, activities of daily living, sit to stand transfers, toilet transfers, and bed to chair transfer. R39's care plan dated 10/22/25, indicated am incontinent of bowel and bladder. need assistance with toileting tasks due to impaired cognition staff assist per mobility care plan for resident to transfer to the toilet, check and change every (2-3 hours)- document refusals. mobility: need assist with transfers and bed mobility due weakness, immobility, and impaired cognition, unable to ambulate anymore, too weak to wheel myself in a regular wheelchair, chair / bed-to-chair transfer: dependent assist of two staff with use of EZ stand, use total lift if tired/weak. R39's nutrition - amount eaten- document amount ate for all meals dated 1/26/26, failed to indicate R39 ate breakfast. R43's quarterly MDS dated [DATE], indicated moderately impaired cognition, utilized a wheelchair, required supervision or touching assistance with eating, dependent on transfers, and substantial/maximal assistance with personal hygiene. R47's admission MDS assessment dated [DATE], indicated moderately impaired cognition, use of wheelchair, lower extremity impairment on one side, dependent for toileting hygiene, upper and lower body dressing, and substantial/maximal assistance for personal hygiene. Resident and Family Observations and Interviews: On 1/20/26 at 12:53 p.m., with R5 and family member (FM)-F, stated R5 used his call light to get in and out of bed; he required use of a lift, and it took two staff. FM-F stated sometimes it took over an hour for staff to respond and sometimes they would come into R5's room and shut the light off saying they would be back, but don't come back. FM-F stated, Everyone in here, meaning family members, complained about how long it took for staff to answer call lights, adding they were short staffed, and it was worse around mealtimes. FM-F stated, you don't want to use the call light at shift change in the afternoon as it took an especially long time. On 1/20/26 at 1:02 p.m., R3 was observed lying in bed and stated he required two staff to transfer from his wheelchair to bed. R3 stated that after breakfast he waited approximately two hours by the dining room door to be assisted back to his room. R3 reported he asked for help and observed two or three women walk by, but staff did not return with the required two-person assistance. R3 stated this situation happens every day. R3 further stated he did not attend lunch because it takes too long to get back to my room after lunch, and indicated prolonged wait times contributed to his decision not to attend lunch. On 1/20/26 at 2:03 p.m., R7 stated he waits almost daily for 30 or more minutes for assistance to get out of bed to use the bathroom and reported delays were worse around mealtimes. R7 stated there had been no management follow through regarding his concerns and reported weekends were worse due to agency staff unfamiliar with resident routines and equipment. R7 stated he had brought concerns to social services (SS)-A but reported no follow through. On 1/20/26 at 2:23 p.m., R13 stated she had to wait a long time for help from staff and sometimes had to have a bowel movement and did not make it in time because staff took too long. R13 further stated some days she did not go down to the dining room to eat because there were not enough staff to bring her back to her room so she would have to wait over an hour to get back to her room after meals. On 1/20/26 at 2:49 p.m., R47 stated it took a long time for staff to come when he turned his call light on. R47 stated he had to have a bowel movement in his brief while in bed because they did not come in time and he did not like having accidents in his brief. R47 further stated he had got used to telling the staff they better come quickly or they were going to be cleaning up a mess. On 1/20/26 at 7:49 p.m., the director of nursing (DON) was observed assisting R34 into his room via wheelchair and confirmed evening cares were delayed. The DON stated R34 typically went to bed at 7:00 p.m. On 1/26/26 at 11:03 a.m., R15 was observed seated in a wheelchair in the day room and stated she was hungry. LPN-A asked whether she wanted breakfast or preferred to wait for lunch since it was almost lunchtime. R15 stated she had not eaten breakfast and would wait for lunch. LPN-A stated R28 had just come to the day room and had not eaten breakfast and had gotten up late due to staffing shortages. Staff Interviews: During an interview on 1/20/26 at 7:28 p.m., LPN-A stated the facility had staffing issues and stated, we just don't have enough staff. LPN-A reported there were not enough nursing staff or nursing assistants (NAs) to meet resident needs including toileting, timely morning and bedtime cares, and answering call lights. LPN-A stated the facility was expected to have six NAs on the evening shift; however, only four NAs were present. LPN-A stated with only four NAs, residents were not assisted timely. LPN-A reported a resident fall earlier that day due to insufficient staff and stated falls had increased due to inadequate staffing and increased use of agency staff unfamiliar with residents' needs. LPN-A confirmed residents were not toileted timely and toileting schedules were not consistently followed unless residents requested assistance or exhibited behaviors. During an interview on 1/21/26 at 8:40 a.m., nursing assistant (NA)-H (agency) stated it was a good place to work but changes could be made. NA-H stated residents got left in bed for long periods, there should be more staff, so much going on, frequently need two NAs in a room and that makes other residents wait. HA-H stated there were a lot of call-in's – both employed staff and agency staff. NA-H stated she left work in tears the day prior because she had 11 residents by herself and six were two-person assists or mechanical lifts. NA-H stated the facility no longer provided walkie-talkies in order to communicate and had spent up to 15 minutes looking for another NA to help her. HA-H stated it was not uncommon for residents to miss breakfast because there was no one to get them up. By the time they did get up, it was almost lunchtime. On the night shift, NAs were supposed to reposition and check/change residents every two hours. NA-H stated there were only two NAs to do that and staff were lucky if they got two or three residents done, adding there were lot of residents with soaked beds in the morning. NA-H stated the evening shift NA's put residents to bed after supper and wasn't sure how often they were checked on. When the night shift came on duty and started rounds, they immediately had to change residents and soiled bedding. The day prior, NA-H asked registered nurse (RN)-A for help and her reply was, I don't understand what's going on – it's like that every day. NA-H took that to mean, what's the big deal – it's like this every day. NA-H stated employed staff were told by the director of nursing (DON) that other facilities of a similar size had the same amount of staffing, so we had nothing to complain about. NA-H stated she doubted the number of residents who were two-person assist had been included in the comparisons. During an interview on 01/21/26 at 11:28 a.m., NA-M stated the facility was expected to have six NAs on day shift but usually only had four or five due to call-ins that were not filled. NA-M stated with only four NAs, resident care was delayed, including answering call lights, toileting residents, and providing meals timely. During an interview on 1/21/26 at 12:57 p.m., registered nurse (RN)-B stated the facility was frequently short staffed and reported there were too many tasks assigned to nursing staff to provide adequate resident care. RN-B stated nursing staff were responsible for medication administration, treatments, documentation, processing and entering physician orders, admissions, and responding to incidents, in addition to providing direct resident care. RN-B stated due to the volume of assigned duties and limited staffing, nursing staff were not always able to provide care in a timely manner. RN-B stated tasks were prioritized, which resulted in delays in treatments, answering call lights, and assisting residents with toileting and other care needs. RN-B indicated the current staffing levels and workload made it difficult to meet residents' needs consistently and adequately. During an interview on 1/21/26, at 1:30 p.m., health unit coordinator (HUC)-E, who was also the nursing staff scheduler, described her role in scheduling nursing staff and the process in completing schedules, filling open shifts, managing call-ins. HUC-E stated there had been a lot of call-ins by both employed and agency NAs. HUC-E stated while the facility had been gradually hiring more nurses and NAs, agency use was still high. HUC-E stated with each call in, they attempted to fill the shift with employed or agency NAs During an interview on 1/21/26 at 3:13 p.m., RN-C stated nursing staff were responsible for medication administration, treatments, paperwork, order entry, and admissions. RN-C stated staff did not always have time to provide timely treatments due to administrative workload. RN-C stated there were increased falls due to staff not being able to answer call lights timely or round regularly. During an interview on 1/21/26 at 1:46 p.m., the assistant director of nursing (ADON) stated floor nursing staff were responsible for medication administration, treatments, entering and processing orders, admissions, and managing incidents. The ADON stated due to workload demands, delays in care and untimely processing of orders were not uncommon. The ADON stated resident cares were rushed and nursing staff did not have dedicated time to process orders. The ADON reported nursing staff had brought concerns to leadership regarding inability to complete assigned tasks; however, there had been no change. The ADON stated a previous desk nurse position that assisted with order entry had been eliminated. The ADON further stated agency staff frequently worked in the facility and were not always familiar with resident routines, contributing to delays in care. During interview on 1/21/26 at 3:13 p.m., RN-C stated nursing staff were responsible for medication administration, treatments, paperwork, order entry, and admissions. RN-C stated staff did not always have time to provide timely treatments due to administrative workload. RN-C stated there were increased falls due to staff not being able to answer call lights timely or round regularly. During further interview on 1/21/26 at 4:15 p.m., with ADON stated after hours when the facility receptionist was off duty, the caller would be prompted to make a selection. If the caller selected the health care wing, the call went to the nurse's station. If no one answered, the caller could leave a message. ADON nurses were responsible to answer the phone if able but usually did not have time. Together with ADON looked to see how many voicemail messages were on the phone at the nurse's station. There had been 61 messages. RN-A stated nurses did not have time to listen to messages and return calls, and agency nurses would not know how. ADON had been unaware of the number of messages on the phone and didn't know how far back they went. ADON admitted many of the calls were likely from family requesting an update on their family member. During interview on 1/21/26 at 4:55 p.m., LPN-A stated evening cares were delayed due to staff shortages and lack of staff familiar with resident routines. LPN-A stated there were more falls in the morning due to staffing shortages and agency staff not familiar with residents, resulting in residents attempting to self-transfer due to delayed rounding. During interview on 1/26/26 at 10:46 a.m., NA-F and NA-E stated they had not gotten R36 up yet for the day nor did he have breakfast. NA-F stated an agency NA called in so they were working short. Both NA-F and NA-E explained most of their residents required two staff assist. Between them, they had 10 residents requiring two NAs to get them up, dressed and to breakfast which took could take up to an hour. Both NA-F and NA-E stated it was not uncommon for residents to be gotten up late and miss breakfast – they could only do so much. NA-F stated when they had brought up the difficulty in getting their work done timely, the DON told them she had called other nursing homes, and no one was staffed better and that they were appropriately staffed. During interview on 1/26/26 at 10:58 a.m., HUC-E, who also served as the scheduler, stated she became aware of a staff shortage at 6:30 a.m. and reported six NAs were scheduled; however, only three were present until approximately 7:30 a.m. The HUC confirmed the facility was short staffed that morning. During interview on 1/26/26 at 10:54 a.m., NA-E stated residents were not provided breakfast on time and reported some residents had not yet eaten due to short staffing. NA-E stated all residents would have been expected to have eaten breakfast by that time. During interview on 1/26/26 at 1:00 p.m., NA-F confirmed the following residents did not receive breakfast: R17, R39, R43, R15, and R36. NA-F reported delays in breakfast service and stated R24 ate at 9:30 a.m., and R28, R25, and R34 ate at 10:00 a.m. During interview on 1/26/26 at 2:35 p.m., RN-K stated they were an agency staff who worked consistently at the facility, and stated they mainly worked the overnight shift and would frequently pick up and work a double shift during the day due to the shortage of staff. RN-K stated on overnights there was only one nurse for 48 residents and stated one nurse was not enough staff especially since they were agency staff and not familiar with the routines of the facility. RN-K stated the overnight nurse was responsible for medication administration, processing orders, stocking medications in the cart and further stated the facility had frequent falls and incident reports and stated one nurse on overnights was not enough staff to provide adequate resident care. Resident Council: During resident council interview on 1/21/26 at 2:13 p.m., R25 stated she had to wait one to two hours for her light to be answered sometimes. R7 stated he had to wait up to one hour, there was so much turnover of staff and the staff did not know the resident routines, so everything took longer. R22 stated a lot of agency staff was used and there were always new faces who did not know the routine. Call Light Response Times : Call light logs were requested for residents/resident representatives who reported long call light wait times. Logs indicated many instances of call light response times ranging from 20 minutes to over an hour. R25 Time frame 12/22/25 through 1/20/26. Call light activated 110 times, which indicated the following: 20-30 minutes = 9 x 31-40 minutes = 15 x 41-50 minutes = 1 x R13 Time frame 12/22/25 through 1/20/26. Call light activated 87 times, which indicated the following: 20-30 minutes = 9 x 31-40 minutes = 2 x 41-50 minutes = 2 x >60 minutes = 2 x R47 Time frame 1/9/26 through 1/20/26. Call light activated 90 times, which indicated the following: 20-30 minutes = 3 x 31-40 minutes = 9 x 41-50 minutes = 1 x >60 minutes = 1 x R7 Time frame 12/22/25 through 1/20/26. Call light activated 917 times, which indicated the following: 20-30 minutes = 72 x 31-40 minutes = 28 x 41-50 = minutes = 7 x 51-60 minutes = 3 x > 60 minutes = 5 x R5 Time frame 12/22/25 through 1/20/26. Call light activated 370 times, which indicated the following: 20-30 minutes = 28 x 31-40 minutes = 12 x 41-50 minutes = 10 x > 60 minutes = 5 (all were over 75 minutes) R3 Time frame 1/5/26 through 1/20/26. Call light activated 416 times, which indicated the following: 20-30 minutes = 21 x 31-40 minutes = 5 x 41-50 minutes = 3 x 51-60 minutes = 2 x > 60 minutes = 2 x Facility Assessment: Facility assessment updated 7/2025, indicated: Acuity - We have multiple mechanical lifts and multiple people with behavior issues and heavy load of hospice care. The assessment indicated 37 residents were dependent upon staff for ADLs (activities of daily living), and 10 were on hospice. Staffing parameters were an estimated range used for staffing consideration; individual extenuating circumstances e.g. needing one on one and would be reviewed and determined how to add additional staff. Staffing continued to be a challenge. The facility utilized an agency to help provide care and to prevent staff burn-out. Bonuses were used to attract new staff. Local recruitment fairs were attended by staff to promote the facility to possible new hires. Facility was engaged with ProCare to help with recruitment. The facility assessment identified a section titled Orientation which included 36 topics to be covered for all nurses and NAs. During an interview on 1/22/26 at 10:40 a.m. the DON and RN-D known as regional director of clinical services were informed of findings related to sufficient staffing and long call light response times. The DON stated the facility was appropriately staffed with nurses and NAs; she had called other facilities and their staffing was comparable. The DON stated the facility staffed according to PPD (per patient day) and did not adjust for the number of two-staff assists. The DON was informed that according to NAs on duty, 50% of their residents required a two-staff assist. In addition, the DON was informed the facility assessment updated July 2025, indicated, We have multiple mechanical lifts and multiple people with behavior issues and heavy load of hospice care. The DON acknowledged that was true. The DON was informed of observations including facility layout (significant distance staff were required to cover), no hand-held devices for staff to communicate when help was needed, and the number of two-staff assists made it a challenge for staff to complete their work timely. Further, the DON was informed of the long call light response times that were identified with review of call light logs. The DON was unaware of the call light response times, and stated their goal was to answer call lights in under five minutes. The DON stated call light response times were discussed at staff huddles and monthly meetings; the DON stated staff were reminded that everyone was to work as a team. If long call lights were identified, the DON stated they looked at what else was going on that day – maybe there was a reason. Requested in writing of the DON on 1/27/26, at 3:55 p.m., and not received: facility staffing plan, including now the number of NAs and nurses were determined for each shift. Facility Call Lights: Accessibility and Timely Response policy with copyright date 2025, indicated all staff members who saw or heard an activated call light were responsible for responding. If the staff member could not provide what the resident desired, the appropriate personnel would be notified.

Based on interview and document review, the facility failed to ensure 6 of 6 agency staff (nursing assistant (NA)-B, NA-C, NA-D, NA-G and registered nurse (RN)-G, RN-I) and 4 of 4 facility staff (NA-E, NA-J, RN-B, RN-J) received appropriate orientation and training prior to starting their first shift caring for residents. This had the potential to affect all 47 residents who resided in the facility.Findings include: Refer to F760: Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with prescriber orders when an incorrect dose of losartan (blood pressure medication) was administered incorrectly for three months, constituting a significant medication error for 1 of 5 residents (R44) reviewed for medication administration. Refer to F684: Based on observation, interview and document review, the facility failed to complete and monitor daily weights, monitor blood pressures, and administer medications in accordance with provider-prescribed blood pressure parameters and treatment orders for 1 of 1 resident (R2) reviewed for edema. In addition, the facility failed to follow physician orders for obtaining daily weights and applying elastic compression bandages to legs for 1 of 1 resident (R26), reviewed for edema. Refer to F698: Based on observation, interview, and document, the facility failed to ensure dialysis communication forms were consistently reviewed, addressed, and incorporated into the resident's medical record, and failed to ensure provider orders communicated by the dialysis provider were implemented in a timely manner for 1 of 1 resident (R3) reviewed for dialysis. Orientation Documentation: During an interview on 1/21/26 at 1:30 p.m., health unit coordinator (HUC)-E, who also helped facilitate staff orientation, stated floor staff trained new employees, both hired and agency staff; there wasn't a designated educator. HUC-E stated NAs received five shifts of orientation and nurses received seven shifts. For agency staff, HUC-E stated orientation was guided by an orientation binder at the nurses' desk, and a document titled Agency Staff Orientation Checklist/CNA. Upon review of the NA checklist, the only reference to resident cares included: use of transfer belt/lifts/oxygen, call lights, door codes, walkie talkie, restorative nursing program, vital sign monitor, reporting event to nurses, POC (point of care) charting, mealtime/feeding/water. Nothing regarding how to determine the unique and individualized needs of residents. During an interview on 1/22/26 at 10:04 a.m., with HUC-E, documentation of orientation was requested for the following agency staff and none were available: NA-B, NA-C, NA-D and NA-G, RN-G or RN-I. Personnel files revealed the following employed NAs did not have documentation of orientation: NA-E (hired 6/10/25), and NA-J (hired 9/12/25). The following employed nurses did not have documentation of orientation: RN-J (hired 9/12/25), and RN-B (hired 11/13/25). Resident Interview: R7's quarterly MDS dated [DATE], indicated no cognitive impairment, utilized a wheelchair, independent with eating, dependent on staff for toileting, dressing, personal hygiene, and transfers. During an interview on 1/20/26 at 2:03 p.m., R7 stated the facility frequently had agency staff who were not familiar with the facility routines and equipment. R7 stated he had brought concerns to social services (SS)-A but reported no follow through. Staff Interview: During an interview on 1/21/26 at 12:26 p.m., NA-G (agency) stated this was his first day; he arrived 45 minutes early and was shown around by another NA. NA-G received an assignment and was informed how his residents transferred. NA-G stated if he had questions, he would ask staff or residents. NA-G stated he had not been given a document such as a checklist to guide his orientation to ensure necessary topics were covered. During an interview on 1/21/26 at 1:46 p.m., the assistant director of nursing (ADON) stated agency staff frequently worked at the facility and may not be familiar with resident care routines. The ADON stated agency staff were expected to arrive 30 minutes prior to the start of their shift. The orientation process consisted of reviewing a training binder and receiving a list of assigned tasks. The ADON confirmed there was no formal, leadership-directed orientation program or competency-based validation process for agency staff. During an interview on 1/21/26 at 3:13 p.m., registered nurse (RN)-C stated the facility utilized a significant number of agency staff and that it was common for agency personnel to be unfamiliar with resident routines. RN-C confirmed agency staff were not provided with formal training. During an interview on 1/21/26 at 3:50 p.m., when shown the agency orientation binder referenced by HUC-E, NA-D (agency) stated she had never seen the binder before, nor had she completed an orientation checklist when she started on 11/29/25. During an interview on 1/21/26 at 4:55 p.m., licensed practical nurse (LPN)-A stated the facility frequently had more agency nursing assistants than employed staff. LPN-A reported agency staff were not familiar with residents' routines and were not provided formal orientation or training to ensure adequate resident care. During an interview on 1/22/26 at 10:40 a.m. the DON and RN-D know as regional director of clinical services informed of findings related nurse and NA competency, specifically the lack of a comprehensive orientation program for agency nurses and NAs, and some employed nurses and NAs. The facility lacked documentation of orientation to ensure relevant and essential topics were addressed. The DON stated they did not have a consistent person to provide orientation and training to staff. Both the DON and RDCS recognized there was a gap in training and admitted they did not have a comprehensive training process. The DON confirmed the facility utilized a significant number of agency nurses and NAs, and stated, Agency staff were not vested and lacked follow through. The DON stated agency staff came 30 minutes prior to start of shift and staff had them review the agency bible, which the DON described as a very large book which took a lot of time to put together, and which had policies and procedures in it. The DON stated agency staff were supposed to review the binder and ask floor staff if they had questions. The DON stated NAs could review paper copies of the Kardex located in a binder at the nurses station to learn individualized needs of residents. The DON was informed the binder did not have a Kardex for R26, and R36's was from November 2025, and had not been updated with interventions after a recent fall. The DON stated NAs could use their iPad to access resident information, but admitted each NA did not had one, nor did they fit in a pocket for ready access. The DON stated the facility did not utilize paper NA task sheets in order for NAs to have key information about residents at their fingertips. The DON admitted agency and employed NAs did not have tools immediately available to them know about a residents unique and individualized needs. Staff meeting agenda provided by the DON for nurses dated 10/17/25, indicated five nurses in attendance and topic titled, training agency staff indicated: book at desk and then need to be escorted to see where things are and given codes needed. We need to be nice (they are helping us). During an interview on 1/22/26 at 4:10 p.m., NA-J (employed) who had been on orientation and following an agency NA stated she had not been given nor was she utilizing a tool to identify training areas to be covered, such as a checklist. NA-J stated she was on her fourth or fifth orientation shift and was still primarily observing. During an interview on 1/26/26 at 9:03 a.m., RN-B stated they had never received formal training or a competency checklist. RN-B stated that implementation of a formal training process would be helpful to ensure adequate care was provided to residents. During an interview on 1/26/26 at 11:53 a.m., HUC-E stated a nurse on duty was assigned to orientate a nurse and a NA to orientate a NA. When asked if nurses had time to take on this additional responsibility, HUC-E stated staff nurses were relied upon because leadership wasn't in the building from 5:00 p.m. until 8:00 a.m. If nursing staff wasn't compliant in providing orientation they were coached and if it continued, the nurse would get a verbal warning. During the same interview, HUC-E stated staff knew what to go over when orienting agency staff by using the orientation checklist and orientation binder at the nurses station. Together, went to the nurses station to view binder and checklist. HUC-E provided a binder titled, Agency Staff Orientation. The pages included abuse policy, unexplained injuries policy, resident rights, abuse, neglect, mistreatment, theft/misappropriation, PCC (Point Click Care - the facility electronic medical record) documentation, infection control topics, mandated reporting, assignments, HIPAA (Health Insurance Portability and Accountability Act), confidentiality and more. There were blank orientation checklists for NAs inside the binder, but none for nurses. HUC-E provided another binder titled Nursing Helper Binder which was utilized as a quick reference for all nurses (employed and agency) and included documentation guidelines, after hours call coverage, fall reporting, suspected infections, postmortem checklist, psychotic meds, skin issue to do list, bowel and bladder three-day tracking, wandering/elopement and more. HUC-E acknowledged their orientation program could be better, and that a new human resources director started in November 2025, and had planned to improve the orientation process. HUC-E admitted if nurses and NAs were not properly trained, it could pose a safety risk to residents. During an interview on 1/27/26 at 7:45 a.m., RN-E (employed) stated if agency nurses came early, they could provide some training such as care plans, and individual needs of the residents, but they did not come earlier enough to do much training. RN-E stated residents would benefit from that training. RN-E stated there was a binder at the nurses' desk agency nurses were supposed to go through, but Honestly, they don't – there isn't time. RN-E stated she had never seen an orientation checklist for agency nurses, but she had for hired nurses. Requested in writing of the DON on 1/27/26, at 3:55 p.m., the facility policy on orientation and training of nurses and NAs, employed and agency. Not received.

Based on observation, interview and document review, the facility failed to ensure complete narcotic and controlled substance reconciliation occurred for two of two medication carts, failed to provide secure storage of disposed medications, and failed to ensure consultant pharmacist involvement and awareness of medication reconciliation and disposal processes. This practice had the potential to affect all 47 residents residing in the facility. In addition, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complications for 1 of 1 resident (R26) reviewed for medication administration. Findings include: Refer to F760: Based on observation, interview and document review, and staff interview, the facility failed to ensure medications were administered in accordance with prescriber orders when an incorrect dose of losartan (blood pressure medication) was administered incorrectly for three months, constituting a significant medication error for 1 of 5 residents (R44) reviewed for medication administration. Narcotic and Controlled Substance Reconciliation, Secured Storage of Disposed Medication, Consultant Pharmacist Involvement During interview and observation on [DATE] at 10:42 a.m., registered nurse (RN)-B unlocked a drawer on the healthcare medication cart she was working on and showed 12 tramadol tablets (narcotic pain reliever), seven lorazepam tablets (anti-anxiety medication with risk for dependence and addiction), and 34 oxycodone tablets (narcotic pain reliever) in individual plastic packages laying loose in the drawer. RN-B stated these medications were in the drawer because the resident refused them or the pharmacy had the wrong order and continued to print excess medications. RN-B stated there was always a pile up of medications in the narcotic drawer and confirmed they were not counted during narcotic reconciliation at shift change and were not documented in the narcotic log book. RN-B stated she notified the pharmacy of the excess medications so they could fix the issue but had not heard back from them. RN-B stated RN-A, also known as the assistant director of nursing, was aware of the problem. During interview and observation on [DATE] at 9:35 a.m., RN-A opened a locked drawer on the transitional care unit medication cart and showed two tramadol tablets, seven oxycodone tablets, and 11 lorazepam tablets in individual plastic packages. RN-A stated she would not expect those medications to be loose in the narcotic drawer, would expect them to be counted as part of narcotic reconciliation, and would expect to be notified of excess narcotic medications so something could be done about it. RN-A stated RN-B had made her aware of it a few weeks ago, but she was not aware it was an ongoing problem. RN-A confirmed the loose narcotics were not counted as part of narcotic reconciliation and that could cause risk for drug diversion. During observation on [DATE] at 1:32 p.m., total from the healthcare medication cart and transitional care unit medication cart narcotic drawers contained eight tramadol, nine oxycodone, one lorazepam in individual plastic packages and uncounted with narcotic reconciliation. RN-A confirmed these medications were uncounted during narcotic reconciliation and not identified in the narcotic log book. During observation on [DATE] at 9:08 a.m., total from the healthcare medication cart and transitional care unit medication cart narcotic drawers contained two oxycodone, three lorazepam, and ten tramadol in individual plastic packages and uncounted with narcotic reconciliation. DON confirmed these medication were uncounted during narcotic reconciliation and not identified in the narcotic log book. During interview on [DATE] at 10:14 a.m., director of nursing (DON) stated she was unaware there were loose, uncounted narcotics in medication carts. She would expect to be made aware, would expect narcotics to be counted as part of narcotic reconciliation to avoid possibility of drug diversion. During continued interview on [DATE] at 9:45 a.m., DON stated the pharmacy machine was only supposed to print what was needed and if it printed extra narcotics, they should be destroyed by two nurses, put in the medication destruction box in the lobby, and then law enforcement would pick up the medications. DON stated it was important for the narcotic medications to be counted and destroyed to avoid drug diversion. During interview on [DATE] at 1:55 p.m., DON stated due to several issues with the facility pharmacy vendor and after hearing of all the medication related concerns she would be switching to a new pharmacy vendor 6/26 and would try to get the switch completed sooner. During interview and observation on [DATE] at 10:04 a.m. assistant director of nursing (ADON) opened the medication storage room. ADON observed five cardboard boxes taped shut stacked against the wall. ADON stated medications were taken from the locked disposal container labeled Healthcare Logistics located in the lobby when the disposal container was full. Boxes were stored in the medication storage room until law enforcement was contacted to pick them up. ADON stated she was not sure the last time law enforcement had been contacted. During observation and interview on [DATE] at 11:46 a.m., DON was shown that the medication disposal container in the lobby was overflowing and was able to reach hands into the disposal box and remove three medication cards and one medication bottle containing intact medications. DON stated she was unaware the disposal was full and could be accessed by anyone in the facility which could cause possibility of unknown drug diversion. Maintenance director detached the disposal box from the wall and moved to a secure area. DON stated she would have expected to have been informed the disposal box was full so it could be emptied. During interview on [DATE] at 1:00 p.m., local law enforcement officer stated he was aware of the medication destruction process at the facility, and he was the one who picked up medications at the facility. Further stated he had not been called for a medication pick up since [DATE]. During interview on [DATE] at 2:14 p.m., consultant pharmacist (CP)-M stated he would expect tramadol, oxycodone, and lorazepam to be reconciled every shift. CP-M stated he did not think it was good practice to take medications out of the medication disposal bin and store them back in the medication room. CP-M stated he told the facility to get a new medication disposal bin a long time ago. CP-M further stated he does not have anything to do with facility policy or procedure review or development, does not attend quality assurance performance improvement (QAPI) meetings, was not aware of their medication disposal process, does not have anything to do with the facility medication reconciliation process and was not as involved at the facility as he should have been. During interview on [DATE] at 4:40 p.m., medical director stated she would expect narcotic medications to be reconciled and if excess medications were being dispensed pharmacy should have been notified and medications destroyed. Timely Re-Ordering of Medication R26's face sheet received on [DATE], included diagnosis of atrial fibrillation (an irregular and rapid heart rhythm). R26's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R26 required supervision or partial assistance with activities of daily living (ADLs). R26 could walk 50 feet with partial staff assistance. R26's physician orders dated [DATE], indicated: Eliquis (blood thinner medication) oral tablet 5 mg (milligrams). Give 1 tablet by mouth two times a day related to atrial fibrillation. R26's care plan with revised date of [DATE], indicated R26 had atrial fibrillation and cardiac medications would be given as ordered. R26's progress note dated [DATE] at 11:55 a.m., indicated medication unavailable. During an interview on [DATE] at 1:35 p.m., RN-I stated she had entered the above progress note and identified the medication not available as Eliquis. RN-I stated R26 was supposed to receive a dose of Eliquis that morning, but the medication was not available. RN-I stated she tried to contact the pharmacy, but the phone in that room did not work. RN-I stated she tried her cell phone and had other medications to call the pharmacy for. RN-I stated it was frustrating. During an interview on [DATE] at 1:55 p.m., the DON and RN-D known as the regional director of clinical services were informed of the medication issues RN-I had been experiencing. The DON stated she would check with RN-I. The RN-D stated the corporate office had been aware of the issues with their pharmacy vendor, were switching vendors in [DATE], and after hearing of all the medication related concerns, would try to get this facility moved up on the list to switch to a different system sooner. During an interview on [DATE] at 2:08 p.m., nurse practitioner (NP)-G was informed of Eliquis being given late to R26. NP-G stated since only one dose had been given late, it would be okay. Facility staff meeting agenda [DATE], written by the DON indicated: Medications and treatments: we cannot chart medication not available - hold order to be obtained and find out why med is not here and get ordered. During an interview on [DATE], at 12:10 p.m., the DON stated she could not recall why R26's Eliquis had been given late on [DATE]. and would have to look into it again. RN-D stated they recognized there had been issues with the pharmaceutical vendor and were looking at it at a corporate level. The DON stated the reason staff meeting agenda dated [DATE], advised nurses not to document when a medication was not available was because she expected nurses to talk to pharmacy and find out why. Medication Errors- Refer to F760 On [DATE] at 7:35 a.m., the DON stated the medication errors were nothing new regarding ongoing medication issues. The DON stated the facility faxes medication orders to the pharmacy and receives confirmation, yet the pharmacy later states the order was never received. The DON confirmed there is no reconciliation process in place at the time medications were dispensed from the pharmacy to ensure they match the physician's orders. The DON stated education had been provided to nursing staff regarding medication administration and ensuring the correct dose is administered. The DON was unable to articulate specific corrective actions taken to ensure accurate receipt and dispensing of medications. The DON confirmed that audits have not been conducted since December despite continued medication discrepancies, and confirmed the staff were not educated to call the pharmacy to make sure the medication orders were received when the order was faxed. The DON stated the medical director had not been involved with the known medication error problems. On [DATE] at 8:43 a.m., during a telephone interview with the contracted pharmacy technician (PT)-O stated reported facility medication orders are e-scribed or faxed to the pharmacy. Facility staff may call the pharmacy or use an online portal system to confirm receipt of orders. Medication changes update in the pharmacy system and are transmitted to the facility through two dispensing methods: an onsite oral strip from the machine or punch card delivery. PT-O stated that once the pharmacy receives an order, it was entered into the pharmacy system. If the medication was available in the onsite dispensing machine, it is electronically transmitted to the machine, and licensed nursing staff may log into the machine, select the resident, and dispense the medication. If not available onsite, medications were dispensed via punch card delivery. The pharmacy technician reported technicians load and restock the dispensing machines twice weekly and facility licensed nurses should not load medications into the machine. All medications stocked in the machine remain the property of the pharmacy until dispensed. stated PRN medications should be removed at the time of administration and controlled substances stored on the cart should be logged in the narcotic record book. PT-O further stated the pharmacy offers training and free in-service education to nursing staff regarding the dispensing system. On [DATE] at 9:22 a.m., the DON stated she had been placing calls to the pharmacy regarding medication errors and had not received a call back. The DON stated they did not remember how to log into the pharmacy portal. The DON stated that none of the facility staff had received training from the pharmacy regarding the pharmacy medication dispensing process or portal information and was unaware that portal training was an available service. The DON reported she had not received any training from the pharmacy company on the process and was not aware the contracted pharmacy provided training to the facility staff. The DON stated the pharmacy technician stocks the medications in the dispensing machine and that facility staff do not stock medications. The DON discussed attempts to establish a process for order verification, stating that the facility had attempted to fax orders, call to confirm receipt, and refax when necessary, describing the process as a real challenge. The DON stated attempts to establish pharmacy system that was reliable system but stated nothing had been successfully implemented. The DON stated the medication errors have been a known issue for months and no formalized process had been put in place to prevent the errors from recurring. The DON stated there was no report currently being utilized to track missed or late medications. The DON stated she was sure there is one in the system but was unsure how to generate the report. When asked whether a report identifying late or omitted medications would be expected given the ongoing medication-related concerns, the DON stated the issue was on the list to discuss with corporate nursing. The DON was unable to provide evidence of routine monitoring or auditing of medication administration records (MARs) for late, missed, or omitted doses. AlixaRx Pharmacy Provider Agreement dated [DATE], indicated the following: Scope of services: pharmacy will provide pharmacy products to facility and it's residents in a prompt and timely manner in accordance with applicable law, collaborate with facility to coordinate pharmacy documentation process. Automated dispensing unit technology: pharmacy will work with the facility to instruct facility's personnel on the proper utilization of all pharmacy equipment. Drug distribution and related services: pharmacy shall furnish all pharmacy products requested by facility and it's residents pursuant to the order of the resident's attending physician, consulting physician, medical director, or other lawful prescriber. Pharmacy shall respond to the reasonable needs of facility regarding transmission of data between pharmacy and facility. Delivery: Pharmacy shall arrange for all new orders and routine reorders to be delivered by pharmacy within a timely fashion to meet the needs of the resident. Facility shall use reasonable efforts to aggregate, organize, and plan all new admissions orders and routine reorders with pharmacy. Facility Medication Storage policy undated, indicated the following: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy or medication rooms to ensure security. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. Facility Destruction of Unused Drugs undated, indicated the following: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with are current applicable state and federal requirements. Our facility uses a waste disposal service or reverse distributor to destroy dangerous drugs and controlled substances. An inventory of dangerous drugs and controlled substances will be verified by the consultant pharmacist. Facility Medication Administration policy undated, indicated the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. Ensure that the six rights of medication administration are followed: Right resident Right drug Right dosage Right route Right time Right documentation Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.). If medication is a controlled substance, sign narcotic book. Correct any discrepancies and report to nurse manager. Facility Medication Orders policy undated, indicated the following: This facility shall use uniform guidelines for the ordering of medication. Documentation of Medication Orders: Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Clarify the order. Enter the order on the medication order and receipt record. If using electronic medication records, input the medication order according to the electronic health record (EHR) instructions and facility policy. Call or fax the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR or treatment record or ensure the order is in the electronic MAR. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd and the date, or discontinue the order as per the electronic software instructions and retype the new order. Enter the new order on the MAR or ensure the new order is in the electronic MAR. Notify resident's sponsor/family of new medication order. The nurse should document an order by telephone or in person on the physician's order sheet or input into electronic record as per facility policy, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical records. Physician orders should be signed per state specific guidelines.

Based on interview and document review the facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven quality assurance and performance improvement (QAPI) program. These findings had potential to affect all 47 residents who resided in the facility.Findings include:See F684: Based on observation, interview, and document review, the facility failed to ensure necessary care and services were provided for 1 of 1 resident (R2) reviewed for non-pressure skin concerns, when staff failed to appropriately assess, treat, and manage bilateral lower-extremity wounds. This included failure to timely notify the provider and obtain and implement wound care orders following a change in skin condition, and failure to ensure wound care was provided as needed. These failures resulted in R2 going multiple days without wound care and placed the resident at risk for worsening skin breakdown, infection, and complications related to delayed treatment. Further, the facility failed to complete and monitor daily weights, monitor blood pressures, and administer medications in accordance with provider-prescribed blood pressure parameters and treatment orders for 1 of 1 resident (R2) reviewed for edema. In addition, the facility failed to follow physician orders for obtaining daily weights and applying elastic compression bandages to legs for 1 of 1 resident (R26), reviewed for edema. See F755: Based on observation, interview and document review, the facility failed to ensure complete narcotic and controlled substance reconciliation occurred for two of two medication carts, failed to provide secure storage of disposed medications, and failed to ensure consultant pharmacist involvement and awareness of medication reconciliation and disposal processes. This practice had the potential to affect all 47 residents residing in the facility. In addition, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complications for 1 of 1 resident (R26) reviewed for medication administration. During review of past complaints and facility reported incidents during survey preparation, a potential trend was noted in October 2025, where three incidences of medications or treatments not been completed as ordered by the provider. During survey, the survey team identified the same concerns. In addition, a significant number of concerns related to the contracted pharmaceutical service had been identified during survey which the facility was aware of but did not address at the QAPI level. During an interview on 1/22/26 at 10:40 a.m., the director of nursing (DON) stated the three facility reported incidents from October 2025, related to failure of nursing staff to administer medications and/or treatment per physician orders had resulted in termination of a long-term nurse. The DON stated the incidents has been brought up at QAPI meetings and, Everyone had been happy with my education and audits. Education and audits were requested and not received. As a result, QAPI minutes were requested.QAPI minutes were received from the administrator for January 2025 through January 2026. The meeting minutes did not reflect, as the DON stated they would, the identification of a trend from October 2025, where medications and/or treatments had not been administered per physician orders. There had been no data reported, no root cause analysis done, no education, no audits, and no follow up to ensure resolution. QAPI meeting minutes were in grid-format with four headings: 1) topic, 2) process owner, 3) summary, trends, root casual factors, recommendations for improvement, decision to develop action plan, 4) X if AP needed. Multiple times summaries documented one month, stayed the same for subsequent months. There had been no evidence topics were selected for QAPI based on high-risk, high volume or problem prone areas. Minutes were primarily focused on information or data sharing. During an interview on 1/27/26 at 2:31 p.m., with the administrator, DON, and registered nurse (RN)-D known as regional director of clinical services, the administrator stated corporate set the QAPI agenda topics, and whoever was the process owner filled in their summary section. The meeting did not have a designated facilitator. Standing topics included marketing, medical records, therapy, wellness, performance improvement initiative program/QIIP, grievance/missing property summary, medical director information, follow up reports/other, pastoral care, survey performance/readiness, consultant reports - pharmacy, approval guidelines, policies, procedures, environmental, culinary, infection prevention, employee satisfaction, recruitment and retention, resident council summary, family council summary, education hours, volunteer hours, census summary and discharge tracking, activities, customer satisfaction surveys, quality trigger measure, AWAIR (workplace accident and injury reduction)/safety, OHFC (office of health facility complaints)/abuse, 30 day re-admits, fall prevalence, incidents/accidents. The designated process owner then added summary notes. The DON admitted she had no training in QAPI, but felt they had an effective program - they just didn't document their work. The DON stated they did not review medication errors or resident events at QAPI. The DON stated they had an event last fall with a resident who fell and sustained burns. The administrator stated that event had not been brought to QAPI for discussion and input. In retrospect, the administrator stated it should have been. Both the DON and administrator acknowledged they should be addressing issues that come up, such as the significant issue of their medication delivery system with medications not being available to staff, but had not considered that. Nor had long call light wait times been considered. Topics identified in QAPI minutes, and correlating concerns identified during survey included:--2/18/25: Daily Nursing Expectations were shared with staff. This was repeated in minutes on 3/18/25, 4/28/25, 5/20/25, 6/18/25, 7/16/25. Nothing more. During interview on 1/27/26 at 2:46 p.m., the administrator and DON could not recall this nor knew what the expectations were. --4/28/25: Nurses: change of condition/assessments/when to call doctor; reviewed within huddles. Education printed for nurses on how to properly assess and document change findings. Copies in each nurse report book.During interview on 1/27/26 at 2:51 p.m., the DON acknowledged this had not been entirely resolved, adding she thought she had done audits for a while and then it had dropped off. --Minutes dated 5/20/25, 8/20/25, 9/24/25, 10/15/25, and 11/19/25, indicated: Onboarding process related to orientation and orientation process: time to onboarding and the actual orientation that is offered. During an interview on 1/27/26 at 2:52 p.m., the DON stated she had been working on orientation as they had not had a human resource director at the time. The DON stated when she started in her role in February 2025, there were so many things to focus on that orientation and training had not been on her radar. --Minutes dated 7/16/25, 10/15/25, and 11/19/25, indicated: Employee satisfaction: Strengths: feel welcomed, work is meaningful, understood goals. Improvement: More consistent staffing, more support and feedback from supervisors during the first 90 days. During interview on 1/27/26 at 2:55 p.m., the administrator stated he had started to review survey results with the new HR director who started in November 2025, adding they wanted to improve staff retention. A mock survey for survey readiness was conducted in September and October 2025, but results had not been included at QAPI for discussion and learning. The administrator, DON and RN-D also know as regional director of services, acknowledged there was a lack of training and knowledge in the QAPI process, and that the facility had not been effectively identifying concerns, analyzing and tracking performance, measuring successes and making sure improvements were sustained. The facility QAPI policy with review date of 6/27/25, indicated QAPI committee consisted of representatives from all departments including pharmacy. However, in 2025, the pharmacists last QAPI meeting attendance was March 2025. Facility Quality Assurance/Assessment and Performance Improvement Plan with review date of 6/27/25, indicated: QAPI program was to utilize an on-going, data driven, proactive approach to advance the quality of life and quality of care for all residents. QAPI principles would drive decision making to promote excellence in all resident and staff related areas. All facility staff, families and residents would be encouraged to be involved in identifying opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and provide ongoing feedback. The QAPI program encompassed post-acute care, long term care and outpatient therapy. The QAPI committee consisted of representatives from all departments including nursing, food and nutrition, pharmacy, laundry, maintenance, health information technology, therapeutic recreation, therapy, business office and administration. Involvement would be varied by topic and may include committee, sub-committee or verbal/written input. The facility would monitor multiple data sources and performance indicators in determining areas of concern, gaps and opportunities and also to determine effectiveness of system modifications and other interventions. All data would be reviewed against state, national or organization benchmarks or thresholds as appropriate and would be reported to the Board of Directors on a quarterly basis. Data for adverse events and medical errors would be tracked, causes analyzed and preventative actions and mechanisms put into place. Potential sources of data may include survey outcomes, complaints, near misses, input from staff, residents, families, medication errors, pharmacist reports, staff retention and Five Star report.

Based on interview and document review the facility failed to implement and maintain an effective Infection Prevention and Control Program specific to antibiotic stewardship. The facility did not have a system to track antibiotic use, culture results, organisms identified, or antibiotic resistance to ensure residents received appropriate treatment, this had the ability to affect all 47 residents. Findings Include:Review of the Infection Prevention and Control (IPC) case log dated 1/22/26, showed documentation included resident name, room number, onset date, current prescription, prescriber, infection type, infection site, diagnosis, and category. However, the log lacked documentation of the date cultures were obtained, organisms identified from culture results, and whether organisms were resistant to prescribed antibiotics.On 1/22/26 at 12:10 p.m., the assistant director of nursing (ADON), identified as the infection prevention nurse, stated antibiotic use was not tracked. The ADON stated the facility completed a log to monitor resident symptoms, possible infections, and provider notification, but did not track culture results or antibiotic effectiveness. The ADON stated follow-up of cultures and ensuring residents were prescribed the correct antibiotic was not facility practice and there was no current process for antibiotic stewardship. The ADON stated providers were responsible to review and track culture results to ensure appropriate antibiotics were prescribed. The ADON confirmed the facility did not track antibiotic indications for use, dosage, duration, culture results, or whether antibiotics were discontinued timely. The ADON further stated if a resident had a urinary tract infection and a urine culture was obtained, the provider was expected to track and communicate results to the facility, and the facility did not have a process to ensure culture results were received or addressed.On 1/26/26 at 3:45 p.m., the director of nursing (DON) and registered nurse (RN)-D, known as the regional director of clinical operations, verified infection surveillance related to antibiotic use and resistance was not tracked on the IPC log and confirmed the facility did not have a formal antibiotic stewardship process.Facility Antibiotic Stewardship Program Policy and Procedure dated 6/25, indicated It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.Director of Nursing - establish standards for nursing staff to assess, monitor and communicate changes in a resident's condition that could impact the need for antibiotics, use their influence as nurse leaders to help ensure antibiotics are prescribed only when appropriate, and educate front line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use.The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the following partners:Infection Preventionist - utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms.Monitoring antibiotic use:Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated, or adjustments should be made (e.g., antibiotic time-out).Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness.Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.Monitor each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic or any antibiotic regimen review as requested by the QAA committee.Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure).Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy).At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include tracking C. difficile infections, antibiotic resistance, adverse drug events related to antibiotic use, or costs related to antibiotic use.Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.New or changed orders for antibiotics based on the antibiotic timeout recommendations will be obtained from the practitioner.

Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas, identified thorough data collection, analysis and evaluation of identified concerns during Quality Assurance and Performance Improvement (QAPI). This had the potential to affect all 47 residents who resided in the facility.Findings include:During an interview on 1/27/26 at 2:31 p.m., with the administrator, the director of nursing (DON) and registered nurse (RN)-B known as regional director of clinical services, the DON stated the facility PIP (performance improvement project) for 2025, had been short stay pressure ulcers, which had been selected by the previous regional nurse consultant. The DON stated there had been no concerns and nothing to improve. Despite this conclusion, the DON could not provide documentation that a performance improvement process had been utilized to arrive at this conclusion. No rationale for selection of this PIP, no data gathered, no feedback from staff, no analysis, no conclusion. Further, the DON stated she did not consider selecting a different PIP when she determined there had been nothing to improve with the short stay pressure ulcer PIP. The DON and administrator admitted a PIP had not been completed in 2025.Facility Quality Assurance/Assessment and Performance Improvement Plan with review date of 6/27/25, indicated: At least annually a project that focused on high risk or problem-prone areas would be addressed through the QAPI program including PIP development. A minimum of one PIP and a maximum of four PlPs would occur simultaneously. The facility used a systematic approach to determining the root cause of an issue and any contributing factors. The team considered the implications of any interventions or changes to systems for potential negative outcomes in other areas. The team would determine whether a pilot test or facility wide change is appropriate based on the facts gathered. Each PIP team determined the timing for conduction of periodic measurements and reviews to evaluate whether new actions/interventions are being followed/performed consistently. lf any backsliding occurred, the team would continue with the PDSA (plan, do check, act) cycle with changes in processes/procedures as required.

Based on observation and staff interview, the facility failed to ensure laundry was handled, transported, and processed in a manner that prevented the spread of infection. Specifically, soiled linens were transported unbagged from resident rooms and through hallways, and the facility failed to implement oversight, staff education, and monitoring of laundry infection control practice, further the facility failed to follow infection prevention and control practices related to enhanced barrier precautions (EBP), wound care, and appropriate use of personal protective equipment (PPE) for 1 of 1 resident (R2) reviewed for non-pressure skin concerns,, failed to identify residents who met criteria for EBP, post required signage, educate staff on EBP versus contact precautions, and ensure staff used appropriate PPE and infection control practices during wound care. Findings include: Laundry On 1/21/26 at 8:16 a.m., observation and interview with staff who requested anonymity, was observed in a utility room, removing laundry from carts. The staff stated laundry was gathered from the soiled utility rooms on each hallway and was routinely soiled laundry was found placed in the laundry carts without bagging the linens prior. Staff further stated laundry from residents with infections, including Clostridioides difficile (C. diff), was not bagged differently, and stated it was not uncommon to find laundry in the laundry carts urine and bowel soiled linens that were transported unbagged. Staff member stated it was an ongoing concern that had been brought up to leadership and the director of nursing. On 1/21/26 at 8:38 a.m., hospitality aide (HA)-J was observed and removed soiled linens from room [ROOM NUMBER] and carried the linens unbagged down the hallway to the dirty utility room. The linens were carried against HA-J's clothing and placed directly into the laundry area without being bagged. HA-J stated they had not been taught that soiled linens needed to be bagged prior to transport. HA-J stated she believed common sense would be to bag linens in the hallway but had not done so previously. On 1/21/26 at 1:46 p.m., interview with the assistant director of nursing (ADON), also served as the infection preventionist, stated it was a previous known issue laundry was being transported unbagged through hallways and stated she did not know the practice was ongoing. The ADON stated known issues with staff not handling laundry as expected but confirmed there were no audits, monitoring, or surveillance in place to ensure compliance with infection control practices related to laundry handling.On 1/22/26 at 7:35 a.m., the director of nursing stated staff were expected to bag laundry prior to removing the laundry from the rooms, and laundry was expected bagged prior to being placed in the soiled laundry cart. EBP and Dressing ChangeR2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, no rejection of care, utilized a wheelchair, dependent on staff for toileting, dressing, and transfers, and partial/moderate assistance with personal hygiene, and transfers, and skin concerns identified moisture associated skin damage (MASD) diagnoses included peripheral vascular disease (caused by narrowing, blockage or spasms in a blood vessel) or peripheral arterial disease (narrowed arteries reduce blood flow to the arms or legs), diabetes mellitus, non-Alzheimer's dementia, hemiplegia (paralysis on one side of the body) or hemiparesis (partial weakness on one side), cellulitis (skin infection ) of right lower limb, reduced mobility, muscle weakness, and edema (swelling).R2's care plan dated 12/29/25, I have diabetes, interventions included: check all of body for breaks in skin and treat promptly as ordered by doctor, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of infection to any open areas: redness, pain, heat, swelling or pus formation; skin: history of venous ulcer right lower extremity, edema in my right lower extremity which sometimes weeps, MASD to groin on and off due to incontinence, potential for further impaired skin integrity due to diabetes, PVD, and impaired mobility related to right side hemiparesis, history of cellulitis to legs interventions included: maintain good skin hygiene, moisturize dry skin PRN, monitor labs and weights as ordered, observe for alteration in skin integrity and report to NP/PA/MD (nurse practitioner/physician assistant/medical doctor), skin inspected by licensed staff week.R2's treatment administration record dated 1/1/26-1/31/26, indicated:Start date 1/27/26, cleansed BLE with wound cleanser, apply collagen to open wound bed, cover with ABD and Kerlix Change daily. one time a day for edema/weeping complete prior to applying compression wrapsStart date 1/26/26, compression wraps, toe to knee. On AM and OFF at HS two times a day for edema/weepingR2's progress note dated 1/15/26 at 11:12 a.m., registered nurse (RN)-B indicated an SBAR note (situation, background, assessment, recommendation) R2's left lower leg is warm and red and irritated, has had several episodes of cellulitis in the past. Most recently in December, Left lower leg warm, red, irritated. Drains off and on. Previously had some blisters that now have scabbed over. Temp 98.2, HR (heart rate) 49, RR (respiratory rate) 18, B/P (blood pressure)178/69, O2 (oxygen) 96%, BS (blood sugar)115, often refuses to have his legs wrapped. Also, refuses to elevate legs during the day. Will often sleep sitting in wheelchair during the night. Recommend: Evaluation from Provider.On 1/20/26 at 11:40 a.m., R46 had a dressing present on the top of his head. R46 stated he had daily dressing changes related to skin cancer. There was no signage or identification R24 was on EBP, no signage was posted, and PPE was not readily available.On 1/21/26 at 12:57 p.m., registered nurse (RN)-B entered R2's room to complete wound care without donning a gown or gloves. No EBP signage was posted, and no PPE was readily available. RN-B removed a bandage scissor form her shirt pocket and disinfected bandage scissors with an alcohol wipe. RN-B left the room to obtain gloves, returned, and donned gloves. During the dressing change, R2's legs were observed to be reddened with drainage. RN-B with gloved hands removed R2's dressing off R2's lower legs. RN-B was observed to place the dirty dressings directly on the floor. RN-B then went to the bathroom with the same gloves touched the bathroom surfaces including the faucet, then used a wet cloth and soap and water and washed R2's legs, and then used a new cloth and pattered R2's legs dry, RN-B then was observed to remove gloves and put on new gloves without disinfecting hands, and stated I should have changed my gloves sooner, and RN-B confirmed hand hygiene was not performed during the dressing change and did not change gloves until later in the process. RN-B was then observed to gather the clothes used during the dressing change and carry with bare hands, carried against their clothing, and placed into a soiled container unbagged in the hallway. RN-B stated if a resident is on EBP gown and glove is worn and stated R2 did not have signage or PPE at the door to indicate R2 was on EBP. RN-B stated the linens were not expected handles with bare hands and was not sure if dirty linens required to be bagged prior to placing in the dirty linen cart. On 1/21/26 at 1:46 p.m., interview with the assistant director of nursing (ADON), and also the infection prevention nurse. The ADON stated residents with chronic wounds may require EBP depending on drainage and containment, and stated, there is still a lot I don't know. The ADON stated she was not aware R2 had a wound and would expect a resident with a wound to be on EBP. The ADON further stated residents with wounds were placed on contact precautions and stated she did not know EBP and contact precautions were different. The ADON confirmed there was no consistent process to identify residents requiring EBP, post signage, or monitor staff compliance.On 1/22/26 at 7:35 a.m., interview with the director of nursing (DON) revealed she would expect gown and gloves to be worn for residents with chronic wounds under EBP. The DON confirmed dirty dressings should not be placed on the floor, gloves should be changed during wound care, and hand hygiene should be performed.On 1/26/26 at 9:46 a.m., DON entered R2's room and to complete R2's wound care. The DON donned gloves but not a gown while providing care to R2 with left lower leg weeping, saturated leg dressing and yellow drainage. The DON used the same gloves to cleanse the wound and handle supplies and later stated, I should have worn a gown and gloves. Facility Infection Prevention and Control Program Policy and Procedure dated 2/25, indicated:Clean linen shall be delivered to resident care units on covered linen carts with covers down.Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets.Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.Environmental services staff shall not handle soiled linen unless it is properly bagged.Enhanced Barrier Precautions Policy and Procedure dated 6/10/25, indicated: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high - contact care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. c. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.

Based on observation and interview, the facility failed to maintain a clean and sanitary environment free from persistent odors for one of three hallways, which resulted in strong and ongoing odors of urine and bowel movements. In addition, the facility failed to ensure clean air/heating vents in common areas including two resident hallways and one day room. This had the potential to affect residents, staff or visitor who resided and/or used hallways and common areas. Findings include: Odors R24's annual Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact, no behaviors, no rejection of care, utilized a walker and wheelchair, required partial/moderate assistance with toileting hygiene, personal hygiene, dressing, toilet transfer, chair to bed transfer, independent with sit to lying and, rolling, no trial of toileting program, occasionally incontinent of urine, always continent of bowel, diagnoses included benign prostatic hyperplasia (BPH) (enlarged prostate), obstructive uropathy (blockage in the urinary tract that hinders normal urine flow), and rheumatoid arthritis. R24's Care Area Assessment (CAA) dated 1/2/26, indicated R24 occasionally incontinent of urine and has a diagnosis of BPH with obstruction. He declines any surgical interventions at this time. He needs assistance with his toileting tasks due to his immobility related to rheumatoid arthritis. R24's care plan dated 1/2/26, indicated bowel and bladder: incontinent of bowel and bladder, regular underwear and will take myself to the toilet without asking for assistance, more episodes of incontinence and refuse to wear pads, staff offers to assist me to the toilet but I will refuses and then toilet myself, R24 removes incontinent pad and do not ask to have a new one put on, diagnosis of BPH with obstruction and declines any surgical interventions, staff assists with changing brief and incontinence cares after each incontinent episode, complete peri cares and manipulate clothing as needed, toilet hygiene- partial assist of one staff, incontinent of bladder and wears medium-large pull up- heavy absorbency, family provides pull ups, toilet transfer: partial assist of one staff with use of gait belt and grab bars to go on and off toilet, bowel & bladder elimination- incontinent of bladder, staff to ensure resident is wearing a brief, encourage and check resident every 2-3 hours. On 1/20/26 at 3:03 p.m., family member (FM)-E stated the entire facility smelled of bowel movements and urine throughout the hallways. On 1/20/26 at 4:11 p.m., the surveyor observed a strong odor of bowel movements and urine throughout the hallway outside of R24's room. On 1/21/26 at 8:13 a.m., the surveyor observed a strong urine odor in the south hallway. On 1/21/26 at 8:31 a.m., R24's room door was open and R24 was not present in the room. A strong urine odor was observed throughout the room, and loose clothing was observed on the floor. On 1/21/26 at 8:32 a.m., R20 was observed in the hallway and stated it was common to have strong and unpleasant urine odors in the hallway. On 1/21/26 at 8:33 a.m., R22 was observed in the hallway and stated there was always a urine odor throughout the hallway and stated it gets stinky. On 1/21/26 at 8:34 a.m., a registered nurse (RN) stated she smelled urine in the hallway and stated it was a very unpleasant odor. On 1/21/26 at 8:28 a.m., a staff member who requested anonymity stated housekeeping staff were aware of a urine odor in R24's room. The staff member stated housekeeping cleaned the room; however, the urine odor persisted. The staff member further stated urine-soaked clothing was often thrown on the floor, bed, and chair, and other residents had complained about the odor. On 1/21/26 at 8:38 a.m., hospitality aide (HA)-J stated urine odors originating from R24 room was common and was reported R24 frequently refused to wear briefs, resulting in urine-soaked bedding, flooring, and chair surfaces. HA-J stated they had reported the issue to nursing staff. On 1/21/26 at 8:58 a.m., another staff member who requested anonymity stated the urine odor in R24's room had been a known issue for months. The staff member stated staff were limited to the cleaning and odor-removal products leadership allowed them to use and were not permitted to use additional odor-eliminating products. The staff member stated urine-soaked clothing was frequently left on the floor and not bagged for laundry, waterproof mattress pads were not in use, and R24 was not consistently encouraged by staff to toilet. The staff member further stated agency staff were not trained on proper laundry handling and sanitation procedures and confirmed the urine odor was very strong. The staff member stated there were multiple occasions when puddles of urine were observed near the chair, and a blanket on the floor was warm and saturated with urine. On 1/21/26 at 11:02 a.m., R24 was observed seated in a recliner in his room and stated he did not wear briefs, did not have a laundry basket, and often placed urine-soaked clothing and blankets on the floor. Pants and a blanket were observed on the floor, and R24 confirmed both items were soaked with urine and had been on the floor since early that morning. A wheelchair cushion with a distinct darker area was observed to be wet, and R24 confirmed the wheelchair cushion was saturated with urine. R24 further stated he placed his urine-soaked blankets on the floor. On 1/21/26 at 11:07 a.m., Health Unit Coordinator (HUC)-E stated the urine odor from R24's room was a known issue and stated staff had counseled the resident and spoken with family; however, the issue persisted and no laundry basket was available in the room. On 1/21/26 at 11:10 a.m., the director of nursing (DON) confirmed urine-soaked blankets were present on the floor and stated she would expect protective pads to be in place on the bed, wheelchair, and recliner. The DON confirmed urine stains were present on the bed linens. On 1/21/26 at 11:25 a.m., NA-H stated she had observed urine odors outside of R24's room since November 2024. NA-H stated R24 frequently refused care and urine-soaked clothing, and blankets were often placed on the floor and required bagging and removal to the soiled utility room. On 1/21/26 at 9:43 a.m., the DON acknowledged the urine odor in R24's room was a known issue and stated the facility was actively working on ways to prevent the odor. The DON confirmed R24 was alert and oriented and was not on a toileting schedule. The DON stated disposable chux (disposable, absorbent pads used to protect surfaces like mattresses and furniture from moisture and fluids, particularly in cases of incontinence). were expected to be in place on R24's bed, recliner, and wheelchair; however, the DON confirmed the chux were not present. The DON stated she did not smell urine in the hallway when R24's door was closed but was informed that staff, visitors, and residents were able to smell urine in the hallways. The DON stated others being able to smell urine in the hallway was a big deal. The DON further stated she had educated staff during huddles to immediately remove urine-soaked clothing from R24's room. The administrator stated R24 was extremely incontinent, alert, and oriented, had refused briefs for months, and had the right to refuse care. The DON stated housekeeping cleaned R24's room daily and nursing assistants were expected to immediately bag urine-soaked laundry; however, the DON acknowledged no audits were completed to ensure compliance. The DON further stated improper handling of urine-soaked laundry posed a risk for contamination and infection control concerns. The DON confirmed the wheelchair cushion was urine-soaked, loose urine-soaked clothing was present on the floor, and other residents should not have to experience urine odors throughout the hallways. Facility Routine Cleaning and Disinfection policy dated 6/10/25, indicated:It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order toprovide a safe, sanitary environment and to prevent the development and transmission of infections to theextent possible.Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products Vents During an observation on 1/20/26 at 6:45 p.m., cold air was felt coming out of a large vent on the ceiling of resident hallway near rooms three, four, and five. The vent was covered in a thick layer of gray dust and fluffy debris. During observation on 1/22/26 at 11:58 a.m., two vents in the hallway of the transitional care unit were covered with gray dust and fluffy debris. An additional vent blowing directly into the main day room near the nurses' station where multiple residents were seated was also covered in a thick layer of gray dust and fluffy debris. During interview on 1/22/26 at 2:49 p.m., housekeeper (H)-A stated she did not clean common area vents and was not sure who was responsible for that. H-A looked at the vent in the hallway near rooms three, four, and five and stated it was very dirty. H-A stated she cleaned only bathroom vents in resident rooms. During interview on 1/22/26 at 12:01 p.m., environmental director (ED)-A stated he was not aware of dirty vents but had heard about it during survey and observed the dirty vents. ED-A stated he reviewed his maintenance logs and cleaning vents was not part of a scheduled cleaning routine. ED-A stated vents needed to be cleaned to ensure less dust and allergens in the air. ED-A stated he would put vents on a monthly cleaning rotation. During interview on 1/22/26 at 2:55 p.m., administrator stated he would expect vents in common areas to be cleaned on a regular basis. Facility Routine Cleaning and Disinfection policy dated 6/10/25, indicated it was the policy of the facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment. Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents.

Based on observation, interview, and document review, the facility failed to ensure the provider was timely notified and appropriate orders were obtained and implemented following a change in condition related to worsening skin integrity for 1 of one 1 resident (R2) reviewed for skin changes. This failure resulted in delayed treatment, lack of wound care orders, and inconsistent care, placing the resident at risk for infection and further skin breakdown. In addition, the facility failed to notify the resident representative when there had been a change in condition for 1 of 1 resident (R26), reviewed for notification of change. Findings include: Physician Notification R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, no rejection of care, utilized a wheelchair, dependent on staff for toileting, dressing, and transfers, and partial/moderate assistance with personal hygiene, and transfers, and skin concerns identified moisture associated skin damage (MASD) diagnoses included peripheral vascular disease (caused by narrowing, blockage or spasms in a blood vessel) or peripheral arterial disease (narrowed arteries reduce blood flow to the arms or legs), diabetes mellitus, non-Alzheimer's dementia, hemiplegia (paralysis on one side of the body) or hemiparesis (partial weakness on one side), cellulitis (skin infection ) of right lower limb, reduced mobility, muscle weakness, and edema (swelling). R2's care plan dated 12/29/25, I have diabetes, interventions included: check all of body for breaks in skin and treat promptly as ordered by doctor, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of infection to any open areas: redness, pain, heat, swelling or pus formation; skin: history of venous ulcer right lower extremity, edema in my right lower extremity which sometimes weeps, MASD to groin on and off due to incontinence, potential for further impaired skin integrity due to diabetes, PVD, and impaired mobility related to right side hemiparesis, history of cellulitis to legs interventions included: maintain good skin hygiene, moisturize dry skin PRN, monitor labs and weights as ordered, observe for alteration in skin integrity and report to NP/PA/MD (nurse practitioner/physician assistant/medical doctor), skin inspected by licensed staff week. R2's treatment administration record dated 1/1/26-1/31/26, indicated: Start date 11/11/24, compression wraps to bilateral lower legs, on am and off HS (bedtime) for edema two times a day for edema in BLE (bilateral lower extremity) related to localized edema. Start date 2/1/25, nurse to complete and document skin check in the evening every Wed, Sat Start date 8/21/25, check feet every HS for any sores, cuts, or changes. Update Wound Nurse/MD as needed at bedtime Start date 10/15/25, cleanse RLE (right lower extremity) prior to compression then apply [NAME] cream. Apply compression. every day shift for dry skin and edema BLE R2's progress note dated 1/15/26 at 11:12 a.m., registered nurse (RN)-B indicated an SBAR note (situation, background, assessment, recommendation) R2's left lower leg is warm and red and irritated, has had several episodes of cellulitis in the past. Most recently in December, left lower leg warm, red, irritated. Drains off and on. Previously had some blisters that now have scabbed over. Temp 98.2, HR (heart rate) 49, RR (respiratory rate) 18, B/P (blood pressure)178/69, O2 (oxygen) 96%, BS (blood sugar)115, often refuses to have his legs wrapped. Also, refuses to elevate legs during the day. Will often sleep sitting in wheelchair during the night. Recommend: Evaluation from Provider. R2's document SBAR communication tool undated, RN-B indicated R's had a red lower left leg, irritated, warm, past history of cellulitis, not on any antibiotic, recently hospitalized for cellulitis no recent changes in condition, left lower leg red warm and irritated, wound open/scabbed areas on both legs, continues to refuse wraps, legs are weepy, sometimes sleeps in bed, likes to sit up in wheelchair. Temp 98.2, HR 49, RR 18, B/P 178/69, O2 96%, BS 115. R2's record review lacked documentation the provider had been notified of R2's left lower leg assessment. On 1/21/26 at 12:57 p.m., RN-B entered R2's room, and stated she would be completing R2 's wound care. RN-B stated R2's order must have changed when she observed an ABD (a highly absorbent dressing designed for wounds with heavy drainage) pad present on R2's left leg, and RN-B stated she did not remember R2 having an order for ABD dressing. RN-B removed R2's socks from both feet and used a scissors to cut off the Kerlix and remove the dressings. The legs were observed to be reddened with yellowish drainage on the left leg. RN-B stated she usually cleans the legs with gentle soap and water. RN-B applied [NAME] cream (moisturizer for dry skin) to R2's lower left and right legs but not to the open areas, then picked up the soiled dressings from the floor, removed her gloves, and offered to rewrap the legs; R2 declined compression wraps. RN-B stated Kerlix (dressing used to cover and protect wounds) was not available, as the facility had run out and stated she would have to use a different type of dressing to secure the ABD. RN-B applied ABD pads directly to both lower legs, securing them with Coban (non-adhesive elastic wrap). RN-B stated staff normally would not use Coban without Kerlix and that Kerlix would absorb drainage and protect the open areas. RN-B was observed to complete the dressing change and then exited the room. RN-B then stated she wrote an SBAR last week due to the change in R2's skin on his legs and were observed warm and weeping, with open areas. RN-B stated she verbally notified the director of nursing (DON), assistant director of nursing (ADON) and the, Health unit coordinator (HUC)-E that R2 had a new issue with his legs and was instructed to complete a Teladoc (virtual doctor) appointment with R2. RN-B stated she did not have time to complete Teladoc visit with R2 due to all her other duties as a nurse that include, medication pass, treatments, dressing changes, and processing orders. RN-B stated the Teladoc system is time consuming, and the floor nurse was responsible for completing the Teladoc system, and stated she completed an SBAR due to the provider being at the facility the following day. RN-B stated she completed an SBAR and gave to either the ADON or DON. RN-B stated she completed a progress note in the EMR the day she observed R2's skin changes on the legs. On 1/21/26 at 4:44 p.m., licensed practical nurse (LPN)-A stated he was not aware R2 had any dressing changes or open areas on his legs and stated if dressing changes were necessary the EMR (electronic medical record) treatment orders would indicate orders. LPN-A confirmed R2 had no dressing change order and was unaware the legs were red and weeping and did not assess them. LPN-A stated he would expect dressing change orders, including gauze and ABD pads, and that the provider should have been notified. On 1/21/26 at 2:57 p.m., the DON stated she remembered seeing an SBAR on R2, within the last week or two and paraphrased the information and notified the provider regarding open areas and weeping areas, and was not sure how the provider was notified but further stated she remembers updating the provider, DON was observed to look through documentation and stated she could not find documentation the provider was notified. The DON stated she would have expected documentation of provider notification and expected the provider to assess R2. On 1/21/26 at 5:06 p.m., during a follow up interview the DON and RN-C known as regional director of clinical services reviewed documentation and were unable to find evidence the provider had been notified of the change in skin condition. The DON found an SBAR in her office undated and stated the SBAR was from 1/8/26; however, upon further review, she determined a progress note dated 1/15/26 matched the SBAR she received. The DON confirmed the provider should have been notified of the change in skin condition and stated it was her responsibility to track SBARs submitted to providers. The DON stated the nursing staff complete the SBARs and either give to her, the ADON, or HUC-E and then she reviews the SBARs for accuracy and either puts the SBARs back in a folder in HUC-E's office for providers to review or gives the SBARS to the providers herself. The DON stated the SBAR from RN-B was not followed up on as expected and she was unsure why documentation could not be located. On 1/26/26 at 4:40 p.m., during a telephone interview the medical director (MD)-F stated the provider was expected to be notified of skin changes promptly. Resident Representative Notification R26's face sheet received on 1/28/26, included diagnoses of congestive heart failure (heart not able to pump effectively), chronic obstructive pulmonary disease (lung disease that restricts airflow), respiratory failure (lungs cannot adequately supply oxygen to the blood), venous insufficiency (leg vein valves are weak preventing proper blood flow to heart), and diabetes. R26's admission MDS dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R26 required supervision or partial assistance with activities of daily living (ADLs). R26 could walk 50 feet with partial staff assistance. R26's physician orders dated 1/19/26, indicated: Wound care; wash with wound cleanser, apply bacitracin, cover with gauze. One time a day. R26's care plan with revised date of 1/8/26, indicated R26 had potential for impaired skin due to weakness, diabetes and obesity. Skin would remain intact. Nursing assistants (NAs) would observe skin with morning and evening cares and report any abnormalities to the nurse. Observe for alteration in skin integrity and report to provider. Skin inspected by licensed staff weekly per schedule. R26's progress note dated 1/14/26, at 11:35 p.m., indicated a NA requested RN-C, to R26's room to assess skin condition. RN-C noted full flap loss skin tear measuring 4.3 centimeters (cm) x 3 cm to right shin area. R26 stated she did not know how it occurred. Wound was cleansed with normal saline and covered with non-adhesive pad and wrapped with kerlix. SBAR (situation, background, assessment and recommendation) left for provider. During an interview on 1/20/26 at 2:30 p.m., family member (FM)-A stated communication with the facility was poor, and I'm so frustrated. R26 stated FM-A sustained a skin tear on her right leg on 1/14/26, but she had not been notified. FM-A stated she first learned about the skin tear when she arrived three or four days later and saw gauze on R26's leg. FM-A stated someone at the facility (she couldn't recall who) talked to her about this and said she would talk to the nurse involved. During an interview on 1/22/26, at 2:45 p.m., RN-C stated he notified the provider when he learned of R26's skin tear on 1/14/26, but admitted he did not notify FM-A because it was late -- about 10:00 p.m. RN-C stated he later found out FM-C wanted to be notified no matter the time. During an interview on 1/26/26, at 9:23 a.m., the DON stated she was aware of FM-A not being informed of R26's skin tear and she spoke to RN-C to remind him family was to be notified in a timely manner when changes occurred. The DON provided meeting minutes dated 10/17/25, where this topic had been discussed with nurses and in which RN-C was in attendance. During an interview on 1/27/26 at 7:40 a.m., RN-E stated she was aware of the skin tear on R26's leg. RN-E stated staff were to notify the family right away with anything unless it was care-planned not to. Facility Prevention and Treatment of Skin Breakdown/Pressure Injury Policy and Procedure dated 12/24, indicated: If a resident is admitted with impaired skin integrity or new pressure injury or a lower extremity ulcer develops, the licensed nurse implements the follow items: Documentation of the skin impairment is completed in the medical record. Staging is completed as necessary by trained licensed nursing associates Standing orders/protocol for skin impairment are initiated Notify attending provider, resident, and resident representative. Attending provider determines wound type and may provide additional orders. Notify Supervisor/designee. Evaluate current pressure reduction interventions and revise resident centered care plan. Notify dietitian for nutritional interventions as appropriate Notify therapy associates and other members of the care team as appropriate for possible additional treatment interventions. Educate resident/resident representative on skin impairment and care plan interventions. When pressure injury is present, the dressing and/or wound as appropriate are monitored daily. Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify attending provider. Notify the attending provider, resident/resident representative and supervisor if the skin injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Facility Change of Condition policy dated 6/10/25, indicated the facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there was a change requiring such notification, including accidents resulting in injury and/or the potential to require physician intervention. Circumstances that required a need to alter treatment such as a new treatment. For competent individuals, the facility must still contact the resident's physician and notify resident's representative, if known. A family that wishes to be informed would designate a member to receive calls. When a resident was mentally competent, a designated family member should be notified of significant changes in the resident health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

Based on observation, interview and documentation review, the facility failed to seek clarification and initiate physical therapy timely for 1 of 1 resident (R43) who had had orders for physical therapy after a fracture. Findings include:R43's face sheet printed 1/22/26 at 4:33 p.m., indicated diagnoses of fracture of right foot, Alzheimer's disease, pain related to hand contracture.R43's care plan dated 11/6/25, indicated need for restorative nursing, will continue to maintain current abilities. Refer to therapy as needed.R43's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, rejection of care one to three days, lower extremity impairment on one side, use of wheelchair, supervision for eating, dependent for toileting, substantial assistance for bathing and dressing.During observation and interview on 1/20/26 at 7:49 p.m., R43 was in bed with daughter (FM)-B at bedside. FM-B stated she planned to take R43 home when therapy was done. FM-B stated an order for physical therapy was written 12/23/25, but therapy had not started yet. FM-B stated she was frustrated because she thought R43 would be back home by now and she could take care of her at home if physical therapy could work with her on transfers. FM-B stated she had asked director of nursing (DON) why therapy had not started but did not get an answer.Facility form titled Clinic Sheet signed by registered nurse (RN)-C, RN-E, and health unit coordinator (HUC)-E dated 12/23/25, indicated fracture of right foot, may start to place weight on right foot to transfer with assistance. May start physical therapy at this time.Facility progress note written by RN-C dated 12/23/25, indicated R43 returned from x-ray with the following orders: May start to place weight on right foot to transfer with assistance. May start physical therapy at this time. Daughter was with R43 at appointment and aware of new orders.Review of R43's physician's orders on 1/21/26 at 1:45 p.m., indicated no order for physical therapy was entered into the facility electronic health record (EHR).During interview on 1/21/26 at 4:30 p.m., RN-C stated he did not remember anything specific about R43's therapy order, but if he signed off on the order a copy would go in a folder and be given to therapy. RN-C stated that likely did not happen if therapy had not been started for R43.During interview on 1/21/26 at 4:45 p.m., HUC-E stated her signature was on the order on 12/23/25, RN-C signed on 12/23/25, and RN-E signed on 12/25/25. HUC-E stated that meant she put orders in EHR, RN-C signed off on them, and RN-E signed off as the final check to ensure the order was processed right. HUC-E stated RN-C could have forgotten to activate the orders, and RN-E should have caught that. HUC-E further stated it did not look like the orders were ever entered into the EHR.During interview on 1/21/26 at 5:02 p.m., DON stated she was not sure what the delay was in getting the therapy order entered but had done it now. DON stated therapy had needed the order to say something different, so they waited for the facility provider to change the order. DON stated therapy had been given the new order on 1/16/26, and would have expected therapy to start sooner for R43.During interview on 1/22/26 at 12:28 p.m., physical therapy assistant (PTA)-I stated it was hit or miss at the facility whether therapy orders were received promptly. PTA-I stated she believed she got R43's order on 12/24/25, and told them on 12/29/25 the order was written incorrectly and needed to say the words eval and treat. PTA-I stated she did not hear anything more about the therapy order for R43 until 1/16/26. DON emailed the provider at 4:45 p.m., and received a response from the provider with the correct order at 4:47 p.m. PTA-I stated it took two minutes for a response and wasn't sure why this couldn't have been done right away. PTA-I stated it was important to start therapy as soon as possible to reduce the risk for further decline.Facility Provision of Physician Ordered Services policy dated 6/10/25, indicated the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality, meaning that care and all services are provided according to accepted standards of practice.

Based on observation, interview and document review, and staff interview, the facility failed to ensure medications were administered in accordance with prescriber orders when an incorrect dose of losartan (blood pressure medication) was administered incorrectly for three months, constituting a significant medication error for 1 of 5 residents (R44) reviewed for medication administration. Findings Include:R44's Minimum Data Set (MDS) dated [DATE], indicated R44 was cognitively intact, required partial/moderate assistance with personal hygiene, and diagnoses included hypertension. R44's care plan dated 12/19/25, indicated R44 at risk cardiovascular status r/t (related to) hypertensive heart disease and atherosclerosis of aorta.R44's provider note dated 10/8/25, physician assistant (PA)-K provider note indicated decrease losartan to 25 mg (milligrams) daily. R44's medication administration record dated 10/1/25-10/31/25, 11/1/25-11/30/25, 12/1/25-12/31/25, and 1/1/26-1/31/26, indicated R44 received losartan potassium oral tablet 25 mg daily. On 1/21/26 at 8:47 a.m., observation and interview with registered nurse (RN)-G was observed to prepare R44's medications and identified a discrepancy between the medication order and the pharmacy label for losartan. RN-G stated the losartan was ordered at 25 mg, but the pharmacy-labeled medication provided in the packet was 50 mg. RN-G verified the order using the computer and packaging, determined the dose was incorrect, and did not administer the losartan.On 1/21/26 at 9:40 a.m., interview with the director of nursing (DON) stated the pharmacy was contacted today regarding R44's losartan discrepancy. The DON stated the pharmacy was filling an older order dating back to June (2025) of losartan 50 mg versus the current 25 mg order. The DON confirmed that since 10/2025, R44 had been receiving losartan 50 mg instead of the ordered 25 mg. The DON stated she would expect nursing staff to verify medication orders against pharmacy packaging.On 1/21/26 at 2:57 p.m., the DON stated an incident report was not completed related to R44's losartan dosing error and confirmed staff were not following the prescriber's order. The DON further stated there had been a lot of medication errors occurring intermittently. The DON confirmed education had been provided to staff; however, corrective actions were not consistently effective.On 1/22/26 at 7:35 a.m., interview with the DON revealed the facility did not complete medication reconciliation at the time medications were dispensed from the pharmacy to ensure the medications matched current orders. The DON confirmed the facility did not routinely call or confirm receipt of new or changed medication orders with the pharmacy, despite ongoing issues for several months in which the pharmacy stated it had not received orders. The DON was unable to articulate what specific actions had been implemented to prevent recurrence of medication errors. The DON further confirmed medication audits had not been completed since December. The DON confirmed the pharmacy performed reconciliation and placed medications into the medication dispensing system; however, the facility failed to verify accuracy upon receipt and failed to identify and correct ongoing medication discrepancies.Facility Medication Administration Policy and Procedure dated 2025, indicated:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines:Ensure that the six rights of medication administration are followed: Right resident Right drug Right dosage Right route Right time Right documentation Review MAR to identify medication to be administered.Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.Correct any discrepancies and report to nurse manager.

Based on observation, interview, and record review, the facility failed to ensure dialysis communication forms were consistently reviewed, addressed, and incorporated into the resident's medical record, and failed to ensure provider orders communicated by the dialysis provider were implemented in a timely manner for 1 of 1 resident (R3) of one reviewed for dialysis.Findings Include:R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact, no rejection of care, utilized a wheelchair, required substantial/maximal assistance with personal hygiene, upper body dressing, dependent on staff for toileting hygiene and transfers; diagnoses included hemiplegia or hemiparesis, depression, dependence on renal dialysis.R3's care plan dated 1/2/26, need hemodialysis r/t (related to) renal failure and interventions included: encourage resident to go for the scheduled dialysis appointments, receives dialysis Monday, Wednesday, Friday transportation provided by facility.Review of R3's dialysis communication forms from 12/15/25 through 1/21/26, indicated forms dated 12/15/25, 12/19/25, 12/22/25, 1/16/26, and 1/21/26. The facility failed to provide any additional forms or documentation of communication from dialysis.R3's dialysis communication form dated 1/16/26, registered nurse (RN)-G indicated: please see attached order for Claritin (medication used to treat allergies and hives), this was ordered on 12/29/25, and do not see on R3's MAR (mediation administration record), will help with rash and scratching.R3's MAR dated 12/1/25-12/31/25, failed to indicate an order for Claritin.R3's MAR dated 1/1/26-1/31/26, indicated start date 1/20/26, Claritin oral tablet chewable 5 mg (milligrams) give 1 tablet by mouth one time a day for itching.On 1/20/26 at 12:57 p.m., R3 was observed lying in bed and reported ongoing itching of his arms for approximately one month and stated he was unsure whether the facility or physicians were addressing the concern. R3 was observed to have multiple scratches of varying sizes on bilateral arms.On 1/21/26 at 3:13 p.m., RN-C stated R3 had a dialysis communication folder that traveled to and from dialysis appointments; however, RN-C reported finding prior dialysis communication forms in the back pocket of R3's wheelchair that had not been reviewed or addressed. RN-C stated the facility utilized a high volume of agency nursing staff and indicated the communication process may not have been followed due to agency staff being unfamiliar with the expectation to review the dialysis communication forms.On 1/21/26 at 9:25 a.m., RN-G stated they were an agency nurse and was observed to remove dialysis communication form in the back pocket of R3's wheelchair dated 1/16/26. RN-G stated they were not educated or trained by the facility regarding the requirement to review dialysis communication forms or ensure provider communication was addressed upon the resident's return from dialysis.On 1/21/26 at 9:43 a.m., the director of nursing (DON) confirmed a dialysis communication form dated 1/16/26, was found in the back pocket of R3's wheelchair and had not been addressed. The DON stated nursing staff were expected to retrieve the dialysis communication form when R3 returned from dialysis and document any provider communication or new orders in a progress note within the electronic medical record (EMR).On 1/21/26 at 10:21 a.m., during a telephone interview, RN-H from the dialysis provider stated concerns regarding R3's skin condition had been communicated through the dialysis communication forms and stated Claritin had been ordered in December to address itching; however, the medication had not been started until the current week. RN-H stated they would have expected the order to be addressed and implemented sooner.On 1/22/26 at 7:35 a.m., the DON stated the facility was unable to locate all dialysis communication forms for R3 and confirmed forms were expected to be scanned into the EMR if not otherwise documented in a progress note. The DON confirmed the facility could not locate a dialysis communication form dated 12/29/25, related to the Claritin order and confirmed the medication was not initiated until 1/20/26. The DON further stated the Claritin should have been ordered and administered as directed by the dialysis provider on 12/29/2Facility Dialysis Agreement dated 3/10/2009, indicated Those areas of the Nursing Home's plan of care in which Clinic and Hospital shall furnish direction to the Nursing Home shall include, but not be limited to: (a) procedures for handling medical and non-medical emergencies, including complications, equipment failure and a Clinic and Hospital contact in case of emergencies; (b) follow-up care, observation, and monitoring;(c) medications; (d) nutritional needs and fluid restrictions; and(e) Resident education.

Based on observation, interview and document review, the facility failed to provide timely toileting for 1 of 1 resident (R4) who required staff assistance with activities of daily living (ADL). Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, delusions, physical and verbal behavioral symptoms, rejection of care, utilized a wheelchair, required maximal/substantial assistance with activities of daily living and transfers, frequently incontinent of urine, occasionally incontinent of bowel, diagnoses included non-Alzheimer's dementia, depression, urinary tract infection, and history of falling.R4's care plan dated 12/1/25, indicated bowel and bladder incontinent of bowel and bladder, require assistance with toileting due to weakness and impaired , toilet hygiene- substantial assist, offer toileting upon rising, before and after meals, HS (bedtime), midnight and 4 a.m.R4's Care Conference Summary dated 11/25/25, indicated family wants staff to get R4 to the bathroom after meals. Staff will be educated on this to ask her if she has to use the restroom. Informed family it is on her care plan to do this but will educated staffR4's documentation of tasks dated 1/26/26, indicated Bowel & Bladder Elimination-Offer toileting upon rising, before and after meals, HS (bedtime) midnight and 4a.m. and R4's documentation included:1/14/26,6:02 a.m.1:30 p.m.1/15/2026,1:04 a.m.4:58 a.m.5:42 a.m.2:16 p.m.14:16 p.m.9:30 p.m.1/16/2026,12:24 a.m.2:26 a.m.05:39 a.m.10:00 a.m.14:08 p.m.10:11 p.m.1/17/2026,12:09 a.m.1:21 a.m.5:15 a.m.9:06 a.m.1:49 p.m.5:59 p.m.8:23 p.m.9:48 p.m.1/18/2026,12:00 a.m.2:00 a.m.4:00 a.m.6:00 a.m.1:22 p.m.8:55 p.m.1/19/2026,1:42 a.m.3:31 a.m.4:00 a.m.6:00 a.m.2:29 p.m.9:17 p.m.1/20/2026,1:03 a.m.4:50 a.m.5:13 a.m.6:21 p.m.8:29 p.m.1/21/2026,1:09 a.m.4:26 a.m.1:50 p.m.8:32 p.m.9:58 p.m.R4's documentation failed to indicate toileting upon rising, before and after meals, HS (bedtime) midnight and 4 a.m.On 1/20/26 at 3:03 p.m., during a telephone interview family member (FM)-E stated they had previously raised concerns with the facility regarding (R4) not being toileted or having briefs changed routinely. FM-E stated R4 frequently smelled of urine and bowel and further stated she had also noticed odors of urine and bowel throughout the facility.On 1/21/26 at 8:09 a.m., R4 was observed seated at a dining room table eating breakfast.On 1/21/26 at 10:58 a.m., R4 observed seated in a wheelchair in the day room.On 1/21/26 at 12:41 p.m., R4 was observed seated at the dining room table eating lunch and receiving cueing assistance from staff.On 1/21/26 at 1:42 p.m., nursing assistant (NA)-G stated they were assigned to R4 today. NA-G stated it was their first day at the facility as agency staff, and stated they knew how the residents transferred by what was written down. NA-G was observed and pulled out a small piece of paper and stated R4 required two people assist with transfers and toileting. NA-G stated R4 had not requested assistance and had not informed staff of the need to be toileted and confirmed R4 had not been offered to be toileted since 9:30 a.m., NA-G stated they were unfamiliar with R4's care and stated would expect R4 to notify staff when they wanted to be toileted. On 1/21/26 at 3:09 p.m., R4 continued to be seated in a wheelchair by the nursing station.On 1/21/26 at 3:13 p.m., NA-D stated they started their shift at 2:00 p.m. and had recently changed R4's brief and observed dried bowel movement on the brief that appeared to indicate R4 had not been changed for an extended period. NA-D stated the timing of R4's last brief change had not been reported during shift report. NA-D stated R4 was expected to be toileted with a brief change every two hours and R4 was not able to verbalize her needs.On 1/21/26 at 3:25 p.m., NA-C stated R4 toileting was expected every two hours.On 1/21/26 at 4:55 p.m., licensed practical nurse (LPN)-A stated staff were expected to toilet R4 every two hours, and stated the facility had staffing challenges of shortage of staff and large amount of agency staff that delayed routine care, due to staffing issues and agency staff unfamiliarity with resident care.On 1/26/26 at 5:42 p.m., the director of nursing (DON) stated staff were expected to toilet R4 per the care plan and document toileting and refusals.Facility ADL Care of Dementia Unit Residents policy dated 2025, indicated;It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents on the dementia unit to ensure all ADL needs are met on a daily basis, while attaining or maintaining the dementia resident's highest practicable physical, mental and psychosocial well-being. The care plan interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary.Facility Policy Activities of Daily Living (ADLs) dated 2025, indicated;Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on observation, interview, and document review, the facility failed to ensure necessary care and services were provided for 1 of 1 resident (R2) reviewed for non-pressure skin concerns, when staff failed to appropriately assess, treat, and manage bilateral lower-extremity wounds. This included failure to timely notify the provider and obtain and implement wound care orders following a change in skin condition, and failure to ensure wound care was provided as needed. These failures resulted in R2 going multiple days without wound care and placed the resident at risk for worsening skin breakdown, infection, and complications related to delayed treatment. Further, the facility failed to complete and monitor daily weights, monitor blood pressures, and administer medications in accordance with provider-prescribed blood pressure parameters and treatment orders for 1 of 1 resident (R2) reviewed for edema. In addition, the facility failed to follow physician orders for obtaining daily weights and applying elastic compression bandages to legs for 1 of 1 resident (R26), reviewed for edema. Findings include: SKIN ASSESSMENT and DRESSING CHANGES R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, no rejection of care, utilized a wheelchair, dependent on staff for toileting, dressing, and transfers, and partial/moderate assistance with personal hygiene, and transfers, and skin concerns identified moisture associated skin damage (MASD) diagnoses included peripheral vascular disease (caused by narrowing, blockage or spasms in a blood vessel) or peripheral arterial disease (narrowed arteries reduce blood flow to the arms or legs), diabetes mellitus, non-Alzheimer's dementia, hemiplegia (paralysis on one side of the body) or hemiparesis (partial weakness on one side), cellulitis (skin infection ) of right lower limb, reduced mobility, muscle weakness, and edema (swelling). R2's care plan dated 12/29/25, I have diabetes, interventions included: check all of body for breaks in skin and treat promptly as ordered by doctor, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of infection to any open areas: redness, pain, heat, swelling or pus formation; skin: history of venous ulcer right lower extremity, edema in my right lower extremity which sometimes weeps, MASD to groin on and off due to incontinence, potential for further impaired skin integrity due to diabetes, PVD, and impaired mobility related to right side hemiparesis, history of cellulitis to legs interventions included: maintain good skin hygiene, moisturize dry skin PRN, monitor labs and weights as ordered, observe for alteration in skin integrity and report to NP/PA/MD (nurse practitioner/physician assistant/medical doctor), skin inspected by licensed staff week. R2's treatment administration record dated 1/1/26-1/31/26, indicated: Start date 11/11/24, compression wraps to Bilateral lower legs, on am and off HS (bedtime) for edema two times a day for edema in BLE (bilateral lower extremity) related to localized edema. Start date 2/1/25, nurse to complete and document skin check in the evening every Wed, Sat Start date 8/21/25, check feet every HS for any sores, cuts, or changes. Update Wound Nurse/MD as needed. at bedtime Start date 10/15/25, end date 1/26/26, cleanse RLE (right lower extremity) prior to compression then apply [NAME] cream. Apply compression. every day shift for dry skin and edema BLE Start date 1/27/26, cleansed BLE with wound cleanser, apply collagen to open wound bed, cover with ABD and Kerlix Change daily. one time a day for edema/weeping complete prior to applying compression wraps Start date 1/26/26, compression wraps, toe to knee. On AM and OFF at HS two times a day for edema/weeping R2's progress note dated 1/15/26 at 11:12 a.m., registered nurse (RN)-B indicated an SBAR note (situation, background, assessment, recommendation) R2's left lower leg is warm and red and irritated, has had several episodes of cellulitis in the past. Most recently in December, left lower leg warm, red, irritated. Drains off and on. Previously had some blisters that now have scabbed over. Temp 98.2, HR (heart rate) 49, RR (respiratory rate) 18, B/P (blood pressure)178/69, O2 (oxygen) 96%, BS (blood sugar)115, often refuses to have his legs wrapped. Also, refuses to elevate legs during the day. Will often sleep sitting in wheelchair during the night. Recommend: Evaluation from Provider. R2's document SBAR communication tool undated, RN-B indicated R's had a red lower left leg, irritated, warm, past history of cellulitis, not on any antibiotic, recently hospitalized for cellulitis no recent changes in condition, left lower left red warm and irritated, wound open/scabbed areas on both legs, continues to refuse wraps, legs are weepy, sometimes sleeps in bed, likes to sit up in wheelchair. Temp 98.2, HR 49, RR 18, B/P 178/69, O2 96%, BS 115. R'2 progress note dated 1/24/26 10:30 p.m., indicated no new skin issues identified, skin issue has not been evaluated front right lateral lower leg redness, wound acquired in-house, unknown how long the wound has been present; front left lateral lower leg redness with dry scabs, wound acquired in-house, unknown how long the wound has been present; front right knee. scab off- red area not completely healed over wound acquired in-house. it is unknown how long the wound has been present. R2's telephone order undated, DON indicated an order from nurse practitioner (NP)-G with orders to cleanser BLE with wound cleanser, pat dry, apply collagen to wound bed, cover with ABD and kerlix, compression wrap toe to knee on in the AM and off and bedtime. R2's record review lacked documentation the provider had been notified of R2's left lower leg assessment, dressing changes, or received new wound orders until 1/22/25, however the orders were not implemented until 1/26/26 On 1/21/26 at 12:57 p.m., RN-B entered R2's room, and stated she would be completing R2 wound care. RN-B stated R2's order most have changed when she observed an ABD (a highly absorbent dressing designed for wounds with heavy drainage) pad present on R2's left leg, and RN-B stated she did not remember R2 having an order for ABD dressing. RN-B removed R2's socks from both feet and used a scissors to cut off the Kerlix and remove the dressings. The legs were observed to be reddened with yellowish drainage on the left leg. RN-B stated she usually cleans the legs with gentle soap and water. RN-B then used a washcloth with water to gently wash the legs, followed by a dry washcloth to pat the legs dry. RN-B applied [NAME] cream (moisturizer for dry skin) to R2's lower left and right legs but not to the open areas, then picked up the soiled dressings from the floor, removed her gloves, and offered to rewrap the legs; R2 declined compression wraps. RN-B stated Kerlix (dressing used to cover and protect wounds) was not available, as the facility had run out and stated she would have to use a different type of dressing to secure the ABD. RN-B applied ABD pads directly to both lower legs, securing them with Coban (non-adhesive elastic wrap). RN-B stated staff normally would not use Coban without Kerlix and that Kerlix would absorb drainage and protect the open areas. RN-B was observed to complete the dressing change and then exited the room. RN-B then stated she wrote an SBAR last week due to the change in R2's skin on his legs and were observed warm and weeping, with open areas. RN-B stated she verbally notified the director of nursing (DON), assistant director of nursing (ADON) and the, Health unit coordinator (HUC)-E that R2 had a new issue with his legs and was instructed to complete a Teladoc (virtual doctor) appointment with R2. RN-B stated she did not have time to complete Teladoc visit with R2 due to all her other duties as a nurse that include, medication pass, treatments, dressing changes, and processing orders. RN-B stated the Teladoc system is time consuming and complex process, and the floor nurse was responsible for completing the Teladoc system, and stated she completed an SBAR due to the provider being at the facility the following day. RN-B stated she completed an SBAR and gave to either the ADON or DON. RN-B stated she completed a progress note in the EMR the day she observed R2's skin changes on the legs. On 1/21/26 at 4:44 p.m., licensed practical nurse (LPN)-A stated he was not aware R2 had any dressing changes or open areas on his legs and stated if dressing changes were necessary the EMR (electronic medical record) treatment orders would indicate orders. LPN-A confirmed R2 had no dressing change order and was unaware the legs were red and weeping and did not assess them. LPN-A stated he would expect dressing change orders, including gauze and ABD pads, and that the provider should have been notified. On 1/21/26 at 2:57 p.m., the DON stated she remembered seeing an SBAR on R2, within the last week or two and paraphrased the information and notified the provider regarding open areas and weeping areas, and was not sure how the provider was notified but further stated she remembers updating the provider, DON was observed to look through documentation and stated she could not find documentation the provider was notified. The DON stated she would have expected documentation of provider notification and expected the provider to assess R2. On 1/21/26 at 5:06 p.m., during a follow up interview the DON and RN-D (regional director of clinical services) reviewed documentation and were unable to find evidence the provider had been notified of the change in skin condition. The DON found an SBAR in her office undated and stated the SBAR was from 1/8/26; however, upon further review, she determined a progress note dated 1/15/26 matched the SBAR she received. The DON confirmed the provider should have been notified of the change in skin condition and stated it was her responsibility to track SBARs submitted to providers. The DON stated the nursing staff complete the SBARs and either give to her, the ADON, or HUC-E and then she reviews the SBARs for accuracy and either puts the SBARs back in a folder in HUC-E's office for providers to review or gives the SBARS to the providers herself. The DON stated the SBAR from RN-B was not followed up on as expected and she was unsure why documentation could not be located. On 1/26/26 at 9:05 a.m., LPN-A stated was not aware of any dressing change orders for R2. On 1/26/26 at 9:07 a.m., the DON stated she talked to stated she spoke with Nurse Practitioner (NP-G) on 1/22/26, when she was completing rounds at the facility and received dressing change orders. The DON stated she assessed R2's legs on 1/22/26, recalling both legs were swollen, red to the knee, and weeping, with a history of cellulitis and chronic discoloration. The DON stated she wrote the order on a telephone order sheet and placed it in the HUC-E office without entering it into the EMR. The DON confirmed she did not document her assessment or enter the orders. The DON confirmed R2 went the entire weekend without wound care due to no orders being implemented and stated, That's on me and I feel sick to my stomach. The DON stated documentation and orders were essential to prevent worsening skin integrity, particularly given R2's history of cellulitis. On 1/26/26 at 9:46 a.m., R2 was observed seated in his wheelchair and stated no wound care or dressing changes were completed over the weekend. The DON entered the room with dressing supplies. The right leg was open to air with flaky, dry skin. The left leg had a Kerlix wrap and ABD dressing saturated with dried yellow drainage. The DON removed the dressing and stated it likely had not been changed over the weekend due to lack of orders. The DON cleansed the wound and applied collagen dressing, ABD, and Kerlix, dating the dressing. The DON confirmed there were still no active orders in the EMR at that time. On 1/26/26 at 10:17 a.m., HUC-E stated telephone orders were placed in a folder in her office after the nurse who received the orders entered the order in the computer, HUC-E stated the telephone orders were not expected placed in her office until the order was entered into the computer. On 1/26/26 at 4:40 p.m., during a telephone interview the medical director (MD)-F stated the provider was expected to be notified of skin changes, orders were expected entered daily, and wound orders were expected completed to prevent worsening of the skin. Facility Prevention and Treatment of Skin Breakdown/Pressure Injury Policy and Procedure dated 12/24, indicated If a resident is admitted with impaired skin integrity or new pressure injury or a lower extremity ulcer develops, the licensed nurse implements the follow items: 1. Documentation of the skin impairment is completed in the medical record. Staging is completed as necessary by trained licensed nursing associates 2. Standing orders/protocol for skin impairment are initiated 3. Notify attending provider, resident, and resident representative. Attending provider determines wound type and may provide additional orders. 4. Notify Supervisor/designee. 5. Evaluate current pressure reduction interventions and revise resident centered care plan. 6. Notify dietitian for nutritional interventions as appropriate 7. Notify therapy associates and other members of the care team as appropriate for possible additional treatment interventions. 8. Educate resident/resident representative on skin impairment and care plan interventions. 9. When pressure injury is present, the dressing and/or wound as appropriate are monitored daily. 10. Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify attending provider. 11. Notify the attending provider, resident/resident representative and supervisor if the skin injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Weights and Blood Pressure Monitoring R2's quarterly MDS dated [DATE], indicated R2 had moderate cognitive impairment, no rejection of care, utilized a wheelchair, dependent on staff for toileting, dressing, and transfers, and partial/moderate assistance with personal hygiene, and transfers, and diagnoses included hypertension, peripheral vascular disease (caused by narrowing, blockage or spasms in a blood vessel) or peripheral arterial disease (narrowed arteries reduce blood flow to the arms or legs), diabetes mellitus, non-Alzheimer's dementia, hemiplegia (paralysis on one side of the body) or hemiparesis (partial weakness on one side), cellulitis (skin infection ) of right lower limb, reduced mobility, muscle weakness, and edema (swelling). R2's care plan dated 12/29/25, self-care: need assist with dressing, personal hygiene, and bathing due to cognitive impairment, immobility related to history of CVA with right dominant side hemiplegia, will sometimes refuse assistance, interventions included obtain weights and vital signs per facility protocol, report significant weight changes to NP/PA/MD (nurse practitioner/physician assistant/medical doctor) and dietician, report abnormal vital sign readings to NP/PA/MD; hypertension with chronic kidney disease and interventions included: give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate (tachycardia) and effectiveness skin: history of venous ulcer right lower extremity, edema in my right lower extremity which sometimes weeps, monitor labs and weights as ordered, observe for alteration in skin integrity and report to NP/PA/MD skin inspected by licensed staff week. R2's treatment administration record and medication administration record dated 12/1/25-12/31/25, indicated: Start date 9/10/25, hydralazine oral tablet 10 mg give 1 tablet by mouth every 6 hours as needed for SBP (systolic blood pressure) > (greater than) 160 Start date 12/10/25, end date 1/9/26, torsemide oral tablet 40 MG (milligrams) give 0.5 tablet by mouth every 24 hours as needed for SOB (shortness of breath)(more than normal); weight gain of more than 3lbs (pounds) in 24hrs (hours) or 5lb in 3 days; hold BP (blood pressure)< (less than) 100/60 Start date 11/23/24, end date 1/14/26, daily weight; notify provider if weight gain is greater than 2lbs/day or 5lbs/wk (week) one time a day R2's treatment administration record and medication administration record dated 1/1/26-1/31/26, indicated: Start date 1/10/26, torsemide oral tablet 20 mg give 1 tablet by mouth one time a day related to hypertensive chronic kidney disease Start date 1/16/26, blood pressure monitoring: SBP > 160, *orders to give PRN (as needed) hydralazine (read PRN orders if given) two times a day Start date 9/10/25, hydralazine oral tablet 10 mg give 1 tablet by mouth every 6 hours as needed for SBP > 160 Start date 1/10/26, daily weight one time a day Start date 11/23/24-1/14/26, daily weight; notify provider if weight gain is greater than 2lbs/day or 5lbs/wk one time a day Provider visit dated 12/11/25, physician assistant (PA)-H indicated follow up hospital visit medication change: torsemide as needed for weight gain and pressure. Provider visit notes dated 1/8/26, PA-H indicated: daily weights, scheduled torsemide 20 mg daily, use PRN (as needed) hydralazine 10 mg every 6 hours as needed for systolic blood pressure greater than 160, and further indicated R2 was seen today for an acute visit nursing reports that his blood pressure was high at 197/81, today and his weights have been creeping up, they have noticed his legs have been more swollen and have been weeping, no shortness of breath, blood pressures have generally been running high, has not been getting the torsemide not often has he gained three or more pounds in a day, will schedule torsemide 20 mg daily (should have gotten PRN torsemide a few times), has not being getting the hydralazine, and discussed this with the DON (director of nursing), there are several occasions when his blood pressure was greater than 160 and he should have been given hydralazine 10 mg, she (DON) assured me they would reinforce this. Blood Pressures on 12/1/25-1/26/26, and the MAR failed to indicate R2 received hydralazine as ordered for SBP>160 1/18/26 at 8:45 a.m., 179 / 91 1/17/26 at 9:02 a.m., 185 / 69 1/15/26 at 3:19 p.m., 171 / 61 1/15/26 at 10:02 a.m., 178 / 69 1/15/26 at 8:25 a.m., 171 / 69 1/14/26 at 8:40 a.m., 169 / 74 1/13/26 at 9:30 a.m., 198 / 80 1/12/26 at 3:43 p.m., 173 / 65 1/12/26 at 8:20 a.m., 173 / 65 1/11/26 at 8:52 a.m., 196 / 81 1/9/26 at 3:58 p.m., 180 / 67 1/9/26 at 3:57 p.m., 180 / 67 1/9/26 at 9:17 a.m., 180 / 67 1/8/26 at 8:53 a.m., 197 / 81 1/7/26 at 3:51 p.m., 183 / 73 1/7/26 at 9:17a.m., 183 / 73 1/4/26 at 3:40 p.m., 178 / 70 1/4/26 at 3:39 p.m., 178 / 70 1/4/26 at 11:25 a.m., 178 / 70 1/1/26 at 3:56 p.m., 176 / 72 1/1/26 at 8:39 a.m., 176 / 72 12/31/25 at 08:46 a.m., 181 / 77 12/27/25 at 8:58 a.m., 179 / 76 12/26/2025 at 9:10 a.m., 165 / 80 mmHg R2's record review indicated no weight was documented on the following dates: 1/3/26, 1/10/26, 1/19/26, and 1/24/26. R2's record review indicated the following dates*** R2 had weight gain of more than 3lbs in 24hrs or 5lb in 3 days and documentation failed to indicate torsemide 40 mg 0.5 tab was administered as ordered and failed to notify the provider of weight gain: ***1/8/26 270.0 lb 1/6/26 265.5 Lbs ***1/4/26 269.5 Lbs 12/31/25 257.5 Lbs On 1/21/26 at 12:57 p.m., RN-B entered R2's room, and stated she would be completing R2 wound care. RN-B removed R2's socks from both feet and used a scissors to cut off the Kerlix and remove the dressings. The legs were observed to be reddened with yellowish drainage on the left leg, and both legs had moderate swelling. RN-B was observed to complete the dressing change and then exited the room. RN-B further stated R2 had daily weights and that she was unaware of a new hydralazine order until the prior week, which directed administration for BP over 160. RN-B stated monitoring of BP and weights, and administration of medication were important to manage R2's fluid due to chronic swelling of the legs. On 1/21/26 at 4:44 p.m., licensed practical nurse (LPN)-A stated R2's BP the previous night was 168/79 and that he administered hydralazine but did not document the administration. He stated the PRN order had been previously being overlooked, and it was recently rewritten on the MAR for nursing to be more aware of the order and education was also provided to nursing staff. LPN-A confirmed the nursing staff received education regarding R2's blood pressure and administering medications per the BP parameters. LPN-A stated it was a known concern R2 was not receiving medications when his BP was high and when had an increase in weight. On 1/21/26 at 5:06 p.m., the director of nursing (DON) and RN-D also known as regional director of clinical services reviewed documentation The DON and RN-D stated that if medications were administered, documentation was expected; without documentation, the facility could not confirm that medications were given. The DON stated it was a known concern that daily weights were not consistently obtained and documented, and facility staff had recently received education on the importance of obtaining and documenting weights. The DON stated nursing assistants collected resident weights and reported them to the nurse, and the nurse was responsible for following up on the weights and implementing provider orders as indicated. The DON further stated facility staff received education regarding R2's ordered medications, including the requirement to administer medications as prescribed when the resident's blood pressure exceeded 160. The DON confirmed that R2's weights were not obtained and documented as ordered, medications were not administered as prescribed, and the provider was not notified of the resident's weight increase as expected. The DON stated all nursing staff received the education and agency staff were provided the information to read in a folder at the nursing station. Facility Vital Signs Policy and Procedure dated 2025, The purpose of this policy is to provide guidelines for the measurement and reporting of vital signs. Policy Explanation and Compliance Guidelines: Routine vital signs include temperature, pulse, blood pressure, and respiratory rate. Nurse aides may be assigned responsibility for obtaining routine vital signs and reporting abnormal findings to the nurse. Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. Vital signs shall be obtained at least in the following circumstances: Upon admission/readmission. Before and after dialysis or other procedure. At least daily for a resident receiving skilled services. At least weekly for a resident receiving custodial care, or non-skilled services. When the resident's general condition changes. Following an accident, such as a fall or other incident. When a resident reports nonspecific symptoms of physical distress (e.g., feeling funny or different). Acceptable ranges for adults: Blood pressure: average <120/<80 mm Hg Vital signs will be obtained by the nurse or therapist, as indicated, when administering certain medications, or monitoring for effectiveness of medications or therapies. For example, Certain cardiac drugs are given only when a resident's pulse or blood pressure is within a certain range. Respirations, blood pressure, pulse, or oxygen saturation may be checked during or after therapy treatments to monitor response to the therapy. WEIGHTS R26's face sheet received on 1/28/26, included diagnoses of congestive heart failure (CHF; heart not able to pump effectively), chronic obstructive pulmonary disease (COPD: lung disease that restricts airflow), respiratory failure (lungs cannot adequately supply oxygen to the blood), venous insufficiency (leg vein valves are weak preventing proper blood flow to heart), and diabetes. R26's admission MDS dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R26 required supervision or partial assistance with activities of daily living (ADLs). R26 could walk 50 feet with staff assistance. R26 was on a diuretic (medication to help kidneys remove excess sodium and water from the body) R26's physician orders dated 1/8/26, indicated: Weight monitoring: Weight gain of two to three pounds or more per day over a two-day period, or five-pound [weight] gain in one week, call provider. One time per day related to CHF. R26's care plan with revised date of 1/1/26, indicated R26 had CHF. Staff were to monitor/document/report to the physician any signs or symptoms of CHF including dependent edema (fluid accumulation that pools in the lowest part of the body due to gravity, typically legs, ankles and feet) of legs and feet and weight gain unrelated to intake, and staff were to monitor weight. Review of R26's daily measured weights which were ordered to start on 1/8/26, indicated from 1/8/26 to 1/25/26, (18 days), R26 was not weighed seven times: 1/8/26: No weight 1/9/26: 180 lbs. (pounds) 1/10/26: 181.5 lbs. 1/11/26: 181 lbs. 1/12/26: 181.2 lbs. 1/13/26: No weight 1/14/26: 182 lbs. 1/15/26: No weight 1/16/26: 182.3 lbs. 1/17/26: 187 lbs. 1/18/26: 186 lbs. 1/19/26: 186 lbs. 1/20/26: 186.2 lbs. 1/21/26: No weight 1/22/26: No weight 1/23/26: No weight 1/24/26: No weight 1/25/26 186 lbs. During an interview on 1/26/26 at 9:39 a.m., RN-A, who was also the assistant director of nursing (ADON), stated R26 was to be weighed daily. RN-A looked in R26's EMR (electronic medical record) and verified the provider order was for daily weights. RN-A then reviewed measured weights in the EMR and stated R26 had not been weighed daily. RN-A stated this had been an on-going problem as nurses had not always communicated to nursing assistants (NAs) when a resident needed to be weighed. As a result, RN-A created a list for NA's, located at the nurses' station and also posted by the scale, for NAs to review in order to determine which residents needed weights and how often. RN-A stated the change was made about two weeks ago and the director of nursing (DON) announced it at huddle meetings and at nurse and NA meetings on 1/15/26 and 1/16/26. Together with RN-A, looked at the list posted by the scale. One sheet indicated weights on a schedule per doctors' orders must be done. R26's name was listed and indicated she was to be weighed every day. On another sheet titled Weight Tracker for January, there were no recorded weights for R26. RN-A stated if a NA (employed or agency) didn't hear the information at a huddle or attend a meeting, they likely would not know about the new lists. RN-A stated another place NAs could look was in a binder in the nurses' station which had paper copies of resident Kardex's (a document used to summarize a resident's plan of care, often used by NAs). Together with RN-A, looked in the binder and there was no Kardex sheet for R26. Reviewed NA meeting agenda dated January 2026, which included: Everyone is to be weighed in the morning before breakfast on shower days. Daily weights are not optional. Nothing on the agenda about the new forms and process implemented by RN-A. Three NAs attended the meeting. Reviewed nurse meeting agenda dated January 2026, which included: Weights. Nothing on the agenda about the new forms and process implemented by RN-A. Five nurses attended the meeting. During an interview on 1/27/26 at 11:08 a.m., the DON was informed daily weights on R26 had not been occurring per physician order, nor were Ace wraps being applied daily per physician order. The DON stated she was unaware and had not been informed by staff. The DON expected nursing staff to carry out physician orders and stated she had no idea why this was occurring. The DON stated she did not routinely monitor to ensure physician orders were being carried out by staff. During an interview on 1/27/26 at 12:57 p.m., NA-A stated she did not know which residents needed weights, adding she thought there was a sheet at the desk. NA-A was not aware R26 needed a daily weight. Facility Weight Monitoring Policy and Procedure dated 2025, Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments should include the following information: General appearance HeightWeightFood and fluid intake Fluid loss or retention Laboratory/Diagnostic Evaluation Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. Documentation: The physician should be informed of a significant change in weight and may order nutritional interventions. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietitian, Dietary Manager, or the nursing department may initiate this process. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. Compression Bandages R26's physician orders dated 1/15/26, indicated staff to wrap lower extremities with Ace wrap (a brand of elastic compression bandages) during the day and off at night two times a day for lower extremity edema (swelling and fluid trapped in body's tissues). R26's care plan with revised date of 1/1/26, indicated R26 had CHF. Staff were to monitor/document/report to the physician any signs or symptoms of CHF including dependent edema (fluid accumulation that pools in the lowest part of the body due to gravity, typically legs, ankles and feet) of legs and feet and weight gain unrelated to intake, and staff were to monitor weight. R26's medication administration record (MAR) indicated application of Ace wraps were to be started on 1/15/26. MAR documentation indicated they had not been applied six out of eight times from 1/15/26 through 1/22/26. 1/15/26: Not applied 1/16/26: Refused (no refusal noted in progress notes) 1/17/26: Not applied 1/18/26: Applied 1/19/26: Applied 1/20/26: Not applied 1/21/26: Not applied 1/22/26: Not applied Nursing progress note dated 1/17/26, at 6:01 a.m., indicated Ace wraps not available, need to be ord

Based on observation, interview and document review, the facility failed to provide timely toileting for 1 of 1 resident (R36) who was dependent upon staff for assistance with activities of daily living (ADL). Findings include: R36's face sheet received on 1/28/26, included diagnoses of Alzheimer's disease (a type of dementia that affects memory, thinking and behavior) and Parkinson's disease (a progressive brain disorder). R36's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, clear speech, rarely/never understood, usually understands. R36 was dependent upon staff for activities of daily living (ADLs) or required substantial assistance. R36 did not walk. R36 was always continent of urine and always incontinent of bowel. R36's care plan with revised date of 10/21/25, indicated R36 was incontinent of bladder and bowel and required assistance with toileting due to Alzheimer's disease. Intervention with revised date of 11/4/25, indicated R36 was to be put on the toilet at these time frames: 5:00 a.m., upon rising, before/after meals, and HS (bedtime). R36's Kardex (a document used primarily by nursing assistants to quickly reference essential resident information) with print date of 1/21/26, indicated: 1) After lunch, to be toileted and lay in bed for a nap, and 2) Turn on water when sitting on the toilet to aide in toileting; 5:00 a.m., upon rising, before/after meals and at HS. During an interview on 1/21/26 at 12:41 p.m., family member (FM)-C stated R36's plan of care was to include toileting, meaning assisting R36 onto the toilet when staff got him up in the morning, and before and after meals. FM-C added, That was my understanding of how it goes. FM-C stated R36 could tell staff if he needed to, Take a leak or take a crap, but staff would need to ask him using terms like that, that he would understand. FM-C stated staff could not assume R36 would tell them when he needed to go. During the same interview, FM-C gave examples of when R36 had not been toileted per the care plan: --1/6/26, FM-D was with R36 in his room in his wheelchair after lunch. At approximately 1:30 p.m., FM-D turned on R36's call light to request staff toilet R36 and lay him in bed. After about an hour, no one came and FM-D had to leave, so she informed staff she was leaving. Staff informed FM-D, they were busy but would move R36 to the dayroom until they could get to him. At approximately 4 p.m., the hospice nurse called FM-D to give her an update and informed her that R36 had been in the dayroom; not laying down in bed. FM-C stated, so clearly, he had not been toileted or laid down after lunch, adding, he should be toileted and put to bed according to the care plan whether or not family was there. --1/13/26, FM-C stated she went to the facility to help R36 with lunch and when she sat down next to R36, immediately smelled BM (bowel movement). FM-C stated R36 had been trying to reach around to his backside to fix the problem. FM-C stated she fed him quickly then took R36 to his room. FM-C stated R36 had BM everywhere - up his back, in his chair and required a clothing change and wheelchair wiped down. FM-C stated R36 had probably been sitting in his wheelchair since breakfast and had not been toileted before lunch. FM-C stated, They did not execute the care plan. FM-C stated she was not happy no one had noticed the odor, or R36's cues trying to get out of his chair and reaching behind him. ---1/20/26: FM-C stated she was with R36 in his room. R36 was in his wheelchair. At approximately 12:30 p.m., she turned on R36's call light to request R36 be toileted and laid in bed as she had to leave by 1:00 p.m. FM-C assumed R36's care plan would be executed and his call light was on, so she left. At approximately 2:30 p.m., she received a call from staff informing her R36 had fallen from his wheelchair. R36 stated, Why wasn't his care plan followed? FM-C stated she spoke to registered nurse (RN)-A who was also the assistant director of nursing (ADON) about the fall. RN-A informed FM-C she had reviewed R36's call light log and told her R36's call light had been turned on at 12:24 p.m., someone shut it off 15 minutes later, and R36 was found on the floor at 1:50 p.m. FM-C stated, I want some faith that when I'm not here he's being well cared for - I need to be able to trust them. FM-C stated most of the nursing assistants (NAs) were very good, but they were overwhelmed with work. During an interview on 1/21/26 at 4:21 p.m., (RN)-A, verified R36's care plan indicated R36 should be toileted at 5:00 a.m., upon rising, before meals and at HS. In addition, RN-A verified per the (EMR) electronic medical record, TASK tab (where NA's documented completion of tasks) that NAs were to toilet R36 upon rising, before/after meals, and HS. Looking for corresponding documentation, RN-A stated she was not able to verify it had been done at the required intervals. RN-A also verified R36's Kardex directed NA staff to toilet R36 at 5:00 a.m., upon rising, before/after meals and at HS. RN-A stated NAs would know to do this because they would have been informed at daily huddles, from NA meetings, or when hired or brought on as an agency NA. RN-A stated after R36 fell on 1/20/26, she added to the Kardex: After lunch, to be toileted and lay in bed for a nap. During an interview on 1/21/26 at 5:33 p.m., nursing assistant (NA)-B, an agency NA, stated R36 was toileted every two hours with an EZ stand (a medical transfer device). Care plan, Kardex and task list indicated R36 should be toileted at 5:00 a.m., upon rising, before/after meals and at HS. During an interview on 1/21/26 at 5:40 p.m., NA-D, an agency NA, stated R36 was toileted at beginning of her shift and after supper with the EZ stand. NA-D stated at bedtime, they changed R36's brief (incontinent pad) in his bed. While NA-E was washing R36 up, applying deodorant and dressing him, NA-E never asked R36 if he needed to use the toilet and R36 never spoke. NA-E cleaned R36's peri-area and applied a incontinent pad. Along with NA-F, assisted R36 onto the EZ stand, into the wheelchair, then to the dayroom. R36 was not toileted per care plan. During an interview and observation on 1/26/26 at 10:46 a.m., observed R36 still in bed with lights out. NA-F and NA-E stated they had not gotten R36 up yet; that he had been in bed all morning and had not had breakfast. NA-F stated due to a call-in, they were working short. NA-F entered the room to prepare R36 for the day. NA-F stated R36 would let them know if he needed to go to the bathroom, or they would ask him, or daughters would tell them. NA-F stated she would sometimes hear him say, I have to take a leak. NA-F stated when she worked, they changed his brief in the morning, and then two other times during the shift, took R36 to the bathroom to sit on the toilet. NA-F removed R36's brief which was plump and moderately heavy. Skin on R36's buttocks was normal color. NA-E entered the room to help with the EZ stand. Neither NA-E nor NA-F when asked, could verbalize the frequency of putting R36 on the toilet that was identified in R36's care plan, Kardex and Task list. During an interview on 1/27/26 at 11:08 a.m., the director of nursing (DON) was informed of findings related to R36 not being toileted per care plan, Kardex and Task list, (5:00 a.m., upon rising, before/after meals and at HS), and NA staff being unaware of the required toileting plan. The DON was unaware of this. In addition, she expected staff to know the plan of care and follow it but did not monitor or audit adherence to a resident's plan of care. Facility ADL Care of Dementia Unit Residents policy dated 2025, indicated; It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents on the dementia unit to ensure all ADL needs are met on a daily basis, while attaining or maintaining the dementia resident's highest practicable physical, mental and psychosocial well-being. The care plan interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. Facility Policy Activities of Daily Living (ADLs) dated 2025, indicated; Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on observation, interview, and document review, the facility failed to provide assistance to complete personal hygiene care for 1 of 1 resident (R3) reviewed who needed assistance with fingernail care.R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact, no rejection of care, utilized a wheelchair, required substantial/maximal assistance with personal hygiene, upper body dressing, dependent on staff for toileting hygiene and transfers; diagnoses included hemiplegia or hemiparesis, depression, dependence on renal dialysis.R3's care plan dated 1/2/26, indicated self-care: assist with dressing, personal hygiene, and bathing due to immobility related to right side hemiparesis from a history of a cva, staff assist of one to hand resident a soapy wash cloth and cue to wash face/hands/arms/torso as able during cares, staff to trim resident's finger and toe nails as needed, personal hygiene: substantial assist of one staff shower / bathe self, Tuesday and Thursday am shift, shave and trim nails after bath.R3's Documentation Survey Report dated 1/26, indicated:Personal hygiene the following dates were blank (no documentation) for day shift on 1/20/26, and blank for evenings on 1/8/26, 1/10/26, 1/11/26, 1/15/26.Shower/bathe substantial assistance with one staff, Tuesday and Thursday AM shift, shave and trim nails after bath indicated:1/8/26, 1/16/25 Not applicable (not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury).R3's Dialysis Provider Clinic Sheet dated 12/8/25, registered nurse (RN)-G indicated concern with how R3 presented today with dirty hands, fingernails and what appears to be BM (bowel movement) on his pants, this is a procedural area and need him to be as clean as possible. On 1/21/26 at 9:25 a.m., a registered nurse (RN-G) was observed pushing R3 in a wheelchair through the hallway toward the facility's south door to await transportation for dialysis. R3 stated he was waiting for the bus to take him to dialysis. R3's hands were observed with dried red substance that covered the back of both hands. R3 stated the substance was blood that had been present for several days. R3's fingernails on both hands were observed with black and brown debris under all nails. R3 stated staff assisted him to wash his face that morning; however, staff did not assist him to wash his hands or provide a washcloth for handwashing. R3 further stated his hands were still sticky from breakfast. RN-G confirmed R3's hands and fingernails were dirty.On 1/21/26 at 9:30 a.m., the director of nursing (DON) observed R3 in the hallway. R3 stated to the DON that he needed his hands and fingernails cleaned. The DON was observed to gasp upon observing R3's hands and fingernails and stated, Oh my, and further stated, What do you got under there? The DON then washed R3's hands and cut and cleaned R3's fingernails.On 1/21/26 at 9:43 a.m., the DON stated R3's hands and fingernails were very dirty and bad and stated, It should not be like that. The DON stated staff were expected to assist R3 with handwashing every morning and whenever his hands and fingernails were visibly dirty.On 1/21/26 at 10:49 a.m., during a telephone interview, RN-H from the dialysis center stated R3 attended dialysis on Mondays, Wednesdays, and Fridays. RN-H stated R3 presenting with dirty fingernails, dirty clothing, and food residue around his mouth was an ongoing concern. RN-H stated these concerns were documented in R3's communication log that traveled with the resident between the dialysis center and the facility.On 1/21/26 at 1:00 p.m., nursing assistant (NA-F) stated she completed R3's morning cares and assisted him to wash his face; however, R3 was not assisted to wash or clean his hands or fingernails. NA-F stated R3 was expected to receive handwashing and hygiene assistance when his hands and fingernails were visibly dirty. NA-F further stated morning cares were rushed due to agency staff unfamiliar with resident care needs and staff having to assist agency staff.Facility Nail Care Policy and Procedure dated 2025, indicated: Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises.

Based on observation, interview, and document review the facility failed to ensure beds were a safe distance away from a wall heater to prevent entrapment and burns for 1 of 1 resident (R1) who had severe cognitive impairment, and a history of self-transfers and falls reviewed for accidents. This resulted in actual harm when R1 rolled out of bed onto the heater which caused second degree burns to his left hip and back. The facility immediately implemented corrective action and the deficient practice was corrected on 12/19/25, prior to the start of the survey and was therefore issued as a past non-compliance (PNC). Findings include: R1's face sheet dated 12/18/25, identified diagnoses of neurocognitive disorder with Lewy Bodies dementia with anxiety, and history of falling. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no issues with hearing or speech, had severe cognitive impairment, no behaviors; required some help with upper body dressing and was dependent on staff for lower body dressing. R1 was independent with rolling in bed and dependent on staff for transferring between surfaces. R1's care plan intervention dated 9/23/25, directed R1 to have bed in low position with safety mat in place. On 8/5/25, if R1 was sitting up at edge of bed, bring to day room and offer snack/drink. The care plan identified complete peri cares and to manipulate clothing as needed, dependent on assistance of two staff to use the toilet. Toilet upon waking up, before/after meals, when going to bed, and midnight. The care plan directed to aid with bed mobility as necessary; R1 was dependent on assistance of two staff for lying to sitting on side of bed, sitting to lying on bed, and rolling left and right. R1's progress note dated 12/18/25 at 8:07 a.m., identified at approximately 7:22 a.m., R1 was found between bed and heat register. R1 was moved safely away from the heat register and injuries noted on left rib cage, left hip, both knees, will be further assessed. R1's Hospice visit dated 12/18/25 at 8:40 a.m., identified R1was found on the floor and had fallen into the heater in his room. R1 had second degree burn on his left hip with three blistered areas. Burn measured 6.0 centimeters (cm) by (x) 6.5 cm. Three blistered areas one farthest left measured 1.1 cm x 0.5 cm, middle one 0.5 cm x 0.9 cm, third 0.2 cm x 0.2 cm. Burns to mid left back area top one measured 2.0 cm x 1.1 cm. lower to the left 5.5 cm x 2.0 cm and area to the right of this 3.5 x 0.8 cm. Right knee bruising 4.5 cm x 3.5 cm and left knee bruising 4.8 cm x 2.5 cm. Does not appear to be having increased pain and oxycodone was given post fall for comfort and ice applied to hip area. Bed has been moved away from heater to prevent further falls with burns. New wound care orders received. R1's physician order dated 12/18/25, directed staff to use Silvadene 1% cream to left hip blisters topically one time a day for burn wound. R1's post fall evaluation dated 12/18/25 identified R1's fall was not witnessed. R1 stated I was trying to get up but that didn't work out so well. Reason for fall was R1 attempted to self-transfer. Injuries included left hip redness and burn marks with three open blister areas, left rib cage reddened and burn marks, reddened knees. Room was rearranged with bed farther away from the heater and floor mats placed on each side of the bed, care plan reviewed and updated. R1's progress note dated 12/18/25 at 3:02 p.m., identified director of nursing (DON) completed measurements of injuries. R1's care plan was updated on 12/19/25, included fall mats to bilateral sides of low bed for injury prevention related to R1 crawling out of bed on knees frequently. R1 is impulsive and frequently crawls out of bed or a chair and crawls to destination. Bed to remain a minimum of 12 inches from wall radiator. Bed and floor mats never to be against radiator. R1's Hospice visit dated 12/19/25 at 8:25 a.m., identified R1's pain appeared to be worsening most likely related to fall with burns. The note indicated the doctor was notified and an order for scheduled oxycodone every six hours and continue with the as needed dose was received. During an interview on 12/23/25 at 2:59 p.m., maintenance director (M)-A stated on 12/18/25, as soon as he heard about the incident, he went online to look at different barriers to possibly install in replace of the existing barriers, if needed. M-A took his heat gun on 12/18/25, checked R1's radiator, and got 11 degrees Fahrenheit near the top, 104 degrees Fahrenheit in the middle, and 145-degrees Fahrenheit on the underside of the heater. DON reported to M-A she had found documentation that beds needed to be minimum 12 inches from radiator. M-A indicated during his research the temperatures of the radiators should be 159 degrees Fahrenheit or below, so on 12/19/25 he did a radiator temperature check on all the rooms in the facility and all were within limits. M-A explained when he started the director of maintenance position, he recalled doing a visual audit to ensure the beds were one foot away from the heater however did not document the results of the audit. M-A indicated he did not continue to audit and thought nursing would be routinely checking to make sure the beds were the one foot away from the heater. During an observation on 12/24/25 at 12:16 p.m., nursing assistant (NA)-C and LPN-B went to R1's room. NA-C demonstrated where R1's bed had been located on 12/18/25 when the burn occurred; LPN-B measured the area between the heater and the observed bed location at 11 inches which was not enough space for R1 to have gotten up. During an observation and interview on 12/24/25 at 6:53 a.m., R1 was laying on his back in bed. Licensed practical nurse (LPN)-B raised R1's bed and moved fall mats away from both sides of bed. LPN-B called NA-D to assist her with turning R1 onto his side while she completed wound care to his left hip. Left hip had no dressing on the site. LPN-B measured the left wound which was described as a red area that measured 2.0 cm x 2.0 cm with a healing wound bed. LPN-B stated, it's got the redness, but the skin looks good in the center and closing. LPN-B cleansed the wound with wound cleanser, applied Silvadene, covered with Telfa, then covered with clear transparent dressing. LPN-B then rolled R1 to his side and observed his back which revealed three spots that were open to air that appeared to be healed. NA-D stated R1's bed had been near the heater as long as he had been in the room. NA-D recalled R1 rolled more toward the door side of the room than the window side with the heater. LPN-B stated tape was put on the floor to keep the beds 1 foot away from the heaters. R1 had a floor mat and end table set up on the heater side of the room, between bed and heater. During a phone interview on 12/23/25 at 4:08 p.m., NA-B stated she was familiar with R1. A lot of nights, R1 would try and get out of his bed. When he did that, staff would feed him and bring him to the nurse's station until he was tired enough to go back to bed. R1 had fallen at least 3-4 times on the night shift in the past. NA-B stated she worked the overnight shift prior to R1's fall on the morning of 12/18/25. R1 had slept good on the overnight shift. NA-B was not able to specify the last time R1 was checked for incontinence but thought it was about 3:00 a.m. NA-B stated to prevent this from happening again, all the beds were moved away from the heaters. During a phone interview on 12/23/25 at 3:30 p.m., LPN-A stated he worked night shifts and was familiar with R1. R1 falls frequently. R1 has confusion and did not know what he was doing. A lot of times when R1was in bed, he would be in the fetal position or have his feet hanging off the side of the bed when he was sleeping. R1 was pretty good with moving around in the bed but needed assistance to actually get out of bed. R1 would typically try and get out of the bed on left side, facing the door. LPN-A worked the night shift on 12/18/25 but could not remember the last time R1 was checked on. During an interview on 12/23/25 at 10:06 a.m., housekeeper (HSKP)-A stated on 12/18/25, she walked past R1's room and looked inside and could not see R1's legs and thought something did not seem right. Nursing assistant (NA)-C was approximately five feet away from HSKP-A, and HSKP-A told NA-C that something did not look right with R1. They turned on the light and found R1 stuck between the bed and heater. HSKP-A thought when they found R1, his legs were on the ground, head on bed, and possibly his torso on the ledge above the heater. HSKP-A thought R1 had rolled himself towards the heater because he was cold. After the incident there was orange duct tape put on the floor, the beds had to stay behind it and a paper at the desk informed staff how far away that beds were to be from the heaters. During interviews on 12/23/25 at 9:54 a.m., and 2:08 p.m.; 12/24/25 at 12:16 p.m., NA-C stated she worked the day shift on 12/18/25, and was familiar with R1. R1 would frequently have his arms and legs hanging off the bed and would lean close to the edge. R1 would roll to the left a lot. R1 was incontinent a lot of the time and would not ask to go to the toilet. During the day shift, staff would keep R1 in the day room so there were more eyes on him. NA-C stated she and NA-A had walked past R1's room but did not go in. At 6:40 a.m. the room was dark, and it looked like R1 was in bed sleeping so they continued to walk past his room. NA-C stated HSKP-A came to her around 7:20 a.m. on 12/18/25, and said R1 did not look right. NA-C and HSKP-A went in the room and found R1 got out on the wrong side of the bed and was stuck between the bed and the heater. The bed was locked and R1 would not have been able to move it to get out. R1's right arm was up on the bed but not enough to sit himself up, both knees were on the floor. When R1 was moved out of the kneeling position, both knees had indents in them like he had been there for a while and had redness to his side and hip area. NA-C touched the heater and reported if she left her hand there for a couple of minutes it was hot enough to cause a burn. After the incident, every room got moved around; orange tape was put on the floor to alert staff where the bed needed to be for safe distance from the heater. The bed should not cross the orange tape. R1's bed got moved immediately from the heater and he had two fall mats, one on each side of the bed. During a phone interview on 12/23/25 at 3:49 p.m., nursing assistant (NA)-A stated she was familiar with R1. R1 required two staff for assistance but he tried to get out of bed by himself a lot, that was why his door was left open. NA-A stated she worked the day shift on 12/18/25 and started at 6:30 a.m. At about 6:40 a.m. NA-A walked past R1's room with NA-C and they peeked in the room but R1 was not yelling, so they continued to walk past. Around 7:20 a.m., HSKP-A got ahold of NA-C. NA-C went to R1's room and called for help on the walkie because R1 was stuck between the bed and the heater. R1's bed was close to the heater, less than a foot away. R1 had little blisters on his left back and left hip, the one on his hip was approximately the size of a strawberry and two spots on his back about the same size. NA-A stated R1 yelled out in pain when the nurse attempted to put ice on the areas. NA-A was unaware when the previous shift had last seen R1 in his bed. NA-A stated the facility placed orange tape on the floor to show where the beds are not supposed to go past if the bed is on the heater side of the room. NA-A stated she had bumped into the heaters before when working with residents and they feel pretty hot. During an interview on 12/23/25 at 9:49 a.m., registered nurse (RN)-A stated on 12/18/25, R1 must have rolled out of bed. R1 was on all fours on the side of his bed when she entered the room. His hip and upper back were touching the heater. RN-A explained there was education provided at nurses meeting 12/19/25, which included keeping the beds 12 inches away from the heater. RN-A had not been educated prior to the incident on 12/18/25 about keeping beds 12 inches from the heaters. During a phone interview on 12/24/25 at 8:47 a.m., hospice RN-I stated she came to the facility at 8:40 a.m. on 12/18/25, to assess R1 after the fall by the heater. RN-I assessed the wounds and on the left mid back area under the shoulder blade was a burn area that was not blistered and measured 2.0 x 1.1 cm, red and pink in color. Lower one to the left of it measured 5.5 cm x 2.0 cm and was also pink and red in color with no blisters. Next to it was another area 3.5 cm x 0.8 cm same as the other two areas with no blister. RN-I applied cool compress to those areas. Left hip area totaled 6.0 cm x 6.5 cm with three areas of blisters forming. The blisters measured: one to the left 1.1 cm x 0.5 cm, middle 0.5 cm x 0.9 cm, to the far right 0.2 cm x 0.2 cm. The blisters would be considered second degree burns and were all separated. R1 was complaining quite a bit from the pain from the burn. RN-I ordered Silvadene cream to be applied to the burns. On 12/19/25, RN-I returned to facility and assessed R1. Blistered areas were still there but had not gotten any bigger. R1 was still having pain from the burns and RN-I requested the doctor to schedule oxycodone every six hours and continued with the as needed doses. The facility should monitor R1 to ensure the burn areas do not worsen or get infected, and R1 to not have increased pain. During an interview on 12/23/25 at 3:30 p.m., DON stated Immediately following the incident, DON assessed R1's wounds. Left hip had a stage two burn with small abrasion in the middle that looked like a scrape from the radiator cover and an area on his left mid-back was less reddened and measured 2.0 cm x 1.1 cm. The sites were healing quite well. DON stated she read the progress note that stated blisters were present, but she never saw the blisters, and they must have resolved an hour after she walked in the room (which conflicted with comprehensive assessment on 12/18/25 completed by the hospice nurse that identified the blisters were still present). Prior to the incident the beds were not being audited to verify length from radiators on wall. DON stated she audited the beds daily beginning 12/18/25, will begin weekly audits, monthly, and quarterly to make sure the facility is in compliance. A new policy was created on 12/19/25. Maintenance reviewed the temperatures of all the room heaters. DON went to all rooms on 12/18/25, and verified the beds were 12 inches from the wall and placed orange duct tape on the floor indicating 12 inches. Education to staff was completed on 12/18/25, and 12/19/25, regarding heaters, bed placement, basic first aid, and how to treat burns. During a second interview on 12/24/25 at 12:13 p.m., DON stated R1 had his left hip towards the heater, and it was touching the heater. R1's right hip was against the bed. R1 was on his knees with right arm on the bed. R1 was facing the wall where the head of the bed was. There was no way R1 would have been able to move away from the heater. R1's bed was 12 inches from the wall at the time of the incident, and that was the regulation (which was not consistent with observation and staff interviews that responded to incident when it occurred). DON went to all resident rooms and made sure the beds were all a minimum of 12 inches away from the heater and/or there was enough room where there would not be an entrapment issue if a resident were to fall or get up on that side of the bed. During a phone interview on 12/24/25 at 9:05 a.m., medical doctor (MD)-A stated the DON sent an email on 12/18/25, about the burns R1 received but did not identify blisters were present. Blisters would be considered second degree burns. The facility should watch for infection, and pain for R1. Silvadene was prescribed and that works amazing, helps immediately, and calms the burn down. The facility Baseboard Radiators/Furniture policy dated 12/19/25, identified the facility will ensure that all heating unit covers/protective shields are intact and in good repair, work with staff, patients, and family to ensure furniture will not be placed against heater units with unsecure covers, transfer sides of the bed will be 12 inches from baseboard heating units. This will be marked on floors to ensure compliance. The DON or designee will audit furniture placement in rooms regarding heating unit quarterly and as needed. Maintenance will monitor heat unit covers for temperature compliance annually and as needed. All touchable heat surfaces should not exceed 159 degrees Fahrenheit. The deficient practice was issued at past non-compliance after the following corrective actions were implemented on 12/19/25, and verified the facility took the following actions, prior to the start of the survey: -assessed R1 for injury and treated on 12/18/25 -rearranged R1's room and placed a fall mat on both sides of the bed to ensure adequate space between wall and bed to avoid getting stuck -applied orange duct tape to the floor in rooms signifying how far the bed could be in reference to the heaters on 12/18/25 -maintenance audited heaters in all rooms and verified temperatures of heaters were under 159 degrees on 12/19/25 -began audits of all rooms including rearranging to keep beds at least 12 inches away from the heaters -education provided at nursing assistant meeting on 12/18/25 -education provided to nurses included first aid and burn treatment along with bed placement at meeting on 12/19/25, all other staff received education on beds and heaters on 12/19/25 -created policy for radiators on 12/19/25

Based on observation, interview and document review the facility failed to monitor for signs and symptoms of infection for 1 of 1 resident (R1) reviewed for change in condition. In addition, the facility failed to safely transport 1 of 1 resident (R1) to an outside appointment reviewed for resident safety. Findings include:Infection monitoring:R1's care plan dated 9/2/25, identified a focus that R1 was at risk for infection due to refusal of vaccinations. Interventions included to educate R1 and resident representative of techniques to prevent infections such as handwashing, adequate rest, nutrition, avoidance of crowds, to monitor for signs and symptoms of infection and staff to follow standard precautions including proper handwashing techniques to minimize microorganism growth.R1's quarterly minimum data set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of Cerebral palsy (a group of disorders caused by a non-progressive brain injury before, during, or shortly after birth that affects a person's movement, muscle control, posture, and balance) and elevated white blood count (a condition when you have too many white blood cells (WBCs) in your blood, which is your body's way of fighting off something, usually an infection or inflammation).R1's nursing progress note dated 9/4/25 at 1:00 p.m., identified acetaminophen 500 milligram (mg) given due to complaint that his right eye hurt and was sore. At 1:20 p.m., an additional note indicated R1's right eye hurt some and was a little red and irritated.will continue to keep an eye on it for now.R1's nursing progress note dated 9/5/25 at 11:24 a.m., R1 again commented his eye was sore to the director of nursing (DON) who happened to look at it and let her know this started on 9/4/25, noted his eyebrow was a little swollen and now was pinkish red and warm to the touch, was wondering if cellulitis was developing. Will call nurse practitioner to get an order for something and some eye drops also, called and left a voicemail for her. R1's Telemedicine Visit dated 9/5/25, at 2:37 p.m., identified nurse asked for an acute visit on the fly for acute evaluation of concerns for cellulitis (a common bacterial infection of the skin and underlying tissues that typically causes redness, swelling, pain, and warmth in the affected area) developing around R1's right eye. R1 reported level 3 of 10 pain. Nursing staff asked to mark the erythema (redness) surrounding his upper eye lid. Upper blepharitis (eye lid inflammation) with erythema, warmth and discharge present. R1 had conjunctivitis (when the white part of the eyeball becomes red and swollen that can cause irritation, itching, or a gritty, [NAME] feeling) present. Assessment/Plan identified:1. Preseptal cellulitis (an infection of the eyelid and soft tissue on the outside of the eye's protective barrier, called the orbital septum)-amoxicillin-pot clavulanate (Augmentin)-(antibiotic) 875-125 mg per tablet. Take 1 tablet by mouth two times a day for 5 days starting Friday 9/5/25, until Wednesday 9/10/25. 2. Start polytrim antibiotic eye drops (a combination of Polymyxin B and trimethoprim used to treat eye infections, including acute bacterial conjunctivitis and blepharoconjunctivitis) as soon as possible when it arrives from the pharmacy. Check E-kit for supply, to be given now.3. Monitor for spread outside the black markings placed today.4. If spread occurs, consider the need for emergency department (ED) evaluation for intravenous (IV) antibiotics.Review of R1's electronic health record does not identify consistent daily comprehensive monitoring of eye infection from 9/5/25 through 9/16/25.During an interview on 9/17/25 at 2:29 p.m., licensed practical nurse (LPN)-A indicated on 9/4/25 R1 had a change in condition when R1 developed redness to his right eye and eye lid that extended above his eyebrow and R1 said it was sore. LPN-A further stated his eye worsened on 9/5/25 due to swelling and warmth and she had nurse practitioner (NP)-A see R1 through a telehealth visit and NP -A ordered oral and eye antibiotics for orbital cellulitis to be started that day. NP-A also had us use a black marker to draw around R1's redness around his right eye and told us if the redness spreads beyond the black marker it would be ok to send him to the emergency department for intravenous (IV) antibiotics. LPN-A reviewed R1's electronic health record and verified there was no daily monitoring of signs and symptoms of infection for R1's right eye cellulitis from 9/5/25 to 9/16/25. LPN-A stated when she worked on 9/10/25, she noticed R1 had developed six to seven papules (small, red, solid bumps that quickly turn into fluid filled blisters with shingles) above his right eye. LPN-A stated she called the physician assistant (PA)-A on 9/10/25 and PA-A thought R1 could have shingles and gave orders to send R1 to the emergency department (ED) right away to have a maxillofacial cat scan (CT) to rule out infection spread, a herpes zoster swab to rule out shingles and some lab tests.During an interview on 9/17/25 at 2:52 p.m., assistant director of nursing (ADON) reviewed R1's electronic health record and verified there was no daily monitoring or comprehensive assessments for signs and symptoms of infection for R1's right eye cellulitis. ADON stated when R1 was put on antibiotics a nursing order should have been placed to do comprehensive assessing and monitoring of R1's infection every shift to assess for a change in condition.During a phone interview on 9/18/25 at 8:31 a.m., FM-B stated R1 was seen by a virtual doctor for his infected right eye on 9/5/25. FM-B stated she was R1's resident representative and was concerned the facility did not have R1 seen in person by a provider from 9/5/25 through 9/10/25. FM-B stated R1 developed shingles in his right eye that looked really infected and was worried about vision loss and infection spread. FM-B stated R1 ended up in the hospital to be treated with IV antibiotics due to the infection being in his eye and so close to his brain.During an interview on 9/17/25 at 3:38 p.m., DON reviewed R1's electronic health record and stated there was no documentation of assessments and monitoring for infection from 9/5/25 to 9/16/25 and there should have been a nursing order put in to monitor for cellulitis every shift so the nurses are reminded what to monitor for and to be alerted to a change in condition so they can notify the provider timely.During a phone interview on 9/18/25 at 11:30 a.m., nurse practitioner (NP)-A stated she saw R1 through a telehealth visit on 9/5/25, and gave orders for the facility to start oral and eye drop antibiotics for concerns with right eye orbital cellulitis to start that day. NP-A stated, on 9/5/25 R1 did not have any vesicles (small fluid filled blisters) on his right eye lid or forehead NP-A further stated she directed staff to draw a black marker around the redness surrounding the eye and to send to ED if redness spreads for IV antibiotics. NP-A would expect assessments of the eye infection every shift to notice any changes to include, itching, fever, increased pain, fatigue, burning, light sensitivity blurred vision and spread of the redness and notify the provider immediately of any changes.Facility policy was requested for infection assessment and monitoring and was not received.Appointments:R1's care plan dated 12/5/24, identified a focus for mobility, needed assist with transfers and bed mobility related to cerebral palsy. Intervention dated 3/4/25, mechanical wheelchair to be taken out of room at night once in bed. Plug in to charge overnight in [NAME] supply closet entrance. An additional intervention dated 12/5/24, identified staff to assist with doors, elevators, inclines and tight spaces as needed. An additional focus dated 9/14/25, identified R1 had weakness and needed his electric cart to move around. Intervention dated 9/14/25, identified staff will bring R1 to events he enjoys.will attend current event sessions that he enjoys when he feels better.Care plan does not identify level of assist for mobility in a manual wheelchair when outside the facility.R1's nursing progress note dated 9/10/25 at 10:46 a.m., identified physician assistant (PA)-A ordered R1 to be sent to the hospital and have varicella-zoster PCR (a highly accurate and fast lab test that detects the virus responsible for chickenpox and shingles) completed to right eye, and CT maxillofacial to be completed. Called FM-B to get a verbal bed hold, left voicemail due to no answer, R1 agreed to go to the hospital. At 11:33 a.m., R1 left the facility van to hospital at 11:20 a.m., waiting for return call from FM-B, called the ED to give report to the nurse.During an interview on 9/18/25 at 8:31 a.m., family member (FM)-B indicated she was the resident representative for R1 and stated there was a big miscommunication when R1 had to be sent to the ED on 9/10/25, for tests for a CT scan and the swab for shingles to be done. FM-B stated normally if she can't be at an appointment for R1 someone from the facility will go with him because when the facility transports him in their van, he can't use his electric wheelchair they have no way to strap it down. FM-B further stated the facility had to put him in a manual wheelchair and R1 was not safe to be left unattended due to being immobile from his cerebral palsy. FM-B stated the facility had tried calling her on 9/10/25, to notify her but she was at work and did not get the message right away. FM-B indicated when she finally got the message, she was unsure what hospital they sent R1 to, so she had to call the facility to find out, when she arrived at the ED the staff had told her R1 hadn't checked in yet. FM-B stated she jumped back in her car and went to the clinic side of the hospital and while enroute had called the facility to find out where R1 was, and the facility told her they were sending a driver to come get him because he was done with his appointment. FM-B stated she got to the clinic and found R1 seated in the manual wheelchair slouched over to his left side, he had to lift his head way up to see me coming. FM-B stated R1 had no core strength due to the cerebral palsy and scoliosis (sideways curvature of the spine) and being in an upright position was very uncomfortable for him. FM-B stated guessed R1 had been seated unattended for about 25 minutes with no way to move himself. FM-B stated R1 hated to be a burden on anyone and had always tried to be independent and that he will not ask for help. FM-B stated she did take R1 to the ED to get his tests done and the driver from the facility brought him back when he was done.During an observation and interview on 9/18/25 at 9:25 a.m., R1 was lying in bed eating breakfast. R1 stated on 9/10/25, he had to go to the ED to get testing done for his right eye problem and had to be transferred in a manual wheelchair because the facility van does not have room for his electric wheelchair that he normally used. R1 stated the manual wheelchair was uncomfortable but he was able to tolerate for short durations. R1 further stated the driver brought him to the clinic and someone tried to check him in on the monitor thing and he didn't have an appointment, and he was left in the waiting room because the driver got a call about another appointment. R1 stated he was unable to wheel himself in the manual wheelchair, so he had to wait for someone to help. R1 stated it was a lack of communication that he was left and when FM-B found him she was not happy. FM-B stated he guessed he waited about 20 to 25 minutes before FM-B got there and she got me to the ED where they did my tests.During an interview on 9/18/25 at 10:49 a.m., director of therapy (DOT)-A stated she was unaware that when the facility transports residents who use an electric wheelchair outside the facility, they transfer the resident to a manual wheelchair before they load them in the van. DOT-A stated R1 had never been assessed for safety in a manual wheelchair and was concerned of how he would be safe in one without a proper assessment due to his cerebral palsy, contractures (permanent shortening or tightening of muscles, tendons, or other tissues that restricts movement) and scoliosis. During an interview on 9/18/25 at 9:51 a.m., receptionist (R)-A stated the ADON told her that R1 needed a ride to the clinic for an eye appointment, so she called the transport driver (TD)-A and asked him to bring R1 in.During an interview on 9/18/25 at 11:05 a.m., TD-A stated he got a call from R-A, and she told him R1 needed a ride to the clinic for an eye appointment. TD-A stated normally when he takes a resident to an appointment, they send paperwork with. TD-A stated he had no paperwork for R1 and assumed R1 had an eye appointment. TD-A stated he got him to the clinic at the eye part and the girl at the clinic put his name in the kiosk and said she didn't think R1 had an appointment. TD-A thought the girl at the clinic would take R1 to his appointment, so he left. TD-A stated when he got back to the facility, he found out he was supposed to have taken R1 to the ED, he stated he felt terrible about the mix up.During an interview on 9/17/25 at 3:38 p.m., DON indicated she was not aware that R1 was left unattended at the ED on 9/10/25, while he was in a manual wheelchair and stated it was not safe for R1 because he was immobile in the manual wheelchair. DON was unsure if R1 was ever assessed for safety in a manual wheelchair and normally used his specialized electric wheelchair that he was independent with mobility in.Facility policy for transporting residents to outside appointments was requested and not received.

Based on observation, interview, and document review, the facility failed to notify a resident's representative of a change in condition for 1 of 3 residents (R3) reviewed for quality of care. Findings include:R1's quarterly minimum data set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of Cerebral palsy (a group of disorders caused by a non-progressive brain injury before, during, or shortly after birth that affects a person's movement, muscle control, posture, and balance) and elevated white blood count (a condition when you have too many white blood cells (WBCs) in your blood, which is your body's way of fighting off something, usually an infection or inflammation).R1's nursing progress note dated 9/4/25 at 1:00 p.m., identified acetaminophen 500 mg given due to complaint of right eye pain and soreness. At 1:20 p.m., an additional note indicated R1's right eye hurt some and was a little red and irritated.will continue to keep an eye on it for now.R1's nursing progress note dated 9/5/25 at 11:24 a.m., R1 again commented his eye was sore to the director of nursing (DON) who happened to look at it and let her know this started on 9/4/25. R1's eyebrow was a little swollen and now was pinkish red and warm to the touch, and the DON wondered if cellulitis was developing. Note identified that the DON would call nurse practitioner to get an order for something, and some eye drops also. Called and left a voicemail for the nurse practitioner. R1's Telemedicine Visit dated 9/5/25 at 2:37 p.m., identified nursing asked for an acute visit on the fly for acute evaluation of concerns for cellulitis (a common bacterial infection of the skin and underlying tissues that typically causes redness, swelling, pain, and warmth in the affected area) developing around R1's right eye. R1's primary care provider started eye drops yesterday, unfortunately they have not arrived yet from the pharmacy. R1 reported 3 out of 10 pain. Nursing staff asked to mark the erythema (redness) surrounding his upper eye lid. Upper blepharitis (eye lid inflammation) with erythema, warmth and discharge present. R1 had conjunctivitis (when the white part of the eyeball becomes red and swollen that can cause irritation, itching, or a gritty, [NAME] feeling) present. Assessment/Plan identified: 1. Preseptal cellulitis (an infection of the eyelid and soft tissue on the outside of the eye's protective barrier, called the orbital septum)-amoxicillin-pot clavulanate (Augmentin)-(antibiotic) 875-125 milligram (mg) per tablet. Take 1 tablet by mouth two times a day for 5 days starting Friday 9/5/25, until Wednesday 9/10/25. 2. Start polytrim antibiotic eye drops (a combination of Polymyxin B and trimethoprim used to treat eye infections, including acute bacterial conjunctivitis and blepharoconjunctivitis) as soon as possible when it arrives from the pharmacy. Check E-kit for supply, to be given now. 3. Monitor for spread outside the black markings placed today. 4. If spread occurs, consider the need for emergency department (ED) evaluation for intravenous (IV) antibiotics.R1's electronic health record was reviewed and does not identify R1's representative was notified of a change in condition with his right eye.During an interview on 9/17/25 at 2:24 p.m., assistant director of nursing (ADON) reviewed R1's electronic health record and stated it does not look like anyone notified R1's family of his change in condition with his right eye and they should have. ADON stated anytime a resident has a change in condition the resident representative should be notified immediately and should be documented in the resident's medical record. During an interview on 9/17/25 at 2:29 p.m., licensed practical nurse (LPN)-A indicated on 9/4/25, R1 had a change in condition when R1 was complaining of soreness in his right eye. LPN-A stated R1 had redness in his right eye and his eye lid that extended above his eyebrow. LPN-A further stated his eye worsened on 9/5/25 due to swelling and warmth. LPN-A stated she did not notify FM-B of R1's change in condition and should have.During a phone interview on 9/18/25 at 8:31 a.m., FM-B stated R1 was seen by a virtual doctor for his infected right eye on 9/5/25. FM-B stated she was R1's resident representative and was upset the facility never contacted her about R1's eye infection. FM-B stated they should have called me when R1's eye first started getting red. FM-B stated she wanted to be notified of any changes R1 had. FM-B stated she didn't find out until she went to the facility to visit R1.During an observation and interview on 9/18/25 at 9:25 a.m., R1 was lying in bed eating breakfast. R1 indicated when he has changes in his health, he would like the facility to notify FM-B.During an interview on 9/17/25 at 3:38 p.m., director of nursing (DON) reviewed R1's electronic medical record and stated there was no documentation that FM-B was notified of R1's change in condition of his right eye. DON indicated FM-B should have been notified immediately and should have been documented in R1's medical record. Facility policy regarding notification with a change in condition was requested and not received.

Based on observation, interview, and document review the facility failed to maintain resident supervision and safety to prevent accidents for 1 of 1 residents (R1) who was an elopement risk left the facility unsupervised through an unlocked door during the night and found outside. This resulted in an immediate Jeopardy (IJ) situation for R1. The IJ began on 12/7/24 when R1 exited the building without staff awareness through an unlocked door to a courtyard between 11:15 p.m. and 3:30 a.m. (on 12/7/24) and found on the ground at approximately 4:10 a.m. with hypothermia and minor injuries. The administrator and chief operating officer (COO) were notified of the immediate jeopardy on 12/11/24 at 3:00 p.m. The facility had implemented immediate corrective action on 12/8/24 to prevent recurrence, so the IJ was issued at past non-compliance. Findings include: R1's Admission Record identifies R1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) was not completed due to R1's admitted [DATE]. R1's Brief Interview for Mental Status dated 12/6/24, indicated R1 had severe cognitive impairment. R1's Elopement Evaluation dated 12/6/24, indicated R1 was at risk for elopement (did not identify risk level) due to expressions of desire to go home, recent admission, and not accepting of the situation [of facility placement]. The focus identified R1 was at risk for elopement. The goals of care included the resident would not leave facility unattended and safety would be maintained. No interventions were identified or implemented. R1's Fall Risk assessment dated [DATE], indicated R1 was at a high risk for fall related to intermittent confusion, 1-2 falls in the past 3 months, decreased muscular coordination, administered 1-2 that increase risk for falls, and had 1-2 diagnoses present that increase risk for falls. R1's document Individual Resident Baseline Care Plan dated 12/6/24, identified R1 was at risk for falls but did not identify safety measures. R1 required one staff assist with dressing, grooming, toileting, repositioning, and ambulation. R1 was alert and oriented to person with confusion and no behaviors. The baseline care plan noted, [R1] very upset at being here, not wanting to express any desires for food or anything. Just wanting to go home. This document did not address R1's risk for elopement or interventions to assure R1's safety. R1's Care plan dated 12/6/24 identified focus of Risk for Wandering/Elopement identified with corresponding goals that included, The resident will not leave the facility unattended and The resident's safety will be maintained. The care plan did not identify safety interventions to prevent or mitigate the risk of elopement. R1's care plan also identified the risk for falls related to a history of falls and recent hospitalization with the corresponding goal R1 will be free from falls throughout this next quarter. Fall interventions directed staff to complete fall risk evaluations, complete labs when ordered and report findings, monitor for medication side effects, and reinforce need to call for assistance. The care plan did not reference the note that was included in the Baseline Care Plan document pertaining to R1's voiced dislike of, and not wanting to be at the facility. R1's facility Progress Notes noted the following: 12/6/24 at 11:23 p.m., indicated early in the shift R1 stated to staff and (FM-A) that she wanted to go home with her dog. R1 continued to be upset/confused about placement. Social worker was notified and talked to R1. R1 spent time watching [television] TV and did not transfer without assistance. Would continue to monitor. 12/7/24 at 6:37 a.m., licensed practical nurse (LPN)-A identified R1 was in recliner at 1:45 a.m. rounds; on 3:45 a.m. rounds R1 was not in her room. Searched the building, checked outside, play park across the street, and in the courtyard. LPN-A notified the administrator, director of nursing (DON), family, police, and the medical director. R1 was found at 4:10 a.m. outside lying on the ground in the [facility] courtyard and ambulance was called immediately. 12/7/24 at 2:22 p.m., was in ICU, Intensive Care Unit at that time. R1's emergency department and hospital records dated 12/7/24 at 6:09 am., Indicated R1 was seen for altered mental status, hypothermia (potentially dangerous drop in body temperature), and sepsis (life threatening complication of an infection) after R1 was found outside. Further identified R1 presented with cold extremities, multiple abrasions throughout bilateral upper extremities, core body temperature of 31.1 degree Celsius (87.98 degrees Fahrenheit). At 7:55 a.m. the record identified R1 was rewarmed with warm intravenous fluids and a BairHugger (forced air warming blanket), and would be admitted to the intensive care unit (ICU). According to the [NAME] Lea Weather Station -KMNALBER38 (reported or published online by Weather Underground) the temperature on 12/7/24 between 1:45 a.m. to 4:15 a.m., ranged from 26.6 degrees Fahrenheit (F) to 32.6 degrees F. During observation and interview on 12/10/24 at 11:30 a.m., R1 had intravenous (IV) access to the left hand, numerous scabs, abrasions, and bruises noted on both right and left hands and arms. R1 indicated the scabs and abrasions on her hands and arm were much better than they had been and got them when she wandered away from home and fell by the corner a couple of weeks ago when it was really cold. R1 stated she could not remember exactly what happened but remembered that she was outside for a while and was really, really cold. R1 further stated that she had some difficulty walking before that but has more difficulty walking after being outside for so long. During an interview on 12/11/24 at 10:50 a.m., family member (FM-A) indicated he received a call on 12/7/24 at 4:00 a.m., notifying him R1 was missing. Further identified he got to the facility right after they found R1 in the outside courtyard. R1 had fallen in the rocks, was very cold, and was all cut up. FM-A joined R1 in the emergency department and stated, was told if she (R1) had been out there another 30 minutes, she would have been dead. FM-A stated, it shouldn't have happened FM-A stated earlier that day, had been confused and also had told staff she wanted to go home. FM-A indicated R1 lived within walking distance from the facility and staff were aware. During an interview on 12/10/24 at 4:15 p.m., LPN-B reported he was the day shift charge nurse on 12/6/24. LPN-B stated R1 had a urinary drainage bag and catheter so he did not think she could walk without assistance. LPN-A stated he had not been aware that R1 was at risk for elopement and for falls. LPN-B recalled on 12/6/24, R1 was upset about needing to be at the facility and wanted to go home. LPN-B reported R1's comments and behavior to the SW. During an interview on 12/10/24 at 4:05 p.m., social worker (SW) indicated she completed R1's initial cognitive assessment on 12/6/24, which identified R1 had severe cognitive impairment. Stated later that day the charge nurse notified her that R1 wanted to leave and was confused. SW visited with R1 and husband regarding R1's desire and ability to visit with their dog. SW thought R1's confusion was due to blood sugars so asked the charge nurse to check R1's blood sugar. The SW had no further contact with R1. SW did not communicate R1's confusion and/or desires to leave the facility nor developing/implementing safety interventions after becoming aware. During an interview on 12/11/24 at 12:00 p.m., registered nurse (RN)-A indicated she had worked day shift on 12/6/24, the day was very busy because there had been two admissions at the same time. RN-A completed R1's initial elopement assessment which identified she was at risk for elopement. Since FM-A had reported R1 did not have wandering behaviors, RN-A thought R1 was at low risk for elopement and did not apply a a wanderguard or implement any safety interventions. RN-A was not aware R1's permanent home was in close proximity to the facility and not aware of R1's statements to other staff about wanting to go home, had RN-A been aware she would have implemented interventions and increased monitoring. During an interview on 12/11/24 at 8:25 a.m., nursing assistant (NA)-B indicated the doors going out to the courtyard were not locked on the night of 12/6/24 and did not think they were ever locked. NA-B indicated she worked the overnight shift on 12/6/24 into 12/7/24. R1 had been a new admission, was not told R1 required assistance nor made aware or had knowledge that R1 was an elopement risk and at risk for falls. Because NA-B did not know, she had not provided any assistance to R1. NA-B further explained on 12/6/24 at 11:15 p.m. she had physically observed R1 last at 11:15 p.m. (12/6/24). At approximately 2:00 a.m. (on 12/7/24) she had went to R1's room, did not see R1 in her room but saw R1's bathroom light on so assumed R1 was in the bathroom at that time. At approximately 4:00 a.m., LPN-A asked for NA-B for assistance in R1's room at which time notified R1 could not be found. Staff that were working began to search for R1. R1 was found at 4:15 a.m. in the facility courtyard lying on a bunch of tiny rocks next to a cement bird bath that was knocked over wearing only sweatpants, short sleeve shirt, and did not have on socks or shoes. R1 was very cold and confused. During an interview on 12/11/24 at 9:45 a.m., LPN-A reported working night shift (12/7/24) when R1 eloped from the facility. LPN-A reported during shift report, she was told R1 was a new admission on 12/6/24, was alert and oriented, and wanted to go home to her dog but the SW calmed her down. LPN-A stated she did not have any contact with R1 until she was found outside in the courtyard at approximately 4:15 a.m. LPN-A noted R1 was not in her room at approximately 3:30 a.m. while walking to another resident's room. LPN-A asked NA-A and NA-B when they last saw R1 and was told NA-B last checked on R1 at 1:45 a.m. but R1 had not been seen since. LPN-A indicated she alerted the police, administrator, and family and began searching. LPN-A reported R1 was found in an unlit area of the courtyard laying on rocks and described R1 as fidgety, confused, cold, pale, mumbling, and R1's catheter bag by her. LPN-A could not remember what R1 was wearing but thought she had a hospital gown and grippy socks on. LPN-A further identified the exit door to the courtyard was not locked and should have been. LPN-A also reported if R1 was identified as an elopement risk, it was the facility policy to put a wanderguard on and notify the oncoming staff. LPN-A stated if she would have known R1 was a fall and/or an elopement risk, she would have checked on R1 more frequently. During an interview on 12/11/24 at 2:00 p.m., the interim administrator indicated R1 was admitted the afternoon on Friday 12/6/24. The interdisciplinary (IDT) each had pieces of R1's admission, however, did not communicate amongst each other to determine actual risks and appropriate interventions. The administrator indicated the facility policy needed to be changed to identify protocol when risk of elopement was identified. Further, the courtyard door did not have a wanderguard system and the door was not locked. Facility policy titled, Elopements and Wandering Residents dated 10/2024, indicated the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Defines elopement as a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The policy also identifies the facility is equipped with door locks/alarms to help avoid elopements. The IDT will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; interventions to increase staff awareness of the resident's risk, modify the resident's behavior or to minimize risks associated with hazards will be added to the resident care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements; charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. Any changes or new interventions will be communicated to relevant staff. The past-noncompliance immediate jeopardy began on 12/7/24 and was removed on 12/8/24, when the facility implemented a systemic plan to ensure all residents were safe. The following actions were implemented prior to survey the facility locked the courtyard doors and placed all residents on 15-minute checks until all residents were re-assessed for elopement risk. When all residents were re-assessed, the residents at risk for elopement were placed on 15-minute checks until individualized interventions were developed and implemented. The facility reviewed all resident care plans, revised the elopement policy. On 12/8/24, the facility re-educated all staff on the elopement policy and on risk factors to watch for. On 12/10/24, upon R1's hospital return, the facility re-assessed R1 for elopement and fall risks and implemented interventions to mitigate the risks.

Based on observation, interview, and document review the facility failed to immediately implement appropriate interventions to protect residents from sexual abuse from R1 who sexually abused R2 in the facility and posed an ongoing risk of serious harm resulting in immediate jeopardy. The IJ began on 10/6/24, when facility failed to implement protection measures after staff observed R1 inappropriately touching R2's breast/chest area on 10/6/24. The administrator, director (DON) and assistant director of nursing (ADON) were notified of the IJ on 10/11/24 at 4:43 p.m. The immediate jeopardy was removed on 10/13/24 at 9.11 a.m. but noncompliance remained at the lower scope and severity level 2 E - pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of facility reported incident dated 10/7/24 at 3:05 p.m., indicated on 10/6/24 around 11:50 a.m., nursing assistant (NA-A) walked out to the day room and saw R1 had his right hand under R2's shirt and appeared to be doing a rubbing/grabbing in a circular motion on R2's chest area. NA-A ran over to R1, grabbed his hand, and said no. NA-A stayed with R1 and R2 and called for licensed practical nurse (LPN-A) to come right away to the day room. LPN-A removed R2 to behind the nurse' station and NA-A took R1 to his room. R1's face sheet included diagnoses of dementia without behavioral disturbance, memory deficit following a cerebrovascular disease, epilepsy (seizure disorder) and hearing loss. R1 was admitted to facility on 6/11/24 from another skilled facility. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, poor decisions, required cues and supervision, with signs and symptoms of delirium without inattention, disorganized thinking or altered level of consciousness. R1 used a walker and a wheelchair with maximal assistance from staff for dressing, transfers, and bed mobility. R1 had no delusions or hallucinations, no behaviors, wandering or rejection of cares noted. During an interview on 10/15/24 at 2:32 p.m., family member (FM)-B stated R1's wife would complain about R1 being touchy, towards the end of her life. R1 had problems with inappropriately touching female residents at previous facility and was why R1 was moved to this facility. FM-B was hopeful that the move would resolve the problem. R1's progress note dated 6/10/24 at 2:21 p.m., R1 was admitted to facility. The note did not identify history of behaviors. R1's physician visit note dated 6/13/24, indicated new admit from a previous facility with behavioral issues and was having problems swallowing his medications whole. R1's Depakote (antiseizure medication also used for behaviors) and Paroxetine (antidepressant) were discontinued. The note indicated R1 had normal behavior, mood, and affect. R1's physician visit dated 6/21/24, noted R1 had lots of behavioral problems, specially making sexual advances towards women at previous facility and continued at this facility. This behavior was a source of concern and embarrassment for family, and they asked for a medication to decrease R1's libido. MD-A re-started low dose of paroxetine to help with behaviors. Nurses to continue with respiratory and behavior monitoring. In review of R1's record, there was no documentation of any behaviors that were referenced in the physician note. R1's progress note dated 6/22/24 at 12:59 p.m., indicated staff reported to nurse, with wake up cares R1 was grabby with the staff and attempting to touch staff buttocks. Staff kindly removed R1's hands and reminded R1 to keep to himself. Note further indicated after lunch time another staff reported R1 was sitting at in the dining room with residents that needed staff assistance to eat when R1 went up to the resident from [room x-unidentified resident]. and put both his hands on her shoulders. Staff intervened and reminded R1 to keep his hands to himself. R1's progress note dated 7/3/24 at 9:50 a.m., care conference held and indicated the Paxil started on 6/21/24 had been helpful with R1's behaviors. R1's behavior care plan initiated on 7/18/24, included Problematic manner in which resident acts characterized by inappropriate sexual behavior (verbal and physical) related to R1 makes inappropriate remarks, resident touches other female residents and/or staff inappropriately The care plan directed the following: -Avoid type of conversation that could encourage or initiate inappropriate behavior, dated, 7/18/24; -Constant supervision in recreation programs, dated 7/18/24; -distract R1 if possible, dated 7/18/24; -document a summary of each episode, dated 7/18/24; -Remove R1 from the public area when behavior was disruptive/unacceptable. Talk with R1 in low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity, date 7/18/24. R1's progress note dated 7/23/24 at 10:49 p.m., indicated R1 went into other resident's rooms, especially [room x-unidentified resident]. R1 was removed and easily redirected. No further occurrences from R1. R1's progress note dated 7/24/24 at 5:25 p.m., indicated R1 was noted to enter other residents' rooms on 7/23/24, no physical contact was made. R1 has history of inappropriate behaviors. Care conference scheduled for 8/2/24 with FM-B and MD-A to review plan of care and current medications to see what else can be done to manage R1's behaviors. R1 put on 15-minute checks to ensure R1 has no behaviors towards other residents. R1's behavioral care plan was revised on 7/24/24, included 15-minute checks to protect other residents from R1's behavior and entering other residents' rooms, dated 7/24/24. During an interview on 10/10/24 at 4:39 p.m., social worker (SW-A), indicated R1 had inappropriate sexual behaviors at previous facility when he was admitted to Thorncrest. SW-A stated no preventative or protection interventions were put into place until 15-minute checks were implemented on 7/24/24, when R1 had inappropriate interactions with R3. R1's progress note dated 7/30/24 at 10:44 p.m., staff member mentioned they overheard R1 in living room state to visitors I'd like to borrow your keys to take R3 out on a date. After super R1 was noted to be moving self-closer to R3. R1 was redirected and moved away female residents. No further concerns noted or reported, will continue to monitor. R1's progress note dated 8/1/24 4:43 p.m., writer noted R1 sitting right in front of R3, who R1 has bothered in the past. R3 looked uncomfortable as R1 was directly in front of R3's wheelchair. Writer took female resident aside. R3 informed writer R1 was not doing or saying anything but would prefer R1 not sitting by her. Writer informed nurse and nurse aide working to monitor. R3's record included a progress note dated 8/1/24, that identified the aforementioned encounter. R3's quarterly MDS dated [DATE], indicated R3 did not have cognitive impairment. R3 had diagnoses of end stage renal disease and diabetes. R3 required moderate assistance with ADLs, wheelchair use and did not walk. R3's progress note dated 6/15/24, identified staff reported R3 initiated hand holding with R1 and R3 told staff she was old friends with R1, R1's record did not identify this encounter. R3's record included a progress note dated 7/19/24, identified activity aide (AA)-A overheard R1 asking R3 for a kiss in the dayroom but R3 denied R1 and R1 moved to a different area of the dayroom, R1 record did not identify this encounter. During an interview on 10/11/24 at 9:44 a.m., R3 was sitting in her wheelchair in her room watching TV. R3 stated she knew R1 from the past. R1 on several occasions would roll up to her in his wheelchair, reach over and hold her hand. R3 was okay with this until R1 rolled into her room and told her You and me and pointed to her bed. R3 put on call light and staff came to remove R1 from R3's room. R3 recalled another incident where R1 was holding her hand and tried to move her had to his private area (penis). R3 stated that made her very uncomfortable. Staff saw what R1 was doing so they removed him from her personal space. Staff have told both R1 and R3 they needed to stay 4 feet away from each other. R3 was not able to remember the dates of either incidents. R3 did not want to ever be close to R1 as she felt he was inappropriate with his actions. In review of R1's and R3's records it did not address these encounters as R3 described and/or could not be ascertained if these incidents were accounted for in the record as they were not specified. During an interview on 10/11/24 at 10:19 a.m., NA-C stated she thought R1 behaviors started a couple of months ago, not sure on date but was able to remember when R1 was admitted , it was mentioned that he had sexual inappropriate touching at previous facility. NA-C stated R1 and R3 needed to be kept separated and R1 was on 15-minute checks since his behaviors had started. NA-C did not think the 15 minute checks were adequate; R1 was independent with wheelchair mobility. During an interview on 10/11/24 at 9:22 a.m., LPN-B stated she did the admission for R1 when he first came to facility in June of 2024. R1's record from the previous facility included notes about R1 sexually touching female residents inappropriately. After R1 was admitted here he started holding hands with R3 and going into R3's room. R3 did not like this, so staff were to try to keep an eye on him and do 15-minute checks. LPN-B did not think the 15- minute checks were adequate because R1 was independent in his wheelchair and he was quick. During and interview on 10/11/24 at 12:41 p.m. R5 who was a male resident reported he was familiar with R1. One day he witnessed R1 rolling up behind a female resident and put his hands right up her shirt. R5 could not recall if there had been staff in the vicinity at the time nor remember if he had reported the incident to staff. R5 could not recall the female residents name she had discharged and could not remember the date but That is something you will never forget! R5's quarterly MDS dated [DATE], identified R5 had moderate cognitive impairment. R1's progress note dated 9/26/24 at 2:09 p.m., indicated R1 followed a resident into their room. R1 was removed and redirected. The note did not identify if R1 had been directly observed going into the room. R1's progress note dated 10/4/24 at 11:17 a.m., indicated R1 was attempting to hold a female resident's hand while she was sleeping. Nurse intervened and separated residents. The note did not identify which female resident, location of this interaction nor the duration. R1's progress note dated 10/5/24 at 11:32 a.m., R1 wandered into a resident's room. Was easily redirected. The note did not identify if R1 was directly observed going into resident's room and what R1 was doing or where R1 was in the room when he was redirected. An undated and untimed facility video recording that was approximately two minutes long was reviewed. At the start of the video a total of 14 residents sat in a semi-circle facing the same direction in front of the nursing station. R1 sat in his wheelchair next to R2's left side. R1 was holding onto R2's right lower arm while R2 had her head resting on her left hand with her eyes closed. Housekeeper (HSK-A) can be seen riding a floor cleaning machine directly behind the residents; he made several passes and did not look towards R1 and R2. At 42 seconds, R1 looked toward R2 and moved his hand up her arm towards R2's chest. HSK-A came back into the picture and did not look toward R1 or R2. At 54 seconds, R1 moved his right hand around R2's chest area and held R2's right hand with his left hand. At one minute marker, R1's right hand went under R2's shirt. At 1 minute 15 seconds, a staff member walked directly behind R1 and R2, she did not turn her head to see R1's hand was up R2's shirt; the staff continued to walk by without intervention. At one minute 18 seconds, licensed practical nurse (LPN)-A brought a resident into the commons area by the medication cart and left without looking toward R1 and R2. R1 continued to move his right hand around under R2 shirt while holding R2's right lower arm with his left hand. At one minute 30 seconds, R1 placed R2's right hand on his right thigh as he continued to move his right hand under R2's shirt as HSK-A went by again in the floor cleaning machine. At 1 minute 35 seconds, R2 leaned back in her wheelchair and lifted her head up. At one minute 45 seconds, a female staff person in blue and white returns and as she went by looked at R1 and R2 and stopped, turned around and told R1 No in a stern voice and removed his hand from under R2's shirt. Staff person pulled down R2's shirt and called out for LPN-A to come right away at one minute 54 seconds. The video concludes when LPN-A entered the room. R1's progress note dated 10/7/24 at 11:39 a.m., indicated R1 was caught with his hands up a female resident (R2) shirt in the day room on 10/6/24 at 11:50 a.m. It was reported R1's right hand was under R2's shirt and R1 was rubbing, grabbing, and making circular motions on R2 chest area. Staff immediately intervened by removing R1 back to his room. R1 was not allowed to sit next to other female residents in the day room or dining room, this will continue to prevent another inappropriate interaction. NP-A was consulted on medications and order received to increase Paxil to 20 mg daily and to follow up with physician assistant (PA) on 10/17/24 for effectiveness. R1's care plan was not revised to identify the intervention for R1 to not allowed to sit next to female residents in the dinning room and the day room. Additionally, R1's record did not identify a comprehensive assessment that would identify the level of supervision R1 required, no changes were made to duration in which R1 was checked on. R2's quarterly MDS dated [DATE], indicated R2 had severe cognitive impairment, required moderate assistance with her activities of daily living (ADLs). R2's diagnoses included cancer, heart failure, and depression. R2's care plan dated 10/10/24 did not address her vulnerabilities. Review of R2's progress note dated 10/7/24 at 12:01 p.m., addressed the incident in which R1 inappropriately touched R2 on 10/6/24 at 11:50 a.m. LPN-A was notified and took R2 behind the nurses' station for observation. R2 did not appear to be disturbed or upset by this happening. No marks noted on skin. During an interview on 10/10/24 at 2:29 p.m., R2 was not able to articulate the correct date or year, however was aware she was in [NAME] Lea, Minnesota. R2 denied anyone touched her inappropriately. During an interview on 10/15/24 at 2:49 p.m., NA-L stated she would feel embarrassed, feel very violated and affect her dignity if someone were to come up to her and start feeling their chest area. During an interview on 10/15/24 at 3:05 p.m., ADON stated would feel violated if someone were to come up to her and start feeling their chest area. During an interview on 10/15/24 at 3:08 p.m. NA-C stated she would feel very upset, violated, and fearful if someone were to come up to her and start feeling their chest area. During an interview on 10/11/24 at 9:15 a.m., a white board was used to communicate with R1. R1 articulated the month, the year, and the town he lived in. R1 denied inappropriately touching female residents, stating bullshit, when asked. R1 denied any problems with the staff or other residents. During an interview on 10/11/24 at 9:01 a.m., HSK-A stated his job was to take care of the floors. He had not been told to monitor or keep an eye on any specific resident. During an interviews on 10/10/24 at 4:15 p.m. and 10/11/24 at 10:03 a.m., NA-A stated when R1 was first admitted to the facility she was not informed R1 had sexually inappropriate behaviors prior to admission to the facility, she was told to just watch if he tried to touch female residents but not why. She later became aware NA-A explained R1 went into other resident's rooms about three times per week, usually happened around mealtimes when staff were not available to make sure he would go back to his room after he ate. NA-A stated she had witnessed the incident between R1 and R2 on 10/6/24 around 11:50 a.m. NA-A was walking back to her unit by the dayroom, when she saw R1's right hand under R2's shirt and seemed to be grabbing and rubbing at R2's chest area. NA-A ran over to the residents and removed R1's hand from under R2's shirt and told R1 No and then yelled for LPN-A to come to day room. LPN-A removed R2, and NA-A took R1 to his room. NA-A did not know how long R1's hand had been under R2's shirt as was not working that unit. NA-A stated she was aware R1 had history of sexually inappropriate behaviors including inappropriately touching female residents. NA-A was aware R1 had demonstrated sexually inappropriate behaviors toward three other female residents R3, R4, and R6. NA-A explained she went into R3 and R6's room, R6 was in the bathroom on the toilet with the door open, R1 was sitting in his wheelchair watching R6 while she was in the bathroom. NA-A recalled another time where she had seen R1 holding R4's hand in the day room, however could not remember the date. NA-A stated the 15 minute check intervention had been in place for a couple of months, additional interventions were to redirect R1 back to his room and make sure he was not at a table with female residents. NA-A stated she did report the incidents with R3, R4, R6 to her nurse but because she worked with multiple nurses she could not recall which nurse she had reported to. In review of R1's, R4's, and R6's records it did not address these encounters as NA-A described and/or could not be ascertained if these incidents were accounted for in the record as they were not specified. R4's significant change MDS dated [DATE], indicated R4 had moderate cognitive impairment and had diagnoses of dementia and anxiety. R4 required moderate to maximal assist with ADL's. R6's quarterly MDS dated [DATE], indicated R6 did not have cognitive impairment with diagnoses of cancer, end stage renal disease, stroke, traumatic brain injury and depression. R6 required moderate to maximal assist with ADLs. During an interview on 10/10/24 at 3:17 p.m., LPN-A stated on 10/6/24 she heard NA-A yell for her to come to the day room. NA-A informed her what happened, and LPN-A removed R2 from the area to behind the nurses' station and called the assistant director of nursing (ADON). LPN-A stated R1 was not to sit by any female residents in the dining room, R1 was to sit at table with all men. LPN-A reported R1 had also touched R3 inappropriately. LPN-A also remembered another incident where R9 told her R1 wheeled himself up to R9 as she was sitting by the medication cart in the day room and R1 attempted to hold her hand but R9 was able to move herself away from R1. LPN-A did not document the incident, could not remember the date of the incident, and did not report the incident and did not document the incident. During an interview on 10/11/24 at 12:40 p.m., RN-A stated she had witnessed R1 wheel over to R4 when she slept in her wheelchair in the day room. R1 reached over, held her hand and rubbed it. RN-A took R1 to his room. RN-A explained in another incident R9 had told her R1 was trying to hold her hand while R9 was waiting at the medication cart but R9 was able to move herself away. RN-A reviewed R1's record and reported the incidents were not documented. During a subsequent interview on 10/15/24 at 12:11 p.m. RN-A stated she did not report these incidents to her supervisors because she thought it was harmless hand holding and did not know of R1's history of inappropriate sexual behaviors. RN-A could not remember specific dates of either incident but recalled they both had been within the last month. R9's admission MDS dated [DATE], indicated R9 had severe cognitive impairment with diagnoses of cancer and stroke. During an observation on 10/11/24 at 8:18 a.m., R1 sat next to R5 at a dinning room table. A female resident (R7) was brought into the dining room by NA-B and placed across from R1 and next to R5. At 8:40 a.m. R5 left the table leaving R1 alone with R7; R1 rolled his wheelchair to sit next to R7. No staff intervened. At 8:50 a.m. R1 self propelled his wheelchair out of the dining room to the dayroom where he stopped and sat 5 feet from a female resident. No staff were present in the day room, which was not in accordance to the care plan. At 8:55 a.m. an unknown staff member moved R1 away from the female resident, and returned to the nurses station. At 8:58, R1 propelled his wheelchair down the hallway to his room without staff assistance. R7's quarterly MDS dated [DATE], indicated R7 had moderate cognitive impairment with diagnoses of dementia. R7 required moderate to maximal assist of one staff with ADL's and used a wheelchair. During an interview on 10/11/24 at 9:30 a.m., NA-B stated she did not know R1 was to not have female residents at his table. During an interview on 10/11/24 at 12:21 a.m., cook-A explained there was not assigned seating in the dining room but residents usually sat in the same places during meal times. Cook-A had been informed earlier in the week R1 was not to have any females at his table. Cook-A was in the kitchen during breakfast and did not identify R1 had been sitting next to R7 at the table, but should have caught it. During an observation on 10/11/24 at 12:45 p.m., R1 sat in his wheelchair in the common area. R4 sat on the couch. R1 moved himself towards the couch where R4 was sitting however, RN-A intervened by taking R1 to his room. During an interview on 10/10/24 at 2:45 p.m., NA-K stated R1 was on 15-minute checks because R1 self-transferred and R1 liked to grope female residents in inappropriate ways. R1 had touched another female resident (R3) inappropriately in the past and that was when the 15-minute checks started. NA-K stated staff were supposed to keep R1 away from female residents and redirect him. NA-K did not think the 15 minute checks were adequate. During an interview on 10/10/24 at 3:08 p.m., RN-E stated when R1 was admitted from another facility where he had been handsy with female residents and was asked to move out. When he was admitted here staff found out R1 knew R3. R1 would go up to R3 and put his hand on her thigh, that's when the 15-minute checks were implemented. RN-E indicated the incident happened in either June or July, but could not recall the exact date. RN-E stated R1 liked to go into other resident rooms, mainly female's rooms but was easily redirected out. In a subsequent interview on 10/15/24 at 3:57 p.m., RN-E was not able to articulate any protective/preventative measure put into place to protect female residents in facility aside from the 15-minute checks. RN-E did not think the 15-minute checks were adequate. During an interview on 10/11/24 at 10:16 a.m., HSK-B stated has not been told to keep watch on any certain residents or certain residents should not be together. During an interview on 10/11/24 at 12:34, MD-A stated he was both R1's and R2's primary care physician. MD-A was not made aware of the incident regarding R1 and R2. MD-A remembered starting the low dose paroxetine for R1's libido but had not heard of any incidents since the start of the medication in June and thought it was helping. It was his expectation the facility notify the physician and the protocol for abuse be followed to keep the residents free from abuse. During an interview on 10/15/24 at 12:51 p.m., DON stated when she had first been notified of the incident between R1 and R2 on 10/6/24 via text message, she did not think too much of it because she was not aware of R1's sexual behaviors or his history until the incident with R2. Had she known the history she would have come into the facility after the incident to start the investigation and to ensure resident protections were implemented. DON stated she had not been aware of the incident in which R5 reported pertaining to R8. DON reviewed R1's record and indicated the documentation of R1's behaviors were not thorough, the documentation for 15-minute checks was not always completed and did not identify specific information on R1's whereabouts or what he was doing, and did not identify incidents as reported to surveyor by nursing staff and residents. DON would have expected more documentation on R1's behaviors and report all incidents or allegations of inappropriate sexual behaviors. DON further stated bringing in a resident with sexual behaviors is like brining in a resident with new medical condition. It takes training to learn how to prevent the incident from happening. DON did not think that the 15 minute checks were adequate and implemented that R1 not sit next to female residents in activities or the dining room after the incident occurred on 10/6/24. Review of facility ' s abuse policy titled Preventing Resident Abuse dated 12/19, did not address the protection of residents from abuse. The policy indicated: policy statement: Our facility will not condone any form of resident abuse and will continually monitor our facility ' s policies, procedures, training program, systems, ect., to assist in preventing resident abuse. j. assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict, or neglect. k. assessing with resident and symptoms of behavior problems and developing and implementing individualized care plans to address behavioral issues. The IJ was removed on 10/13/24 at 9:11 a.m., when it was verified, the facility completed the following actions: -The facility reviewed and updated their abuse policy and procedure pertaining to resident-to-resident sexual abuse - R1 ' s care plan was updated with 1:1 while awake to prevent him from having contact with vulnerable females related to his sexual inappropriate touching. -R1 will have a video monitor on while sleeping. -R1 is not to be left by any female residents at any time. -The facility provided education to all facility staff on the policy and on immediate implementation of individualized care plan and protection measures. -The facility completed trauma informed care assessments and care plan updated, on the residents affected by R1 ' s behaviors.

Based on observation, interview and document review, the facility failed to implement pressure ulcer care interventions to reduce the risk of development and/or decline of pressure ulcers for 1 of 3 residents (R2) reviewed for pressure ulcers. This failure resulted in actual harm for R2 who experienced a decline in a facility acquired pressure ulcer. Findings include: R2's face sheet dated 1/20/20, indentified an admission to the facility date of 1/2/19. In additions, [DIAGNOSES REDACTED]. The face sheet had also been updated to indicate R2 was admitted to hospice 1/14/20. R2's significant change minimum date set (MDS) assessment dated [DATE], indicated R2 had moderate cognitive impairment, and required extensive assistance of 2 staff for activities of daily living, including repositioning. In addtion, the MDS identified R2 had acquired 1 unstageable pressure ulcer, received scheduled and as needed pain medication, and had a life expectancy of less then 6 months. The previous quarterly MDS dated [DATE], indicated R2 did not currently have a pressure ulcer but was at risk for developing a pressure ulcer. A corresponding care area assessment (CAA) dated 1/20/20, identified R2 had a deep tissue injury injury of the left heel related to pressure. R2's Braden scale skin risk assessment dated [DATE], indicated a score of 11 which indicated R2 had a high risk for pressure ulcer development. R2's care plan dated 8/31/19 indicated a problem area of potential for alteration in skin or pressure ulcer r/t (related to) diabetes, loss of mobility, suprapubic cath (catheter), [MEDICAL CONDITIONS], CAD ([MEDICAL CONDITION]). Current skin tear and tx (treatment) to area Rt (right) lumbar spine. The care plan interventions included: Please monitor my skin with all cares provided. Always report any changes in my skin to my charge nurse for assessment. watch for red areas, open areas, brusing, swelling, rashes or any other skin concerns you notice. preventative measures in use: pressure reducing cushion in seat of the w/c, float heels in bed. Report to nurse any bruising/bleeding; consult with MD/NP (medical doctor/nurse practitioner). Labs and meds as ordered. Reposition q (every) 4 hours -bed, and q 2 hours -chair based on tissue tolerance. Skin treatment as ordered. A care plan revision dated 1/21/19, identified a deep tissue injury on the left heel and a pressure reducing bed mattress was added to the care plan. Interventions included, pressure reducing cushion for seat of wheelchair, float heels in bed, reposition every 2 hours bed and chair based on tissue tolerance. R2's interdisciplinary progress note (IPN) dated 1/19/20, at 2:20 p.m., indicated, R2's left heel was noted to be pinkish/red. No changes in texture, not mushy or boggy. Continue to float heels and check and change every 2 hours to maintain integrity. Continue to monitor. Additionally, on 1/20/20, at 8:30 a.m., IPN indicated, resident is provided repositioning this a.m., noted that heels are on the bed. Left heel is dark red/maroon in color at this time. Appears to be a deep tissue injury. Resident's heels are floated at this time. Pressure skin form is started. Director of nursing (DON) notified. Will notify nurse practitioner (NP). Wound measures 5.9 x 4.2 centimeters (cm). Will continue to monitor. During a interview on 1/23/20, at 5:09 p.m., RN-A, indicated she was called to R2's room on 1/19/20, by the hospice nurse who asked RN-A to view the wound on R2's heel. RN-A stated I cared for him the 2 days prior, I knew the wound was not there before 1/19/20. RN-A stated on 1/20/20, when she assessed the heels again, found a deep tissue injury. RN-A reviewed the turn schedule from the night before and found he was only repositioned 2 times and heels were not floated off the bed. RN-A described R2's skin as intact, deep maroon in the center with white tissue around it. Family was present and were notified of the change in skin integrity. RN-A further indicated every hospice patient was to be checked and changed every 2 hours, and stated there was not a pillow at the end of his bed, his heels were not floated on a pillow so that heels cleared the mattress. RN-A confirmed she passed the information along in report on 1/19/20 at shift change. During an interview on 1/23/20 at 3:04 p.m., the registered nurse manager, RN-B stated R2's heel wound was identified by day shift nurse who had reported the wound to the evening nurse at shift change on 1/19/20. Further, RN-B stated at the time of discovery on 1/19/20, the heel had been described as pink, red in color and blanchable. RN-B stated on 1/20/20, the heel was found to be dark red, and R2's feet had not been elevated and had been left in direct contact with the mattress. RN-B said documentation from the overnight shift had revealed R2 was only turned and repositioned two times during the night, and the heels had not been elevated off the mattress. During an interview on 1/23/20 at 3:10 p.m., the DON stated she had investigated the incident. The DON stated on 1/19/20, the day shift RN-A, who is also the wound nurse for the facility, had observed R2's heel to be pink, but blanchable. As a result, RN-A had updated the 24 hour report on 1/19/20, to include checking and changing R2 every 2 hours, to float heels, and to indicate R2 had decline in condition. The DON stated this updated information had been reported to the evening licensed practical nurse, LPN-A at change of shift 1/19/20 however, LPN-A had failed to notify the nursing assistants who were responsible for R2's care. In addition, LPN-A had failed to create the 24 hour report sheet for the next day, to include the updated information for report on 1/20/20. The DON verified R2 had only been repositioned 2 times during the night shift, and by morning RN-A had found the heel to have deteriorated further. The DON confirmed RN-A had found R2 to have his heels resting on the bed, and had described R2's left heel as dark red, maroon in color, and had assessed it to be a deep tissue injury. The DON stated RN-A had immediately floated R2's heels off the bed, and had notified the DON and nurse practitioner (NP). The DON stated there had a breakdown in communication. The facility's policy revised 7/2017, Prevention of Pressure Ulcers/Injuries included: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors .Mobility and repositioning .3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort.

Based on observation, interview and record review the facility failed to: (1) conduct a thorough analysis to determine the cause of a resident's falls; (2) develop appropriate patient-centered interventions; (3) implement fall interventions; and, (4) evaluate effectiveness of interventions to prevent and/or reduce the likelihood of future falls for one (R32) of three residents reviewed for falls in the sample of five. This resulted in actual harm when after five prior falls, R32 fell on [DATE] and sustained a right [MEDICAL CONDITION] and underwent surgical repair, and since R32 experienced nine avoidable falls. Findings include: Review of R32's listed [DIAGNOSES REDACTED]. Review of R32's Significant Change in Status Minimum Data Set (MDS) assessment, dated 8/6/18 indicated R32 was re-admitted to the facility on [DATE]. Review of R32's MDS assessments dated 8/6/18 and 9/5/18, under Brief Interview for Mental Status (BI[CONDITION]), Section C0500, revealed a score of 10 which indicated R32 had moderate cognitive impairment. Review of R32's care plan indicated, [DATE]: I (R32) scored 7 on BI[CONDITION], indicating severe impairment (A cognitive impairment is severe when the person loses the ability to understand the meaning or importance of something and the ability to talk or write). I am at risk for alteration in cognition .I exhibit LT (long term) memory deficits with some ST (short term) impairments, limited recall and episodes of forgetfulness/confusion. Review of R32's care plan created on 7/01/14 indicated, Risk for fall characterized by history of fall, multiple risk factors related to: dementia with risk for wandering and elopement. I forget to ask for assistance at times. I am also frequently incont (incontinent) of urine. Falls 3-19-18, 4-5-18, 6/16/18, 7/9/18, 7/22/18. R32's care plan goal indicated No injury from fall with a target date of 11/06/2018. Review of R32's undated interventions for this fall risk care plan indicated, Assist handles added to bed to help with bed mobility or positioning. Encourage resident to use handrails or assistive devices properly. Ensure environment is free of clutter and well lit. Low bed and mat at bedside. Maintenance applied Antiroll-back brake system (to wheelchair) (An anti-rollback device is designed to prevent a wheelchair from rolling back and away from the user as he/she attempts to sit down in or stand up from the chair) and screen for therapy done. Reinforce need to call for assistance. Resident to wear proper and non slip footwear. Review of R32's fall incidents revealed the following: 1. 3/19/2018 04:17 (4:17am) Falls Note Text: Writer heard resident call out for help and went to residents room. Noted resident lying on L) (left) side on floor next to bed. Resident is alert and oriented. Resident told writer that she was trying to get up from bed and got legs tangled in blankets then slid off the side of bed . Review of R32's nurse's notes and fall risk data dated 3/19/18 indicated no analysis as to why R32 was trying to get up at 4:17am. The fall care plan indicated no new interventions to prevent or reduce the risk of R32 falling again. 2. 4/5/2018 00:15 (12:15am) Falls Note Text: Staff heard resident yell 'help.' Staff responded and found resident laying on bathroom floor on L) (left) side. Writer noted wheel chair near resident that did not have brakes locked .Resident stated she was going to the toilet and fell when transferring to toilet. Resident admitted that she forgot to put the brakes on the wheelchair.resident complained of some mild pain on back of R) (right) calf. Review of R32's fall care plan that indicated Maintenance applied Antiroll-back brake system was unclear whether this was a new fall intervention for R32 at this time or if the Antiroll-back brake system had failed. 3. 6/16/2018 20:15 (8:15pm) Falls Note Text: Found res (resident) lying on floor of her room by her WC (wheelchair), laying on her left side. Was calling out for assistance. States she was trying to turn around, and fell to floor. C/O (complained of) left shoulder discomfort. Review of R32's nurse's notes, fall risk data dated 6/16/18 and other related falls documentation provided by the facility indicated no analysis to determine the cause of R32's fall. The care plan indicated no new interventions. 4. 7/9/2018 14:15 (2:15pm) Falls Note Text: Heard res yelling for help. Found res lying on floor in her room. Res states she doesn't know what happened .Res unsure if she fell asleep, and fell out of WC (wheelchair). Has large goose egg lump over left eye. Res C/O head pain. Review of R32's nurse's notes, fall risk data dated 7/9/18 and other related falls documentation indicated no analysis to determine root cause of R32's fall, no evaluation of R32's wheelchair, and no indication that a new fall intervention had been entered in R32's care plan. 5. 7/22/2018 07:38 (7:38am) Falls Note Text: This nurse heard patient yelling out for help. Found patient sitting on floor in room in fron t (sic) of her recliner. Noted a sweater that patient had been sitting on slid right along with patient. Review of R32's nurse's notes and fall risk data dated 7/23/18 indicated no analysis and investigation that led to R32's fall, no evaluation or R32's seating, and, no indication that new interventions had been entered into her care plan. 6. 8/22/2018 13:15 (1:15pm) Falls Note Text: staff heard patient calling out and upon entry of room patient was laying on floor on her right side facing her bed .asked patient what she was trying to do prior to her falling and she said she was trying to get into her bed, patient was in her recliner and got up and was walking to her bed and said she slipped, and fell landing on her right hip .a call was placed to ambulance to be sent in (to the hospital) to be evaluated .was transported to the hospital. Review of R32's nurse's notes at 4pm indicated, .ER (emergency room ) called, Report res (resident) did break her right hip. Review of the facility Incident Report (IR) Summary revealed that R32's incident was reported to the State Agency on 8/22/18 at 5:29pm. Review of the same IR under investigation summary, revealed She had been assisted to the recliner by staff after completing her noon meal. (R32) had just completed skilled therapy on 8/14/18 due to non-compliance with participation .She has frequent self transfers and if often redirected and reminded to ask for assistance .(R32) did not request assistance of staff when she fell . It appeared that she stood up and attempted to use her bedside table as a supportive device, causing her water to spill and the mug to lay on the floor. She did not call for help after the spill and continued to self ambulate and slipped and fell to the floor .Full reassessment will occur after her return from the hospital. R32 returned to the facility on [DATE]. Review of R32's Care Assessment Area (CAA) for falls dated 9/5/18 under Analysis of Findings revealed, fell with right hip fx (fracture) and subsequent surgical repair. Does also receive [MEDICATION NAME] (antidepressant medication), which may increase risk for fall .difficulty maintaining sitting balance .impaired balance during transitions .cognitive impairment, other dementia. Review of the same CAA, it asked, Will falls be addressed in the care plan? The answer indicated yes. It also asked to describe impact of this problem/need of the resident and your rationale for care plan decision. The respone indicated, See care plan developed but no rationale was provided. Review of R32's revised fall care plan dated 8/29/18 revealed, Risk for fall characterized by history of fall, multiple risk factors related to: dementia .I forget to ask for assistance at times. Fall 3-19-18, 4-5-18, 6/16/18, 7/9/18, 7/22/18, 8/22/18: Fall with Right [MEDICAL CONDITION]. admitted to hospital and surgical repairs. Falls 10-5-18, 11-2-18, 12-25-18, 2-5-19, 3-25-19, 3-31-19, 4-1 R32's care plan goal indicated, No falls. Review of the same care plan under fall interventions revealed: 10-5-18 Fall r/t (related to) self transferring behavior. VS (vital signs) and neuro's (neurological assessment: check for level of consciousness, perform pupil check, check for muscle strength) initiated. 11-2-18 Fall r/t self transferring behavior. 12-25-18 Sign put on bathroom door reminding resident to use call light for help and toileting assistance. 2-5-19 Fall r/t self transferring behavior. Sign is in place to remind to call for assistance with call light. 3-25-19 Fall assessment completed. 3-31-19 Reminded to use call light that was in reach. 4-1-19 Room re-arranged to visualize resident easier. Reinforce need to call for assistance. Note that the above care plan included interventions requiring reading a sign and remembering to use the call light or ask staff for assistance despite that R32's had been assessed to have severe cognitive impairments. Further review of R32's fall incidents indicated: 7. 10/5/2018 17:22 (5:22pm) Falls Note Text: Heard patient yelling out help me found patient lying on her back on the floor next to her recliner. Patient's w/c breaks (sic) were not locked and patient was trying to self transfer and fell . Review of R32's nurse's notes, and other fall related notes indicated no analysis to determine the reason for R32's self transfer and fall. The care plan intervention dated 10-5-18 of Fall r/t self transferring behavior did not indicate any specific directions to staff on how to handle self transferring behavior or how to correct the problem with R32 not locking her wheelchair brakes that could help reduce R32 from falling. There was no indication if R32's anti-roll back brakes, which had been previously care planned, had been inspected to verify that they were functioning properly. 8. 11/1/2018 05:40 (5:40am) Falls Note Text: Resident was found on the floor by the aide. Resident states that she was trying to get some cream for her buttock and got weak and fell to the ground. Review of R32's nurse's notes, and other falls related notes indicated no analysis to determine the cause of R32's fall. The care plan indicated no changes with the fall prevention interventions. 9. 12/25/2018 01:30 (1:30am) Falls Note Text: CNA (certified nurse aide) heard resident holler out for help, CNA responded then summoned this nurse. Upon entering room noted resident sitting on the floor with legs out in front of her, partway between her bed .Brief partly off and was incontinent of loose stool. Upon questioning resident states she took herself to the bathroom and was on her way back to bed when she lost her balance and fell . Call light was not activated and questioned resident why she didn't use it, replied what call light? Noted call light within reach and tied to mobility bar on bed. Review of R32's nurse's notes and fall risk data dated 12/25/18 indicated no analysis to determine the cause of R32's fall. There was no analysis of R32's toileting pattern to evaluate for possible scheduled toileting program. There was no indication of any revision to the approach to remind R32 to use her call light despite the fact that R32 had said, what call light and that it was documented that the call light was within R32's reach. 10. 2/5/2019 01:00 (1am) Falls Note Text: During visual check at this time CNA (certified nursing assistant) noted resident sitting on her bathroom floor and summoned this nurse. Upon entering room noted resident sitting on the bathroom floor in front of her toilet with legs extended in front of her. Upon questioning resident states she walked to the bathroom from her recliner without walker or wheelchair, toileted and then fell walking back to her recliner stating 'my legs just gave out on me'.Questioned resident why she didn't push her button for help, replied well were (sic) is it. Showed resident call light by her recliner, states well that doesn't do me much good in here. Sign already in place on bathroom door reminding resident to use her call light for assistance. Review of R32's nurse's notes and care plans indicated no information to evaluate effectiveness of fall interventions and whether the interventions were deemed appropriate for R32. There was no documentation indicating that staff recognized R32's inability to know where the call light was located or when to use it. 11. 3/25/2019 23:45 (11;45pm) Falls Note Text: Staff heard resident call for help and found resident in her room sitting on floor in front of recliner. Resident stated she slid off recliner when questioned about what happened. Resident stated she was trying to get up by self. Writer noted resident had call light within reach on recliner but did not activate call light to ask for help. Review of the nurse's notes and fall risk data dated [DATE] indicated no analysis to determine the cause of R32's fall. The care plan intervention dated 3-25-19 of Fall assessment completed indicated no specific directions to staff on what steps to implement to prevent R32's from falling and whether this intervention was relevant. Again there was no documentation indicating that staff evaluated R32's cognition after noting that all the call light was within reach R32 did not use it. 12. 3/31/2019 10:40 (10:40am) Falls Note Text: Heard a loud crash and found patient lying on the floor in front of her recliner with food tray spilt all over her and the floor. Patient attempted to self transfer and fell on her bottom. The care plan intervention dated 3/31/19 was Reminded to use call light that was within reach. Again R32's ability to remember to use the call light was not evaluated and no new intervention was added. 13. 4/1/2019 16:15 (4:15pm) Falls Note Text: Heard res yelling for help. Found res lying on right side beside her bed. Last seen sitting in recliner. States she was trying to answer her phone. C/O (complaint of) right arm/shoulder discomfort while lying on floor, no further c/o after getting off of the floor. 14. 6/26/2019 03:05 (3:05am) Falls Note Text: Staff went to residents room to do cares on resident. Noted resident laying on her left side on floor next to bed on top of two pillows. Noted call light was within reach, bed on low position and lighting in room adequate. Resident stated she did not know why she was on the floor when questioned. Writer asked resident why she did not use call light and resident stated that no one would help her leave this place if she put the call light on.resident complains of BL (bilateral) shoulder pain and rates pain at 5 on 0/10 pain scale. There was no documentation to indicate that staff had considered R32's cognitive ability to follow instructions related to using her call light. 15. 7/12/2019 22:35 (10:35pm) Falls Note Text: Staff heard resident call for help and noted resident laying on left side on floor in her room. Resident denies hitting head. Resident stated he got up from chair and lost balance. Review of R32's nurse's notes, and other fall related documents indicated no analysis to determine the root cause of R32's falls from April - July 2019. Observations revealed the following: 8/5/19 at 3:30pm - R32 was in the activity room, in a wheelchair participating activities along with other residents. 8/6/19 at 10am - R32 was in her room, head bent down, was dozing on and off. R32 was observed sitting in a wheelchair. The width of the wheelchair seat appeared too small to accommodate the width of R32's hips and the seat depth was too short. While R32 was dozing on and off, R32's was sitting in a slouched position and was at risk of falling forward. There was no staff in R32's room to reposition her. 8/6/19 at 10:15am - R32 was still dozing in her wheelchair. The phone was ringing. The phone was on top of her nightstand and was not accessible to R32. R32 was attempting to stand up on her own without assistance to answer the phone. 8/6/19 at 12:23pm - R32 was sitting on a recliner chair seven feet away from the bathroom, facing the bathroom door. The outside bathroom door had a sign that indicated to push the red button for assistance. However, the door was wide open and the sign was hidden, therefore, R32 could not see the sign. During an interview on 8/6/19 at 10:17am with Nursing Assistant (NA)1, who was assigned to care for R32, NA1 stated that R32 needed help for toilet use. NA1 also stated that R32 had tendencies to slide either from the recliner or the wheelchair. When asked if R32 used the call light for assistance, NA1 stated not all the time. When asked if she reminded R32 to use the call light for assistance, NA1 stated R32 could follow directions when NA1 was by her side. NA1 also stated that R32 would not remember to use the call light even if R32 was instructed to use the call light a half an hour ago. NA1 stated R32 was forgetful and confused. When asked if reminding R32 to use the call light made R32 remember to use the call light, NA1 stated, That is why I check her frequently because I know she's forgetful and will not remember to use it. When asked if R32's phone was within reach, NA1 stated, no. During an interview on 8/6/19 at 10:35am with the Occupational Therapist (OT), when asked for her roles in providing seating and wheeled mobility services, the OT stated that after a referral was made by nursing she will evaluate for the appropriate wheelchair size for the resident. When asked if she had received a referral to evaluate wheelchair size for R32, OT stated she did not recall. The OT went to R32's room to evaluate her wheelchair. The OT asked R32 to sit farther back to the wheelchair. The OT stated that R32's wheelchair was too small and R32 needed a wider seat and an increase in seat depth. The OT stated that having an appropriate size of wheelchair would help prevent R32 from sliding down from the wheelchair and thus may prevent falls. During an interview on 8/6/19 at 12:30pm with NA1, when asked how R32 would read the sign posted on R32's bathroom door when the door was wide open, NA1 stated that the other NA who assisted R32 used the toilet did not shut the door. When asked if R32 could read the sign while seated in her recliner, NA1 then asked R32 to read the sign. R32 was not able to read the sign. NA1 assisted and read the sign for R32. When NA1 asked R32 if R32 understood what was read to her, R32 stated, No, I don't want pop. R32 was confused and could not comprehend the signage posted on her bathroom door. During an interview on 8/6/19 at 10:40am with the MDS nurse, the MDS nurse stated that she reviewed R32's fall incidents and developed and updated fall care plans. The MDS nurse stated that the floor nurses should initiate fall care plan interventions each time R32 had a fall. The MDS nurse indicated that R32 did not use the call light for assistance and that R32 was impulsive wanting to transfer herself to and from chair without assistance. The MDS nurse also stated (R32) is a very difficult resident. When asked whether reminding R32, who had severe cognitive impairments, multiple times to use the call light was an appropriate fall intervention, the MDS nurse stated no. When asked, since R32 was confused and forgetful if R32 would be able to carry out the task to remember to use the call light, the MDS stated no. During this same interview with the MDS nurse, the surveyor and the MDS nurse jointly reviewed R32's fall care plans. The MDS nurse confirmed that R32's care plan had limited fall interventions and that it was not a person-centered care plan. When asked if R32's fall interventions have been evaluated for appropriateness, the MDS nurse stated it needed to be reviewed and revised. The MDS nurse stated that since mostly R32's falls were related to toileting needs that scheduled toileting before and after meals and at bedtime may reduce incidence of R32 using the bathroom unassisted. When asked if scheduled toileting plan was in R32's care plan, the MDS nurse stated, it should be added in R32's care plan. When asked if R32's fall incidents since March 2018 to July 2019 had been evaluated and analyzed to determine the root cause and the risk factors that led to her falls, the MDS nurse stated, No, but we recently developed a Falls committee to ensure we discuss the possible cause of the resident's falls and provide immediate and appropriate interventions. During an interview on 8/6/19 at 11:30am with the Director of Nursing (DON), the DON stated that R32's fall interventions had not been re-evaluated. The DON acknowledged that reminding R32 to use the call light was not an effective intervention due to her cognitive deficits. The DON also confirmed that R32's fall incidents lacked investigation and analysis to determine the root cause of her falls. The DON stated that the purpose for the Fall Risk Data (form) was to help analyze R32's falls and to identify the possible causes. The DON confirmed that the Fall Risk Data forms completed for R32 had incomplete data and that some sections were left blank. When asked if R32's falls had been analyzed for trends and patterns that included time, day of the week, location of the fall, and the circumstances surrounding R32's falls, the DON stated I don't know if we have done that. No, I don't see any notes. That was supposed to be the MDS nurse's responsibilities. At 3:15pm, when asked if the consultant pharmacist was involved in reviewing R32's multiple falls and if any recommendations were made, the DON stated that the consultant pharmacist attended QAPI (Quality Assurance and Performance Improvement) meetings and participated in review of R32's falls. The DON stated that the consultant pharmacist did not have any concerns with R32's medications as possible contributing factors to her falls. When asked for the pharmacy review notes related to R32's falls, the DON stated, We don't have documentations for that. During this same interview with the DON, when asked if nursing assistants used a care guide for R32, the DON stated. Yes, it's the kardex. Reviewed R32's kardex provided by the DON indicated, Special Instructions for bathing, dressing, toileting, pain, transfer and Other that included information but were not limited to, frequently used items including phone - kept within reach.Maintenance applied Antiroll-back brake system and screen for therapy done (sic). The kardex indicated no instructions about R32's frequent falls and how to prevent R32's from falling. The DON confirmed that R32's kardex did not have enough information to guide the NA to prevent R32 from falling. The DON made a comment that R32's kardex was terrible and stated that there should be a separate Fall heading' on the kardex with all the fall interventions. Review of the facility's policy revised on July 2017 titled, Accidents and Incidents - Investigating and Reporting indicated, All accidents or incidents involving residents.shall be investigated.The following data as applicable, shall be included on the Report of Incident/Accident form.The nature of the injury/illness (e.g., bruise, fall.) Incident/Accident reports will be reviewed by the IDT (interdisciplinary team) team as needed after the incident to care plan appropriate interventions and the QAPI Team monthly for trends related to accident.and to analyze any individual resident vulnerabilities. Review of the facility's policy revised on March 2018 titled, Falls and Fall Risk, Managing indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under Resident-Centered Approaches to Managing Falls and Fall Risk indicated, The staff.will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident.In conjunction with the consultant pharmacists and nursing staff, the attending physician/primary care provider will identify and adjust medications that may be associated with an increased risk of falling.If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Under Monitoring Subsequent Falls and Fall Risk indicated, The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. Online review at https://www.nhsinform.scot/healthy-living/preventing-falls/falls-and-dementia titled, Falls and Dementia indicated Dementia is a syndrome (a group of related symptoms) that is associated with an ongoing decline of the brain and its abilities. Some of these symptoms include memory loss and difficulties with thinking, problem solving, communication and language.There are different personal risk factors that cause people to fall, however, people with dementia are at greater risk because they: are more likely to experience problems with mobility, balance and muscle weakness can have difficulties with their memory and finding their way around can have difficulties processing what they see and reacting to situations may take medicines that make them drowsy, dizzy or lower their blood pressure are at greater risk of feeling depressed may find it difficult to communicate their worries, needs or feelings Antipsychotic, benzodiazepine and anti-depressant medications are sometimes used to treat the symptoms of dementia. These medications can put you at risk of falling as they're known to cause: drowsiness, dizziness. Dementia can affect the way we perceive and process information from our eyes.

Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance for 1 of 3 residents (R2) reviewed for accidents. R2 suffered harm as a result of a fall from a shower chair. Findings include: R2's face sheet dated 7/29/19, identified [DIAGNOSES REDACTED].), major [MEDICAL CONDITION], dorsalgia (back or spine pain) and [MEDICAL CONDITION]. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R2 had intact cognition, required extensive assist with all activities of daily living (ADLs), and required total assist of 2 for all transfers with a mechanical lift. The MDS further indicated R2 had experienced no falls in the previous quarter. R2's return from the hospital 48 Hour Care Plan dated 7/26/19, identified R2 required 2 assist for dressing and undressing, 1 nursing assistant (NA) to keep eyes on her and within [MEDICATION NAME] distance, and required 2 staff assist and a mechanical lift for transfers. R2's care plan dated 6/21/19, indicated R2 was a fall risk, required two assists and a mechanical lift with transfers and bed mobility, and required one assist with bathing and grooming. The care plan had been revised 7/26/19 to include the decline in activities of daily living following hospitalization for pneumonia, and [MEDICAL CONDITION] embolism following a fall with fracture. Therapy, for conditioning and strengthening, had also been added to the care plan. In addition, the care plan was updated to include the two staff assist while dressing and undressing, one to keep eyes on her within [MEDICATION NAME] distance. Review of incident report on 3/4/19, at 5:34 p.m., indicated R2 leaned forward while removing her shirt over her head while seated in the shower chair in her room. Although NA-A was present and was helping to take off R2's shirt, R2 slid forward in the shower chair. The Incident Report documentation indicated NA-A grabbed R2's shoulder to prevent her from falling on her face. However, R2 fell landing mostly on her legs and turned onto her bottom. R2's legs were criss crossed. This incident resulted in hospitalization for [MEDICAL CONDITION] femur shaft, and [MEDICAL CONDITION] end of the left tibia with surgical intervention. When R2 returned to the facility she had physical therapy and occupational therapy to promote better trunk strength and coordination. The Incident Report also included: R2 does not have the back strength to hold herself up if she is to lean forward, which resulted in her falling from the chair. Review of an Incident Report from 7/19/19 at 3:04 p.m., indicated R2 was sitting in a bath chair, arm rests down, non-slip pad in place. NA-B was preparing R2 for a whirlpool bath and turned around to get a belt for the chair, R2 leaned forward to remove her own shirt and fell out of the chair onto the floor landing in a semi prone right side stance with her legs behind her. R2 was sent to the emergency room (ER) the following day and was diagnosed with [REDACTED]. R2 returned from the ER with a splint on the lower right extremity, and pain medications. A follow up appointment was scheduled with the orthopedic physician within the week. Immediate interventions upon her return included for the resident to have two staff at all times when undressing and dressing self. Although R2 had known predisposing conditions which created a fall risk for her, no comprehensive assessment to determine appropriate interventions had been conducted between the 3/4/19 and 7/19/19 falls. The hospital reports were reviewed and included: 7/20/19 History: Presents to ER with L side ankle pain. The patient had a fall at her nursing facility yesterday. She had a X ray performed of her rt (right) ankle and was found to have a fracture. The pt (patient) came to this ER early this morning for splinting of this fracture. Shortly after arriving back at her facility she then began to complain of pain in her left ankle. X rays were not performed of this side. The pt did not receive any med (medication) for pain at her facility the Pt is unable to move her bilateral lower legs chronically. Her sensation remains intact. She denies any injury or pain else where. Additionally, the hospital history notes from 7/19 and 7/20/19 included: There are old fractures of distal tibia and fibula head with mild deformity. 1. No definite evidence of acute fracture or dislocation. 2. Moderate [MEDICAL CONDITION]. And 7/19/19 Pain from fall on 7/19 history of Tib Fib fracture. 1. Moderate osteopenia of the bones. 2. Non displaced fracture of distal left tibia. 3. Acute impacted fracture of proximal tibia. 4. Acute impacted fracture of fibular neck. 5. There are changes of [MEDICAL CONDITION] joint disease. Impression acute tibia and fibular fractures. During an interview with R2 on 7/29/19 at 2:20 p.m., R2 stated, I have severe [MEDICAL CONDITION]. It happened the same identical way both times. I was sitting in the bath chair that they take you to the tub room in. R2 when she began removing her shirt she began to fall. She stated the nursing assistants were in the room and said, Going forward they want me to sit in the chair and let the aides take my shirt off. They also always have two aides during cares. The Dr. told me my bones are so brittle they break. R2 also stated she had experienced ataxia since she was a child, and had not walked in [AGE] years. The Director of Nursing (DON) was interviewed on 7/29/19 at 2:56 p.m., the DON indicated the falls on 7/19/19 and 3/12/19 were identical. The DON verified following the 3/12/19 fall, the facility had initiated therapy to have R2's ataxia and trunk strength worked on. After the 7/26/19 fall, the care plan was updated to include a second nursing assistant in the room to encourage R2 to keep dressing and undressing, but stated, Now the aide must be hands on.