Every finding on record at Three Links Care Center

Based on interview and document review the facility failed to ensure safe transfers with a full body mechanical lift for 1 of 3 residents (R1) reviewed for falls/safety. The facility's failure resulted in an immediate jeopardy situation for R1 when he slipped out the full body mechanical lift sling and fell from an elevated height. R1 was hospitalized due to a new fracture of the right femur and needed surgical intervention. The IJ began on 9/12/25, when 2 of 2 nursing assistants (NA)-A and NA-B did not follow manufacturer's recommendations for a safe lift transfer using the full body mechanical lift and the sling was not attached properly. As a result, R1 fell from the lift and sustained a new fracture of the right femur that needed surgical intervention. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 9/19/25 at 8:59 a.m. The facility implemented immediate corrective action on 9/12/25 to prevent reoccurrence, so the deficient practice was issued at past non-compliance (PNC).Findings include: R1's face sheet dated 9/12/25, identified diagnoses of unspecified fracture of the shaft of right femur (long bone located in the thigh) with routine healing, artificial hip joint, hemiplegia (a condition characterized by paralysis or weakness on one side of the body) and hemiparesis (one sided muscle weakness), and cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage to the brain). R1's Significant Change Minimum Data Set (MDS) dated [DATE], identified R1 had a diagnosis of fracture of shaft of right femur, was dependent on staff for all transfers, had no falls since admission/readmission, and was cognitively intact. R1's care plan activities of daily living focus, identified R1 had a self-care performance deficit related to hemiplegia-stroke. Interventions initiated on 5/3/25, were as follows: assist of two with total mechanical lift between surfaces using a large hourglass sling. R1's progress note dated 9/12/25, identified R1 had a fall from the total mechanical lift and had to be sent to the emergency department (ED) due to hitting head. The root cause of R1's fall seemed to be that there were two black loops on the sling and each aide picked different black loops causing slack to be in the sling which made one side of the sling fall off the arm of the total mechanical lift. R1's fall risk management report dated 9/12/25 at 12:05 p.m., indicated two staff placed R1 in a sling to transfer from wheelchair to bed. Staff positioned R1 to turn to begin transfer and during that time, the sling loop slid off the lift arm and resident slid to the ground. R1 struck his head and was sent to the ED for evaluation. Interdisciplinary team (IDT) intervention: Immediate education completed with all staff on different loops of the sling, mechanical lifts and Inservice scheduled with lift company and slings.R1's facility post-fall evaluation dated 9/12/25, indicated that R1 had a fall during a transfer in a lift and the reason for the fall was evident, due to upper black loop used and lower black loop used.R1's hospital ED note dated 9/12/25, indicated R1 was seen following a fall in the nursing home, and unfortunately there was equipment failure, and the strap slipped off the lift they were using and R1 fell to the ground and struck the back of his head. Two computed tomography (CT) done of the head and no significant findings and no palpable defects or tenderness noted to the hips or femur. R1's hospital ED did not identify imaging of his or femur was completed. R1's progress note dated 9/12/25 at 9:19 p.m., identified R1 was seen in ED for evaluation for head strike and had two computed tomography (CT) scans six hours apart to make sure no new head bleed. Repeat CT was stable and no new orders. R1's clinic orthopedic visit note dated 9/16/25, indicated R1 was seen for a post operative visit to evaluate a right hip resection that was done 2 months prior and Unfortunately, there was an accident at R1's nursing facility 4 days ago where there was a malfunction with the total mechanical lift that resulted in a fall from an elevation for R1. R1's x-rays of the right hip and femur identified a new fracture of the mid shaft of his right femur at the site of prior cerclage (internal fixation method using wires around bone) wires and recommended admission to hospital for surgical intervention. R1's hospital operative note dated 9/18/25, indicated R1 had a complicated history of recalcitrant (resistant to treatment) requiring multiple revisions in the past, ultimately leading to a [NAME] (removal of the upper portion of the femur) resection. Unfortunately, there was an accident in R1's nursing facility 6 days ago and R1 was dropped from the full body lift when there was an equipment malfunction. This resulted in a femoral shaft fracture at the mid-diaphysis (middle section of the long bone) of his remaining femur. At this time there is no functionality of his femur given the prior [NAME] and recommended resection (removal of all or part) of his remaining proximal (situated near) femur, proximal to the site of the fracture. During an interview on 9/18/25 at 11:44 a.m., NA-A and NA-B stated they engaged in the transfer of R1 when he fell out of the sling on 9/12/25. NA-A stated she believed she attached the top slings to R1, but did not verify that the same length loops were attached on the other side. NA-B stated she attached the bottom sling loops, making sure they were the same color. NA-A and NA-B then began lifting R1 out of his wheelchair and NA-B stated she verified that two black loops were attached, but did not verify that the loops were the same length and only looked at the color of the loops. R1's right leg was sticking out, so NA-B bent down to move R1's leg and as NA-A and NA-B began to turn R1 towards the bed, there was a release of tension on the sling on the left arm and the sling came off of the lift. R1 began to fall out of the sling and hit his head on the ground. R1's right leg was still in the sling as he was on the ground for a few seconds and then he fell completely out of the sling on his right side. NA-A and NA-B further stated they had not noticed that the type of sling R1 used (hourglass) sling had two separate black loops, however, NA-A and NA-B stated they were aware that the same length loops needed to be attached during a transfer to prevent release of tension, but did not ensure the same lengths were used. NA-B and NA-A stated they had not received any specific training on the specific type of sling that R1 used on the day of the fall. During an interview on 9/18/25 at 9:48 a.m., administrator stated the facility did a re-enactment of the transfer of R1. During the re-enactment, NA-A and NA-B stated they hooked up R1's hourglass sling using the correct length loops, however, could not replicate any release of tension from the full body mechanical lift arms. Because R1's sling had two sets of black loops, we attempted the transfer using two different length black loops on the lift, and upon doing so we noticed a release of tension on one of the shoulder loops and it came off the arm of the lift. After this finding, the facility determined the use of the two different length black loops on the sling was the root cause of R1 falling out of the sling to the ground. The facility then placed a tape on the second set of black loops on all of the hourglass slings and began immediate education with nursing staff on the type of sling with different color loops to ensure the same length was used for all transfers. During an interview on 9/18/25 at 8:57 a.m., ADON stated R1's hourglass total mechanical lift sling that NA-A and NA-B used prior to R1's fall on 9/12/25, had 2 sets of black loops (one set on the top of the sling and one set on third set of loops), however, she was not aware this type of sling had two sets of black loops and could cause a risk for placing the incorrect length when attaching the sling. ADON stated, The loops of the sling do not just slip off and during the re-recreation of the transfer when using two different lengths of black loops, we noted a tension release and caused the sling to come off the arm of the lift. ADON further stated, She was 99% sure the incorrect loops were used by NA-A and NA-B and this is why R1 fell out of the sling to the ground. During an interview on 9/18/25 at 2:56 p.m., R1's medical doctor (MD)-C stated if any resident fell from a lift at two feet would put that resident at risk for serious injury or harm. During an interview on 9/19/25 at 11:37 a.m., orthopedic surgeon medical doctor (OS-MD) stated R1 had been seen on 9/16/25, for a scheduled follow-up and had been informed R1 had a fall from a total mechanical lift four days prior. R1 had imaging done of right hip and right femur and was found to have a new transverse (according to the Cleveland Clinic a transverse fracture are a type of broken bones, usually caused by falls or car accidents) fracture of the femur. OS-MD further stated, most definitely the fall from the lift caused the fracture of R1's femur and put him at risk for serious risk for harm and did cause serious harm for R1 due to needing surgery. Review of the facility's Mechanical Lift Policy dated 5/28/25, identified facility staff would use appropriate techniques and processes when utilizing mechanical lift devices to lift and move residents, to protect the safety and well-being of staff and residents, to promote quality care, and to follow applicable laws regarding use of power-driven mechanical lifts. Review of the facility's Fall Prevention and Management Policy dated 6/5/23, identified The interdisciplinary team (IDT) would evaluate the fall by reviewing the fall incident report to determine a Root Cause Analysis (RCA) of the fall and further interventions may be put into place according to the determined cause of the fall, to help prevent further falls. Any further interventions that were developed would be documented. The immediate jeopardy was issued at PNC after it was verified the facility implemented the following prior to survey: -R1 was sent to ER for evaluation following fall on 9/12/25, and will be reassessed on return from the hospital for proper sling size and care plan updated. -Sling and lift used for R1's transfer was removed from use until inspected and found to be free of malfunction. -NA-A and NA-B had return demonstration competency testing done on 9/12/25, for safe lifting using the mechanical lift. -The facility reviewed their policy and procedure for safe mechanical lift transfers and developed a plan to ensure identification via color coding the sling loops to ensure the correct one being used. Policy will be adjusted after mechanical lift representative reviews policy on 9/23/25, if needed. -All residents utilizing similar slings like R1 have had the proper sling to use marked with the colored tape to identify the same loops.-All residents who utilized the mechanical lifts had slings inspected, care plans reviewed to ensure the proper sling size in the care plan. -The facility began re-education with return demonstration, to nursing staff on manufacturer's recommendations of using the full body mechanical lift to include checking the straps for tension and using proper sling size according to the care plan beginning on 9/12/25, and will be having mechanical lift representative provide education on 9/23/25, to all of the nursing staff.

Based on interview and document review, the facility failed to ensure resident choices for bathing preferences were assessed and honored for 1 of 1 residents (R1) reviewed for choices. Findings Include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 had intact cognition with no hallucinations or delusions. The assessment indicated R1 needed moderate staff assistance with dressing, toileting hygiene, personal hygiene and footwear. On 7/28/25 at 6:33 p.m., R1 stated that she preferred to have a shower in the evening. R1 stated the facility had always given her showers during the day except for one time when they did not have time to complete it during the day and gave her a shower in the evening. R1 stated how much she enjoyed the shower in the evening and I have told everybody how much I liked the shower in the evening. R1's care plan, printed 7/29/25, identified the following: -Resident preferences will be considered when providing care with the following preferences: bedtime preference of 10 p.m., music preference of inspirational/religious the importance of being around animal such a s pets was very important. - BATHING/SHOWERING: I am able to: Limited A-1 with 2WW and gait belt- HS ROUTINE: I am a night owl. I prefer to call for assistance when I am ready for bed. On 7/29/25 at 11:34 a.m., licensed practical nurse (LPN)-C provided a copy of the shower/bath schedule and stated this was the schedule the facility used for resident showers/baths. Facility shower schedule, printed 7/29/25, identified R1 prefers shower only and R1's showers were offered weekly on Mondays. The facility shower schedule lacked identification of R1's preference for an evening shower. Furthermore, the shower schedule indicated, Day bath aide 6-2pm and any leftover baths would be coordinated with evening staff to complete, and the nurse would continue to do weekly bath audits day/eves. R1's July 2025 medication and treatment administration record (MAR), printed 7/29/25, identified the following order:-Total body skin assessment every Monday AM (day) shift starting 5/26/25. Per record, was completed 7/7/25, 7/21/25, and 7/28/25. On 7/14/25, it was documented with a 9 which indicated other/see progress notes. R1's Resident Preferences Evaluation, dated 5/29/25, identified R1 had a sponge bath bathing preference. Furthermore, the assessment indicated R1 preferred an afternoon or evening time of day for bathing. R1's progress notes, dated 5/22/25 to 7/29/25, were reviewed. R1's progress notes, dated 5/29/25, indicated a resident preference evaluation had been completed which identified R1 preferred to bathe in the afternoon or evening and preferred a sponge bath. The progress notes lacked evidence of any additional conversations of R1's preferences or how the facility was going to help meet resident's preferences. During an interview on 7/30/25 at 8:55 a.m., nursing assistant (NA)-D stated that she did majority of the showers for residents in the facility. NA-D stated the shower schedule was determined by the care coordinators and the days were set, typically, by room numbers. NA-D stated when residents moved into the facility they were assessed to determine if they preferred day or evening showers or if they preferred baths or showers. NA-D stated there were no residents who had a preference for evening showers. NA-D stated she did as many showers as she could during the day but occasionally, she was unable to complete a shower and then it got done in the evening, but the showers were not scheduled in the evenings. NA-D reviewed the shower schedule and verified there was not an identified preference for R1 to have an evening or afternoon shower. NA-D stated R1 got one shower a week on Mondays and preferred to have a shower, not a bath. NA-D stated she had always given R1 her showers in the mornings and verified she has given R1 almost 75% of her showers. During an interview on 7/30/25 at 11:45 a.m., registered nurse coordinator (RN)-B stated an assessment was completed on admission to identify resident preferences. RN-B stated if a preference for bathing times was identified, the information would be passed along to the rest of the team and the bath schedule would be updated. RN-B stated she was aware of one resident that preferred an evening bath and verified it was not R1. RN-B reviewed Resident Preferences Evaluation, dated 5/29/25 and verified R1 had identified a preference for an afternoon/evening sponge bath. RN-B stated some of the assessment forms had changed since May, the life enrichment department had completed this assessment, and she was not aware of this. RN-B stated since the preference had been identified during an assessment, the expectation would be R1 would be offered her bathing preference in the afternoon or evening. During an interview on 7/31/25 at 8:59 a.m., life enrichment director (LED) verified she completed the Resident Preference Evaluation for R1 on 5/29/25. LED stated this was a newer form for the facility. LED reviewed the form and verified R1 had identified a bathing preference. LED stated she had not passed this information along as this was information nursing had always evaluated, and she thought nursing had this information. LED stated the facility had newer forms and it has been a learning process, and the facility was working on new processes to increase communication with the team to ensure preferences were met. During an interview on 7/31/25 at 10:35 a.m., director of nursing (DON) stated the expectation would be for the facility to do everything they could to honor a resident's identified preference. DON stated they had recently switched some assessments, and some of the preferences (bathing preferences) were previously assessed by nursing and were switched to the activity assessment and they were working through this. A facility policy titled Dignity, revised 4/17/23, was provided. Policy indicated reasonable accommodation of the resident's needs, preferences (including sexual), and physical limitations will be directed towards assisting the resident in maintaining independent function, dignity and well-being. A policy on resident preferences/choices was requested and not received.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded, with the potential for inaccurate federal reimbursement and resident care planning for 1 of 5 residents (R48) reviewed for MDS accuracy. Findings include:The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicates clinical standards do not support reverse staging or back-staging as a way to document healing as it does not accurately characterize what is occurring physiologically as the ulcer heals, as the tissues lost will never be replaced with the same type of tissue (page M-7). The manual instructs that once a pressure ulcer is healed, it should be documented as a healed pressure ulcer at its highest numerical stage, as it would remain at an increased risk for future breakdown and require continued monitoring and preventative care (page M-8). The manual indicates that a previously closed pressure ulcer that reopens should be reported at its worst stage, unless currently presenting at a higher stage or unstageable (page M-7). The manual indicates that healed versus unhealed ulcers in the section refer to whether or not an ulcer is closed versus open (page M-2). The manual further defined a healed pressure ulcer as completely closed, fully epithelialized [to be covered by the tissue type typically making up the outer layer of healthy skin], covered completely with epithelial tissue or resurfaced new skin (page M-2).R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated R48 had one stage two pressure ulcer that was not present on admission and no stage three pressure ulcers. R48's provider note dated 3/11/25, indicated the provider was able to visualize the depth of the wound, and R48 had a stage 3 pressure ulcer on her right foot between her toes. R48's wound note dated 6/19/25, indicated R48 had a recurrent stage two pressure ulcer on her right foot between her great and second toe that was currently unhealed with the presence of slough and increased drainage. R48's progress note dated 6/24/25, indicated the wound between the toes on the right foot remained open. R24's Comprehensive Skin Risk assessment dated [DATE], indicated R48 had a healed stage two pressure ulcer on her right foot between her right and second toe as the area was scabbed. During an interview on 7/29/25 at 1:27 p.m., registered nurse (RN)-C stated R48 had a recurrent skin injury that was between the great and next toe on her right foot. RN-C reviewed his notes and stated that the last time he saw that the wound was open was on 7/11/25.During an interview on 7/30/25 at 8:12 a.m., RN-D, an MDS coordinator, confirmed she had completed R48's latest quarterly MDS. RN-D confirmed R48's wound had not been healed at the time of assessment. RN-D stated she had coded the wound as a stage two but had not realized at the time that R48 previously had a stage three pressure ulcer in that spot. RN-D stated that usually, when someone has a pressure ulcer, they will add a diagnosis indicating this to the diagnosis list. RN-D stated that this was not completed, so she had not realized R48 previously had a stage three pressure ulcer in that same spot. RN-D stated that if she had known, she would have coded the wound as a stage three. During an interview on 7/30/25 at 12:46 p.m., nurse practitioner (NP)-A stated she had assessed R48's right foot pressure ulcer when it had first been found multiple months ago and had staged it as a stage three related to the wound's depth. NP-A stated the wound was between R48's in the crease between her first and second toe, was caused by pressure from her contracture, and had since recurred in the same spot. During an interview on 7/31/25 at 10:29 a.m., the director of nursing (DON) stated she would defer questions regarding the MDS to the MDS coordinator.The Facility's MDS 3.0 Assessment policy dated 8/20/24, indicated all interdisciplinary team members involved in completing portions of the MDS record must review and under the current version of the RAI user's manual. The policy indicated the MDS coordinator was responsible for conducting audits to identify errors and make appropriate corrections during the encoding period to ensure accurate information was submitted.

Based on observation, interview, and record review, the facility failed to maintain the dignity of 1 of 2 residents (R31) reviewed who were cognitively impaired and had facial hair. Findings include:R31's admission Minimum Data Set (MDS) assessment dated [DATE], identified admission to the facility on 7/10/25, with diagnoses of non-Alzheimer's dementia, arthritis, depression, and cataracts. R31 had moderate cognitive impairment, used a wheelchair for mobility, required substantial assistance from staff for hygiene to include combing hair, shaving, washing/drying face and hands, baths, showers, and oral hygiene.R31's care plan dated 7/10/25, identified activity of daily living (ADL) interventions for bed mobility, oral cares, toilet use, transfers, bathing and showering, dressing and eating. Bathing and showers required a mechanical lift with assist of two staff for transfers. The plan lacked interventions to address shaving or grooming facial hair. A care sheet for July 2025 lacked documentation R31 received any type of grooming or shaving facial hair.R31's behavior assessment report dated 7/17/25, identified no physical or verbal behaviors were directed towards staff.R31's N-Adv ADL Only report (a report in the electronic medical record used by nursing staff to review or audit documentation related to ADL's which are key for MDS assessments) dated 7/17/25, identified extensive assistance for personal cares.R31's N-Adv Resident Preferences Evaluation report, dated 7/17/25, indicated an interview for daily and activity preferences was not conducted. The first question on the evaluation was, should interview for daily and activity preferences be conducted and a box was checked NO. The questions on the evaluation were used to identify resident preferences, for example, time of day for bathing, dressing, or bedtime.R31's weekly bath log dated 7/15/25 and 7/29/25, indicated R31 received a bath and included a field to document the cleaning of a shaver. The report lacked documentation a shaver was cleaned.R31's admission care conference report dated 7/22/25, identified total assist with all ADLs.R31's Kardex dated 7/29/25, identified cares but lacked information that addressed grooming or shaving facial hair.During an observation on 7/28/25 at 5:01 p.m., R31 had several white chin hairs, approximately 1/4 inch long and a full white mustache. During an observation on 7/29/25 at 11:50 p.m., R31's chin hairs were still present after a bath.During an interview on 7/29/25 at 12:33 p.m., licensed practical nurse (LPN)-A stated R31 had a bath this morning and it was always on Tuesday mornings. During an interview on 7/29/25 at 12:37 p.m., nursing assistant (NA)-B stated R31's bath was given that morning and they would shave her chin hair, if asked. NA-B stated they believed residents had to bring in their own shaver and R31 did not have her own, so they wouldn't do it. NA-B confirmed R31 had chin hair and a mustache but did not have a shaver. During an interview on 7/29/25 at 12:40 p.m., nursing assistant (NA)-A stated residents needed to supply their own razors, and NA-A was aware of one female resident with a razor and wanted to be shaved. NA-A indicated most residents who refused to be shaved had documentation on the care plan. NAs document baths in the tub book binder located in each tub room and if residents were shaved, NAs document the shaver was cleaned.During an interview on 7/29/25 at 12:44 p.m., NA-B reviewed the tub book and verified R31 received a bath on 7/15/25. The column with clean shaver was marked with a straight line indicating the task was not completed. NA-B verified a bath was completed today, 7/29/25, but not charted in the tub book, but would be before the end of the shift. NA-B verified that R31 was not shaved during their baths. During an interview on 7/29/25 at 12:45 p.m., R31 was unable to state if facial hair bothered her.During an interview on 7/29/25 at 1:25 p.m., family member (FM)-A stated R31 would be bothered by having facial hair and used to tweeze chin hairs. R31 has been confused but they would expect the facility to take care of facial hair during baths.During an interview on 7/30/25 at 7:27 a.m., registered nurse (RN)-A stated the expectation was female facial hairs were plucked or shaved during their bath. Usually the assessment identified resident preferences, but if it was not documented that a resident refused it was expected to be done during their bath. The resident must supply a razor. During an interview on 7/30/25 at 9:01 a.m., nursing assistant (NA)-C verified R31 had hair above her lip (mustache) and several white chin hairs approximately 1/4 inch long. NA-C verified there was not a razor in R31's room but stated R31 would not refuse shaving if it was offered. During an interview on 7/31/25 at 10:42 a.m., the ADON stated the facility had personal care items available upon admission, but the family would need to supply specialty items. Bath aides should be offering shaving for female residents, and if a resident wanted to be shaved, the family was asked to bring in an electric razor. If a resident did not have family, they could work with the clinical coordinators for donations but wouldn't leave a resident unshaved unless it was their preference. The ADON stated she was unaware the aids were not shaving females if there wasn't a razor in the room.A policy for ADL's was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 2 residents (R3) reviewed for infection control related to the management of a tube feeding.Findings include:R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated R53 was cognitively intact, and had no behaviors or hallucinations. MDS also indicated R53 had difficulty swallowing and received enteral feeding via a tube.R53's Clinical Diagnosis Report dated 7/31/25, indicated dysphagia following cerebral infarction, pharyngeal dysphagia, diverticulum of esophagus, gastrostomy, anxiety and gastro esophageal reflux.R53's Clinical Orders Report indicated R53 had orders for enteral feeding, medications via tube feeding, and nothing per mouth. Orders Report also indicated special instructions for EBP.R53's care plan printed on 7/31/25, titled feeding tube, directed staff to use infection control precautions and related techniques following the manufacture recommendations when stopping, starting, flushing, and giving medications through the feeding tube.During observation on 7/28/25 at 3:28 p.m., a sign posted on R53's door indicated R53 was under EBP and identified staff must wear gloves and a gown for high contact resident care activities including cares or use of the feeding tube. During observation on 7/28/25 at 3:33 p.m., registered nurse (RN)-E entered R53's room, washed her hands, put on gloves, but did not put on a gown. RN-E explained to R53 she was scheduled to received Tylenol, a water flush, and it was time to start her tube feeding. RN-E did not wear a gown throughout these procedures.During interview on 7/28/25 at 4:11 p.m., RN-E stated I was supposed to wear a gown, and I did not. I just forgot. RN-E stated R53 was on EBP precaution because she had a tube feeding and was at risk for infections.During interview on 7/31/25 at 9:40 a.m., nursing assistant (NA)-E stated staff did yearly training online, and throughout the year they did specific training for different infections. NA-E added, we just had additional training last week about standard precautions. There are signs posted in the residents' doors instructing staff to wear protective equipment like gowns, gloves, and sometimes masks. We need to read the signs before we enter the rooms to make sure we don't spread infections. We must wear the equipment to prevent giving something to the patients that are already compromised and to protect ourselves.During interview on 7/31/25 at 9:47 a.m., licensed practical nurse (LPN)-E, stated when a resident received medications through a tube feeding, he or she would be on enhanced barrier precautions. We will need to wash our hands, wear gloves and gown to prevent the spread of infections. We receive infection control education at least a couple times a year and at every nurses monthly meeting we talk about it.During interview on 7/31/25 at 9:54 a.m., assistant director of nursing/infection control nurse (ADON) stated, RN-E was supposed to wear a gown while caring for R53 because R53 had a tube feeding and the nurse administered a medication, flushed the tube with water and started R53's tube feeding. ADON stated the EBP was in place to protect R53 from infection or bacteria, and to protect the staff, as it was an infection control concern for the resident.Facility policy titled Enhanced Barrier Precautions dated 8/20/2024 indicated facility will apply EBP to prevent the spread of multidrug-resistant organisms (MDROs). Policy indicated EBPs shall be used when providing high contact care to residents who are colonized or are infected with an MDRO when contact or other precautions do not apply. EBP should also be used for residents with chronic wound and/or indwelling medical devices (e.g., urinary catheters, feedings tubes, central lines, tracheostomy).

Based on observation, interview, and document review, the facility failed to comprehensively re-assess for safe self-administration of medication given via a nebulizer for 1 of 1 residents (R37) reviewed for self-adminstration of medications. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 had intact cognition and was diagnosed with respiratory failure and Chronic Obstructive Pulmonary Disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness). The MDS indicated that R37 was receiving hospice services. R37's Self Administration of Inhaled Medications assessment dated [DATE] and 5/14/24, indicated R37 was able to demonstrate correct administration of medication via a nebulizer after staff set-up. R37's Self Administration of Inhaled Medications assessment dated [DATE], indicated R37 was able to correctly demonstrate how to use a nebulizer but due to staff reports of R37 falling asleep while completing the medication administration, he is not administering medication safely. The assessment indicated the nurse would now need to observe R37's nebulizer treatments. R37's order summary indicated R37 dated 5/22/24, included the following orders: -Dated 6/28/23, one vial of ipratropium-albuterol inhalation solution (medication used to relax and open the airways) via a nebulizer six times a day for shortness of breath. -Dated 7/5/23, 2.5 milligrams of albuterol sulfate inhalation solution (medication used to relax and open the airways) via a nebulizer for shortness of breath 12 times a day. -Dated 8/13/23, R37 would like to self-administer nebulizer treatment so staff should set up the treatment and staff were to update hospice or the care coordinator with concerns. -Dated 5/22/24, indicated R37 was not consistent while self-administering his medication via a nebulizer and was occasionally falling asleep during treatment. The order indicated the nurse/trained medication aide was to observe R37's nebulizer treatments. During an observation on 5/20/24 at 6:42 p.m., R37 was observed sitting in his recliner appearing to be asleep. R37 had an audibly running handheld nebulizer that was upside down, as his hand with his nebulizer had fallen to his lap. The nebulizer medication cup appeared half full of a solution. During an interview on 5/20/24 at 6:44 p.m., licensed practical nurse (LPN)-A stated she had set up R37's nebulizer with the ipratropium-albuterol inhalation solution but R37 was able to complete the treatment by himself after set-up. LPN-A stated she had observed R37 fall asleep while completing the nebulizer treatment in the past, but she was unsure who completed the assessment to determine if R37 was safe to self-administer the medication. During an interview on 5/22/24 at 10:24 a.m., registered nurse (RN)-C, the hospice nurse, stated it was very common for R37 to fall asleep during his nebulizer treatments and it had been occurring since he was admitted to this facility in 2023. RN-C stated R37 would take his oxygen cannula off while completing the nebulizer treatments and then R37 would fall asleep, the nebulizer would fall out of his mouth, and his oxygen saturation would lower quickly but RN-C did not normally stay with R37 while he completed his treatments. RN-C stated he had thought R37 falling asleep during nebulizer treatments was a known occurrence but it was hard for nursing staff to stay with R37 during these treatments as he had 18 of them a day and took a significant amount of time to complete. During an interview on 5/22/24 at 2:09 p.m., RN-A, the nurse manager, stated she was in charge of assessing if residents could safely self-administer medications. RN-A stated floor staff had not informed her of R37 falling asleep while completing nebulizer treatments. RN-A stated R37 completed nebulizer treatments during the day and night and she had previously completed the assessment during the day so she was unsure if he was falling asleep while administering the medication at night. During an interview on 5/23/24 at 9:53 a.m., the director of nursing (DON) stated she would have expected the nursing staff to alert the nurse manager if R37 was falling asleep during treatment so methods for safe administration could have been developed after re-assessment. The DON stated it was important for nursing staff to ensure R37 was receiving these medications properly so R37 could receive the full benefits of the medication. The facility's Self-Administration of Medications by Residents policy dated 5/1/24, indicated if a resident wished to self-administer medications, facility staff would assess their ability to do so and document the findings. The policy indicated that a periodic re-assessment of the resident's continued appropriateness for self-administration would be completed. If it was determined to be unsafe for the resident to self-administer the medication, options for safe administration of the medication would be assessed.

Based on interview and document review, the facility failed to ensure identified preferences for bathing routines (i.e., twice weekly) were honored to promote quality of life and resident' choice for 1 of 2 residents (R7) reviewed for choices during the survey. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had intact cognition. On 5/20/24 at 2:09 p.m., R7 was interviewed, and she expressed frustration with her bathing routine adding, I was getting two baths a week but now they [staff] told me I'd only be getting one. R7 stated staff told her this a few weeks prior and she was not given a reason for the reduced bathing schedule, at least to her recall. R7 reiterated she wanted her second (in a week) bath re-scheduled adding, That would be nice. R7 stated she assumed they reduced it due to a lack of staff adding, They got so many people [other residents] here. R7's care plan, dated 4/10/24, identified R7 needed assistance with activities of daily living (ADLs) due to weakness and difficulty with mobility. The care plan outlined R7 needed extensive assistance to complete bathing which had a recorded frequency, Weekly. The intervention was initiated 4/12/24. R7's most recent Resident Care Conference Summary - V7, dated 4/27/24, identified R7 had a care conference on 4/17/24, along with multiple sections provided and completed by various medical disciplines (i.e., social services, nursing). This summary outlined R7 and registered nurse manager (RN)-A both attended the care conference along with a section labeled, Care Plan, which had several responses listed and corresponding checkmarks placed next to the staff' recorded response. This included a checkmark placed next to, Personal preferences reviewed/updated. However, the summary lacked any more specific information on what preferences were reviewed, explained or what, if any, updates to them were made with corresponding rationale. When interviewed on 5/21/24 at 1:17 p.m., nursing assistant (NA)-A stated the facility used a bath aide who completed most baths for R7. On 5/21/24 at 2:42 p.m., RN-A and RN-B were interviewed. RN-A verified they had reviewed the facility' current bath schedule and R7 was scheduled for only a weekly bath. RN-A stated R7 had been scheduled for a twice weekly bath and, to their knowledge, should still be adding they guessed staff may have brought it upon themselves to remove the second one. RN-A stated they were unsure exactly when or why the second scheduled bath had been removed adding, I thought she was still getting it. RN-A explained bathing schedules were reviewed with each resident upon admission and reiterated R7 was supposed to be getting two baths a week adding such was also an intervention for R7's skin issues. RN-A stated they would follow-up with R7's normal bath aide when they returned to work about why the second bath had been removed. RN-A and RN-B verified bath schedule changes, such as going from two a week to once weekly, were typically for the most part done by them and reiterated they would investigate the concern with R7's bath schedule. A provided bath schedule, untitled or dated, listed multiple residents names, including R7, along with a header reading, Wednesday. This verified R7 was only getting a weekly bath. Further, the listing identified bolded wording at the bottom, Do not change bath schedule. Update CC [mangers] with concerns. A provided listing, untitled, outlined R7's completed baths with spaces to record the date, weight, and corresponding staff initials. This identified R7 received a bath on 4/3/24, 4/6/24, and 4/10/24. Then, after 4/10/24, the written dates were listed as 4/17/24, 4/24/24, 5/1/24, 5/8/24, and 5/15/24 (i.e., once weekly). The form lacked any written evidence demonstrating rationale for the removal of the second bath nor evidence R7 had consented to such. Further, R7's medical record was reviewed and lacked evidence or justification for the removal of the second bath as had been in place and verified by nursing leadership (i.e., RN-A) as being an intervention for R7. A provided Person Centered Care Planning policy, dated 4/2023, identified the care center would develop a care plan consistent with resident's rights and needs. A facility' policy on choices and bathing preferences was requested, however, none was received.

Based on interview and document review, the facility failed to ensure resident' trust account balances above the state-required supplemental security income (SSI) threshold (i.e., $3,000) were identified and acted upon to ensure ongoing coverage and reduce the risk of complication for 2 of 2 residents (R13, R42) reviewed who had balances exceeding the threshold. Findings include: A Minnesota Medical Assistance Treatment of Assets and Income, dated 9/2023, identified a person with medical assistance (i.e., Medicaid) living in a nursing home must contribute most of their income towards the cost of such care. The article outlined, The MA [medical assistance] asset limit is $3,000 for an individual and $6,000 for a couple, plus $200 for each dependent. A provided Trial Balance list, dated 5/22/24, identified all resident' trust accounts and their subsequent balances for the care center. This list identified R13 had an active balance recorded, [$]14,648.82, and R42 had an active balance recorded, [$]12,740.57. R13's Clinical Census, printed 5/23/24, identified R13 had a current payer source recorded, Medicaid, with an effective date listed, 6/10/2024. However, R13's medical record was reviewed and lacked evidence any attempt to reduce the assets (i.e., spend down) had been discussed or attempted to ensure the Medicaid coverage was not terminated due to being over the SSI threshold. R42's Clinical Census, printed 5/23/24, identified R42 had a current payer source recorded, Medicaid, with an effective date listed, 10/1/2023. However, R42's medical record was reviewed and lacked evidence any attempt to reduce the assets had been discussed or attempted to ensure the Medicaid coverage was not terminated due to being over the SSI threshold. On 5/22/24 at 12:11 p.m., accountant (A)-A was interviewed and verified they were responsible for the resident' accounts. A-A explained the role and management of them had been handed off to them at the end of 2023, and the care center was actively working to change banking institutions. A-A acknowledged R13 and R42 had balances in excess of ten-thousand dollars, and stated R42's family had recently contacted them about the excessive amount and possibly needing to spend down. However, A-A stated this had not, to their knowledge, been acted upon yet to actually facilitate a spend down as they were unaware exactly what had to be done adding, Nobody filled me in. A-A stated they were unsure exactly what, if any, limits on personal asset or cash were allowable under Minnesota Medicaid law adding, [Someone] mentioned they [residents] needed to be at a certain limit but I never really knew what that limit was. A-A stated they were unsure if anyone had approached or discussed the need of a spend-down with either R13 or R42. On 5/22/24 at 12:45 p.m., a telephone call was attempted with each R13 and R42's family. However, neither of them were able to be reached and a return call was never received. On 5/23/24 at 8:37 a.m., R13 was interviewed, and stated he resided at the care center for going on three years now and handled his own statements and, if needed, signed his own documents still but with some input and oversight by his family member. R13 verified he was on Medicaid and stated nobody, to his recall, had ever discussed the current balance, or a subsequent spend-down of it, with him. R13 stated he was surprised to learn the account had so much in it and expressed aloud, What am I supposed to do? R13 stated he wasn't sure what, if any, items he could purchase to spend-down the funds but added, I'm sure I could find something. On 5/23/24 at 9:56 a.m., the administrator was interviewed and stated they had a telephone call placed to the social worker about R13 and R42's balances, but had not followed up on it thus far. At 10:06 a.m., A-A joined the interview and stated the care center being transitioned to a new management company combined with them seeking a new banking institution for the trust funds may have contributed to the confusion on the spend-down not happening. A-A stated they reviewed the funding sources and expressed R13 and R42's funds had likely been building awhile prior to it being identified by the survey team. A-A stated they had not typically been reviewing the balances for amounts (i.e., over $3,000) but would moving forward. The administrator stated the social services department would reach out to R13 and R42's families and ensure the funds were spent down timely. A provided Resident Trust Accounts/Funds policy, dated 4/2020, identified

Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed to reflect assessed needs and interventions with pain relief for 1 of 2 residents (R7) reviewed for pain management. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had intact cognition and demonstrated no delusional behaviors. Further, the MDS outlined R7 consumed a schedule pain medication, received non-pharmacological interventions for pain, and occasionally complained of pain (including with affect on activities and sleep) during the review period. On 5/20/24 at 2:17 p.m., R7 was interviewed and expressed they had pain in their left leg from a fall weeks prior. R7 stated, It aches in this leg. R7 stated they were unsure if the physician was aware of it or not, and expressed the pain was worse with movement. R7 stated they were unsure if staff were aware of her pain or not adding, I don't know. R7's most recent Pain Data Collection - V9, dated 3/22/24, identified R7 had osteoarthritis and an active pressure injury which could cause pain. A pain assessment interview was completed, where R7 identified having pain in her buttocks, lower back and right foot. R7 rated this as happening, Occasionally, with some effect on sleep and activities. R7 was recorded as consuming scheduled pain medications, including a narcotic (i.e., Tramadol), and listed some non-medication interventions to be done including repositioning, offloading, and heel boot use. However, R7's electronic care plan, last reviewed 4/10/24, lacked any developed problem statements, goals, or what, if any, interventions were being done for R7's assessed pain. When interviewed on 5/21/24 at 1:17 p.m., nursing assistant (NA)-A stated they had worked with R7 multiple times and verified R7 did, at times, complain of pain to them adding, She does. NA-A explained the staff use a mechanical lift to transfer R7 and, usually mid-transfer, R7 would state, OK, that's enough. NA-A stated R7 was good at letting me know about pain. NA-A stated the care center used to have more consistent staffing but lately it had been a lot of different people [i.e., agency] throughout the week. Further, NA-A stated nurses would typically communicate interventions to them using a verbal report and through the electronic kardex on the computers. On 5/21/24 at 2:42 p.m., registered nurse managers (RN)-A and RN-B were interviewed. RN-A verified they had reviewed R7's care plan and it lacked a pain statement or subsequent interventions adding, You busted me. RN-A stated R7's assessed pain, and subsequent interventions, should have been care-planned adding they were not sure how it had been missed. RN-A stated R7 was very arthritic and anytime she moves or stands up, her bones crack. RN-A verified the care plan, including the interventions, pulled to the NA Kardex and expressed they use the care plan like a tool to help ensure some interventions get signed off, too. RN-A and RN-B both verified a care plan was important to have developed and updated as it was like the bible and a guide to taking care of the patient. A provided Person Centered Care Planning policy, dated 4/2023, identified the care center would develop a comprehensive person-centered care plan which included measurable objectives and timeframes to meet specific goals and needs. The comprehensive care plan was to be developed within seven days of completion of the MDS and should describe the services to be furnished to the resident adding, Care plans are avalable to staff using the electronic medical record (EMR) system.

Based on observation, interview, and document review, the facility failed to comprehensively assess for range of motion (ROM) after a significant change for 1 of 1 residents (R31) evaluated for limited mobility. Findings include: R31's significant change Minimum Data Set (MDS) dated [DATE], indicated R31 had severe cognitive impairment with no history of behaviors or rejection of cares. R31 had ROM impairment to one upper extremity, no ROM impairment to lower extremities, and was dependent on staff for all activities of daily living (ADLs). R31's diagnoses included unspecified dementia, traumatic brain injury and contracture of left hand. R31's care plan printed 5/22/2024, indicated R31 required total assist with ADL's. During an interview on 5/20/2024 at 6:03 p.m., family member (FM-A) stated they wanted R31 to participate in ROM/therapy exercises. FM-A stated she was informed by therapy R31 sleeps all the time and would not be appropriate for exercises. FM-A stated R31 is awake and participates in ball toss during visits. During observation on 5/21/24 at 1:13 p.m., R31 was observed sitting in a Broda chair ( specialized wheelchair for positioning) in the common area awake and tracking conversations around her. During observation on 5/22/24 at 9:18 a.m., R31 was observed sitting in a Broda chair in the common area with eyes closed however did open eyes with conversation. During observation on 5/22/24 at 12:28 p.m., R31 was seated in a Broda chair in common area awake. R31 made eye contact during conversation however was not verbal. R31's functional ability screen dated 4/29/2024., indicated R31 had upper extremity ROM impairment to one side and no impairment to lower extremities. R31 was dependent on staff for all ADL's. A hospice communication note dated 4/22/24, indicated R31 discharged from hospice due to a prognosis of greater than 6 months. R31's progress note dated 4/22/24, indicated R31 discharged from hospice services. R31's Care Conference Summary dated 4/9/24, indicated [family] has been playing catch with her [R31] which she seems to enjoy. A review of the staff task list and nursing assistant Kardex (care sheet) lacked ROM exercises. During interview on 5/22/24 at 9:58 a.m., nursing assistant (NA-C) stated therapy does exercises with R31. During interview on 5/22/24 at 1228, therapy director (TD) indicated R31 was last seen in December 2023. TD stated the facility has a functional maintenance program (as opposed to a restorative program) that requires a provider order to establish. TD stated therapy staff then evaluate a resident and design a functional maintenance program for nursing staff to perform. During interview on 5/23/2024 at 8:44 a.m., nurse manager (NM-A) stated therapy screens all resident's quarterly, with changes in condition and as needed. R31 was previously evaluated by occupational therapy due to contracture to left hand. A copy of ROM exercises dated 11/29/2023, signed by occupational therapy, was provided. NM-A stated R31 enrolled in hospice in December of 2023 due to a decline in health. R31's health then stabilized. During a care conference on 4/5/2024, family was updated R31 was likely no longer going to meet qualifications for hospice and would be discharged from hospice. NM-A stated she has not spoken to FM-A since R31 was discharged from hospice because R31's next care conference is scheduled for 6/2024. A copy of a quarterly therapy communication/screen form dated 3/7/2024, indicated R31 was not a candidate due to hospice enrollment. NM-A stated she should have put a request in for a therapy screen when R31 was discharged from hospice but just missed it. During interview on 5/23/24 at 10:24 a.m., the director of nursing (DON) stated functional management plans are developed by the therapy department. DON confirmed therapy screens all resident's quarterly and makes recommendations accordingly. Therapy requests are also made with change in conditions. DON stated the facility has standing orders for therapy screens and will reach out to MD/NP for continuing orders after therapy screen. DON stated it sometimes takes a few weeks after a change in condition is noted to get things in place. A St. [NAME] Health Services of [NAME] Inc. Restorative Nursing Program policy reviewed and amended 4/6/20 indicates (Care center) will have a Restorative Nursing Program that promotes a residents' ability to achieve and/or maintain their optimal function, in accordance with the resident's comprehensive assessment and person-centered plan of care. Paragraph A under Procedure indicates: Residents will be evaluated on admission, ongoing and at least quarterly to determine the need for restorative nursing services by the Restorative Coordinator or nursing designee and/or Contracted Therapy. Paragraph C indicates: The restorative Nursing Coordinator or nursing designee will develop the program(s), in collaboration with Therapy if the program is recommended by Therapy, for residents who are identified as having the potential to benefit from the program(s). Paragraph D indicates: A Restorative Assessment will be completed by the RN Restorative Coordinator or by nursing staff under the supervision of the RNC. This will include identifying and care planning the resident's need for restorative nursing services, goal(s), and interventions to meet the goal(s). Paragraph f indicates in part: Restorative Coordinator or designee will monitor on an ongoing basis all aspects of the individualized restorative programs being offered.

Based on interview and document review, the facility failed to ensure dental services were offered or provided in a timely manner to prevent complication (i.e., trouble eating, pain) for 1 of 1 resident (R39) after it was determined their dentures were loose and not fitting correctly. Findings include: R39's admission Minimum Data Set (MDS), dated [DATE], identified R39 admitted to the care center on 4/11/24 from the acute care hospital. The MDS recorded R39 as having intact cognition and demonstrating no delusional thinking. Further, a section labeled, Section L - Oral/Dental Status, identified R39 as having broken or loose fitting denture(s) and no natural teeth (i.e., edentulous). R39's Census listing, printed 5/22/24, identified R39's current payer source as, Private Pay. On 5/20/24 at 1:34 p.m., R39 was interviewed and expressed, I don't have teeth. R39 explained she had several dental implants but still had dentures, however, was not wearing them due to them being loose-fitting. R39 stated she thought, to her recall, she told staff they were loose but could not recall what, if any, options for dental care and addressing the loose dentures had been offered. R39 stated she would like to get a dental appointment arranged, if able, to address them adding, It really bothers me. R39's Ancillary Services Consent, dated 4/11/24, identified a section labeled, Apple Tree Dental, with a written X marking placed next to, No. The form was signed by R39 on 4/11/24; however, the form lacked what, if any, other dental options were offered or discussed with R39 (i.e., community services). R39's subsequent Quick Guide (i.e., initial care plan), dated 4/11/24, outlined basic care-related information including a section labeled, Dentures:[,] which had black-colored markings recorded to demonstrate upper and lower sets were used with added written dictation, at home. However, R39's initial Oral Dental Review 12-22-17 - V2, dated 4/17/24, identified R39 was edentulous. The subsection labeled, Dentures, had options to select which set was used (i.e., upper, lower) and what, if any, problems with them were identified. However, these spaces were left blank and not completed. The conclusion of the evaluation labeled, Summary, identified dictation which read, . has no natural teeth, upper and lower dentures . does not like to wear them [dentures] as not fitting properly with recent weight loss . denies oral pain, able to brush mouth herself after staff set up . Dietitian is following with resident. The form lacked what, if any, options were discussed or offered to R39 when the loose-fitting dentures were identified. R39's Resident Care Conference Summary - V7, dated 4/18/24, identified each respective discipline who participated in the conference and form. This included a section labeled, Section SS. Social Service, which outlined R39's admission conference was held and dictation, Med changes, appointments, weight, intake BMs, and activity preferences reviewed. However, the form lacked evidence if a dental examination, including from outside the facility-sourced service, had been discussed or offered despite R39 being identified with a loose-fitting denture set the day prior on evaluation. In addition, R39's subsequent Oral Dental Review 12-22-17 - V2, dated 5/15/24, identified R39 had a significant change in status and remained edentulous. The subsection labeled, Dentures, now had markings placed to demonstrate R39 used an upper and lower denture, however, the spacing to record what, if any, issues with them was left blank. Further, the evaluation again concluded with a section labeled, Summary, and dictation which read, . has no natural teeth, upper and lower dentures . does not like to wear them [dentures] as not fitting properly with recent weight loss . denies oral pain, able to brush mouth herself after staff set up . Dietitian is following with resident. The form, again, lacked what, if any, options were discussed or offered to R39 despite the loose-fitting dentures still being identified. R39's medical record was reviewed and lacked specific evidence R39 had been offered or provided with a dental examination service after 4/17/24, when it was identified on evaluation that she had loose-fitting dentures; nor after 5/15/24 when the loose-fitting appliances were again identified. When interviewed on 5/21/24 at 1:08 p.m., nursing assistant (NA)-A explained R39 needed quite a bit of help to complete most cares and described her cognition as forgetful. NA-A stated R39 would, at times, do her own oral care after set-up assistance was provided and added R39 was missing most of her teeth adding further R39 doesn't put dentures in. NA-A stated they thought there was a set of dentures for R39 but reiterated, She said she never puts them in. NA-A stated R39 had never reported dental concerns to their knowledge and explained if a dental appointment was needed, then the clinical coordinator would likely set one up. On 5/21/24 at 2:42 p.m., registered nurse managers (RN)-A and RN-B were interviewed. RN-A explained R39 had been offered the Apple Tree Dental service upon admission (4/11/24) and, at the time, declined it adding R39's payer systems were, in general, was pretty complicated due to being admitted on Medicare A then, afterwards, finding out she was also a Veteran. RN-A stated R39 originally had planned to discharge back home and, on her own, pursue dental services but now was looking at more long-term placement. RN-A stated dental services had been discussed with R39 to her recall and, at one point, information had been given to R39's family member but no follow-up had been done since adding, Nothing was pursued. RN-A acknowledged the medical record lacked evidence of a dental appointment being discussed or offered after the loose dentures were identified and expressed, We talked about it but [it's] not documented. RN-A stated R39's dentures, to their knowledge, remained at home but expressed the recently completed significant change evaluation should have taken care of all this and the dental needs, if wanted or needed, re-visited adding, We missed that dental piece. RN-A stated it was important to ensure dental visits were offered and, if needed, provided timely as loose-fitting dentures could cause mouth sores or increase a residents risk of choking while eating. Further, RN-B explained they were going to review their (RN-A and RN-B) hand-off process to ensure transitions from short-term to long-term care didn't miss items like dental appointments. A provided Dental Services policy, dated 1/2017, identified the care center would provide or obtain dental services, including both routine and emergency services, from an outside source to meet resident' needs. A procedure was listed which included, Assistance with making dental appointments, if necessary or if requested.

Based on observation, interview, and document review, the facility failed to ensure proper infection control practices were utilized while completing personal hygiene and urinary catheter care for 1 of 1 residents (R25) reviewed for urinary tract infections (UTI). Findings include: R25's significant change Minimum Data Set (MDS) dated [DATE], indicated R25 had intact cognition and was diagnosed with heart failure, kidney disease, and respiratory failure. The MDS indicated R25 was dependent on staff for toileting hygiene, bed mobility, and transfers. R25's care plan dated 2/22/24, indicated R25 had a history of a UTI related to an obstruction of the urinary tract and also utilized a urinary catheter. The care plan indicated that R25 required assistance with catheter care every morning and night. The care plan indicated R25 required the assistance of two staff members with bathing and dressing. R25's order summary dated 2/22/24, indicated R25 had an indwelling urinary catheter in place and output was to be assessed every shift. R25 had an order dated 3/15/24, for 500 milligrams (mg) of ciprofloxacin to be given two times a day for severe sepsis, UTI for seven days. During an observation on 5/22/24 at 7:15 a.m., nursing assistant (NA)-B was observed in R25's room with gloves on preparing a basin with soap and water while R25 lay in bed. NA-B was observed to set the basin down on the bedside table and assist R25 with removing her pajamas. NA-B then soaked the washcloth in the soapy water and cleansed under the residents' arms and breasts. The washcloth now had a pinkish/brown coloring and was dunked into the soapy water in the basin, wrung out, and then used to clean under R25's abdominal fold. NA-B then dunked the same washcloth in the soapy water, wrung it out, and cleansed the area around R25's catheter. NA-B was then observed to drop the washcloth in the basin and without changing her gloves, opened R25's closet door and grabbed a clean incontinence brief from the closet. NA-B then assisted R25 to lay on her side. NA-B took the same washcloth from the basin and in multiple strokes up towards the resident's head and back down towards the resident's catheter, washed the anal area. NA-B removed the old incontinence brief, put the new incontinence brief below the resident, and applied a skin-protecting cream to R25's anal area, without completing hand hygiene and changing gloves. During an interview on 5/22/24 at 7:37 a.m., NA-B stated she normally used one washcloth for all of the resident care including catheter care. NA-B stated she had completed hand hygiene and put on/took off gloves when entering and exiting R25's room but had not in between those times. NA-B stated she should have completed hand hygiene and changed her gloves before gathering supplies from R25's closet and applying the cream. During an interview on 5/22/24 at 2:17 p.m., the director of nursing (DON) stated she would have expected the NA to change her gloves and complete hand hygiene before and after completing catheter and perineal care. During an interview on 5/23/24 at 9:58 a.m., the DON stated that a clean washcloth or a clean side of the washcloth should have been used when completing resident personal cares, especially catheter care. The DON stated that if a clean washcloth was not used for catheter care, should worry about R25 developing an infection. The undated facility Urinary Catheter Care and Management policy indicated the purpose of the policy was to maintain resident safety by following infection control practices while inserting and handling catheters. The policy indicated standard precautions should have been utilized while completing daily maintenance of urinary catheters. The policy indicated staff should have demonstrated competency in catheter care before performing the task unsupervised.

Based on interview and document review, the facility failed to ensure resident' trust account statements were provided on, at least, a quarterly basis for 1 of 1 resident (R29) reviewed who expressed never receiving such statement. The lack of provided statements had the potential to affect an additional 26 of 26 residents identified to have trust accounts at the care center. Findings include: R29's significant change Minimum Data Set (MDS), dated [DATE], identified R29 had intact cognition. On 5/20/24 at 3:08 p.m., R29 was interviewed and verified he had a trust account which was managed by the care center adding, It's got only like 100 bucks or so. R29 stated he opened the account many months prior, however, had never received a statement from the care center with any balance outlined adding, No, not seen that. A provided Trial Balance list, dated 5/22/24, identified 27 residents, including R29, had active accounts as of the listed date. R29 was identified as having an account with a balance recorded, [$]150.02. A grand total of $32,727.87 was listed for the 27 residents to have active accounts at the care center. During the recertification survey, from 5/20/24 to 5/23/24, evidence of a statement being provided to the residents, or their respective representatives, was requested. However, none was provided. On 5/22/24 at 12:11 p.m., accountant (A)-A was interviewed and verified they were responsible for the resident' accounts. A-A explained the role and management of them had been handed off to them at the end of 2023, and they verified R29 had an active account with a positive balance. A-A stated they, thus far in 2024, they had not mailed out any statements to the residents or their representatives but expressed their new management company had just updated them recently to do so. A-A stated the care center was in process of changing banking institutions, and voiced they would not be aware when a statement had been sent to each respective resident' with their current balance. A-A reiterated, I was just made aware recently that we would be sending out statements [by the management company]. When interviewed on 5/23/24 at 9:56 a.m., the administrator stated A-A would be the person responsible to ensure statement were mailed or provided since the previous person had resigned in 2023, but she added, I don't know if he has or hasn't. The administrator stated they were unsure exactly when the last statements had been sent due to just recently starting employment at the campus themselves; however, they voiced the care center was actively working on getting them sent now. A provided Resident Trust Accounts/Fund policy, dated 4/2020, identified the care center would administer resident' funds in accordance with Minnesota statutes. The policy outlined each resident with funds deposited would have separate, interest-bearing accounts maintained and the accountant would manage the day to day operations of the accounts. The policy included, RTA [accounts] Statements should be sent to the resident or authorized individual, including but not limited to, Quarterly to all residents and the Social Worker regardless of their account balance.

Based on interview and document review, the facility failed to provide adequate assistance as identified by the care plan to prevent accidents when transferring 1 of 3 residents (R1) reviewed for accidents. This failure resulted in R1 sustaining serious injuries requiring hospitalization and surgery. The immediate jeopardy began on 10/2/23 at approximately 1:05 p.m. when while R1 was transferred by nursing assistant (NA)-A with one assist instead of two as directed by the care plan, became weak and fell to the floor. R1 sustained an open fracture of her left ankle which required surgical intervention and an extended stay at a hospital. The administrator and director of nursing (DON) were notified of the IJ on 10/13/23 at 3:15 p.m. The facility had implemented corrective action to prevent reoccurrence by 10/3/23, therefore, F689 is being issued at past non-compliance. Findings include: R1's care plan dated 10/9/23 indicated R1 transferred with assist of two staff members with a transfer belt. A Falls Note dated 10/2/23 indicated R1 was being transferred from the tub chair to her recliner by nursing assistant (NA)-A. R1's left knee buckled, and she was lowered to the floor. R1 complained of pain and was transferred to the emergency department (ED). On 10/10/23 nurse practitioner (NP)-A's note indicated R1's left tibia/fibula X-ray noted a displaced fracture of the distal fibula with tibiotalar subluxation (the ankle bones were out of joint) and open fracture (a bone fracture that has an open wound or break in the skin near the site of the broken bone, most often caused by a fragment of the bone breaking through the skin) of the medial malleolus (the largest bone segment in the ankle). Resident had open reduction internal fixation (ORIF, surgical repair) of the fracture and was discharged back to the facility on [DATE]. On 10/12/23 at 12:23 p.m. R1 was interviewed. R1 stated one of the staff was transferring her when she fell . R1 stated her leg became weak. R1 stated when she went down to the floor, she heard her ankle crack, and it hurt so bad. R1 stated she knew she was supposed to have two staff transfer her, but she didn't say anything. On 10/13/23 at 11:56 a.m. R1 was interviewed again, and stated her ankle had twisted sideways during the transfer. R1 stated she had been living independently, and the plan had been for her to return home. R1 stated she didn't know if she would be able to return home after the fracture. On 10/12/23 at 1:38 p.m. NA-A stated she had not transferred R1 alone until 10/2/23 when she fell . NA-A stated she did not have time to look at R1's care plan to check on her transfer status. NA-A stated R1's leg gave out, and NA-A helped ease R1 to the floor with the transfer belt. On 10/12/23 at 2:34 p.m. registered nurse (RN)-A stated she went to assess R1 after the fall. RN-A stated she visualized blood coming out of R1's TED stockings, and when she rolled up the toe of the TED stocking, she noted bone coming out of R1's skin. On 10/12/23 at 2:55 p.m. the physical therapist (PT)-A stated prior to the fall, R1 was to be transferred with assist of two staff and a transfer belt. On 10/12/23 at 3:39 p.m. the director of nursing (DON) stated residents current transfer status is listed in the Kardex (care plan) and staff were to look at the Kardex at the beginning of their shift. On 10/13/23 at 12:45 p.m. PT-B stated R1 had left sided weakness and was progressing in her transfer status prior to the fall. The Care planning policy dated 5/11 directed care plans were to be updated as appropriate to reflect residents' current status. The past non-compliance immediate jeopardy began on 10/2/23. The immediate jeopardy was removed and the deficient practice was corrected by 10/3/23 after the facility implemented a systemic plan that included the following actions: NA-A was removed from working pending investigation of the incident. All nursing staff were re-educated on following the care plan for resident transfer status, all residents transfer status were reviewed to ensure the status matched the care plan, and audits were conducted on transfers. This was verified through interview and document review.

Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers using the main production kitchen. This had potential to affect all residents who could potentially consume the items. Findings include: On 8/14/23 at 1:42 p.m., an initial kitchen tour was completed with the director of culinary service (DCS) present. A single CrownTonka walk-in commercial freezer was in use, opened, and inspected. The outside of the freezer door had a white sign posted which read, Be very careful in freezer! Floor is very [underlined] slippery!! Walk like a penguin!! Inside, the unit had a cooling fan mounted to the top of the unit which had various black-colored, foam-wrapped piping entering the fan unit on the right side. The wrapped piping exited the back of the unit, ran along the back wall of the freezer to the opposite side, then entered the wall. However, the piping had visible ice built up in numerous places including along the unit. On the left side, where the piping entered/exited the freezer into the wall, the ice build up was thick and reached down the wall past the shelving which had various food items stored; and the entire piping track had ice build-up present which, in areas, was thick enough to have ice build-up hanging down from the piping towards the food product. The floor of the freezer and the metallic shelving used also had ice build-up present on them. Immediately below the cooling unit and ice-covered piping, there were several food items stored including opened boxes of 16 frozen pizzas, one opened box of 4 ounce (oz) individual ice cream cups, and several more unopened boxes of various ice cream products. The frozen pizzas were contained in a cardboard box which was soft and somewhat mushy-feeling to touch, and were wrapped in a commercial plastic wrap which had visible ice shards laying on top of it (from the ice above); and the opened box of ice cream cups also had ice shards sitting directly on the product (i.e., lids of the ice cream cups) along with the unopened boxes. A gauge present inside the unit measured -2 degrees Fahrenheit (F). DCS acknowledged the ice build-up and explained the freezer was old and needed to likely be replaced. DCS stated the ice build-up, to their understanding, was caused when the defrost cycles activated and caused the water to come over the drip pan and cause the build-up. DCS stated the facility' maintenance team was aware of it and had worked on it before. DCS explained the ice build-up issue had been happening for a couple years now with warmer months (i.e., Summer) being worse for it. On 8/15/23 at 8:45 a.m., a return visit to the kitchen was completed. The same CrownTonka walk-in freezer was observed and inspected, and the ice build-up remained as prior along with the same food items stored below; however, now an additional foil-wrapped pan which had hand-written, Lasagna 6/15, was present next to the ice cream cups which had visible ice shards present on it along with ice stuck to the foil. At 8:59 a.m., cook (CK)-A observed and verified the various food items had ice build-up present on them. CK-A explained the ice build-up had been happening for couple weeks to their recall but added the issue comes and goes. Further, CK-A stated they had never been directed or asked to not store food items below the ongoing ice build-up, and subsequent dripping and potential cross-contamination of the water or chemicals inside the piping, but added moving the food was likely a good idea. When interviewed on 8/15/23 at 9:10 a.m., DCS stated the ice build-up issues in the walk-in freezer had been happening for probably about two years. DCS explained an outside refrigeration company had been in to inspect the equipment and they expressed a new walk-in freezer was needed to ultimately correct the ice build-up issues but cost was a consideration. DCS stated the freezer was still holding proper temperature but explained the equipment had several defrost cycles it went through which were normal, per the manufacturer, and was where the ice build-up issue was coming from when the drip pan, used to collect the condensation, overfilled or allowed it to run over. DCS acknowledged the food items continued to be stored under the ice build-up in the freezer and expressed they felt it was just the boxes being affected and not the food items. DCS stated if ice build-up was physically present or touching the food items, such as the ice cream cups, then they would pitch and discard those items as the ice thawing (i.e., defrost cycle) could potentially cross contaminate the food. Further, DCS stated the environmental service director (ESD) could explain more about the freezer and it's repair needs. When interviewed on 8/15/23 at 9:22 a.m., the ESD stated an outside refrigeration company had been in and replace it was the recommendation. ESD explained the freezer was old and the walls were starting to concave which allowed air to enter and cause the ice build-up which had been ongoing and happening for a long, many, many years. As a result, the maintenance team was going into the freezer a couple times each month and breaking down the ice. Further, ESD stated they had expressed to the dietary department to not store food products under the ice build-up as it could lead to freezer burned items. On 8/15/23 at 2:55 p.m., DCS was interviewed, and they explained the defrost cycles were normal for the freezer and nothing should thaw during them. However, DCS acknowledged the boxes felt moist or condensed as a result which could, potentially, be a sign the ice was going through the start of a thaw cycle before re-freezing. DCS stated they just moved all of the food items from under the ice build-up and expressed they told staff nothing on those back racks until the issue was fixed. Further, DCS stated they were unable to locate a manufacturer book due to the freezer's age but expressed the cooling unit was probably original still. When interviewed on 8/17/23 at 9:55 a.m., the registered dietician (RD)-A stated they were aware the freezer had been having an ice build-up issue which had even been raised at the safety meetings. RD-A stated the ice build-up could cause unwanted wetness on the food products and any contaminated or damaged items should be discarded. RD-A stated a 'mushy' box would indicate moisture, however, expressed there wasn't much other space in the freezer to store items. RD-A reiterated if food products were smashed or appeared unfrozen, then they would be discarded and not used. However, RD-A acknowledged the ice build-up and having items stored below it did present a potential cross contamination issue. A provided Food Storage-Perishable policy, undated, identified all perishable food would be stored at proper temperature . and is suitably protected to guard against contamination and growth of disease causing bacteria. The policy outlined several steps to ensure refrigeration was maintained, however, lacked any guidance or direction on what, if any, steps were taken to ensure proper freezer storage given the repeated ice-build up from the dated equipment.

Based on interview and document review the facility failed to comprehensively assess, develop and implement interventions to address unplanned weight gain for 1 of 1 resident's (R13) who sustained an undesired weight gain of 41 pounds over the last 15 months. Findings include: The Centers for Disease Control and Prevention (CDC) About Adult BMI article dated 6/3/22, indicated a body mass index (BMI) for adults (over the age of [AGE] years) of 30.0 and above was obese. The article also indicated people who were obese were at an increased risk for many disease and health conditions including but not limited to: death, high blood pressure, diabetes, heart disease, stroke, osteoarthritis (a degenerative joint disease), mental illnesses (depression, anxiety) and a low quality of life. R13's significant change Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition, was independent for eating, required limited assistance for transferring and extensive assistance for all other activities of daily living (ADLs). R13's diagnoses included coronary artery disease (CAD, excessive plaque in the heart), diabetes, morbid obesity, deep vein thrombosis (DVT-a blood clot in the lower extremities that can travel to the lungs or heart and be fatal), high blood pressure, chronic kidney disease, atrial fibrillation (irregular heartbeat resulting in increased clot formation in the heart), Alzheimer's disease, congestive heart failure (CHF), obstructive sleep apnea, abnormal weight gain, kidney stones, heart attack, and stroke. R13's Care Area Assessment (CAA) dated 5/17/23, indicated R13 triggered for ADL function, psychosocial wellbeing, mood state, falls, nutrition, dental care, pressure ulcers, and psychotropic drug use. R13's care plan dated 7/20/23, indicated R13 enjoyed activities including playing cards, following sports, church, socializing, and music. R13 used to do woodworking, went to parties, coached kids sports and gardened. Interventions included family visits for socialization and treats and inviting R13 to group activities. The care plan also indicated R13 was at risk for falls due to weakness and had an ADL deficit related to frailty, CHF, and CAD. R13 also had an alteration in cardiac and respiratory status and preferred to sleep in his recliner due to shortness of breath. Interventions included encouraging adequate nutrition. The care plan also indicated R13 had diabetes. Interventions included monitoring R13 for hyperglycemia including increased appetite, offering diet condiments, smaller desserts, lower sugar drinks, and reviewing choices as needed. R13's Weights and Vitals Summary indicated R13's admission weight dated 9/27/21, was 236 pounds and remained consistent until the following weights were recorded in pounds: -5/11/22, 239 -5/18/22, 243.5 -5/25/22, 246 -6/1/22, 250 -6/8/22, 251.5 (a 5.23% increase in one month) R13's Weights and Vitals Summary indicated R13's weight remained consistent from 6/8/22 to 8/21/22, when R13's weight began to steadily increase as follows: -8/16/22, 249 -8/21/22, 254.2 -8/30/22, 256 -9/9/22, 258 -10/12/22, 258 -11/16/22, 260 -12/14/22, 262 -1/4/23, 261 -2/8/23, 262 -2/21/23, 264 -3/15/23, 266 -3/22/23, 269.5 -4/12/23, 270 -5/3/23, 262 (a 2.96% decrease in two weeks) -5/17/23, 273 (a 4.20% increase in two weeks) -6/21/23, 275 -7/26/23, 278.5 -8/16/23, 280 (a BMI of 42.6) R13's orders dated 7/11/22, indicated to encourage R13 to walk to meals per R13's family request. R13's Nutritional Assessments indicated the following: -1/30/23, R13's weight had gradually increased over the previous quarter. R13 had been drinking more regular soda and extra fluids. Interventions included offering diet condiments and smaller portions of some foods with a goal for R13's weight to be stable. -current weight: 260 pounds -goal weight: 220-225 pounds -5/3/23, R13's weight had gradually increased over the previous quarter. R13 had been drinking more regular soda and extra fluids such as lemonade and chocolate milk. Interventions included offering diet condiments and smaller portions of some foods with a goal for R13's weight to be stable. -current weight: 262 pounds -goal weight: 220-225 pounds The assessment lacked documentation addressing R13's significant weight loss (2.96%) over the two weeks before the assessment, or the significant weight gain (4.20%) during the two weeks after the assessment. R13's nutrition note dated 11/29/22, indicated R13's weight had increased the previous month from the mid 250's to low 260's. Since mid-summer months has increased 10# [pounds]. The note indicated, although for a short time, R13 had increased his water consumption, R13 had been asking for more chocolate milk and drank occasional soda and had increased behaviors in the dining room. The note further indicated the RD spoke to the provider regarding R13's weight gain. The provider was going to prescribe sertraline for R13's behaviors and advised R13 may have some weight change in relation to the medication. No further interventions were indicated to manage R13's weight changes. R13's hospital discharge summary dated 3/30/23, indicated R13 was treated for shortness of breath. Recommendations included to lose weight, as extra weight made it harder to breathe. R13's mini-nutrition note dated 5/3/23, indicated R13 had no decrease in food intake or weight loss over the previous three months and had a BMI of 23 or greater but a Mini-Nutrition Score indicating R13 was at risk for malnutrition. No further interventions or assessments were indicated. R13's care conference note dated 6/8/23, indicated R13 had gradual weight gain due to the consumption of high caloric, sugary drink and the lack of water. The note stated diet powdered drinks were discussed. No further information regarding outcome, education or interventions were documented. R13's provider note dated 7/11/23, indicated R13's weight had continued to increase. The provider indicated he believed it was secondary to excess caloric intake and minimal mobility with no evidence of fluid overload. During an observation and interview on 8/14/23 at 7:19 p.m., R13 was sitting in his room in a recliner. R13's breathing was over 20 breaths per minute, shallow with a long expiratory phase, and could be heard across the room. R13 spoke two to three words at a time and stated he became out of breath whenever he got up. R13 stated although he had had difficulty breathing for about a year, it had gotten worse over the last couple of weeks. R13 further stated the doctor or nurses had never talked to him about it, although the doctor told his family he needed to lose weight. During an observation and interview on 8/15/23 at 1:07 p.m., R13 was sitting in his recliner speaking three to four words at a time. R13 stated his breathing was a little heavier that day. R13 stated at breakfast, his friends had even asked him what was wrong, stating he seemed out of breath. During an interview on 8/16/23 at 10:03 a.m., nursing assistant (NA)-D stated she had noticed R13 having more difficulty breathing the last two weeks and had requested assistance wheeling to the dining room, when previously R13 had been able to wheel himself. During an interview on 8/16/23 at 10:28 a.m., licensed practical nurse (LPN)-B stated although she was aware R13 had increased shortness of breath for past last week and had gained weight, his oxygen saturation was 96% and he appeared stable, therefore, he was not given oxygen. During an interview on 8/16/23 at 12:27 p.m., registered nurse (RN)-H who was the nurse manager for R13's unit, stated R13 had not been walking much during the last two months, possibly due to a DVT he had in his leg. RN-H stated she was aware R13 had gained weight and thought he had been working with the registered dietician (RD). During an interview on 8/16/23 at 12:51 p.m., the nurse practitioner (NP) stated although R13 had a history of CHF, she and the physician believed R13's weight gain was due to excessive caloric intake rather than an exacerbation of his CHF or fluid retention. During an interview on 8/16/23 at 1:36 p.m., the RD stated R13 was independent with eating and often asked for four cartons of chocolate milk or lemonade at meals. The RD stated she had spoken to R13 about his food choices and weight gain, although she was unable to provide documentation regarding those conversations. The RD further stated she did not know why R13 had gained so much weight over the previous year and it was probably due to a variety of reasons. The RD also stated she had not completed a risk vs. benefit form with R13 regarding his food preferences and/or excessive caloric intake and the effect it could have on his health and breathing. During an interview on 8/17/23 at 8:47 a.m., R13 stated the RD had talked to him that morning regarding his weight. R13 stated he did not realize he had gained as much weight as he had, or that it could be contributing to his difficulty breathing. R13 stated he was going to drink water instead of chocolate milk and the RD was going to assist him to fill out his menu preferences with healthier choices. R13 further stated he was very happy because he could start going to activities again and he had a family wedding to attend the following month that he wanted to be healthier for. R13 stated he would have liked to have known about his weight gain earlier and did not have a goal to gain weight after his admission to the facility on [DATE]. During an interview on 8/17/23 at 10:17 a.m., the director of nursing (DON) stated NAs took resident weights according to their orders and relayed result to the nurse. The nurse should assess the resident's weight and notify the nurse manager and RD if a change was identified. The RD should then assess the resident, asking about their food preferences, educate them on healthy alternatives, and complete a risk vs. benefit form if the resident preferred to continue engaging in unhealthy food choices. The DON further stated the facility did not have a procedure for the management of excessive weight gain for residents as the concern was more for residents who lost weight. A facility policy regarding significant weight change was requested but not received.

Based on observation, interview and document review, the facility failed to ensure the Atrium dining room cleaning chemicals were secured away in a locked cabinet or cart, which had the potential to affect 26 of 50 residents who could access the Atrium dining room. Findings include: On 5/16/22, at 2:15 p.m. during observation of the Atrium dining room, a three-quarter full bottle labeled Ecolab Sink Surface Cleaner, a half full container of Diversity Oxivir Tb, a three-quarter full bottle of Clorox Fusion Cleaner Disinfectant, a half full bottle of 3M neutral cleaner, a half-full bottle of Alpha Hp Bathroom Cleaner, and a three-quarter full bottle of TrueKleen Lime off were in the Atrium dining room unsecured in a lower-level cabinet to the left of the sink. One resident was observed walking with a walker and another resident was observed propelling self in his wheelchair in and around near the cabinets in dining room where the chemicals were in an unsecured cabinet. On 5/16/22, at 2:30 p.m. nursing assistant (NA)-C verified the chemicals were in the cabinet unlocked and unsecured. NA-C further stated she was unsure if the chemicals needed to be locked up in a cabinet. On 5/16/22, at 2:42 p.m. health unit coordinator (HUC)-A verified the six bottles of chemicals were in an unlocked unsecured cabinet in the Atrium dining room. On 5/16/22, at 2:43 p.m. registered nurse (RN)-G verified the chemicals were in the dining room cabinet and the door was unsecured and unlocked. RN-G further stated the facility has residents who are independent with mobility and wander into the dining room throughout the day. On 5/17/22, at 8:54 a.m. the certified dietary manager (CDM) stated the dietary staff go into the dining room cabinet frequently, and no staff mentioned to her the cabinet lock was broken. CDM further stated staff should have reported concerns about the lock being broken as soon as they noticed it not locking. CDM stated it was a concern to have chemicals unsecured in an area residents can access. On 5/19/22, at 9:18 a.m. the environmental service director (ESD) stated he thinks someone used a wrong key and forced the cam-style lock to stay unlocked. ESD further stated no staff reported concerns regarding the lock not working in the Atrium dining room. ESD stated the chemicals are not supposed to be stored in the dining room and should only be in the designated secured areas away from resident ability to access. ESD further stated it was a safety risk and there are residents who wander into the dining room alone. On 5/18/22, at 9:40 a.m. the director of nursing (DON) stated the locked was fixed, and all chemicals were removed, and the facility was actively working on education with staff regarding the storage of hazardous chemicals. The facility Environmental Audit dated 5/9/22, lacked indication the cabinet lock was not intact or broken. The Ursource material safety data sheet (MSDS) for TruKleen Lime-Off dated 5/5/15, indicated the descaler was hazardous to a person's health. The MSDS indicated to health hazards with exposure to eye, skin, or ingestion. The MSDS further indicated to seek immediate medical attention if ingestion or eye or skin contact occurred. The Ecolab MSDS for Neutral Cleaner dated 5/22/18, indicated the cleanser was hazardous to a person's physical health. The MSDS indicated to avoid contact with eyes. The MSDS further indicated to seek immediate medical attention if eye contact occurred. The Ecolab S&S Sanitizer MSDS dated 5/12/20, indicated S&S Sanitizer was hazardous to a person's health. The MSDS indicated to avoid contact with skin, eyes, skin, inhaled, or ingestion. The Diversey Oxivir TB Cleaner MSDS dated 2/2/18, indicated S&S Sanitizer was hazardous to a person's health. The MSDS indicated to avoid contact with skin, eyes, skin, or ingestion. The facility policy Safe and Secure Environment undated, indicated there are designated storage areas for items which could pose a risk or danger such as chemicals and toxic materials. The facility policy lacked indication chemicals should be secured away from residents.

Based on observation, interview and record review, the facility failed to ensure the head of bed (HOB) was properly elevated during infusion of a gastrostomy tube (GT) feeding for 1 of 1 resident (R36) reviewed for tube feeding. Findings include: R36's admission Minimum Data Set (MDS) dated [DATE], revealed R36 was on a gastrostomy feeding tube (GT-a medical device used to provide liquid nourishment, fluids, and medications by bypassing the oral intake). R36's Care Area Assessment (CAA) dated 3/3/22, indicated R36 was a total assist of two staff for all activities of daily living (ADL's), and received all of her feeding, medication, and hydration by tube feeding. R36 CAA further indicated R36 needed her head of bed (HOB) elevated to 30 to 40 degrees related to her continous tube feeding. R36's Admission Record dated 5/19/22, indicated R36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's Speech Therapy Evaluation dated 3/24/22, indicated R36 was nothing by mouth, and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R36's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's current nursing assistant Kardex indicated R36 was nothing by mouth for eating and had tube feeding. Kardex lacked indication staff should maintain R36's head of bed to at least 30 degree angle while feeding was infusion. R36's care plan dated 5/22, indicated R36 had tube feeding for nutritional needs related a subdural hematoma (bleed inside the brain) but lacked indication she had an intervention for the head of the bed to be elevated. During an observation on 5/16/22, at 4:26 p.m. R36 was observed in her room, lying in bed with the bed raised to roughly a 5-degree angle and appeared to be lying flat. R36 had shifted down in her bed to the crease and was lying on her right side. R36 had tube feeding being administered during that time. On 5/16/22, at 4:30 p.m. registered nurse (RN)-C verified R36's head of bed (HOB) was elevated at less than a 5 degree angle while her tube feeding was running. RN-C stated R36 could be at risk for aspiration pneumonia (condition in which foods, stomach contents, or fluids are breathed into the lungs through the wind pipe causing infection) while hooked up to the tube feeding. RN-C did elevate the HOB but only to a 20 degree angle. On 5/16/22, at 4:34 p.m. RN-F stated R36's HOB should be elevated at least at a 30-degree angle while tube feeding was infusing. RN-F verified elevating the head of the bed was not on the nursing assistant Kardex or care plan. On 5/16/22, at 4:39 p.m. nursing assistant (NA)-C stated she normally repositioned R36 from side to side, and when asked regarding the head of the bed being elevated NA-C stated she was unaware of the need to have the head of the bed elevated during tube feeding. On 5/16/22, at 6:20 p.m. director of nursing (DON) stated her expectations for staff were to ensure R36 had her head of the bed elevated at least at a 30-degree angle during tube feeding to reduce the risk of aspiration pneumonia. DON further stated nursing staff are responisble for ensuring R36 is positioned correctly during feedings. Review of the facility's policy Care and Management of a Feeding Tube dated 1/18, indicated the procedure guidelines were for the safe administration of enteral feeding and medications through an enteral tube. The policy directed staff to place resident head of bed to at least a 30-degree angle during administration of enteral feeds and for a minimum of 30 minutes afterward.

Based on observation, interview and document review, the facility failed to ensure appropriate interventions were taken to reduce the risk of infection for 1 of 2 residents (R36) who used tube feeding and the equipment was observed soiled while R36 was administered tube feeding. Findings include: Review of R36's admission Minimum Data Set (MDS) dated [DATE], revealed R36 was on a gastrostomy feeding tube (GT-a medical device used to provide liquid nourishment, fluids, and medications by bypassing the oral intake). R36's Admission Record dated 5/19/22, indicated R36 had diagnoses of traumatic subdural hemorrhage ([CONDITION(S)] causing bleeding within the space of the brain) with loss of consciousness, diabetes, dementia, gastrostomy (artificial external opening into the stomach for nutritional support). R36's care plan dated 3/24/22, indicated R36 was on tube feeding for nutritional needs but lacked direction to staff to ensure tube feeding equipment was kept clean. R36's nursing Kardex dated 5/16/22, indicated R36 was to have tube feeding as prescribed, but lacked indication to ensure tube feeding equipment was kept clean. On 5/16/22, at 6:13 p.m. R36 was observed in her room not connected to her tube feeding. The tube feeding pole, base, hook, and infusion pump were soiled with dry caked on tan colored tube feeding formula. R36's nightstand was also found to have dry caked on tan colored tube feeding formula on the top and on the drawers. On 5/17/22, at 8:14 a.m. R36 was seated in her wheelchair in the common area near the nurse's station, connected to and receiving her tube feeding. The tube feeding pole, base, hook, and infusion pump were soiled with dry caked on tan colored tube feeding formula. The locking collar had a piece of tissue paper protruding halfway out and appeared to be helping with holding the position to stay in place. Remove sentence? On 5/18/22, at 8:53 a.m. licensed practical nurse (LPN)-A verified the infusion pole, infusion pump and handle were soiled with what LPN-A identified as dried caked on tube feeding formula. LPN-A further stated the pump and pole should be kept cleaned for infection control reasons but was unable to answer who was responsible for ensuring the poles were kept clean and in good repair. LPN-A stated, I am not sure how frequently or who is responsible for cleaning. On 5/18/22, at 8:57 a.m. registered nurse (RN)-A verified the infusion pole and infusion pump was soiled with dried tube feeding formula. She stated it was the responsibility of the nursing staff to ensure the R36 tube feeding equipment was kept clean and in good repair. RN-A further stated the equipment should be wiped down daily and as needed when it becomes soiled. RN-A stated the unclean equipment could present a risk for bacteria to grow and transmit an infection. On 5/18/22, at 11:20 a.m. RN-A confirmed there were no interventions on R36 care plan to wipe down or clean R36 tube feeding equipment. She further stated she had made sure both residents on tube feeding in the facility had their tube feeding equipment cleaned after the surveyor had alerted of concerns. During interview on 5/18/22, at 12:22 p.m. director of nursing (DON) stated her expectation for nursing staff was to ensure resident equipment including tube feeding poles and pump was kept clean and when visibly soiled with formula to clean it up immediately. DON further stated concerns regarding not keeping the equipment clean would present an infection control risk for residents. A facility policy was requested on cleaning tube feeding equipment, but none was provided.

Based on interview and document review, the facility failed to ensure routine device monitoring was completed for their wanderguard door systems. This practice had the potential to affect all residents whom had wanderguard devices in place at the time of the onsite visit for 5 of 5 residents (R1, R2, R3, R4, R5). Findings include: R1's face sheet printed 7/13/21, indicated diagnoses of mild cognitive impairment and ataxia (condition where muscle control or coordination of voluntary movements, such as walking or picking up objects is affected) following a cerebral infarction (stroke). R1's care plan dated 5/13/21, indicated R1 could self-propel himself in manual wheelchair without assist. R1's care plan dated 7/1/21, indicated R1 was at risk for wandering/elopement and wanderguard was placed under his wheelchair on 6/30/21. R2's face sheet printed 7/13/21, indicated symptoms and signs involving cognitive functions following cerebral infarction (stroke). R2's care plan dated 5/16/21, indicated R2 was at risk for wandering/elopement and a wanderguard was placed under his wheelchair. R2 would self-propel in his wheelchair around the facility. R3 face sheet printed 7/13/21, indicated diagnoses of dementia with behavioral disturbance and muscle weakness. R3's care plan dated 6/28/19, indicated R3 was at risk for wandering/elopement and a wanderguard had been placed. R3 would wander in her wheelchair. R4's face sheet printed 7/13/21, indicated a diagnosis of dementia. R4's care plan dated 9/25/20, indicated R4 was at risk for wandering/elopement and a wanderguard had been placed. R4's care plan dated 10/4/18, indicated R4 would self propel in her manual wheelchair. R5's face sheet printed 7/13/21, indicated diagnoses of [CONDITION(S)] and mild cognitive impairment. R5's care plan dated 7/1/21, indicated R5 was at risk for wandering and a wanderguard had been placed. R5 would self-propel in her manual wheelchair. During interview on 7/13/21, at 11:10 a.m. the director of environmental services (DES) stated when a new wanderguard tag was put into service it was checked at the front door to ensure functionality. He stated he did not know if all of the doors were connected to the wanderguard system as he had not checked them. During interview on 7/13/21, at 11:37 a.m. DES stated the front door was the only door armed with the wanderguard system. During interview on 7/13/21, at 12:17 p.m. the assistant director of nursing (ADON) stated there were three exits armed with the wanderguard system: the front door, the dining room door, and the door by the chapel. She stated she did not know when they were last tested , nor did she have a log to document testing by nursing staff, but they were tested when a resident got close to the doors and the alarm would sound. She stated she did not know if testing was recommended by the manufacturer. During interview on 7/13/21, at 12:58 p.m. Accutech technician stated wanderguard system door functionality should be tested on ce per month. During interview on 7/13/21, at 2:38 p.m. the administrator stated his expectation was for environmental services to check the functionality of the wanderguard systems for the three armed exit doors in the facility. The administrator stated the DES had been in his position for about a year. During interview together on 7/13/21, at 2:59 p.m. the DES stated he had not checked the functionality of the wanderguard system on the three exit doors in the facility that were armed. The ADON stated nursing had not checked the functionality of the wanderguard system on the three doors that were armed, except when a resident came close to it, and the alarm would have alerted staff. The administrator provided documentation that showed the door locks were checked on a monthly basis but not the wanderguard functionality. Facility policy titled Elopement Risk dated 7/19, indicated a door security alarm was in place and environmental services staff would monitor all door alarms per manufacturer's guidelines or recommendations. Accutech wanderguard manufacturer's instructions provided by the facility, dated 12/15/21, lacked recommendations for assessing door system functionality.

Based on observation, interview and document review, the facility failed to provide adequate supervision when 1 of 1 resident (R29) was pushed by another resident (R73) resulting in a fall. This resulted in actual harm for R29 who suffered a pelvic fracture as a result of the fall. In addition, the facility failed to ensure the safety of 1 of resident (R10) who had fallen and failed to provide needed education to employee who had not followed the care plan. Additionally, the facility failed to provide an environment free from a tripping hazard to ensure the safety of 1 of 1 resident (R29) who was at risk for falls. Findings include: Family member (FM)-B was interviewed on 1/16/20, at 1:01 p.m. and stated R29's life changed after R73 pushed R29 causing R29 to sustain two detached fractures of the upper and lower pubic rami bone (pelvic fracture). FM-B explained it took over a week to confirm the fractures due to a portable x-ray completed at the facility showing a past fracture. FM-B stated R29 began to have pain after the fall 1/8/20, which did not improve so R29 was taken to the hospital where they diagnosed a current fracture. FM-B stated R29 was now scared of R73 and had told FM-B I am scared, I am scared of him. FM-B stated she was told both R73 and R29 were trying to sit in the same chair when R73 pushed R29. FM-B stated she wanted the facility to lay out a care plan to reassure FM-B that R73 would not push my mom again. FM-B stated the hospital's social worker had suggested R29 move closer to the desk so the staff could watch better. FM-B stated, I just need to know what the plan is. F29's Fall Report dated 1/8/20, identified R29 fell in the dining room after R29 and another resident attempted to sit in the same chair. The other resident was noted to have pushed R29 in the chest area, which caused R29 to lose her balance and fall onto her right side. R29 was noted to limp and stated her hip and upper leg were sore. In addition, bruises were noted to R29's right elbow which measured 9 centimeter (cm) long by 3 cm by 3 cm, right hip measured 4 cm by 2.5 cm, and right front knee bruising measured 3 cm by 4 cm and was almost noted as swollen. The report indicated nursing assistant (NA)-A witnessed the incident. The facility investigative filed submitted 1/8/20, indicated R73 pushed R29 when both R73 and R29 attempted to sit in the same chair. When R73 pushed R29 in the chest area R29 was unable to regain her balance falling to her right side. FM-A was interviewed via telephone on 1/17/20, at 8:59 a.m. and stated she was not aware R73 pushed another resident and indicated R73 would get agitated when asked to do something. Nursing assistant (NA)-C was interviewed on 1/17/20, at 9:21 a.m. and stated R73 would hit, swing out and push staff when providing personal cares. NA-C was unaware R73 had any issues with another resident and was only aware of altercations with staff however, indicated R73 could switch moods quickly. R73 was observed on 1/17/20, at 9:27 a.m. seated calm in recliner in common area with magazine in hand. Attempts to interview R73 at that time were unsuccessful. Licensed practical nurse (LPN)-A was interviewed on 1/17/20, at 9:28 a.m. and stated R73 would push and hit staff during cares and indicated staff were to offer him a stuffed dog to hold to decrease the incidence of pushing and hitting. LPN-A stated she was not aware R73 had hit or pushed another resident and was only aware of altercations with staff. The Nurse Practitioner (NP) was interviewed via telephone on 1/17/20, at 9:37 a.m. and stated R29's x-ray completed at the facility showed a subacute right pelvic fracture however, NP indicated this did not correlate with R29's acute onset of pain. NP stated on 1/10/20, she called the x-ray company who again indicated a subacute fracture which possibly happened five to twelve weeks prior. NP indicated on 1/15/20, R29's pain and bruising correlated with an acute fracture and she called R29's family and it was decided R29 would be transferred to the hospital. NP explained a computed tomography (CT) was completed at the emergency room which showed an acute fracture, believed to be a result of R29's fall after having been pushed by R73. R29 was interviewed on 1/17/20, at 10:01 a.m. and was unable to answer questions. At that time, R29 was observed lying calmly in bed with her wheelchair and walker at her bedside. R73's Behavioral Symptoms Care Area assessment dated [DATE], identified R73 wandered on the unit into other resident rooms, yelling and threatening staff and raised his hand towards staff and directed staff to reapproach, use calm and quiet approach, medications as ordered and observe for changes. R73's Vulnerable Adult Care Plan created 6/18/19, identified R73 was combative with staff which included striking and kicking out with toileting, perineal and other hygiene tasks and directed staff to see activity of daily living (ADL) and fall risk, cognition and communication and elopement/wandering and elimination and skin focuses for additional interventions. R73's Elimination Care Plan revised 9/25/19, identified R73 was always incontinent and directed staff to inform nurse when R73 was combative striking or kicking out during toileting cares. R73's Cognition and Communication Care Plan created 1/8/20, identified R73 had severe cognitive impairment and was able to understand verbal language only occasionally and directed staff to identify yourself with each interaction, face R73 when speaking, make eye contact, reduce distractions, understands consistent, simple, directive sentences, provide with necessary cues stop and return when agitated, use pictures or real items, gestures and facial expressions, lavender essential oil at 2:30 a.m. to reduce agitation with overnight cares in the early morning, assist with all decision making, limit choices, use cueing, task segmentation and one-step instructions. R73's ADL/mobility Care Plan revised 1/10/20, identified R73 had cognitive impairment and history of being resistive to cares and directed staff to hand-hold guidance of one staff and two when resistive or wandering into others rooms, cues for bed mobility, cue and prompt with one to two staff to dress and with hygiene, assist with eating, offer stuffed dog to hold before starting cares at night, assist of two staff with hand-hold guidance for transfers and wheelchair with anti-rollback. R73's Elopement/wandering Care Plan revised 1/13/20, identified R73 had agitation with hygiene/toileting due to dementia with behavioral disturbance and directed staff to observe whereabouts on unit frequently, ensure family sign R73 out at desk, redirect, resided on secured dementia care unit, picture and word toilet on R73's bathroom door, name on room door, guide to bed and validate feelings. R73's Fall Risk Care Plan revised 1/15/20, after survey began, identified R73 was at risk for falls and directed staff to lead R73 to a chair and encourage to sit as he allows to avoid more than one person attempting to sit in a chair, non-skid socks, manual wheelchair with anti-rollback, hip pads, bed at appropriate height and see ADL/mobility bowel and bladder and mood/behavior interventions as appropriate. R73's care plan lacked evidence of incident with R29 on 1/8/20, when R73 was noted to have pushed R29 due to both R73 and R29 attempting to sit in the same chair. Furthermore, R73's care plan lacked evidence regarding R73 not wanting others close to him. R29's Vulnerable Adult Assessment Care Plan revised 9/20/19, identified R29 was at risk for injury to self or others due to dementia diagnosis and directed staff to monitor whereabouts and redirection. R29's Vision Care Plan revised 1/10/20, identified R29 cannot see right field of vision and directed staff to assist R29 in crowded areas such as dining room. R29's Care Plan revised 1/15/20, after survey began, identified R29 was at risk for falls due to loss of balance when turning head to the left and directed staff to place silent bed alarm, anti-roll back wheelchair, bed at appropriate height, call light within reach, proper footwear, therapy as ordered and ambulate as tolerated. R29's care plan lacked evidence of R29 having been pushed by R73 on 1/8/20, which resulted in a fall and pelvic fracture. R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 had moderately impaired cognition and diagnoses which included dementia and anxiety. The quarterly MDS indicated R29 had no behaviors during the reference period and required extensive assistance from one staff for ADLs (activities of daily living). R73's quarterly MDS dated [DATE], identified R73 had severe cognitive impairment and diagnoses which included dementia and anxiety. The quarterly MDS indicated R73 had physical behavioral symptoms one to three days during the reference period. The quarterly MDS further indicated R73 required extensive assist of two staff with ADLs. R73's Progress Notes (PN) dated 1/8/20, indicated R73 and another resident were attempting to sit in the same chair and R73 pushed the other resident on the chest, causing her to stumble. Other resident unable to regain her balance and fell to the floor. R73 and R29 separated immediately and R73 was under constant supervision throughout the evening. R29's PN were reviewed 1/8/20 through 1/16/20, and revealed the following: -The PN dated 1/9/20, R29 had x-ray related to right hip pain. A subsequent PN dated 1/9/20, indicated R29's x-ray showed no acute fracture, however identified a subacute right superior and inferior pubic rami (pelvic area) fracture; -The PN dated 1/10/20, indicated staff were educated to assist R29 when in crowded areas such as dining room; -The PN dated 1/13/20, indicated R29 had subacute pelvic fracture happened at least 5 weeks ago per NP following x-ray results review; -The PN dated 1/14/20, indicated R29 had an orthopedic appointment scheduled for 1/21/20. A subsequent PN dated 1/14/20, indicated updated care plan to include recent fall intervention anti-roll back wheelchair to reduce risk of falls; -The PN dated 1/15/20, after survey began, indicated care plan updated following fall on 1/8/20, and directed staff to observe R29 when coming into the dining room to ensure everyone had their own chair. A subsequent PN dated 1/15/20, indicated R29 had severe pain all the time due to hip fracture. Additionally, the PN dated 1/15/20, indicated NP updated regarding R29's pain; NP spoke to family and family decided to take R29 to the emergency department to have her hip checked out again and get more x-rays to see if there is more wrong .; -The PN dated 1/16//20, indicated R29 was admitted to the hospital for pain control due to R29 having had two complete displaced fractures of the Rami on the right side. A subsequent PN dated 1/16/20, indicated R29 returned from the hospital reviewed CT of right hip noted acute fractures of the right superior and inferior pubic rami mild right hematoma noted. R29's Emergency Department Note dated 1/15/19, indicated R29 had a CT of right hip and there was an acute oblique comminuted mildly displaced fractures of the medial aspects of the right superior pubic rami and the midportion of the right inferior pubic rami and mild right pelvic hematoma. The note further indicated R29 had conditions which included, not limited to fracture, sprain, contusion, dislocation, vascular damage, nerve damage, ligament damage, tendon damage, and other etiologies. Based on history, physical exam and imaging impression was fractures of multiple pubic rami. The administrator, the director of nursing (DON) and registered nurse (RN)-A were interviewed on 1/17/20, at 11:18 a.m. RN-A stated R73 was not upset when he pushed R29. DON stated R73 did not have intent when he pushed R29. DON stated R73 had not shown agitation toward other residents since 1/8/20. DON stated R73 and R29 were two people who have dementia perception issues and there was nothing that indicated agitation with the other resident. DON further stated R73 only had a history of striking out with cares towards staff. DON explained R73 could have been reaching out for the chair with his arm and ended up pushing R29. DON stated R73 did not mean for it to happen and indicated RN-B was present at the time of the incident on 1/8/20, and said R73 appeared apologetic. RN-B was interviewed on 1/17/20, at 12:27 p.m. and stated No I was not present when the altercation between R73 and R29 happened. RN-B explained she was in the dining room five minutes earlier and R73 and R29 were at two different tables then I left and when I returned NA-A notified RN-B that R29 had fallen. RN-B stated R73 extended his arm to say this is my chair and when R73 made contact with R29; R29 lost her balance and fell . RN-B stated R73 did not appear to be upset, however seemed surprised. RN-B stated R73 intended to sit in the chair and was like with his arm no I am sitting here. RN-B confirmed she completed R29's fall incident reported and acknowledged He [R73] did push her, it was a not this is my chair, it was enough with his hand to make R29 off balance and fall. NA-A was interviewed via telephone on 1/17/20, at 1:15 p.m. and recalled on 1/8/20, in the dining room R73 and R29 were observed attempting to sit in the same chair and R73 pushed her away then she fell . NA-A explained R29 usually sat in the chair, and NA-A went behind R73 stating if you approach R73 he will hit you. NA-A stated, I think that was why he pushed her away, she was too close when she approached him. NA-A stated it was too late, and NA-A was unable to intervene due to being too far away. NA-A stated, You need to be careful when approaching [R73] otherwise he gets very aggressive and agitated. NA-A stated R73 had not been aggressive toward other residents prior to this incident, but had only previously been aggressive towards staff. NA-A stated R73 did not look angry or upset that is just the way he is he doesn't like people close too him. The facility's medical director was interviewed via telephone on 1/17/20, at 1:24 p.m. and stated it was his expectation for the facility to follow their policies and procedure for resident to resident altercations. The Resident Protection Program Policy approved 3/2019, indicated abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The policy indicated resident to resident abuse may not cause serious harm. If it was willful (meaning the individual intended the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish) or causes serious harm it should be reported. Even though a resident may have cognitive impairment, he/she could still commit a willful act. The population of the facility included individuals whom met criteria for skilled care as well as specialty programs including dementia care. Every resident was unique and subject to abuse based on a variety of circumstances which included physical plant, environment, health status, behavior and cognitive level. The interdisciplinary team would identify the vulnerabilities on the resident care plan. The facility's population presents the following factors, which could result in maltreatment of residents and indicated the assessment, planning of care and services, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents whom have had behaviors such as entering other residents' rooms, wandering and socially inappropriate behaviors. R10's admission MDS dated [DATE], identified moderately impaired cognition based on a Brief Inventory of Mental Status score of 9. R10 required extensive assist from staff with activities of daily living. R10 was frequently incontinent of urine and continent of bowel. R10 had history of falls and had falls since admission. R10's Care Are Assessment worksheet dated 12/3/19, identified staff were to anticipate all needs, provide for all cares, cue and redirect R10 as needed. Staff were to provide incontinent cares and assist with toileting. R10 had one fall since admit on 11/27, with no injury. R10's admission Fall Risk Data Collection assessment dated [DATE], placed R10 in the high risk fall risk score category. Furthermore, Resident is a fall risk d/t [due to] medications, need for hands on assistance, variability in the level of assistance needed. R10's care plan dated 11/21/19, indicated R10 was at risk for falls or injury related to history of one to two falls prior to admission and diagnosis of history of cerebral vascular accident (stroke) with left sided weakness and impaired cognition. Required assist of one with transfers and ambulation with four wheeled walker. R10 has a history of self-transfers. Interventions as of 11/21/19, included bed at appropriate transfer height, call light within reach at all times, education regarding fall prevention, proper footwear on when up. The facility Fall Scene Investigation Report dated 11/27/19, at 4:15 p.m. indicated R10 fell because shoes were slippery and R10 was left alone in the bathroom. R10 had no pain and no injuries were indicated. The care plan was updated on 11/27/19, to indicate fell in bathroom on 11/27/19. Stay with her while she is on the toilet to prevent self transfer. R10's Kardex report indicated fell in bathroom on 11/27/19. Stay with her while she is on the toilet to prevent self-transfer. Progress note dated 12/9/19, at 6:45 p.m. indicated R10 fell while self transferring from the toilet, with NAR [nursing assistant, registered] briefly out of room to get pad. The facility Fall Scene Investigation Report dated 12/9/19, at 6:40 (a.m. or p.m. not indicated) indicated staff went to closet to grab pad. Pads not in closet. The fall happened because R10 was left on toilet and self transferred. There was no mention if education was provided to the staff due to care plan not followed. When interviewed on 1/16/20, at 10:39 a.m. clinical coordinator RN-A verified the fall on 11/27/19, had an intervention placed that required staff to stay with R10 on the toilet. RN-A verified the care plan was updated. The shoes with slippery soles were sent home with the daughter. When asked if the care plan was followed for the fall dated 12/9/19, RN-A stated, I wasn't here at the time. I would assume pads are kept in the closet, I'd have to follow up on it further. I'd assume there was an investigation, after 12/9, it was put in the care plan to gather the needed supplies. When interviewed on 1/16/20, at 11:28 a.m. NA-C stated she is familiar with R10's care. NA-C knew R10 was a fall risk and the instructions were on the kardex so staff know what interventions are in place. When interviewed on 1/16/20, at 12:01 p.m. DON stated the clinical coordinator is responsible to re-evaluate fall interventions. Fall interventions are re-evaluated after the IDT (interdisciplinary team) meeting that takes place at quality meetings on Wednesdays. When asked to review the falls from 11/27/19, and 12/9/19, DON stated, it looks like they didn't follow what the plan was. DON stated it would be the expectation that the care plan should be followed and interviews and interventions should be included in the initial fall note. On 1/16/20, at 3:59 p.m. information was requested from RN-A for any training that was provided after the fall events for R10, especially for following the care plan. There was no education provided to NA involved in the incident nor other facility staff about following the care plan after the fall on 12/9/19. On 1/16/20, at 4:45 p.m. DON stated there was no further education provided to staff after the fall on 12/9/19, regarding the importance of following care plan. On 1/16/20, at 4:51 p.m. a voicemail and request for return call was left for NA-J, whom was working with R10 during the fall on 12/9/19. No return call was received. When interviewed by phone on 1/16/20, at 4:51 p.m. RN-C recalled working for a couple hours during R10's fall on 12/9/19. RN-C stated, Well I remember my CNA [certified nursing assistant] came to tell me that she [R10] fell . I came in and she [R10] was on the bathroom floor. The CNA said she turned her back to get something out of the closet. I think she was following care plan. I didn't suspect any wrong doing she just turned her back for a second. The facility policy Falls/Prevention/Intervention dated 3/19 identified Risk Assessment to be completed in Point Click Care (computerized charting system) after a fall occurs. Risk management follow up to be completed by the clinical coordinator within 48 hours of incident occurring. Interdisciplinary quality meeting will meet weekly to review falls and make suggestions for changes to plan of care. The facility policy Care Planning and the MDS 3.0, dated 5/11, indicated care plans are individualized for each resident to identify their needs and preferences, including measurable goals and interventions. Additionally, care plans are updated as appropriate to reflect resident's current status. On 1/13/20, at 2:30 p.m. R29's bed alarm cord was observed lying on floor and outward from under the bed. A portion of the cord was wrapped into a bundle but lying on the floor. The cord was at least a foot from under the bed. During observation on 1/14/20, at 9:34 a.m. the bed alarm cord was lying on floor near foot of bed and outward from under the bed. A portion of the cord was wrapped into a bundle but lying on the floor. The cord was about two to three feet long from the lower midpoint of the bed to the sensor control panel at the base of the bed board. The cord was outward at least a foot from under the bed. On 1/14/19, at 1:10 p.m. R29 was observed in her room standing up near foot of bed in front of wheelchair and attempted to walk around the foot of the bed while holding on to the foot board. NA-E was in room near resident attempting to redirect resident. Review of Admission MDS dated [DATE], indicated R29 diagnoses included dementia and [CONDITION(S)] (a neurological condition that causes unwanted, involuntary muscle movements and sounds known as tics). R29 was frequently incontinent of bladder, had no functional limitation to lower extremity, severe cognitive impairment; required extensive assist of 1 staff for bed mobility, dressing, toileting, personal hygiene and limited assist with transfers, walking in room and unit, and locomotion on and off unit. Balance was not steady from seated to standing, walking with assist, turning around and facing opposite direction and not steady during transfers between bed, chair, and wheelchair. Review of updated care plan dated 1/13/20, indicated R29 had a risk for falls or injury. Risk for fall included history of Cerebral Vascular Accident (stroke), hypertension, cognitive impairment, impaired gait with instability/balance, loss of balance when turning head to the left. Interventions included the placement of a temporary silent bed alarm placed on 1/9/20, to alert staff if R29 was attempting to get out of bed. When interviewed on 1/14/20, at 3:25 p.m. NA-E explained the bed sensor alarm was a quiet alarm placed to notify staff when R29 attempted to get out of bed since R29 was a fall risk and had been injured after a fall about a week earlier. R29 did stand up on her own and was observed walking self into the bathroom by NA-E about a day or two prior and redirected. Staff tried to keep the bed sensor alarm cord under the bed but verified cord was outward and not under the bed and further indicated it was possible for R29 to trip on the bed alarm cord and fall. NA-E explained he would immediately go and find something to tie the bed alarm cord under the bed so that it was not outwards from under the bed. On 1/17/20, at 11:47 a.m. DON indicated maintenance was responsible to check and audit bed alarms and bed alarms were assessed during quarterly meetings. DON stated the facility was trying to decrease the use of bed alarms and further explained it was the expectation for staff to notify the nurse managers immediately as soon as staff was aware of a safety risk/hazard to any resident. Staff were expected to notify the nurse manager who was unaware of the bed alarm cord as a tripping hazard in R29's room. Review of undated facility policy titled Falls/Prevention/Intervention, included bed, floor or chair alarm to alert staff, only if other interventions ineffective, reevaluate at weekly Quality meeting.

Based on observation, interview, and document review, the facility failed to implement a preventive maintenance program to reduce avoidable accidents, for 1 of 5 residents reviewed (R3), who required transfer with the aid of an EZ Stand lift. During a routine transfer, the EZ Stand lift malfunctioned and R3 fell from the lift to the floor. R3 sustained a broken femur from the fall and died four days later from sequelae as a result of the fall. Findings include: Observations on [DATE] at 10:45 a.m. established that the facility had a total of eleven mechanical lifts that were shared among three care areas, including long-term care residents, transitional care residents, and memory care residents. Five of the mechanical lifts were full body lifts; six of the mechanical lifts were EZ Stand lifts like the type R3 used. Four of the six EZ Stand lifts were older models that had rubber safety tabs on the upper lift arms (#891, #238, #242, and #174), whereas, the two newer EZ Stand lifts were equipped with metal safety clips on the upper lift arms. The purpose of the rubber safety tabs and metal safety clips was to keep the resident's harness straps properly secured to the lift arm, during lift use. At the time of the investigation, the rubber safety tabs on EZ Stand lifts #891, #238, #242, and #174 were installed correctly, firm, and not tattered. R3's care plan, dated [DATE], indicated that R3 required extensive staff assistance with all activities of daily living, secondary to advanced age, weakness, and right-sided physical deficits from polio. R3 was nonambulatory but could bear weight for transfers with an EZ Stand lift and the assistance of two staff. R3 used the EZ Stand lift to toilet during the day; R3 preferred to use a bedpan after 2:00 p.m. due to difficulty bearing weight when she became tired. R3 was alert, conversant with minor forgetfulness, and expressed her care preferences to staff. This information was consistent with the medical provider's progress note regarding R3's status, dated [DATE], and interview of R3's family member. The progress notes, dated [DATE] at 8:20 a.m. indicated that R3 fell to the floor during a transfer off the toilet when the EZ Stand lift malfunctioned. The rubber safety tab popped off the lift arm and released the right harness strap, causing R3 to fall to the side that came unhooked. The lift was being operated by one nursing assistant instead of two staff. R3 was immediately assessed by a nurse. R3 was unable to move her right leg without extreme pain. X-ray confirmed a fracture above the right knee. Neither Tylenol nor Oxycodone effectively managed R3's pain. At 12:00 p.m., R3 was transferred to the hospital for further evaluation and treatment. The hospital record, dated [DATE] at 12:41 p.m., indicated that R3 presented with significant pain due to an acute fracture of the right distal femur. R3 was not a surgical candidate due to comorbidities and advanced age. Comfort care was elected. R3's right leg was immobilized. Intravenous Dilaudid and Fentanyl were given for pain control and R3 was kept overnight for observation of pain status. R3 was discharged back to the facility on [DATE] on comfort care interventions, including a Fentanyl patch and Roxanol for pain control. The discharge summary noted that R3's condition was likely terminal. The progress notes indicated that R3 returned to the facility on [DATE] at 3:19 p.m. Comfort care measures were administered over the next three days as R3 progressively declined with less oral intake and increased pain. R3 died on [DATE] at 5:00 a.m. R3's death certificate identified R3's cause of death as sequelae from right distal femur fracture. The death certificate noted that R3 was being transferred with an EZ Stand when it malfunctioned and led to her fall. Nursing Assistant (NA)-E was interviewed on [DATE] at 1:20 p.m. NA-E stated she had performed R3's care many times over the years. R3 had always been transferred with the EZ Stand lift. Prior to (MONTH) (YEAR), only one staff assisted R3 with EZ Stand lift transfers. NA-E had independently transferred R3 multiple times prior to (MONTH) (YEAR). In (MONTH) (YEAR), the facility implemented a new policy requiring two staff to assist all residents with any type of mechanical lift transfers. NA-E was aware of the policy change and that two staff were necessary to transfer R3 with the EZ Stand lift. On the morning of [DATE], R3 had been transferred to the toilet by two staff and provided with privacy, per usual; R3 activated the call light when she was finished, per usual. NA-E responded to R3's call light around 8:15 a.m. R3 wanted to be transferred off the toilet; R3 said her backside was hurting. NA-E checked for another staff to help with R3's transfer but other care givers were providing morning care to residents in their rooms and not available. NA-E then assisted R3, alone. NA-E checked R3's harness; the harness was properly attached to R3 and the EZ Stand lift. NA-E then assisted R3 to a standing position with the EZ stand lift. NA-E provided R3's peri care and conducted a skin check of R3's perineal area and buttocks, while R3 stood and held onto the handles of the lift. Just as NA-E was preparing to place R3's incontinent product, NA-E heard a tearing noise; the rubber safety tab on the right side of the lift arm popped off and the right side of R3's harness suddenly detached. NA-E tried to support R3 as she fell to the floor from the right side of the lift. NA-E yelled for a nurse. The rubber safety tab from the lift was on the floor underneath the sink. RN-C was interviewed on [DATE] at 8:55 a.m. RN-C stated she assessed R3 on [DATE] when R3 was on the bathroom floor. R3, who never complains, said her right leg hurt and R3 appeared distressed. R3's right foot flopped over so RN-C did not attempt range of motion. RN-C medicated R3 with Oxycodone and applied an ice pack while waiting for x-ray to arrive. X-ray confirmed a femur fracture and R3 was transferred to the hospital. R3 came back to the facility the next day (Friday) on comfort measures. Staff provided R3 with total care throughout the weekend and R3 passed away Monday morning. The EZ Stand lift that malfunctioned was sent to maintenance along with the rubber safety tab that came off during the transfer. RN-C was unsure if the facility had a preventive maintenance program for mechanical lifts. At least fifty percent of the residents use mechanical lifts and staff perform hundreds of mechanical lift transfers daily. NA-G, NA-H, and NA-J were interviewed on [DATE] after observations of their resident care with a mechanical lift transfer. All three nursing assistants stated they used mechanical lifts routinely throughout each day, including the four EZ Stand lifts that had rubber safety tabs. All three nursing assistants denied ever having a rubber safety tab completely dislodge from a lift during a transfer, but all three nursing assistants had experienced situations when the rubber safety tabs were either loose, cracked, or worn out, so the lift could not be used safely and they took it to maintenance for repair. Geriatric Nurse Practitioner (GNP)-B was interviewed on [DATE] at 9:35 a.m. GNP-B stated R3 was nonambulatory for years and had always required transfer with the aid of an EZ Stand lift. Historically, staff had safely transferred R3 with the EZ Stand lift and the assistance of one staff until the policy recently changed and mandated two staff to assist residents with all mechanical lift transfers. If R3's transfer had been completed by two care givers, R3's fall from the lift on [DATE] would have most likely still occurred with the same outcome, given R3's right-sided weakness from polio, nonambulatory status, severe osteoporosis, and failure of the lift to support R3's weight of 184 pounds. When the lift malfunctioned and the harness disengaged from the right lift arm, R3 fell to the right side, which was her weak side. R3 sustained a broken femur, did not recover, and died four days later. The coroner determined that R3 died from the effects of the fall. Environmental Services Director (ESD)-F was interviewed on [DATE] at 11:25 a.m. ESD-F stated his role was to oversee the facility's maintenance needs. On [DATE], staff brought an EZ Stand lift (#891) to the maintenance department for repair after one of the rubber safety tabs dislodged during a resident's transfer. The rubber safety tabs on both sides of the lift arm were loose, due to wear. ESD-F replaced both rubber safety tabs and inspected the lift; no other operational issues were identified during the lift's inspection. ESD-F's records showed that the lift was last serviced on [DATE] but the records did not include any details about what was checked, repaired, or replaced. Prior to (MONTH) (YEAR), the facility did not have a preventive maintenance program. Mechanical lifts were not monitored for routine maintenance. When staff had operational problems with a lift, staff would bring the lift to maintenance for repair. ESD-F frequently replaced rubber safety tabs on four lifts (#891, #238, #242, and #174) because they would loosen with wear. After the [DATE] event with R3, the facility ordered four new lift arm hangers with metal safety clips to replace the existing lift arms that had rubber safety tabs; the lift arms with metal safety clips are more durable and increase security of the sling strap placement. Until the new lift arms arrive, ESD-F has been conducting daily inspections of the rubber safety tabs on all four of the older lifts, to ensure the rubber safety tabs are functional. The facility hired a consultant during (MONTH) and (MONTH) (YEAR), who helped the facility develop a preventive maintenance program. The preventive maintenance program was implemented on (MONTH) 1, (YEAR) and includes monthly inspections of every lift, with a documented full exam and documented necessary repairs. Administrator (ADM)-A was interviewed on [DATE] at 10:15 a.m. ADM-A stated he hired a consultant in (MONTH) (YEAR) to fully review the facility's maintenance needs and assist in the development of a preventive maintenance program, which was absent prior to [DATE]. ADM-A received feedback from the consultant on [DATE]; the facility implemented a preventive maintenance program on [DATE]. R3's fall from the #891 EZ Stand Lift occurred on day 12 of the preventive maintenance plan. The #891 EZ Stand Lift had not yet been serviced after the preventive maintenance program started. The consultant, who was onsite at the facility during (MONTH) and (MONTH) (YEAR), had checked all eleven of the lifts in (MONTH) (YEAR) and again in (MONTH) (YEAR). The consultant's written report, dated [DATE], indicated the facility needed to fully implement a preventive maintenance program to anticipate, track, and verify routine service schedules and related lifespan replacement cycles for operational and resident service equipment. The report indicated that EZ Stand lift #891 was checked and operable on [DATE] and [DATE], however, details about what was inspected on the lift was absent on both dates, including the condition of the lift's rubber safety tabs. The manufacturer's instructions for the EZ Way Stand lift, dated [DATE], indicated that the following components and operating points be scheduled for inspection at intervals not greater than one month and any detected deficiency must be rectified before the stand is put back into service: check all bolts on the base, pivot, rear wheel, front wheel, linkage, spreader, arm mast pivot bolt, shin pad, mounting bolts of actuator top and bottom, and foot platform assembly pins; check safety tabs to make sure they are installed correctly and not missing or torn. It is the responsibility of the purchaser to ensure that regular maintenance inspection is conducted on this device by competent staff.

Based on interview, and record review, the facility failed to provide adequate supervision and assistance when staff did not use a gait belt with ambulation for 1 of 3 residents reviewed, R1, with a risk of falls. This resulted in actual harm when R1 sustained a subdural hematoma when she was walking without a gait belt and fell and hit her head on the wall. Findings include: R1's medical record was reviewed. R1 was cognitively impaired, weak and had decreased balance and impaired coordination. R1's care plan indicated R1 was dependent on staff to assist with activities of daily living. R1's care plan indicated one staff was to assist with R1's mobility needs and provide contact guard assistance. Staff were to use a gait belt and walker, and one staff was to walk with R1 when R1 was ambulating with her walker and one staff was to push the wheelchair with oxygen. R1 was receiving hospice care while at the facility. A nursing progress note dated [DATE] at 5:37 p.m. indicated R1 was walking in the hallway and lost her balance and fell at 5:00 p.m. The note indicated a nursing assistant was present and witnessed the fall. The note stated a transfer belt/gait belt was not being used when R1 fell . The facility's incident report and internal investigation of the incident, dated [DATE], were reviewed. They indicated R1 was using her walker and was walking out of her room. Nursing Assistant (NA)-B was present and pushing R1's wheelchair behind R1. NA-B was attempting to change R1's oxygen tubing, and R1 lost her balance, fell sideways into the wall and hit her head. R1 sustained an injury to the top of her head. R1 was alert and oriented after the fall and stated she was fine. The internal investigation indicated NA-B was not using a transfer belt with R1 at the time of the fall. A nursing progress note dated [DATE] at 10:48 a.m. stated R1 refused breakfast and complained of a headache and then became unresponsive. R1 was transferred to the emergency room per physician's orders [REDACTED].>A nursing progress note dated [DATE] at 3:16 p.m. stated emergency room staff told the facility that R1 had a massive brain bleed and that R1 would be transferred back to the facility for R1's end of life. R1's death worksheet indicated R1 died on [DATE], and it listed the manner of death as an accident. The immediate cause of death was a closed head injury which resulted from a fall that occurred at the nursing home. When interviewed on [DATE] at 8:30 a.m., director of nursing (DON)-A stated NA-B was not using a gait belt with R1 at the time of R1's fall on [DATE]. NA-B was placed on administrative leave following the incident. In addition, NA-B was provided counseling and re-education related to R1's fall and NA-B's failure to use a gait belt. NA-B was interviewed on [DATE] at 12:20 p.m.and she stated she was working with R1 at the time of the [DATE] fall. She said she was very familiar with R1. She said she did not have the transfer belt with her when she was working with R1 on [DATE] because she left the transfer belt in another resident's room prior to entering R1's room. Prior to the fall, R1 walked to the bathroom with her walker, went to the bathroom, washed her hands and used her walker to walk from the bathroom. NA-B said she was walking behind R1 with the wheelchair but was not using a gait belt to hold on to R1. R1 lost her balance after she walked back from the bathroom and was standing with her walker in the room while waiting for NA-B to transfer the oxygen tubing to the portable oxygen tank. When R1 fell , she hit her head against the wall. NA-B said she was placed on administrative leave following the incident and returned to work on [DATE]. The facility has provided her with ongoing re-education related to gait belts since the incident occurred. The facility has also provided re-education related to using gait belts to additional staff. The facility policy titled Transfer Belts dated [DATE], indicated all nursing assistants are required to use a transfer belt while on duty and to use a transfer belt when assisting residents. The use of of a transfer belt is required at all times when walking residents or with assisted transfers.

Based on observation, interview, and document review, the facility failed to ensure the resident's environment was free of hazards for 2 of 6 residents (R1 & R2) when R1's bed was positioned against his room's heating unit, and R2 was positioned in a recliner very close to a heating unit which had an unsecured cover. This resulted in actual harm for R1 who experienced a blister to his left fifth finger, and a potential for harm for R2. Findings include: Review of R1's medical record revealed a [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicates a vulnerable adult risk assessment was completed and R1 was at risk for injury due to his [DIAGNOSES REDACTED]. A nursing progress note dated 1/14/17 at 5:14 a.m. indicated R1 was found with his left arm hanging between bed and wall. R1's hand was resting on the heater board. R1 had a 2 centimeter (cm) x 2 cm burn of the left fifth finger. The bed was moved away from the heater right away. The skin was cleansed, bacitracin applied, petroleum gauze applied, and covered with telfa dressing and tape. R1 did not complain of pain or discomfort. A nursing progress note dated 1/14/17 at 9:05 a.m. noted the burn and the top layer of skin was missing, pink intact underneath. The on call maintenance staff was notified of broken heater cover. The on call nurse practitioner (NP) and family were notified. A review of a progress note dated 1/14/17 at 9:08 a.m. indicated there was an order from the NP to continue current treatment and watch for signs and symptoms of infection. A progress note dated 1/15/17 at 11:40 a.m. indicated the resident denied pain. No signs or symptoms of infection was noted. There was macerated skin surrounding the wound. A progress note dated 1/17/17 at 11:06 a.m. indicated that the left small finger remained clean, dry, and covered with dressing. R1's bed against remained against the opposite wall to prevent further isolated incidents. A progress note dated 1/19/17 at 9:42 a.m. noted the wound to measure 2.8 cm x 2.0 cm, wound bed color was pink, with moderate amount of serous drainage under part of dressing and on skin. No edema or increased redness was noted. An interview dated 1/19/17 at 11:00 a.m. with the director of nursing (DON) indicates that the older style heating baseboards were in the process of being replaced. The day following the incident, the DON sent an all staff message through the point click care system, that all beds must be moved away from the heater baseboards. An interview dated 1/19/17 at 2:33 p.m. with employee B revealed that the on call maintenance staff person came in to the facility the day of the incident and fixed the broken heater cover after being notified of the incident. The bed was moved away from the heating unit. He also states that the old heating units were in the process of being replaced by a newer model unit. An interview dated 1/19/17 at 4:25 p.m. with the Director of nursing (DON), revealed that the facility did not have a policy for bed placement near the heater boards to prevent burn injury. An interview dated 2/15/17 at 11:19 a.m. with registered nurse (RN)-C indicated that she notified maintenance, administration, and family, that the resident had suffered a burn. The on call nurse practitioner was also notified for further treatment orders. An interview dated 2/15/17 at 2:15 p.m. with RN-D revealed that she was assisting on night checks when the resident was found with his arm hanging over the bed in the space between the bed and the heater baseboard, with the hand resting on the heater baseboard. RN-D and another staff person immediately moved the resident and the bed away from the heater baseboard. The resident continued to sleep and did not express pain. The resident's burn was treated immediately with cleanser, bacitracin, vaseline gauze, and kerlix. Review of R2's medical record revealed a [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE] indicates R1 was at risk for injury due to dementia. On 1/19/17 at 3:55 p.m., R2 was observed napping in her recliner which was positioned near the heater baseboard on the window side of the room. The cover of the heater was unsecured and the heating source was exposed. The distance was within arm's reach. LPN-E was alerted to observe the chair placement, and the unsecured heater baseboard. She stated that the resident is mostly immobile. LPN-E and a second staff person immediately moved the resident in her recliner away from the heater baseboard. R2's bed was on the other side of the room away from the heater. On 1/19/17, at 5:01 p.m., during the exit review with the DON, observation of R2's chair placement near the broken heater baseboard was reviewed. She was not aware of the finding. Facility policy dated 1/17/17 titled Accident Report, indicates that all beds will be positioned away from the radiators-unless resident and family choice, which will be care planned and risks will be explained.