Every finding on record at Truman Senior Living

Based on interview and document review, the facility failed to ensure an alleged violation involving neglect were reported to the State Agency within the required timeframe after becoming aware that staff failed to follow a resident's transfer care plan by transferring the resident without the required gait belt for 1 of 1 resident (R1) reviewed for falls. Findings include:R1's face sheet dated 6/24/26, identified diagnoses of Alzheimer's disease (a progressive brain disorder that damages memory), chronic kidney disease (a long-term condition where the kidneys are damaged), osteoporosis (a medical condition where the bones become thin and weak), and diabetes (a condition where your body uses glucose as fuel). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, had not behavioral symptoms, no rejection of care, had no impairment on upper or lower extremities, used a walker/wheelchair, partial/moderate assistance for bed mobility, substantial/maximum assistance for transfer, and no falls since admission. R1's mobility focus care plan dated 8/15/25, identified R1 had impaired mobility related to inability to walk independently. Goal to be able to perform activity within physical limits. Interventions as follows:-Ambulation as therapy indicates (dated 8/15/25). -Family requested no use of mechanical lifts at this time. However, if refuses to stand and transfer with two staff, educate resident that lift will be used for both staff and own safety (dated 5/1/26). -Per therapy: Encourage to continue with stand pivots using four wheeled walker (4WW) to all seated surfaces. Will need moderate assist of one. Cue her to lean forward. Lift from gait belt and her pant line. Do not pull from front. She can walk distances with 4WW, and gait belt applied (dated 5/1/26). R1's fall incident report dated 7/17/26 at 4:30 p.m., identified R1 was found on the floor partially lying on her back with her knees slightly bent. R1 was crying and stating her left knee was hurting. Witness statement from nursing assistant (NA)-A identified that during a transfer to wheelchair with walker from the recliner, without a gait belt, R1 was lifted by the waistband when her knees gave out and she fell to the floor.During an interview on 7/24/26 at 4:19 p.m., nursing assistant (NA)-A stated she had assisted R1 during a transfer on 7/17/26 and did not use a gait belt during the transfer at the time R1 fell. NA-A explained she had moved R1 and placed a gait belt on R1 prior to calling the nurse to come and assess R1, because she was afraid she was going to get in trouble. During a phone interview on 7/24/26 at 1:57 p.m., licensed practical nurse (LPN)-A stated she had been the nurse working at the time of R1's fall on 7/17/26. After R1 had fallen she completed a full assessment of R1, who was having pain in her left knee. R1 was picked up off the floor and was later sent to the emergency room for evaluation but did not have any fractures and was sent back to the facility. LPN-A stated she had received a phone call from family to inform her they had reviewed camera footage at the time of the fall and identified that NA-A had not used a gait belt at the time of R1's fall. During a follow up phone interview on 7/24/26 at 4:59 p.m., LPN-A did not recall if she had notified the DON or administrator of R1's care plan not being followed at the time of the fall. During an interview on 7/24/26 at 2:14p.m., director of nursing (DON) stated she had not been aware until 7/19/26 that following R1's fall that occurred on 7/17/26 that a gait belt had not been used at the time of R1's fall. DON explained this had not been reported to the SA and the facility just began their investigation of the fall but should have reported this to the SA as well. During an interview on 7/24/26 at 2:20 p.m., administrator stated after the facility had discovered NA-A had not followed R1's care plan at the time of her fall on 7/17/26 by not using a gait belt to maintain resident safety, this should have been reported to the SA, however, had not been reported. Review of the facility's Abuse, Neglect, and Exploitation Policy dated 7/2026, identified the facility will have written procedures to assist staff in identifying the different types of abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. Possible indicators of abuse include, but not limited to:-Resident, staff, or family report of abuse.-Physical marks such as bruises or patterned appearance such as a handprint, belt or ring mark on a resident's body.-Physical injury of a resident of unknown source.-Resident theft of property or missing property.-Verbal abuse or a resident observed.-Physical abuse or a resident observed. -Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning, and repositioning. Reporting/Response:The facility will have written policies that include: Reporting all alleged violations to the administrator, state agency, adult protective services, and all other required agencies with specified timeframes: Immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involve abuse or resulted in serious bodily injury, or; Not later than 24 hours if the events that caused do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and document review the facility failed to ensure use of the correct sling was used according to manufacture instructions for a total body mechanical lift 1 of 1 resident (R2) reviewed for safe transfers involving mechanical lifts. In addition the facility failed to complete a comprehensive fall investigation analysis to identify root cause/causal factors to prevent and/or reduce the risk of falls and/or falls with major injury for 1 of 3 residents (R4) reviewed for falls. Findings include R2's face sheet dated 7/24/26, identified diagnoses of dementia, heart failure, spinal stenosis (narrowing of the spaces within the spine). R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment, no behaviors, no rejection of cares, used a wheelchair, dependent for all transfers, and had no falls since admission/or prior assessment.R2's mobility focus care plan dated 4/13/23, identified R2 had a potential for a decline in mobility related to lack of motivation, obesity, heart failure, anxiety, major depressive disorder and chronic pain. Goal to maintain ability to hold her feet up when propelling in wheelchair. Interventions as follows:-Transfer using full body mechanical lift using large sling. During an observation and interview on 7/24/26 at 10:00 a.m., nursing assistant (NA)-C explained the facility had multiple total body mechanical lifts and stored the slings in the storage room. Upon entering the storage room, it was observed to have multiple different manufacture slings hanging on hooks. NA-C stated some of the full body mechanical lift slings they have in storage are from when people come from the hospital and we just keep the slings in case we need a sling for emergencies, such as if the correct sling is being laundered. NA-C further explained the slings from the hospital are not the correct manufacture lifts the facility uses and could potentially put a resident at risk for falling out of the lift if they are used during a transfer. During an observation and interview on 7/24/26 at 10:08 a.m., NA-B came out of R2's room and was propelling a Direct Supply Atlas Lift out of the room. Hospice NA-A was in R2's room making her bed. R2 was in her wheelchair with a tan sling with burgundy edges underneath her. NA-A stated R2 had just been transferred using the Direct Supply Atlas Lift, however, they had used an incorrect manufacture sling during the transfer. NA-A explained R2 should have been used the sling designed for the specific lift, however, they sometimes just grab whatever sling is available. During an interview on 7/24/26 at 10:14 a.m., NA-B stated R2 was in the incorrect manufacture sling for the total body mechanical lift that was used for her transfer and should have been the sling designed for the lift. According to the Direct Supply Atlas Floor Lift manufacture owner's manual dated 7/2016 indicated that only slings and accessories designed for use with Direct Supply resident lifts should be used. Use of other manufacturers' components or accessories may compromise the operation of this resident lift. During an interview on 7/24/26 at 11:40 a.m., director of nursing (DON) stated during a resident transfer using a full body mechanical lift only the correct manufacture sling should be used to match the lift that is being used and if staff use the incorrect manufacture sling this could cause the resident to fall out of the sling. Review of the facility's Safe Patient Handling/Transfers Policy dated 2/26, identified the sling designed for the lift is utilized with that specific lift. R4's face sheet dated 7/24/26, identified diagnoses of disease of the spinal cord and neuromuscular dysfunction (a wide group of conditions that impair the function of voluntary muscles). R4's baseline care plan dated 7/13/26, identified R4 was not a fall risk. Although R4's baseline care plan identified R4 was not a fall risk, review of R4's record did not identify a fall risk assessment had been completed on 7/13/26. R4's Morse Fall Scale (a tool used to determine a fall risk) dated 7/14/26, identified R4 as a high fall risk due to having falls in the last six months, had impaired gait, overestimates or forgets limits. R4's admission Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment, had no behaviors or rejection of cares, had impairment on one side of lower extremities, dependent with bed mobility/transfers, had no falls in last month prior to admission, and had two or more falls since admission with no injury.R4's unwitnessed fall incident report dated 7/13/26 at 7:00 p.m., identified R4 was found on the floor by his dresser. R4 had been observed 15 minutes prior to the fall. R4 stated he was trying to get in his chair. Immediate intervention of assisted off the floor and added an alarm to bed and recliner. R4's unwitnessed fall incident report dated 7/16/26 at 4:20 a.m., identified R4 was found lying on the floor in front of his dresser. R4 had removed his catheter and found near residents' recliner.R4's unwitnessed fall incident report dated 7/16/26 at 11:50 p.m., identified R4 was found on the floor next to his bed after his bed alarm went off. Predisposing physiological factors of being confused and incontinent. Other factors of being confused and believes he is able to walk and unable to redirect. Immediate action was taken to the dining room with nursing staff.R4's fall focus care plan dated 7/17/26 (revised 4 days after the initial fall on 7/13/26), identified R4 had an actual fall related to self-transferring or poor cognition, poor balance, poor communication/comprehension. Goal to not sustain a major injury. Interventions as follows:-Electric sensor placed next to bed to alert staff when getting out of bed (dated 7/17/26-Fall mat next to bed (dated 7/17/26).-Provide a lipped-edge mattress on the bed for safety (dated 7/17/26).-Provide a low bed for safety (dated 7/17/26).-Provide activities that promote exercise and strength building where possible (dated 7/17/26).-Resident does not always follow the care plan. Staff to catch and assist when resident is seen not following the care plan (dated 7/17/26). Review of R4's record from 7/13/26 through 7/24/26 did not identify a root cause analysis had been completed for R4's falls that occurred on 7/13/26 nor 7/16/26. During an interview on 7/24/26 at 4:36 p.m., DON stated R4's baseline care plan initiated on 7/13/26 had not identified R4 as a fall risk, however, when a fall risk assessment had been completed on 7/14/26 that identified R4 as a high risk for falls, his care plan should have been revised to add fall prevention interventions to mitigate the risk of falls and this was not added until 7/17/16 following three falls in the facility. DON further explained R4's falls had not had a comprehensive root cause analysis completed for any of the falls that have occurred since 7/13/26 and should have been done shortly after each fall to assist the facility in determining the appropriate fall prevention interventions to mitigate the risk of future falls. Review of the facility's Fall Prevention Program Policy dated 2/26, identified each resident of the skilled nursing facility will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes resident's risk according to low, medium, or high risk.-Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. -The nurse will indicate on the care plan the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. -High Risk Protocols: The resident will be placed on the facility's Fall Prevention Program. Indicate fall risk on care plan. Place Fall Prevention Indicator (such as star, color coded sticker) on the name plate to resident's room. Place Fall Prevention Indicator on resident's wheelchair. Implement interventions from Low/Moderate Risk Protocols. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the residents' assessment, including but not limited to: Assistive devices. Increased frequency of rounds Medication regimen review Low bed Alternate call system access Scheduled ambulation or toileting assistance Family/caregiver or resident education Therapy services referral -When any resident experiences a fall, the facility will: Assess the resident; Complete a post-fall assessment; Complete an incident report; Notify physician and family; Review the resident's care plan and update as indicated; Document all assessments and actions; Obtain witness statements in the case of injury.

Based on observation, interview and document review, the facility failed to ensure the resident's representative was notified of a new bruise for 1 of 1 resident (R5)who was reviewed for skin injury. Findings include: R25's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated diagnosis of Alzheimer's Disease, Non-Alzheimer's dementia with behavioral disturbance and hemiplegia (complete paralysis on one side of body) and hemiparesis (partial weakness on one side). R2 had severe cognitive impairment with moderate hearing loss and adequate vision. R25 had delirium with symptoms of inattention and disorganized thinking but no behaviors. R25 was dependent on staff for all activities of daily living. R25's plan of care last revised on 4/30/25, indicated R5 had a cognitive impairment as indicated by her diagnosis of Alzheimer's disease and was unable to answer questions. Interventions included allowing R25 time to process information; approach R25 from the front, make eye contact and explain cares before providing them; ask yes and no questions to aid in decision making; monitor for and address signs of pain or discomfort and report to nurse as needed; provide calm, comfortable, homelike environment. On observation 12/30/25 at 8:17 a.m., R25 was lying in bed with lights off. A bed alarm was present. R25 had a bruise to her left temple circular in shape and approximately 3x4 centimeters in size. Color was dark purple. On observation 12/30/25 at 9:55 a.m., R25 was sitting in her Broda chair with a stuffed cat in her lap. The bruise remained present and unchanged on her left temple. When asked if it hurt, R25 did not respond. On interview 12/30/25 at 10:43 a.m., family member (FM)-A stated she had noticed bruises on R25 multiple times on her head and a few times on her arms over the past 6 months. FM-A stated she thinks when the aides are in a hurry, they are sometimes careless. FM-A stated she had witnessed them almost hit R25 in the head with the lift hanger a few times. FM-A stated she became aware of the current bruise when she came to visit and staff never notified her prior to her arrival 2 days later. FM-A added she also had not notified in the past of the bruises (on her arms) she has seen on R25 over the past 6 months. On interview 12/30/25 at 3:58 p.m., nursing assistant (NA)-C brought R25 back from music activity in her Broda (positioning wheelchair) chair. NA-C stated she had worked 12/26/25, evening shift and R25 did not have a bruise on her left temple area. NA-C stated she returned to work 12/28/25, and noticed the bruise and reported it to the nurse. NA-C stated her role was to report changes to the nurse and was unsure what they do with the information once its reported. Facility Incident Report dated 12/28/25 at 4:37 p.m. included when getting resident up noted a 4 cm by 3 cm reddish purple spot on the left side of her face near her eye. Origin is unknown but resident has been known to rub her face. Area appears very dry so lotion was applied. Resident is unable to verbalize any details. On 12/30/25 family, provider, director of nursing and administrator were notified. 12/30/25 monitoring was added to orders until area resolved. Night staff reported that resident sleeps with her left hand under the side of her face and this was confirmed this morning by writer while resident was sleeping in that position. Incident report was completed by director of nursing. A nursing order dated 12/31/2025 at 6:00 a.m., by the director of nursing included 3 cm red area on left side of upper face. Monitor daily until resolved for increase in size. A progress note dated 12/28/25 at 4:37 p.m., by licensed practical nurse (LPN)-B indicated when resident got up noted a 4 cm by 3 cm reddish purple spot on the left side of her face near her eye. Origin is unknown but resident has been known to rub her face. Area appears very dry so lotion was applied. A phone interview 12/31/25 at 12;25 p.m., with NA-D who worked shift prior to discovery of injury indicated R25 slept most of her shift and shift was uneventful and she never noticed a bruise on R25's temple area. Denied ever getting R25 out of bed using the lift but did indicate R25 was turned and repositioned throughout the night but stated R25 always holds onto the grab bar with her hand and to her knowledge R25's face never hit the grab bar on the bed. On interview 1/2/26 at 10:40 a.m., director of nursing (DON) indicated she was notified Tuesday afternoon 12/30/25 regarding R25's bruise and was unaware of this prior. The DON completed an incident report on 12/30/25 and implemented monitoring of the area on 12/31/25. The DON stated she would expect an incident report to be completed at the time of discovery of the injury and also for family to be notified. On interview 1/2/26 at 11:25 a.m., licensed practical nurse (LPN)-B stated she discovered the bruise on R25's temple area on Sunday, 12/28/25. LPN-B stated she was not sure if it was from R25 frequently rubbing that area and she noticed her skin was dry so she applied lotion. LPN-B stated when they laid R25 in the bed, it was noted she put her hands up in the area where the injury was so that likely caused the injury. LPN-B stated she forgot to complete an incident report and forgot to notify the family of the bruise. Facility Notification of Changes policy, undated, included: Circumstances requiring notification includes: Accident resulting in injury or potential to require physician intervention, or circumstances that require a need to alter treatment which may include a new treatment or discontinuation of current treatment. Contact information of the resident's legal representative or family member must be recorded and periodically updated.

Based on interview and document review, the facility failed to ensure resident medication status was accurately coded in the Minimum Data Set (MDS) assessment for 1 of 1 resident (R21) reviewed for medications, specifically insulin. Findings include:R21's face sheet received on 1/6/26, included diagnosis of type 2 diabetes mellitus (when the body does not produce enough insulin or use it properly).R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R21 had diabetes.R21's physician orders included Trulicity (Trulicity is not insulin. It is a glucagon-like peptide-1 (GLP-1) receptor agonist which controls blood sugar by signaling brain to feel full, slowing digestion and stimulating insulin release) subcutaneous solution pen-injector 0.75 mg (milligram) /0.5 ml (milliliters) at bedtime every Wednesday related to type 2 diabetes mellitus. R21's care plan dated 10/14/25, indicated R21 had diabetes type 2 and required medication for control.R21's MDS, Section N indicated the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry was one. During an email exchange on 12/31/25 at 12:47 p.m., the facility MDS coordinator indicated she used a document titled MDS 3.0 Drug Class Index developed by MED-PASS with revised date of 9/25, to guide her when coding MDS assessments. During an interview on 12/31/25 at 1:15 p.m., the administrator was informed of findings and stated she would have expected MDS assessments to be coded accurately. Facility MDS 3.0 Completion policy undated, indicated the responsibility of all sections of the MDS would be assigned. Persons completing part of the assessment must attest to the accuracy of the section they completed. All disciplines shall follow the guidelines in Chapter 3 of the current RAI (Resident Assessment Instrument) Manual for coding each assessment.

Based on observation, interview and document review, the facility failed to ensure a falls care plan for 1 of 1 resident (R5) was updated to include the current interventions. Finding include: R5's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R5 understands and is understood and had intact cognition. R5 was dependent on staff with transfers, and partial to moderate assistance with oral hygiene, independent with eating and requires substantial to maximal assistance with dressing and personal hygiene. R5 uses a manual wheelchair for mobility. R5's diagnoses included high blood pressure, coronary artery disease, renal insufficiency, diabetes mellitus, depression and asthma. R5's plan of care last updated 8/20/25, indicated R5 was at moderate fall risk as evidenced by the most recent Morse Fall Scale score (a fall scale calculator that predicts risk of falling) related to impaired cognitive function which can affect her reasoning. Interventions included R5 had a low bed so she can reach the floor and bariatric size for extra space side to side (4/13/23). R5 had been known to ease herself to the floor to sit. She had stated she prefers to sit on the floor instead of in a recliner. Treat each case as an un-witnessed fall per facility protocol (6/19/25). Contact pharmacy for consult to evaluate medications (1/20/21). For no apparent acute injury, determine and address causative factors of the fall (1/20/21). Monitor every shift for 72 hours and as needed for pain, bruising, change in mental status or new onset confusion, sleepiness, inability to maintain posture, agitation and contact provider as needed (1/20/21). Resident is not to have any blue chucks in her wheelchair seat due to potential for sliding out of wheelchair (5/8/25). On 1/1/26 an order was received from provider for silent bed alarm and plan of care was updated with this information. R5's task list included safety checks to be completed on location and room activity every 2 hours. R1's Comprehensive Care Area Assessment (CAA) dated 12/23/25, included R5 was at risk for falls related to impaired gait and mobility and level of assistance required with transfers. Contributing factors included history of falls, prior to admission, medications that affect level of alertness, weakness and physical performance limited. Morse Fall risk last completed on 1/1/26, included a R5 was a moderate fall risk. Fall risk assessments completed 12/19/25, 9/28/25, 7/27/25, 6/20/25, 5/8/254/19/25, and 3/31/25 post falls and also quarterly. Score remained consistent with moderate fall risk. On 3/31/25 and 4/1/25, a fall occurred and the intervention was to lay resident in bed when she was sleeping. The care plan did not include this as an intervention to prevent falls. On 5/8/25, a fall occurred ant the interventions was to not have any blue chucks (absorbent pads) in her wheelchair. This was included in the plan of care. Second intervention of anti-roll back brakes was requested and medical supply company was contacted. Due to R5's use of oxygen facility was told they cannot be installed on her chair. A GradA-aide (prevents the wheelchair from rolling backwards while also maintaining forward movement) was used instead to prevent rolling backwards of chair. This was not included on the plan of care. On 5/30/25, a fall occurred and the intervention was to reattempt therapy which R5 refused. This was not included in plan of care. On 7/26/25 and 7/28/25, a fall occurred and the intervention was that resident was to be monitored and staff to allow R5 to sleep as long as she wants in the morning. This was not included on the plan of care. On 8/29/25 and 9/28/25 R5 had a fall and staff was re-educated on safety for R5. On 12/13/25 R5 had a fall and staff was re-educated on lying resident down but resident had been refusing to lay down this evening when the fall occurred. This was not included on the plan of care. On 12/19/25 R5 fell out of her wheelchair and had a large hematoma on left side of forehead. Attempted therapy but unable to pick up on caseload at this time as R5's abilities had not changed. On observation 12/30/25 at 11:35 a.m., R5 was in her wheelchair in the dining room with oxygen on at 1L nasal cannula. R5 had device on back of chair to prevent wheelchair from rolling backwards. R5 had a low bed in her room. R5 had a light green bruise above left eye on her forehead. R5 denied any pain in the bruised area. On 12/30/25 at 2:55 p.m., R5 remained in her wheelchair at the nurse's station. On 12/31/25 at 7:08 a.m., R5 remained in her bed with lights off. Door was slightly ajar, bed was in low position and R5 was on her left side. On 12/31/25 at 7:59 a.m., R5 remained in her bed with lights off in room but was now lying on her back. On 12/31/25 at 9:59 a.m., nursing assistant (NA)-A stated she had checked on R5 a few times but she hasn't wanted to get up yet this morning. NA-A stated R5 repositions herself in the bed and is able to move side to side without assistance. NA-A stated R5 was impulsive and uncooperative at times. NA-A stated for interventions to prevent falls they checked on R5 frequently and R5 had a low bed so if she tries to get up, she would not get hurt. On 12/31/25 at 11:30 a.m., R5 was sitting in her wheelchair in the dining room with her oxygen on. On interview 1/2/26, licensed practical nurse (LPN)-A stated yesterday 1/1/26, R5 was found on the floor by her bed with no apparent injury. Provider was notified and ordered a bed alarm to be implemented. LPN-A stated the alarm is only for when she is in bed. LPN-A stated they keep a close eye on R5 throughout the day and she tends to hang out by the nurses station desk. LPN-A stated R5 does have sleep issues and sometimes sleeps all day and other days she is up and around the nurses station all day and night. LPN-A stated she had seen R5 fall asleep while sitting in her wheelchair a lot. On interview 1/2/26 at 10:00 a.m., nursing assistant (NA)-B stated they tend to keep R5 by the nurses station whenever she is in her wheelchair. NA-B stated R5 had times where she is anxious and other times where she won't cooperate with staff. NA-B indicated for interventions to prevent falls they checked on R5 frequently when she is in bed. On interview 1/2/26 at 10:11 a.m., the director of nursing (DON) stated that even though some interventions were not on the plan of care such as close observation, it was listed on the tasks and was being completed. When questioned about brakes on the wheelchair, attempting to get R5 to lay down if falling asleep in wheelchair, and staff to allow R5 to sleep and not wake her, the DON stated they were not on the task list and also confirmed they were not on the plan of care. Facility Fall Risk Assessment (undated) policy included: The risk assessment will contain the following components: Identify environmental hazards and individual risks, including the need for supervisionEvaluate and analyze hazards and risks. An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals and current standards of practice in order to reduce the risk of an accident. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.

Based on interview and document review, the facility failed to ensure resident medication status was accurately coded in the Minimum Data Set (MDS) assessment for 1 of 2 residents (R17) reviewed for medications. Findings include: R17's facesheet printed on 11/14/24, included diagnosis of type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar). R17's current quarterly MDS assessment dated [DATE], indicated the number of days that insulin injections were received during the last seven days, as seven. R17's admission MDS dated [DATE], indicated the same, as did R17's significant change MDS dated [DATE]. R17's physician orders included: --glimepiride 1 mg (milligram), give 0.5 mg by mouth in the morning related to type 2 diabetes mellitus --Jardiance 25 mg by mouth in the morning related to type 2 diabetes mellitus --Orders did not include insulin injections R17's care plan dated 4/30/24, indicated he was on an oral diabetic medication for management. During an interview on 11/13/24 at 11:15 a.m., the director of nursing (DON) stated the MDS coordinator was not available. The DON states R17 was not on insulin and had never been on insulin; that R17 took oral medications for diabetes. The DON reviewed R17's orders in the EMR (electronic medical record) and confirmed R17 did not have orders for insulin, adding the MDS should not have been coded for insulin. During an interview on 11/14/24 at 8:36 a.m., registered nurse (RN)-A who was also the MDS coordinator stated she thought the medication - Jardiance - was an insulin injection and not a pill, and that was why she coded the MDS as R17 being on insulin. Facility Maintaining MDS Assessments policy dated 9/2024, addressed storage of the MDS, but not accuracy of the MDS.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that identified R1 had failed to use call light appropriately and/or refusals to use the call light for 1 of 1 (R1) resident reviewed for care plan. Findings include: R1's, 7/07/24 quarterly Minimum Data Set (MDS) identified R1 had severely cognitive impairment, little interest, or pleasure in doing things, and feeling down, depressed, or hopeless for never to 1 day. R1 was dependent on staff with cares and was incontinent with bowel and bladder. R1 had a diagnosis of anxiety and manic depression. R1 had taken antipsychotic and antidepressant on a routine basis. R1's, undated care plan identified R1 had verbal aggression related to her bipolar disorder and the goal was for R1 to have 1 or fewer episodes per week. Staff interventions were to administer medication, analyze places, times, circumstances, triggers and what de-escalate the behaviors. Staff were to understand R1's situation and allow time to express her feelings, provide choices for care and activities and talk to her with care and inform her of what staff were doing. R1's, undated care plan identified there was no mention for R1 to use a call light for assistance. Interview on 8/21/24 at 3:29 p.m. with director of nursing (DON) stated changes to R1's care plan was modified recently and was unsure if the care plan had been implemented in a timely manner. Interview on 8/21/24 at 3:31 p.m., with administrator stated R1's interventions should have been reflected in a timely manner on her care plan. Review of January 2024 Comprehensive Care Plans policy identified the facility would assess residents' goals, preferences, outcomes during admission and before discharge from the facility. The facility would include interdisciplinary team to prepare residents individual care plan that was to reflect resident's needs, interventions, measurable objectives and timeframes identified on the residents comprehensive assessments.

Based on interview and document review, the facility failed to complete appropriate assessments and failed to reposition and document that repositioning for 1 of 1 resident (R1). Review of the report filed to the State Agency identified on 8/13/24 at 2:30 p.m., two nursing assistants placed R1 on a bedpan at approximately 12:30 p.m., and was found by staff remaining on the bed pan at approximately 4:15 p.m., when R1 call out to staff notifying them staff had forgotten to return and remove R1 off the bed pan. R1's, 7/07/24 quarterly Minimum Data Set (MDS) identified R1 had severely cognitive impairment, little interest, or pleasure in doing things, and feeling down, depressed, or hopeless for never to 1 day. R1 was dependent on staff with cares and was incontinent with bowel and bladder. R1 had a diagnosis of anxiety and manic depression. R1 had taken antipsychotic and antidepressant on a routine basis. Interview on 8/20/24 at 9:07 a.m., with family member (FM)-A stated she received a phone call from the facility's registered nurse (RN)-A of R1 had been found with a bedpan under her buttocks for hours and was forgotten by the staff and appeared to be upset. She stated RN-A had informed her that there was no excuse for R1 to be left on a bed pan and stated R1 did have her call light within reach. She had her call light next to her. R1 has had good care at the facility and added RN-A had informed her they would implement an action plan to prevent R1 from developing pressure ulcers on her bottom. Interview on 8/20/24 at 10:23 a.m. with R1 stated she did not remember the incident of her being left on a bedpan. When asked if she could press her call light, R1 stated she did not want to, but then stated staff had treated her well here. Asked if resident had any concerns, she stated no. Asked if she had issues with her bottom since the incident, she stated no. Asked her if she had continued to use the bedpan since the incident a week ago, she stated, yes. R1 did not say anything else after being questioned and proceeded to watch television. Interview on 8/20/24 at 10:25 a.m., with social services explained that R1 had no impaired cognition and would verbally communicate her need to the staff. She stated R1 had difficulty forming a relationship with staff when she was admitted to the facility last year and took time to acclimate to staff in the facility. R1's Brief Interview for Mental Status (BIMS) assessment were assigned to a previous employee, who no longer works at the facility and confirmed R1 would need an updated BIMS assessment to be completed. Interview on 8/20/24 at 10:33 a.m., with nursing assistant (NA)-B stated R1 would sometime use her call light and sometimes she would not use her call light. She stated R1 required frequent checks throughout the day even when she used the bedpan and would assist her with personal cares as needed. She stated she was unaware if R1 had displayed behaviors of not using the call light when she needed assistance. She stated handover communication and rounding in the facility had been difficult to implement. She stated she on a few occasions she would punch in for work and was obligated to find nursing staff for handover communication of resident updates. She had clocked out of the facility and went home and had not given report to her colleagues at the end of her shift. Interview on 8/20/24 at 10:45 a.m., with registered nurse (RN)-A stated she received a call from the administrator Tuesday afternoon that R1 had been on her bedpan for hours and had not been checked. She stated she had called LPN-B approximately at 5:30 p.m. and informed her to reposition R1 every hour. She stated she informed LPN-B to update the oncoming night nurse of the incident and document R1's condition throughout the night. She stated she had completed education on the phone with NA-A, NA-B and NA-F and sent the information to the director of nursing (DON). She stated there was a breakdown in communication between the oncoming and off going staff and confirmed the facility had reported the incident. She had modified R1's care plan to include a timer be placed outside her door to alert staff to check on R1 and stated the intervention was to remind staff to check on R1 when she was on the bedpan. Interview on 8/20/24 at 11:45 a.m., licensed nurse (LPN)-A stated she had not seen handover communication implemented for oncoming and off going staff and found it to be challenging for agency staff. She stated facility staff were adamant to give report to agency staff and were left to search for the charge nurse on shift to receive resident updates. Interview on 8/20/24 at 1:45 p.m., with NA-A stated she had started her first day at the facility and was to work independently with residents on the unit. She stated R1 had requested to use a bedpan and she along with NA-D had repositioned and placed R1 on the bedpan. She stated she had checked on R1 minutes later and R1 needed more time on the bedpan. She stated she informed NA-D she would check on R1 before completing her shift and stated she forgot to check on R1. She stated RN-A had called her and informed her that R1 was left on the bedpan and apologized to RN-A and noted she had received training on the phone from RN-A. Interview on 8/20/24 at 1:58 p.m., with LPN-B stated she was informed by NA-E and NA-F that R1 was found on the bedpan and went to R1's room to assess her skin and had found R1's buttock had bruising and an outline of the shape of her bedpan. She stated she had placed a call to RN-A, the administrator, and the director of nursing (DON). She stated RN-A had informed her to reposition R1 every hour and to report the incident to the oncoming nurse to monitor R1's buttocks during the overnight shift. Interview on 8/20/24 at 4:27 p.m., with family member (FM)-A stated the facility did not inform her of a timer placed outside of R1's door and stated if staff was to know the timer had been implemented to notify staff to check on R1 when on the bedpan, there was no problem with the intervention. Interview on 8/20/24 at 4:58 p.m., with NA-C stated R1 required extensive assist with 2 staff for activities of daily living and transfers and had observed R1 used the call light on occasionally. She stated R1's care plan had interventions for to reposition R1 every and could not document it on the Point Click Care (PCC) online medical record, system. She stated the facility would have to modify the entry on PCC for it to show the frequency of when R1 was to be repositioned and had no way to document when R1 was repositioned. She stated on several occasions she had punched in for her shift and had to assist resident with cares when she had not received report from the off going shift. She stated she had no knowledge of those resident care needs during her shift and would expect the facility to have a system in place for handover communication amongst staff. Interview on 5:12 p.m., with LPN-B stated nursing assistants was to reposition R1 every 2 hours and were expected to document on PCC when they had completed the task. LPN-B reviewed and attempted to access the documentation on PCC and confirmed she noted repositioning was scheduled every shift and not every 2 hours and confirmed nursing assistants were not able to document the frequency of the task. She stated she was not aware it had been an issue for the staff and was not aware of how to correct it. Interview on 5:18 p.m., with NA-D stated R1 required 2 people to assist her with cares and stated when she utilized PCC, R1's care plan required R1 to be repositioned every 2 hours and confirmed her task were scheduled to complete once a shift on PCC. She stated she would expect communication amongst the nursing team to improve and found it difficult to take care of residents and their needs appropriately when she was not well-informed during handover communication. Interview on 5:28 p.m., with NA-E stated R1 was on a check and change scheduled as stated on PCC. She stated she had assisted R1 along with NA-F approximately at 4:30 p.m., on 8/13/24 and had removed the bedpan from R1 buttocks. She stated R1 appeared upset and had informed the charge nurse to assess R1's skin. She stated she was aware that R1 can use the call light but has not seen R1 use it frequently. NA-E stated she completes handover communication with the oncoming shift staff and would check on residents after her shift report. She confirmed she was not able to chart on residents who had to be repositioned every 2 hours on PCC. She stated the task would only show up to be documented once a shift. Interview on 8/21/24 at 8:09 a.m., with physical therapist stated he had assisted residents at the facility for a period of 11 months. He stated R1 had the capability to use her call light and had seen her use her call light on a few occasions and had informed staff to position the call light next to R1's fingers. He stated he was not aware that R1 had not used her call light and was not aware she had been found on her bedpan for an extended period. He stated given the situation of R1's incident, he stated R1's muscle decline would progress over time and the facility would need to implement additional interventions that would assist R1's communication and mobility needs long term. Interview on 8/21/24 at 9:34 a.m., with NA-F stated she did not receive handover communication that R1 was placed on a bedpan. She stated she had entered R1's room to get her up for supper and stated R1 appeared upset and said she was left on the bedpan. She stated NA-E had assisted R1 off her bedpan and had informed the nurse. She stated she was informed by LPN-B to reposition R1 hourly and document when she had completed the task. She stated the PCC system did not allow her to chart every hour only once per shift. She stated the facility had no process in place for nursing assistants to document on paper when she had repositioned R1 during her shift. She stated the facility had lacked report sheets to chart residents last bowel movements or toileting schedules. Interview on 8/21/24 at 10:12 a.m., with NA-G stated she was informed of R1's incident on her shift. She stated handover communication at the facility was a challenge when the oncoming shift did not show up to work on time. She stated since R1's incident, the facility had not implemented appropriated handover communication amongst the staff. She stated R1's care plan identified she was to be repositioned every 2 hours and could not document every 2 hours on PCC, when she had repositioned R1. She stated PCC system had been set up for her to document on R1 every shift, instead of every 2 hours. Interview on 8/21/24 at 10:16 a.m., with LPN-A and LPN-B confirmed the facility had no process in place for nursing assistants to complete handover communication, appropriately. LPN-B stated nursing assistants were expected to access PCC to verify resident updates or talk to the charge nurse on shift. Interview on 8/21/24 at 10:21 a.m., RN-B stated staff were expected to assess and document task interventions that were assigned on PCC for residents and was linked to each resident care plan which collected data from resident assessments. She stated, R1's care plan had interventions for staff to reposition R1 every 2-hours and confirmed PCC was not set up for staff to chart their interventions as reflected on R1's care plan and could not prove staff had completed the task as reflected on R1's care plan. Interview on 8/21/24 at 1:22 p.m., with medical director confirmed the facility had informed her of R1's incident and was aware the facility had implemented interventions for R1. She stated every 2-hour repositioning was appropriate for R1 and would expect the facility to complete accurate documentation of resident interventions when changes are made to reflect improvement of resident care. She agreed therapy services would be appropriate to determine R1's needs that would manage R1's physical mobility impairment. Interview on 8/21/24 at 3:29 p.m., with DON stated her expectations was for R1's assessments and interventions to be reflected accurately on R1's medical record. Review of December 2023 Rounds Shift Report identified the facility would use round shift report during a 24-hour period to ensure continuity of care. The facility staff would complete shift to shift report, that contained confidential information, used for ongoing and on-coming staff to include toileting, repositioning, and observations of resident's condition. Review of 7/2024 Facility Assessment identified the facility would embrace a person-centered care culture, and provide services based on resident's needs, such as, mobility assistance, rehabilitation, incontinence prevention and care, and assistance with activities of daily living. The facility would encourage residents to include their own daily routines and schedules and would be added on residents individualized care plans. Lastly, the facility would communicate to providers and staff expectations of care delivery and clinical reasoning to promote high-quality care for residents.

Based on interview and record review, facility failed to ensure 1 of 1 nursing assistant (NA)-C was deemed competent upon hire or yearly thereafter to provide care to residents. Findings include: Review of NA-C's employee file identified a hire date of 6/03/24. Review of NA-C timesheets identified she had worked at the facility on 6/16, 6/17, 6/19, 6/20, 6/21, 6/24, 6/25, 6/27, 6/28, 6/29, 6/30, 7/01, 7/02, 7/03, 7/05, 7/06, 7/07, 7/08, 7/09, 7/11, 7/12, 7/13, 8/05, 8/06, 8/07, 8/08, 8/09, 8/10, 8/11, 8/12, 8/14, 8/15 and 8/16/24. Review of NA-C, 5/08/24 Relias (online training program) identified she had completed a clinical asssessment training. The facility did not provide facility specific competencies for NA-C upon hire. Interview on 8/21/24 at 3:31 p.m., with administrator and director of nursing agreed competency training should be given to all employees to reflect current knowledge of the facilitys resident specific needs and services. Review of January 2024 Orientation policy identified the facility would provide department orientation plan that would reflect the skills and competencies of each employee before contact with residents. Secondly, the facility department checklist would be used to document training and competency evaulations during the employee's orientation until the employee had demonstrated competency and skills to meet residents needs. Review of July 2024 Facility Assessment identfied the facility would utilize an action plan to complete assesments of residents needs to determine staffing services. In addition, the facility would provide, contract staff and training for those staff according to the specific care area needs of the residents.

Based on observation, interview, and record review the facility failed to ensure appropriate supplemental oxygen was delivered according to physician orders and failed to revise or develop a respiratory care plan for 2 of 2 residents (R1 and R2) reviewed for respiratory care. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], identified R1 had moderately impaired cognition and diagnoses which included chronic obstructive pulmonary disease (disease of the lungs). R1 required staff assist with dressing, toileting, transferring, and personal hygiene. The MDS also identified use of oxygen therapy. R1's hospital Physician's Plan of Care dated 3/13/24, indicated R1 had been hospitalized for aspiration pneumonia, COVID-19, and urinary tract infections (UTI). Further ordered R1 to receive continuous supplemental oxygen (O2) therapy at 1-3 liters per minute (LPM) by nasal cannula to keep 02 saturation greater than 90%. R1's hospital Physician's Plan of Care dated 3/15/24, indicated R1 had been observed at the hospital on 3/14/24 and 3/15/24 for Hypoxia (low oxygen level) with no change to original O2 orders but to maintain O2 sats at 90-98% with use of nasal cannula or a simple mask, to ensure O2 is connected and if R1 becomes hypoxic, and check oxygen is working every shift. R1's clinic physician order updated on 3/17/24, indicated may increase O2 to 5L per simple mask as needed to maintain O2 saturation greater than 90%. R1's care plan last updated 4/13/23, identified R1 was at high risk for respiratory infections related to COPD and because of the COPD placed her at increased risk for breathing problems. Further identified R1 used oxygen at night. R1's goal was for O2 sats will remain 89% or greater on room air during the day when assessed. Associated interventions directed staff to monitor for difficulty breathing, remind R1 not to push beyond her endurance level, monitor for signs/symptoms of acute respiratory insufficiency, monitor/document/report as needed any signs/symptoms of respiratory infection. The care plan was not revised after R2's hospital visits and therefor inconsistent with physician orders. R1's visual Kardex (abbreviated care plan) report dated 3/19/24, did not address R1's oxygen dependence. During observation and interview on 3/19/24 at 11:27 a.m., R1 was sitting in her wheelchair in the doorway of her room with head hanging down, eyes closed, and not responding to voice. R1 had O2 nasal cannula tubing on and hooked up to a portable liquid oxygen tank on the back of her wheelchair with the control knob was set at 2.5 LPM. The portable oxygen tank content gauge on the regulator was observed to be in the red zone which indicated the tank was empty and there was no oxygen flow. This surveyor immediately requested assistance of staff. Nursing assistant (NA)-A responded at 11:32 a.m. and verified the O2 tank was empty. Further stated, she had last checked the tank at 9:00 a.m. (approximately 2 hours prior) and it was not empty at that time. NA-A stated they do not have any set time to check the tanks [for working order], just every couple of hours. NA-A indicated she would get a good tank. This surveyor then requested a nurse to assess R1 due to non-responsiveness. Licensed practical nurse (LPN)-A responded with NA-A at 11:38 a.m. to check R1's O2 level. R1's O2 level at that time was 86% and was slow to respond with physical touch. O2 tank was replaced and at 11:42 a.m., R1's O2 levels were improving at 91-92%. LPN-A stated, the tank must have run out, [R1] will usually tell us if she is short of breath. NA-A and LPN-A used a mechanical lift to lay R1 in bed and at 11:47 a.m., O2 level was 98-100%. R2's admission MDS dated [DATE], indicated R1 had mild cognitive impairment and diagnoses of respiratory failure and diabetes. R2 was dependent on staff for all cares and received oxygen therapy. R2's physician Order Summary Report dated 3/19/24, included the order for O2 at 0.5 to 4 LPN via nasal cannula for sats less than 90% related to chronic respiratory failure. R2's care plan dated 10/30/23, identified R2 was considered high risk for respiratory infections related to co-morbidities and part of the high risk population and communal living environment. The care plan did not specifically address R2's dependence on oxygen therapy that included goals of treatment and associated interventions. R2's visual Kardex report dated 3/19/24, did not address R2's oxygen dependence. During an observation on 3/19/24 at 12:40 p.m., R2 was observed sitting in her wheelchair at the dining room table with nasal cannula oxygen tubing in her nose that was connected to a portable liquid oxygen tank on the back of the wheelchair. The tank control knob on the regulator was set to 2 LPM, but the tank was in the red zone, indicating no oxygen was being delivered to R2. NA-A was assisting R2 with eating and observed that the portable oxygen tank was turned off and not delivering any oxygen to R2. NA-A turned valve on the regulator counterclockwise which allowed for oxygen delivery. NA-A told NA-B that she had not turned R2's [oxygen] tank on when she got her up [out of bed]. NA-B replied she had turned it on but must have bumped it and shut it off at some time. R2's O2 levels were unknown at that time but R2 did not demonstrate any symptoms of respiratory distress. During an interview on 3/19/24 at 1:25 p.m., NA-B indicated she had helped NA-A assist R2 out of bed just prior to lunch but could not remember what time. NA-B stated she had turned R2's O2 tank on but may have bumped it and turned it off accidentally when moving her. Further stated she was unsure how long portable O2 tanks last but guessed about 5 hours. During an interview on 3/19/24 at 2:01 p.m., NA-A verified R2's O2 tank was not turned on at 12:40 p.m. and she had turned it on at that time. Further stated she did not know how long the portable tanks last but was dependent on what the liter flow rate was set to. During an interview on 3/19/24 at 5:00 p.m., NA-C indicated she did not recall getting any training on the use of O2 at this facility. Further indicated portable oxygen tanks were checked when putting them on a resident and then at least once a shift. During an interview on 3/19/24 at 5:07 p.m., LPN-A indicated the portable O2 tanks last depending on the amount of oxygen being delivered and guessed about 4-5 hours but was not sure. During an interview on 3/19/24 at 2:05 p.m., the Northwest Respiratory Senior Representative (NRSR) indicated if a portable O2 tank was in the red zone, it was not delivering any O2 to the resident and the tank needed to be changed immediately. NRSR explained the duration of the portable O2 tank was dependent on the size of the tank and the amount of O2 [LPM] flow that was given. Further indicated there was no recent record of any training provided to the facility's staff. During an interview on 3/19/24 at 3:10 p.m., the director of nursing (DON) indicated awareness of the two incidents of O2 portable tanks not delivering oxygen and further explained the expectation of staff was to check the O2 tanks at every contact with the resident to assure they were working (delivering O2). The staff were to refer to the physician's orders or the Kardex for direction. Then verified that oxygen use was not addressed on the Kardex. On the spot training was in process and a more formal training was being scheduled. Review of facility policy titled Oxygen administration, revised October 2010, directed staff to review the care plan and check the mask, tank, etc. to be sure they are in good working order and securely fastened. The policy lacked direction on which staff were allowed to assist with O2, how often to check for proper working order, how to determine when to replace a tank, and implementing a respiratory care plan and interventions required.

Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 1 of 1 residents (R8) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 22 residents residing in the facility. Findings include: During an interview on 2/27/24 at 12:41 p.m., with R8 who was the resident council president, and who according to a quarterly Minimum Data Set (MDS) assessment dated [DATE], was cognitively intact. The interview took place in R8's room due to the facility being in Covid-19 outbreak status. R8 stated mail was delivered to the facility on Saturdays, described as a small stack of mail wrapped up, and the nursing staff locked it away until Monday when the activities director delivered it. Review of resident council meeting minutes from January 2023 through February 2024, (minus two months: February and September 2023), indicated R8 had been present at each of the 12 meetings. During an interview on 2/27/24 at 11:28 a.m., nursing assistant (NA)-A, stated the facility received mail on Saturdays and a nurse took the mail and kept it locked in the medication room until Monday. NA-A stated on Monday, the business office staff went through the mail first, then the activities director delivered it to residents. During an interview on 2/27/24 at 1:53 p.m., the administrator stated the activities director who facilitated resident council meetings was not available for interview. During a telephone interview on 2/27/24 at 3:13 p.m., NA-B who had filled in for the activities director during a leave of absence in 2023, confirmed mail was delivered to the facility by the post office on Saturdays and locked in the medication room until the business office staff looked through it on Mondays. NA-B stated mail was not delivered to residents on Saturdays because the facility didn't want residents to receive mail they should not have, such as bills, in order to prevent misplacement of them. NA-B stated as a result, mail was not delivered to residents until it was sorted by the business office staff on Mondays. During an interview on 2/27/24 at 5:25 p.m., the administrator was informed of findings. The administrator acknowledged mail was not delivered to residents on Saturdays due to not wanting residents to receive mail they should not have -- such as bills. As a result business office staff previewed the mail first before delivering it to residents on Mondays. The facility Resident Right to Privacy in Communication policy with revised date of 12/2023, indicated the social service designee, or other designated staff member, would ensure each resident received any mail addressed to that particular resident promptly.

Based on interview and document review, the facility failed to provide ongoing communication to residents about their rights (e.g., through resident groups). This had the potential to affect all 22 residents residing in the facility. Findings include: During an interview on 2/27/24 at 12:41 p.m., with R8 who was the resident council president, and who according to a quarterly Minimum Data Set (MDS) assessment dated [DATE], was cognitively intact. The interview took place in R8's room due to the facility being in Covid-19 outbreak status. R8 stated the resident council met monthly and meetings were facilitated by the activities director who also took minutes for the meetings. R8 stated she did not recall resident rights ever being talked about or reviewed at resident council meetings. Review of resident council meeting minutes from January 2023 through February 2024, (minus two months: February and September 2023), indicated nothing regarding resident rights. The minutes indicated R8 had been present at each of the 12 meetings. During an interview on 2/27/24 at 1:53 p.m., the administrator stated the activities director who facilitated resident council meetings was not available for interview. During an interview on 2/27/24 at 5:25 p.m., the administrator indicated was aware resident rights were not reviewed at resident council meetings as she had attended some meetings and could verify that. The facility Resident Council Meetings policy with revised date of 12/2023, indicated examples of meeting topics including resident rights.

Based on observation, interview and document review, the facility failed to have an integrated care plan to coordinate services between the facility and the hospice agency to ensure those services were being provided for 1 of 1 resident (R6) reviewed for hospice care. Findings include: R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R6 was rarely/never understood, dependent on staff for dressing, hygiene, transfers, utilized a wheelchair, received hospice care, and diagnoses indicated non-traumatic brain dysfunction, and non-Alzheimer's dementia. R6's care plan dated 12/13/23, indicated R6 was receiving hospice services and interventions included: consult with physician and social services to have hospice care for resident in the facility, encourage support system of family and friends, hospice provider: . (name of agency) Hospice, keep the environment quiet and calm, observe closely for signs of pain, administer pain medications as ordered. On 2/26/24, at 2:17 p.m., licensed practice nurse (LPN)-A stated R6's care plan indicated she was on hospice, and the hospice binder at the nursing station would have R6's hospice plan of care and specific hospice information. While in the nurse's station, observed LPN-A look through R6's hospice binder and stated there was not a hospice plan of care in the binder for R6. LPN-A further stated R6's EMR did not have an order for hospice or a scanned hospice care plan for staff to know the specifics or details of R6's hospice plan of care. On 2/26/24 at 2:31 p.m., the director of nursing (DON) was asked for R6's hospice plan of care and the DON was observed to look through R6's hospice binder located at the nurse's station. The DON stated there was a calendar in the binder, and stated she was not sure if the calendar was up to date. The DON confirmed the binder did not include the hospice plan of care and observed the binder section and tab labeled hospice care plan did not include any information. The DON stated the plan of care from hospice was expected in the hospice binder for staff to find specifics regarding R6 hospice care. The DON stated she was not sure of the facility process when residents were admitted to hospice and how the plan of care was received from hospice. On 2/26/24 at 2:53 p.m., observed and heard DON on a telephone call and requested R6's hospice plan of care as the facility did not have one for R6. After the telephone call, the DON confirmed R6's calendar located in the binder was not accurate and stated the hospice agency would fax the facility R6's hospice plan of care. On 2/27/24 at 11:00 a.m., LPN-B stated R6's hospice plan of care was expected in the binder and observed LPN-B to look through R6's hospice binder and turned to the tab labeled plan of care and LPN-B confirmed the plan of care was not in the binder as expected. LPN-B stated the DON was responsible to ensure the hospice plan of care was in the binder. On 2/27/24 at 11:05 a.m., registered nurse (RN)-A, also known as the MDS coordinator, stated she was not sure who was responsible to ensure the hospice plan of care was available. RN-A stated the hospice plan of care was expected uploaded into the EMR or a hard copy placed in the resident's hospice binder, and confirmed a copy was not scanned in the EMR. RN-A further stated the facility practice was not to enter an order into the EMR for residents when they were admitted to hospice and stated staff would know a resident was on hospice by the facility care plan. On 2/27/24 at 11:17 a.m., the administrator and DON stated they expected an order on R6's EMR to admit to hospice and the hospice plan of care in the binder or scanned in the EMR. The administrator and DON stated the facility did not have a process currently to ensure the hospice plan of care was received from hospice and available to the facility staff. On 2/27/24 2:17 p.m., during a telephone interview R6's hospice intake coordinator, stated the hospice process was to fax the facility a resident's plan of care at time of admission to hospice. The hospice intake coordinator stated R6 was admitted to hospice on 11/22/23, and expected the facility to call if the plan of care was not received and the facility was expected to have a copy of R6's plan of care . The facility Hospice Program policy dated 7/17, indicated: 12d. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident. 2. Hospice election form 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practical physical, mental and psychosocial well-being. 14. The coordinated care plan will reflect the resident goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative,

Based on observation and interview, the facility failed to provide a sanitary environment in the kitchen and failed to ensure dishwashing sanitization was appropriately monitored. This had the potential to affect all 25 residents currently residing in the facility. Findings include: On 12/27/22, at 1:06 p.m., the following was observed in the kitchen: (ceiling tiles were 2 feet by 4 feet). 1) A pipe that ran the length of the rear of the kitchen above 2 food prep counters and hand washing station identified as clean by C-A was covered with dirt, dust and debris. 2) Three ceiling tiles in the same area over the mixer and clean food prep area at the rear of the kitchen had 3 tiles missing. 3) Two tiles over clean uncovered water glasses, cups, and tin food storage bins was missing. 4) Two tiles and surrounding structure over large food prep area was covered in dark furry dirt and debris. During interview on initial tour on 12/27/22, at 1:09 p.m., cook (C)-A indicated the ceiling tiles had been missing for awhile but was not sure how long. During interview and observation on 12/27/22 at 1:15 p.m., dietary aide (DA)-A was prepping and washing dirty dishes. DA-A indicated they monitor temperatures of the wash cycle and make sure the temperature is 120 degrees Fahrenheit (F). DA-A showed clip board where documentation of the temperature was completed at all 3 meals. All temperatures for December was documented at 120 degrees F. C-A indicated the dishwashing is both chemical and temperature sanitizer. C-A indicated they do have test strips but do not test the dishwasher as the maintenance company comes and does the actual testing. Observed DA-A run 3 loads of dirty dishes through washer. Temperature was 120 degrees F. DA-A did not run a test strip to test the sanitization level. During observation and interview on 12/28/22, at 1:05 p.m., maintenance (M)-B was in the dishwashing area with C-B. M-B indicated he was called to come and examine the machine as they have had some problems with it. M-B indicated the machine is a chemical sanitizer and not temperature. The particle count needs to be between 50-100 parts per million (PPM) so they set the machine at 75 PPM. M-B tested the machine at the end of a test wash using test strips which indicated 75 PPM. M-B indicated he tests the machine monthly on his routine checks for the machine. During interview on 12/28/22, ay 1:18 p.m., C-B indicated something got lost along the way as they previously had a high heat dish washer before switching to the low temperature dishwasher. C-B confirmed staff are not monitoring the chemical levels and only M-B has been completing monthly. C-B added staff have been monitoring the wash temperature. During interview on 12/28/22 at 1:49 p.m., C-B indicated facility maintenance is responsible for ceiling tiles and housekeeping is responsible for cleaning the vents, pipe and ceilings in the kitchen area. C-B confirmed the tiles were missing and the tiles and had been missing for awhile and estimated for at least over a month. During interview and tour of the kitchen on 12/29/22, at 8:51 a.m., M-A confirmed the dirt and debris on the 2 ceiling tiles and surrounding support was present above the food prep area and needed to be cleaned. C-A was prepping food on this counter at this time with an open bowl of cheese sauce and cabbage present. M-A confirmed the tiles were missing above the clean dish storage area and above clean prep area at the rear of the kitchen where a jelled cranberry/raspberry desert and bananas were sitting over the open tiles. M-A indicated the replacement of the tiles had been pushed down the list of things to do and with the roof issues the ceiling tiles may need to changed multiple times per week. M-A confirmed the pipe at the rear of the kitchen was covered in dust and debris and required cleaning. A policy and procedure titled Dishwasher dated 7/2/20 included: - Upon arrival, fill dishwasher with hot water using the fill button -Run an empty cycle while observing the temperature is within the appropriate range. -Spray and clear excess debris from any dishes that will be placed in the dishwasher -During each meal service, record the temperature of the water in the machine and record on the appropriate chart. -After each meal service, refer to the appropriate cleaning list for the machine.

Based on observation, interview and document review, the facility failed to ensure personal protective equipment (PPE) was implemented to prevent the spread of Covid-19 per guidance by the Centers for Disease Control (CDC) when testing residents for Covid-19. During an observation, staff failed to wear eye protection and to change gloves and perform hand hygiene for 4 of 4 residents (R8, R4, R18, R12) tested for Covid-19, potentially affecting all 25 residents. Further, the facility failed to have a water management program consistent with nationally accepted standards (e.g., ASHRAE [American Society of Heating, Refrigerating and Air-Conditioning Engineers] or CDC). This had the potential to effect all 25 resident who resided in the facility. Findings include: PPE During an observation on 12/27/22, from 4:07 p.m. to 4:12 p.m., nursing assistant (NA)-C was observed going room to room, consecutively swabbing the nares of R8, R4, R18 and R12 in that order, without wearing eye protection and without removing gloves and performing hand hygiene between residents. During an interview on 12/27/22, at 4:14 p.m., when NA-C was asked, NA-C acknowledged she should have changed gloves and performed hand hygiene between residents, stating, Yeah, I probably should be, adding she didn't usually do Covid-19 testing of residents and had not remembered to perform hand hygiene, nor wear eye protection. During an interview on 12/30/22, at 9:55 a.m., registered nurse (RN)-B stated NA-C had informed her she had not performed hand hygiene between residents when swabbing for Covid-19. RN-B stated when she had asked NA-C to test residents for Covid-19, she had not reminded NA-C to wear eye protection and to change gloves and perform hand hygiene between residents. Facility policy titled Abbott BinaxNOW Covid-19 Antigen Testing, dated 11/4/20, indicated eye protection would be worn during the specimen collection and processing, and gloves would be changed and hand hygiene performed between each person being swabbed. Water Management Program During an interview on 12/29/22, at 9:37 a.m. the environmental services director (ESD)-A provided the facility Water Management Plan with implementation date of 3/1/18, and revised date of 8/5/22, for review. The plan was a four page document with the word DRAFT across the first page. ESD-A stated he had minimal knowledge of Legionella, just experience from working in the facility for [AGE] years. Other than the four page Water Management Plan, ESD-A stated there were no other policies or references he used. The plan indicated a water management program was essential in some facilities to reduce the growth and spread of Legionella in buildings. The plan identified the team responsible for the program which included ESD-A, the administrator, the infection preventionist, a [NAME] representative and an individual from the City utilities department. ESD-A stated the team had never met to discuss the water management plan or Legionella prevention. ESD-A was not aware if there had ever been a facility risk assessment done to determine if a water management program was needed to reduce the risk of Legionella growth and spread. The plan included colored water flow diagrams; ESD-A stated he didn't know where the diagrams came from. The diagrams were similar in design and color as examples found in the CDC Legionella Control Toolkit dated 6/24/21, and had been customized to the facility. The plan indicated maintenance staff would perform weekly water temperature checks and keep a log of the temperatures. Temperature checks would occur in a sampling of resident rooms, at the water heater, the recirculating hot water return, and eye wash stations. According to ESD-A during an interview on 12/29/22, at 12:16 p.m., water temperatures were measured with an infrared laser gun pointed at the pipe or the water coming out of the faucet. Logs from November and December 2022, were reviewed. --Water heater: Temperatures ranged from 71 degrees F (Fahrenheit) to 84 degrees F. --Recirculating hot water return: Temperatures ranged from 73 degrees F to 80 degrees F. --Eye wash stations: Temperatures ranged from 63 degrees F to 96 degrees F. --Resident rooms: The logs indicated four rooms were selected each week to have the water temperature checked. Temperatures ranged from 94 degrees F to 104 degrees F. These water temperatures were in the range most favorable to the growth of Legionella (77-113 F). During the same interview, ESD-A stated his assistant went into empty wings and checked toilets monthly. If there was no water in the toilet, his assistant would flush the toilet and run water in faucet to reload the trap with water in order to prevent smell. ESD-A stated faucets were changed if they had calcium build up. Shower heads were changed if a nursing assistant informed him of flow problems, and stated there were no filters in the shower heads. The plan indicated cold water was heated by a water heater set at 140 degrees F. During an observation and interview on 12/29/22, at 12:16 p.m., ESD-A removed the cover off a metal box attached to the water heater and stated the water heater was set at 135 degrees F. In addition, ESD-A stated the water going to various parts of the facility, including resident rooms went through a mixing valve at 112 degrees F. This temperature was measured by pointing an infrared laser thermometer at the pipe. The water temperature of 112 degrees F was in the range most favorable to the growth of Legionella (77-113 F). From the CDC Legionella Control Toolkit dated 6/24/21, temperature control limits indicated: --Store hot water above 140 F and maintain circulating hot water above 120 F. --Store and maintain circulating cold water below the growth range most favorable to Legionella (77-113 F). ESD-A did not know the temperature of the cold water going into the mixing valve. The plan indicated water quality was measured by the City on a bi-monthly basis. ESD-A provided a drinking water report dated 2017, in which included copper, lead, nitrate, chloride and fluoride levels. During an interview on 12/30/22, at 9:00 a.m., ESD-A stated he didn't know if the facility water was disinfected and called the city utility department to learn the city water was disinfected with chlorine. Reviewed paper documents titled Preventative Maintenance, provided by ESD-A to verify flushing toilets and running water in vacant resident rooms. There was an entry on each document titled Empty Stools/Sinks for this task, indicating it was to be completed monthly, but it had not been done for the months of July, August, September or December (though 12/29/22). The form did not indicate which rooms had been flushed. The facility had multiple empty resident rooms -- the C wing had been closed for years and the D wing had been vacated on 12/14/22. ESD-A stated water was shut off to the vacated wings. When informed there was still water present when faucets were turned on in bathrooms on the D wing on 12/29/22, at 10:30 a.m., ESD-A stated there might still be water leftover in the lines. During an interview on 12/30/22,at 9:55 a.m., RN-B stated she had not been involved with the facility water management plan as it related to Legionella. RN-B stated the facility had had no cases of Legionella.

Based on observation, interview, and document review, the facility failed to ensure 2 of 3 residents (R8 and R10) observed to have medications left at their dining tables were assessed and approved to be able to safely self-administer medications. Findings include: R8's Admission Record printed 12/30/22, included diagnosis of mild cognitive impairment, depression, chronic kidney disease stage III, heart failure, osteoarthritis, and acquired absence of right leg below knee. R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated mild cognitive impairment, adequate hearing and vision and extensive assistance of 1-2 staff with activities of daily living. Review of R8's care plan dated 11/30/21, indicated self-administration of medications was not addressed on care plan. No record of an assessment for competence in self-administration of medications was found in R8's electronic medical record (EMR). R10 R10's Admission Record printed 12/29/22, included diagnosis of multiple sclerosis (immune system attacks the protective layer around nerve making it difficult for the brain to send signals to the rest of the body), depression, and inflammatory polyarthropathy (affects 5 or more joints simultaneously and is associated with autoimmune conditions). R10's quarterly MDS assessment dated [DATE], included intact cognition and requires staff assist of 1-2 with activities of daily living. R10's care plan dated 9/27/22, indicated R10 is capable of self-administration of nebulizer and Pataday (antihistamine used to treat itching and redness of eyes) eye drops medication after setup by nursing per Medication Self-administration Safety screen. R10's care plan dated 1/7/20, included R10 prefers medication be co-administered as per Election of Co-Administration form. Interventions included crushed medication will be administered one agent at a time and not mixed for co-administration unless requested by resident or resident representative. Crushed medications will be co-administered as per R10's preference. Non-crushed medications will be co-administered as per R10's preference. R10's medical record included Medication self-administration Safety screen completed 6/21/22, included medication #1 as Pataday solution 0.2% and medication #2 as fluticasone propionate both included storage at the bedside with resident and R10 may self administer the medications. During observation and interview on 12/27/22, at 5:19 p.m. trained medication aide (TMA)-A placed the below medications in 2 separate medication cups: -baclofen 20 mg tablet -Tylenol 325 mg tablet, 2 tablets -apixiban 5 mg tablet -calcium citrate + vitamin D 315 - 250 mg unit 1 tablet -cranberry tablet 450 mg tablet -Hiprex 1 gram tablet -hydroxchoriquine Sulfate tablet 200 mg tablet -sulfasalazine tablet 500 mg, 2 tablets -potassium chloride Extended Release tablet 20 MEQ, 6 tablets. TMA-A was observed to place the 2 full pill containers on the dining room table next to R10's plate and stated here are your medications and returned to the medication cart. TMA-A indicated R10 can co-administer her medications. TMA-A then pulled R8's medication card for Mirtazapine 7.5 mg and placed one tablet in a medication cup. TMA-A proceeded to set cup next to R8's plate while she was eating and returned to the cart. TMA-A upon questioning indicated R8 can co-administer medications once medications are placed in the medication cup and demonstrated on the electronic medical record (EMR) where it indicates if they can co-administer the medications. The EMR indicated co-administer medications on both R10, and R8's medical record on the top banner. During interview on 12/29/22, at 7:56 a.m., TMA-A indicated she wasn't sure what co-administration means but thought it meant they can take the medications themselves once placed in the medication cup. TMA-A added she is near by and makes sure they take their medications but indicated she does not stand next to them and observe them taking the medications. During interview on 12/29/22, at 8:10 a.m., licensed practical nurse (LPN)-A indicated the EMR indicates if a resident can co-administer medications. Upon review, LPN-A indicated R10 and R8 can both co-administer medications. When questioned what co-administration means, LPN-A indicated staff can put the pills in front of resident and know they will take them. LPN-A added she makes sure they take their medications but does not stand next to them and watch them swallow them. During interview on 12/29/22, at 10:11 a.m., the director of nursing (DON) indicated co-administer means staff can give all the medications at the same time but does not mean the resident can self-administer the medications by staff setting them next to them and walking away. The DON indicated she would expect all staff to watch the resident until all medications are taken if no self-administration assessment has been completed. During interview on 12/29/22, at 1:07 p.m., registered nurse (RN)-A indicated R8 to her knowledge has not been assessed to complete self-administration of medications. RN-A indicated R10 has been assessed to safely administer eye drops but not any of her other medications. RN-A confirmed there was no self-administration of medication assessments in the EMR for R8. R10 was only assessed for her eye drops and fluticasone nasal spray. RN-A added the self-administration assessments are completed annually. A form titled Election of Co-Administration of Medications form included: -Per pharmaceutical regulations, all medications that are crushed due to swallowing concerns or other issues will be administered one agent at a time and not mixed for co-administration unless requested by the resident and/or the resident representative. The residents' and/or the resident representatives preference for medication administration will be care planned and followed accordingly. A policy on self-administration of medications and medication administration was requested and none received.

Based on observation, interview, and document review, the facility failed to ensure shaving was completed for 1 of 1 resident (R7) reviewed for activities of daily living (ADLs) and was dependent upon staff assistance for provision of cares. Finding include: R7's quarterly Minimum Data Set (MDS) assessment, dated 11/9/22, indicated R7 had severely impaired cognition and required extensive assistance from staff to maintain personal hygiene. R7's care plan, last reviewed on 11/16/22; indicated R7 required extensive to total assistance with all ADL's, unable to care for self, related to severe cognitive impairment. ADL function had deteriorated due to dementia (memory loss), decrease in physical function, and end of life (hospice). Care plan directed staff to ensure appearance was neat and clean daily, staff to perform all facial shaving for R40, offer cues as needed so R40 aware of cares provided. Facility skin observation tool, indicated R7 was bathed, had facial hair removed on 12/25/22. On 12/18/22, R7 was bathed, facial hair not removed, staff documented not needed. On 12/11/22, R7 was bathed, facial hair not removed, staff documented not needed. During an observation, on 12/27/22 at 4:58 p.m., R7 was observed to have had long facial hair present under chin and above lips. During observation and interview, on 12/28/22 at 9:56 a.m., R7 was observed to continue to have long facial hair present under chin and above lips. Nursing assistant (NA)-B indicated R7 required total assistance from staff with all cares, unable to verbally communicate needs,and was not resistive to or refused cares provided by staff. NA-B indicated awareness that it was R7's preference to be free of any facial hair, was shaven per staff once weekly on bath days and as needed (PRN). NA-B observed R7's facial hair under chin and above lips, and confirmed hair was long and should have been removed on R7's last scheduled bath day, on 12/25/22. NA-B stated she would shave R7's long facial hair present under chin and above lips. During an interview, on 12/28/22 at 1:36 p.m., licensed practical nurse (LPN)-A indicated R7 was totally dependent on staff for all ADL needs, including hygiene. LPN-A indicated awareness of R7's preference to be free of long facial hair, would expect staff to remove facial hair at time when noted when cares provided, especially on scheduled bath days. While observed and interviewed, on 12/28/22 at 1:40 p.m., the director of nursing (DON) indicated it was her expectation staff shaved residents on bath days and as needed when noticing longer facial hair, including female residents. The DON indicated awareness R7 was totally dependent upon staff for all care needs, including hygiene. The DON stated awareness of R7's preference to be free of any facial hair. The DON observed R7's facial hair at time, confirmed length of hair under chin and above lips was very long. DON stated staff documented R7 was shaved last on 12/25/22, but must have missed areas by not pulling skin under chin and above lips taut (pulled tight). The DON indicated she would shave R7's longer facial hair under chin and above lips immediately. Facility policy titled, Activities of Daily Living (ADLs), revised 7/15/22, indicated a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and document review, the facility failed to further evaluate hearing loss, assist to ensure resident received proper services and treatment to maintain/improve hearing and communication for 1 of 1 resident (R6) reviewed for hearing. Findings include: R6's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had severely impaired cognition, had clear speech, made self- understood, sometimes understood others, had moderate difficulty hearing, had hearing aids. Diagnosis included dementia (memory loss). R6's face sheet, printed 12/30/22, indicated care providers and included audiologist. R6's physician order summary report, printed on 12/30/22, included provider orders for hearing aid batteries, staff to instill 2 units in both ears every 24 hours as needed for hearing aid function- size P312, start date 2/8/21. R6's care plan indicated to ensure hearing aids are in place and functioning, try using Sonic Ears if having trouble with hearing aids in, communicate with resident/family/caregivers regarding resident capabilities and needs. A copy of R6's care plan was requested, and not received. Care plan conference summary, dated 12/19/22, indicated staff interview had to be completed for R6 due to hearing difficulties and vision impairment. Care plan conference summary, dated 9/2/22, indicated staff interview had to be completed for R6 due to hearing difficulties and vision impairment. Care plan conference summary, dated 6/6/22, indicated R6 was having difficulty comprehending what interviewer was asking or saying therefore staff interview had to be completed. During an interview, on 12/27/22 at 5:22 p.m., family member (FM)-C indicated awareness of R6's difficulty hearing, hearing loss worsened over past year, had hearing aid bilaterally, staff had been replacing hearing aid batteries frequently to maintain/improve hearing, but not effective. FM-C indicated staff had not discussed with FM-C of having hearing or hearing aids evaluated, stated staff informed FM-C hearing changes due to R6's progressive decline in cognition. During observation and interview on 12/29/22 at 7:20 a.m., R6 was observed sitting in her room in her wheelchair watching TV, bilateral hearing aid present to ears. Surveyor attempted to converse with R6, R6 looked at surveyor, did not respond to questions asked. During an interview, on 12/29/22 at 8:27 a.m., nursing assistant (NA)-C indicated awareness of R6 being hard of hearing, had bilateral hearing aid to assist with hearing, always wanted hearing aids left in place to ears. NA-C stated communication with R6 was difficult, could communicate more effective with R6 when speaking slowly, clearly at face level, using hand gestures. While interviewed, on 12/29/22 at 9:11 a.m., NA-D indicated awareness of R6 being hard of hearing, had bilateral hearing aid to assist with hearing, and difficult to communicate with. NA-D stated could communicate with R6 more effectively when up close to R6 and directly at face level, speaking clearly and slowly. NA-D indicated unawareness if staff had bilateral hearing aid evaluated for malfunction, stated she thought bilateral hearing aid had been repaired a long time ago, date unknown. NA-D indicated awareness of orders to replace bilateral hearing aid battery twice weekly and as needed (PRN). NA-D stated R6's hearing remained unchanged with replacement of bilateral hearing aid battery. During an interview, on 12/29/22 at 12:19 p.m., licensed practical nurse (LPN)-A indicated awareness of R6 being hard of hearing, had bilateral hearing aid to assist with hearing, bilateral hearing aid battery had been changed on multiple occasions, bilateral hearing aid filters cleaned in past by staff which helped some, unsure when last time bilateral hearing aid checked or cleaned. LPN-A stated nursing staff checked and cleaned R6's bilateral ear approximately 1 month ago, somewhat effective in improving R6's hearing. LPN-A indicated she thought R6's daughter was informed by staff to have bilateral hearing aid checked for malfunction several months ago, R6's daughter did not pick-up bilateral hearing aid from facility. LPN-A unable to produce documentation of staff discussion with R6's family member to have bilateral hearing aid further evaluated for malfunction/replacement, stated unawareness if R6's changes in hearing had been followed-up on by staff. While interviewed, on 12/30/22 at 7:56 a.m., the director of nursing (DON) indicated awareness of R6 being very hard of hearing, had bilateral hearing aid to assist with hearing, stated R6 spent most of her time in her room due to impaired hearing and cognition. The DON indicated she, along with other nursing staff, recently checked R6's ears, and changed bilateral hearing aid battery approximately 2 weeks ago. The DON stated she was able to remove cerumen to one ear canal, other ear canal impacted with cerumen, and needed cerumen softener to loosen, removed cerumen to other ear next day, and noted improved hearing for R6. The DON indicated unawareness if staff had ever contacted R6's family members to discuss having bilateral hearing aid checked for malfunction/replacement, and unaware if R6's hearing had been further evaluated per physician. The DON stated if staff aware of continued or worsening changes in hearing after implementation of physician orders and facility standard procedures for impaired hearing, it was her expectation for staff to notify the DON and resident's family to discuss further follow-up and evaluation. The DON indicated registered nurse (RN)-C manages a lot of R6's care needs and to follow-up with her, as RN-C may have more information regarding R6's hearing changes than DON aware of. During an interview, on 12/30/22 at 8:24 a.m., RN-C indicated awareness of R6 being very hard of hearing with bilateral hearing aid to assist with hearing in place, unaware of when R6's bilateral hearing aid was last checked or when R6's hearing was last evaluated, stated had not been checked in past year, had not contacted R6's family recently to discuss any needs for follow-up of R6's hearing or bilateral hearing aid. RN-C stated due to worsening of R6's hearing, it would be appropriate for R6's hearing to be further evaluated and bilateral hearing aid checked/replaced if needed. Facility policy titled, Care and Use of Hearing Aids, revised date 8/31/22, consisted of; it is the practice of this facility to assist residents in using their hearing aids, batteries normally last 1 week with daily wearing of 10 to 12 hours, ear molds should be replaced every 2-3 years or as determined by resident/family (POA)/audiologist, routinely check battery compartment to ensure it is clean, batteries are inserted correctly, and compartment is shut completely, routine follow-up with an audiologist is recommended to evaluate effectiveness of current hearing aids according to resident or family (POA) wishes.

Based on observation, interview and document review, the facility failed to ensure staff provided restorative services to meet the assessed needs for 1 of 1 resident (R10) reviewed for restorative services. Findings include: R10's Face Sheet printed on 12/29/22, indicated an admitted ,d+[DATE] with diagnoses of multiple sclerosis (MS) (disabling disease of the brain and spinal cord with communication problems between the brain and the rest of the body), inflammatory polyarthropathy (arthritis that affects more than four joints), lymphedema (swelling in the arms and legs), peripheral vascular disease (a slow and progressive circulation disorder) and history of pulmonary embolism (pulmonary arteries in the lungs get blocked by a blood clot). R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], included R10 is understood and understands, has intact cognition, no behaviors including refusal of care and required extensive assistance of 2 staff with bed mobility, transfers, dressing and toileting. R10 used an electric wheelchair and does not walk. R10 has no functional limitation with range of motion. R10's care plan dated 7/9/2020, indicated R10 has impaired mobility and the potential for an increase in contractures related to MS and rheumatoid arthritis requiring extensive assistance with transfers and bed mobility. Goal included R10 wil continue to passively participate in left extremity stretching 2 days per week or more as documented by restorative nurse aide (RNA). Interventions included standing in parallel bars 2-6 times. If bars are not accessible use EZ stand with cues for gluteal (3 muscles that make up area commonly known as the buttocks) activation 3-5 days/week. Supine stretches in wheelchair or bed 2 times for 10 or 15 reps, 3 to 5 days per week. Passive range of motion (PROM) to left upper extremity for 3-5 days/week, arm bike and pulleys 3-5 days per week. During interview on 12/27/22, at 2:58 p.m., R10 was sitting in her room in her electric wheelchair. R10 was able to move right arm and hand. Left fingers were curled in towards her palm and R10 was only able to move minimally. Fingers were not digging into her palm. R10 indicated she wears a wrist brace for about 3 hours per day to prevent further contractures. R10 was not able to move either of her legs. R10 indicated she is supposed to have PROM exercises but it doesn't happen very often because of staffing or call ins and the restorative aide has to go work on the floor instead. During observation and interview on 12/28/22, at 8:37 a.m., R10 indicated she did not receive PROM exercises yesterday and so far not today either. R10 doesn't expect she will as the restorative aide is working and providing direct cares again today. During observation and interview on 12/29/22, at 7:23 a.m., R10 indicated she has not had any PROM so far this week. R10 indicated it gets done when they have enough people to provide direct care. R10 added it is hit and miss with getting PROM as sometimes done it 4 days in a row and then can go up to a week without any at all. R10 indicated she has gotten weaker and believes her left arm has gotten weaker. R10 attempted to move her arm which moved minimally but was not able to move it off the arm rest of the wheelchair. R10 indicated she can barely move her legs which she demonstrated with only slight movement. R10 added she believes the worsening of movement is all related to her MS progressing. During interview on 12/29/22, at 8:19 a.m., nursing assistant (NA)-E indicated she is considered the restorative aide but with staffing challenges and staff call ins, she provides direct patient care a lot of the time. NA-E indicated she was on the schedule 12/27/22 this week but due to a call in was not able to complete restorative care. NA-E indicated generally she gets scheduled 3-4 times per week when they have adequate staff. NA-E added I get pulled to work on the floor a lot. NA-E indicated R10 is weak and her left arm is getting worse and has had a lot of fluid issues recently. NA-E estimated 50% of her time is spent in direct care giving and the other 50% in restorative care. Review of restorative documention included: September 2022 restorative therapy was completed 6 times for the month. October 2022 restorative therapy was completed 7 times for the month. November 2022 restorative therapy was completed 6 times for the month. During interview on 12/29/22, at 9:58 a.m., nursing assistant (NA)-C indicated nursing assistants do not do restorative care. NA-C added only one NA-E completed that. NA-C indicated NA-E does get pulled to provide direct patient care a lot. During interview on 12/29/22, at 10:01 a.m., NA-D indicated they do not complete any restorative care and have never been instructed to complete it. During interview on 12/29/22 , at 9:02 a.m., physical therapy aide (PTA) indicated therapy has not seen R10 for awhile and has a restorative program to assist with maintaining muscle strength in her lower extremities. PTA added with MS, restorative therapy will help maintain her range of motion and strength and even with a decline related to MS, it wil help slow the process down. During interview on 12/29/22, at 9:42 a.m., occupational therapy aide (OTA) indicated she has worked with R10 frequently throughout her stay and most recently last month with the EZ stand as her legs were not staying within the foot pedals and she was losing her grip on the hand holders. OTA indicated minimally staff should perform PROM and exercises three times a week but every day is ideal. OTA added restorative is very beneficial to long term care residents for quality of life. OTA evaluated R10's left arm and indicated it was more swollen than when she had seen it the last time and may be stiffer but her ability to move her hand and arm had not changed. OTA added R10's MS has progressed since R10 arrived at the facility. During interview on 12/30/22, at 8:15 a.m., the director of nursing (DON) indicated the facility has had some staffing issues and the restorative aide has had to provide direct patient care instead of her restorative duties. The DON indicated ideally the restorative aide should be scheduled 3-4 days per week, but for awhile that hasn't been possible. The DON indicated the nurses and NA's are not responsible for completing ROM exercises. The DON added R10 has been declining related to her MS and it would be beneficial to have restorative therapy 2-3 times per week. Review of physical therapy notes indicated R10 was last evaluated and treated by physical therapy 2/18/22 through 4/22/22 related to muscle weakness generalized and MS. A discharge noted indicated R10 was able to return to baseline status after therapies were completed and R10 continued to require an EZ stand for all transfers. R10 was discharged to the same skilled nursing facility. Requested occupational therapy notes but none were received. A policy and procedure titled Prevention of Decline in Range of Motion dated 7/25/22 included: -Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. - The facility will provide treatment and care in accordance with professional standards of practice which includes but is not limited to appropriate services (specialized rehabilitation, restorative, maintenance), appropriate equipment (braces or splints) and assistance as needed (active assisted, passive, supervision). -Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practioner. -Interventions will be documented on the residents person centered care plan. Documentation should include, but not limited to type of treatments, frequency and duration of treatments, measurable objectives and resident goals. -A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record.

Based on observation, interview and document review, the facility failed to document and monitor weight loss for 1 of 1 resident (R20) who had weight loss following major surgery. Findings include: R20's face sheet printed on 12/30/22, included diagnoses of aftercare following surgery on the digestive system, malignancy (cancer) of the anus, and Crohn's disease (chronic inflammatory bowel disease). R20's 5-day Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact, independent with eating and required limited assistance of one staff when walking. R20's care plan dated 11/15/22, indicated R20 had a nutritional problem following perineal (space between genitals and anus) reconstruction surgery and colostomy (surgical operation where piece of colon is diverted to an opening in the abdominal wall) due to malignant neoplasm (cancerous growth) of anus, followed by an abdominal perineal resection (surgery to remove the anus, rectum and part of the sigmoid colon). The care plan indicated R20 would maintain adequate nutritional status by maintaining weight at or above 170 pounds through the next review date of 2/15/23. R20's physician orders dated 11/20/22, indicated R20's weight was to be obtained weekly on Tuesday bath day and entered into POC (Point of Care, a section in the EMR (electronic medical record) where nursing assistants (NA's) documented. During an interview on 12/27/22, at 5:57 p.m., R20 stated he didn't know if he had lost weight since admission about a month ago, adding he recently had major surgery. During observations on 12/28/22, through 12/30/22, R20 was observed eating breakfast and noon meal in the independent dining room, unassisted. During record review, upon admission on 11/17/22, R20 weighed 179 pounds and on 12/20/22, R20 weighed 168 pounds; a 6.15% weight loss. There was no weight recorded for Tuesday bath day, 12/27/22. During record review, dietician review notes dated 12/8/2022, indicated R20's last weight was 171.4 pounds (a weight loss of -4.24% since admission). The dietician note indicated R20 was on a daily supplement and had been consuming 76-100% of meals. No nutrition changes were recommended. During an interview on 12/28/22, at 11:26 AM, together with nursing assistant (NA)-A, looked at R20's paper bath sheet dated Tuesday 12/27/22. The space for the weight to be recorded was blank. NA-A stated R20 had been weighed that morning (12/28), by coworker (NA)-B at about 8:30 a.m. and had weighed 166 pounds. (A 7.26% weight loss since admission). The weight of 166 pounds had not been documented in the EMR. R20's weights since admission: 11/17/2022, 179 pounds 11/18/2022, 173.4 pounds 12/6/2022, 171.4 pounds 12/13/2022, 171 pounds 12/20/2022, 168 pounds 12/28/22, 166 pounds During an interview on 12/28/22, at 10:20 a.m., trained medication aide (TMA)-A stated NA's weighed residents and were to document the weight in POC. NA's could only see the current weight, no previous weights, and stated nurses would review the weights to see if there was a weight loss. During record review on 12/29/22, 8:02 a.m. R20's measured weight of 166 pounds from 12/28, had still not been documented in the EMR. During a telephone interview on 12/29/22, at 8:57 a.m., the dietician was unaware of R20's further weight loss since her evaluation on 12/8/22, and would check into this and make any necessary changes. During an interview on 12/29/22, at 10:41 a.m., licensed practical nurse (LPN)-A stated NA's obtained resident weights and would tell her right away what the weight was and she would enter it into the EMR and compare it to previous weights. LPN-A looked in the EMR and verified R20's last documented weight was 168 pounds on 12/20/22. LPN-A was not aware of an additional weight being obtained on R20 on 12/28/22. During an interview on 12/29/22, at 12:28 p.m., NA-A, NA-B and NA-C all had knowledge of R20 being weighed on 12/28. NA-B obtained the weight (166 pounds) but could not recall if she documented it in the EMR. NA-A overhead NA-B radio R20's weight to LPN-A over the walkie talkie on 12/28. NA-C thought she saw a note on LPN-A's medication cart with R20's weight of 166 pounds on it. The NA's acknowledged that documenting and reporting resident weights was important. NA-A stated they were not able to see in the EMR if a resident had a weight loss, they could only see the weight they entered, and stated the nurses monitored residents for weight loss. Despite several NA's becoming aware a weight had been obtained and not documented on R20, this information was not relayed to nursing staff. During record review on 12/30/22, at 7:58 a.m., R20's weight of 166 pounds from 12/28, had still not been documented in the EMR. During an interview on 12/30/22, at 12:35 p.m., the director of nursing (DON) stated the NA who obtained a residents weight was supposed to document it in the EMR. The DON reviewed R20's weights in the EMR and verified the weight of 166 pounds obtained on 12/28, had not been documented, and verified the 13 pound weight loss (7.26%) since admission. The DON stated she expected NA's to document resident weights timely, and for nurses to monitor resident weights and inform the provider of a significant weight loss. The DON stated it appeared there was a process problem related to staff accountability for documenting and monitoring resident weights. Facility policy titled Weight Monitoring, dated 2022, indicated a significant unintended change in weight (loss or gain), or insidious weight loss (gradual unintended loss over a period of time), may indicate a nutrition problem. Newly admitted residents would be weighed weekly for four weeks; residents with weight loss would be weighed weekly, and if clinically indicated, weight would be monitored daily. A significant change in weight was defined as: 5% change in weight in one month, 7.5% in three months and 10% in six months. The physician would be informed of a significant change in weight. The policy did not indicate staff responsibility in measuring and recording resident weights.

Based on interview and document review, the facility failed to ensure staff appropriately monitored, assessed and intervened, for 1 of 2 residents (R25) reviewed for respiratory care, who displayed significantly reduced oxygen saturations with a decline in physical condition requiring emergency care. The facility's lack of assessment, staff education and failure to implement appropriate interventions, resulted in an Immediate Jeopardy (IJ) with the potential for serious harm, injury or death. In addition to R25, 1 other resident (R283) who currently resided in the facility at the time of the revisit survey was identified as at risk due to respiratory issues requiring a [MEDICAL CONDITION] (continuous positive air pressure) equipment to be used to assist with breathing. The Immediate Jeopardy (IJ) began on [DATE], when R25 was sent to the emergency room by ambulance due to respiratory distress, low oxygen saturation, related to potential malfunctioning equipment, lack of nursing assessment and intervention. The administrator and director of nursing (DON) were notified of the IJ situation on [DATE], at 5:10 p.m. The IJ was removed on [DATE], at 7:15 p.m. however, non-compliance remained at the lower scope and severity of (G) isolated with actual harm that is not Immediate Jeopardy. Findings include: Review of R25's medical record indicated he was admitted on [DATE], with [DIAGNOSES REDACTED]. airway pressure machine, a device used to prevent the airways closing during sleep). There was no mention of an assessment involving R25's knowledge or capability of using his [MEDICAL CONDITION]. R25's physician's orders [REDACTED]. Staff were to clean the [MEDICAL CONDITION] mask weekly and check the reservoir tank for the [MEDICAL CONDITION] every HS shift. R25 was ordered to have Oxygen delivered via nasal cannula at 2 liters per minute (LPM) continually every day and night shift. Review of R25's progress notes indicated: (1) [DATE] at 11:07 a.m., a nurse was called to the therapy department after a fall. R25 was sitting on his buttocks on the floor at the time the nurse arrived. R25 denied he had any discomfort or pain. His blood pressure (BP) was ,[DATE], pulse was 84, respiratory rate was 22, and O2 sats were 88% off oxygen. R25 was assisted to his wheelchair by a mechanical lift, and O2 was placed back on. Vital signs were to be monitored for 72 hours along with any changes the resident may have. There was no documentation in the nurses notes to indicate vitals were monitored for 72 hours as indicated to be or therapy staff were interviewed to the cause of the fall, or injuries that may have happened. (2) [DATE] at 3:14 p.m., R25's Medical doctor (MD) called to see how R25 was doing after the fall. The MD asked staff to advise him of R25's condition. Nursing staff told MD R25 was doing ok with no pain or bruising. Nursing staff would continue to monitor and report changes. (3) [DATE] at 11:50 a.m., R25 was having increased shortness of breath (SOB) and was much more lethargic. His O2 sats were between ,[DATE]%. R25 was now using his [MEDICAL CONDITION] between meals while in his room. His color remained pale. There was no documentation or notes related to (r/t) R25's respiratory status or notification to the doctor of his decline in health. (4) [DATE] at 11:48 a.m., R25 continued to be lethargic. His oxygen saturations (O2 sats) were anywhere from ,[DATE]%. Staff were unable to maintain his O2 sat at 90%. R25's MD was called and R25 was sent to the emergency room . (5) [DATE] at 2:26 p.m., R25 returned from the emergency room (ER) with orders to have his [MEDICAL CONDITION] machine checked and to ensure there was good wave form when checking oxygen saturation. R25 was to return to the ER for new or worsening symptoms. (6) [DATE] at 2:40 p.m., a call was placed to R25's family member, informing her of his [MEDICAL CONDITION] machine needing to be checked. (7) [DATE] at 6:11 p.m., R25 was having a hard time staying awake at supper. R25's tablemate was concerned and asked the nurse to check R25. The nurse had to wake R25 up several times over the course of his meal. There is no mention of any vital signs taken to include O2 sats at that time. (8) [DATE] at 10:59 p.m., staff noted R25's machine not working. There was no mention staff checked R25's vitals or completed a thorough assessment of his condition, to ensure he had no signs or symptoms of respiratory distress. (9) [DATE] at 9:50 a.m., R25 needed assistance of 2 with transfers related to health decline. There was no mention of any vitals being taken at that time, nor any further respiratory assessment being completed. (10) [DATE] at 8:24 a.m., the MD was called to notify R25 had coded that a.m. and was being sent to the ER via ambulance. (11) [DATE] at 8:35 a.m., family was notified of R25's ER transfer. (12) [DATE] at 9:54 a.m., the ambulance service called to inform R25 was being airlifted to another larger hospital in Rochester, MN. (13) [DATE], at 10:11 a.m., nursing staff entered documentation surrounding the events from earlier that a.m The documentation indicated that when the licensed practical nurse (LPN)-A was entering the room that morning, she found R25 in bed without O2 or his [MEDICAL CONDITION] on. When she asked R25 why he did not have his O2 and [MEDICAL CONDITION] on he mumbled incoherently. LPN-A placed his O2 on at 2 LPM and elevated his head to 30 degrees. LPN-A checked his O2 sat and found it to be 60%, which was significantly below R25's expected 90%. Earlier that a.m., nursing assistant (NA)-A assisted R25 to his wheelchair (W/C) with the mechanical stand lift. NA-A stated R25 was able to assist and was speaking to her. NA-A then noticed R25 had stopped speaking and his head fell back. NA-A called for help. R25 became cyanotic (blue color of skin caused by lack of oxygen). Chest compressions were started while the resident was in his W/C and staff called 911. An automated external defibrillator (AED) was applied, but no shock was advised. Compressions continued. A femoral pulse was noted as present. The ambulance (EMS) and sheriff's department arrived. An ambu bag was used to assist with breathing and R25's O2 was at 85%. R25 was able to move all extremities. EMS transported R25 to the ER in Fairmont. Fairmont ER called and stated R25 was being transferred to a hospital in Rochester via helicopter. (14) [DATE] at 4:04 p.m., nursing staff called for an update from the hospital on R25's condition. R25 was intubated (tube into the lungs to assist with breathing). Hospital staff were continuing medical exams and were going to check a head computerized tomography (CT) and an ultrasound. R25's O2 sats were 90%. Family was present. (15) [DATE] at 10:35 a.m., R25's family member called. R25 was now off sedation with hopes of removing his breathing tube. The family member asked if R25 had fallen during his respiratory arrest, as the CT showed a brain bleed, she was told was consistent with a fall. Nursing advised R25 had not fallen during the event, nor was he on the floor at that time. If R25 had fallen prior to the [DATE] event, he would not be able to get himself back up. R25 was unresponsive with some eye movement. The family member was quoted as saying Things do not look that good. (16) [DATE] at 2:00 p.m., R25 was off the ventilator and would now be entering hospice end-of-life care. During interview with LPN-A on [DATE] at 12:30 p.m., LPN-A stated she had started her shift the morning of [DATE] at 6:00 a.m Sometime shortly after receiving report, LPN-A went to R25's room (at approximately 7:00 a.m.). LPN-A found R25 without his O2 or [MEDICAL CONDITION] on. R25's sats were at 60% (normal oxygen saturations typically are 90% or above, 60% would indicate severe hypoxemia). R25 was mumbling incoherently at the time. After applying oxygen to R25, LPN-A left the room and did not return. LPN-A stated she thought since R25's O2 saturations were starting to climb back up into the middle 60's he was ok to be left alone. LPN-A verified she had not performed a respiratory assessment or checked vitals at that time. LPN-A stated because she was sure R25's O2 sats would come up, she did not return to R25's room until notified of his [MEDICAL CONDITION] later that morning at approximately 8:00 a.m. LPN-A said she did not call R25's physician, or procure emergency services at that time despite the critically low oxygen saturation value and change in R25's mentation. LPN- A stated if a resident's O2 sats were low, she should recheck in 1 hr. LPN-A was unaware what O2 sats level were considered critical. LPN-A stated R25's normal sats were in the low 90's. LPN-A was unaware when to assess or reassess a resident for safety in critical situations, or when to call emergency medical services (EMS) when a resident had critically low oxygen sats and/or level of conscious changes. LPN-A stated staff check R25's oxygen at night prior to going to bed, but acknowledged she was unaware of any other routine checks. LPN-A also said she felt it was useless to send R25 to the ER (on [DATE]) as they would just say he was fine after he arrived like they had done previously on [DATE]. During further interview on [DATE] at 12:30 p.m., LPN-A stated on [DATE], R25 was sent to the ER because of low O2 sats and they (the ER) did nothing. ER staff reportedly asked her what they were to do about his low O2, as by the time R25 arrived on [DATE], his oxygen was in the high 80's. LPN-A again explained the resident's tablemate had called her over to see what was the matter with R25. LPN-A said she'd asked R25 how he was doing but added, He kept falling asleep .He complained something was wrong, and continued to keep falling asleep. LPN-A said she'd called the MD and obtained orders to send R25 to the ER and sent R25's [MEDICAL CONDITION] machine along with R25. LPN-A said, Staff thought it was malfunctioning R/T (related to) R25's low oxygen levels. R25 was known to have mumbled speech when his oxygen got low. LPN-A stated she was unsure whether R25's machine was or was not functioning, and said, I don't know how to run them. LPN-A said the ER had reported the facility needed to get it checked so she called the family member and told her to come get the [MEDICAL CONDITION] machine, and instructed the family member to take it to the supplier. LPN-A said since it was not the facility's equipment, it was the family's responsibility to get the equipment checked for working order. During the same interview, LPN-A stated she felt R25 was able to properly apply the mask and use the machine on his own. She said she thought he did so because he was known to independently remove his mask during the night. She was unsure exactly how to place the mask or operate the [MEDICAL CONDITION] machine herself. LPN-A said she had looked at the instructions for the [MEDICAL CONDITION] at the time staff thought it was malfunctioning on [DATE], and had not understood what to do. LPN-A stated R25's [MEDICAL CONDITION] was still at the facility. Review of the record revealed there was no assessment performed on R25 to ensure he knew how to operate the [MEDICAL CONDITION], nor was he capable to do so. LPN-A stated staff had no professional references or policies to follow for abnormal vital signs or critical events. She said the DON and administrator are notified by nursing staff of every hospital transfer. During interview on [DATE] at 12:45 p.m., LPN-A was observed in R25's room. R25 stated the breathing machine was not identified directly as either a [MEDICAL CONDITION], but had a sticker on the machine stating to call with questions. LPN-A said she had never called the number on the machine for concerns related to potential malfunctioning of the equipment. LPN-A said since the equipment had not been supplied by the facility, but rather by a government agency, she (LPN-A) had called R25's family to come get the machine and have it fixed. LPN-A was unable to state how staff ensured R25 was safe with a malfunctioning machine. LPN-A confirmed staff had not had education on the use or maintenance of R25's [MEDICAL CONDITION] machine. Further, LPN-A identified one other resident, R283, as a current resident who also utilized a [MEDICAL CONDITION] even though staff were unaware how to ensure [MEDICAL CONDITION] equipment was placed or working properly. Nursing assistant (NA)-A was interviewed on [DATE] at 1:05 p.m. NA-A stated she'd been told by LPN-A, immediately after report on [DATE], between approximately 6:15 and 6:30 a.m. not to get R25 up for the day because his oxygen was low. NA-A stated she'd gone into R25's room to get him up at approximately 7:45 a.m. without receiving notification it was ok to do so by LPN-[NAME] NA-A said R25 had been mumbling but was awake, so NA-A thought it was ok to take R25 over to the main bathing room to shower. NA-A explained she had used the mechanical lift on R25 to transfer him out of bed and into his wheelchair. She then proceeded to wheel him across the hall into the bathing room. NA-A said she began readying R25's shower when she noticed he was not speaking anymore. NA-A said she'd looked over at R25, and noticed his eyes were rolled back into his head with his head hung back, and he was gray in color. NA-A said she then called for help and when the nurse arrived she began cardio [MEDICAL CONDITION] resuscitation (CPR). Review of R25's (MONTH) (YEAR) Documentation Survey report indicated Vitals (Blood pressure, temperature, pulse, respirations and pain) from (MONTH) 21-[DATE]th, (YEAR), showed on: (1) [DATE], during the hours of 2:00 p.m. to 10 p.m., all vitals were marked N/A (not applicable). (2) [DATE], during the time of 6:00 a.m. to 2:00 p.m., there is 1 notation of his respiratory rate being assessed. The score was 22 breaths per minute (BPM) (normal ,[DATE] PM), meaning R25 experienced shortness of breath. (3) [DATE], during the hours of 2:00 p.m. to 10 p.m., all vitals except pain were marked N[NAME] Pain was assessed as N meaning R25 had no pain. (4) [DATE], [DATE], and [DATE]. during the hours of 10:00 p.m. to 6:00 a.m. all vitals except pain were marked N[NAME] R25's pain was assessed on those 3 days. There is no mention of R25's oxygen saturation having been checked by staff during the month of (MONTH) on the report. R25's [DATE] care plan revealed he had an advanced directive for Full Code. R25 had a Physician order [REDACTED]. R25 had a self-care deficit related to (R/T) his [MEDICAL CONDITION] and required extensive assist with activities of daily living (ADL). Staff were to monitor for signs of difficulty breathing. R25 was able to self-administer nebulizer medication treatments after setup by staff. R25 was at risk for neglect from others related to his nursing home placement. Staff were to identify R25's vulnerability and risk through assessment. R25 was noted use a Bi-PAP (Bi-level Positive Airway Pressure) machine HS with supplemental oxygen R/T CRF and [MEDICAL CONDITION], however, R25's current treatment sheets indicated he used a [MEDICAL CONDITION]. R25's goal was to have no signs or symptoms (SX) of poor oxygen absorption. There was no mention of how or how often staff were to monitor or assess R25 to ensure he had no complications from his [MEDICAL CONDITION] or history of CRF. Review of R25's [DATE], Minimum Data Set (MDS) indicated he had a Brief Interview for Mental Status score of 14, indicating normal cognition. R25 required extensive assist with bed mobility, transfer, dressing, and personal hygiene requiring the assistance of 1 staff. R25 weighed 380 lbs. R25 was documented as receiving oxygen but was not noted to be on a [MEDICAL CONDITION] or Bi-PAP while a resident. Review of R25's Care Area Assessments (CAA) completed on [DATE], completed by the MDS coordinator indicated he had sever [MEDICAL CONDITION] disease, but no shortness of breath. R25 had poor memory and anxiety with an inability to perform ADLs without significant physical assistance by staff. R25 's cognitive deficits included stamina, ability to express himself, and make decisions with altered mental status. R25 had a change in communication, vision, hearing, and cognition. R25's goals indicated he was to maintain his current level of functioning and physical limitations such as weakness. There was no mention of his limited visual ability from his [DIAGNOSES REDACTED]. Review of R25's [DATE] Medication Administration Record [REDACTED]. There was no mention of when staff were to check R25's oxygen levels to ensure he had no adverse effects from his [MEDICAL CONDITION] and history of CRF. Review of R25's [DATE] emergency room documentation indicated his discharge [DIAGNOSES REDACTED]. Patient instructions listed were: (1) Continue current medications. (2) Have your [MEDICAL CONDITION] machine checked. (3) Make sure there is a good waveform when checking oxygen saturation. (4) Follow-up in clinic within one week. (5) Return to the ER for new or worsening symptoms. Review of R25's [DATE] at 9:38 a.m., emergency room documentation indicated he was an inpatient at that time admitted for [MEDICAL CONDITIONS] (high potassium) [MEDICAL CONDITION], pacemaker, [MEDICAL CONDITION] (CAD), [MEDICAL CONDITION] exacerbation, heart failure, and diabetes. He was sedated and a mechanical ventilator to breathe for the resident was placed. MD progress notes revealed he was a [AGE] year-old male, admitted directly from the triaging hospital. R25 was reported to be suffering from worsening respiratory symptoms. He was reported found that day at the nursing home cyanotic and unresponsive. No pulse was detected and CPR was started. Upon arrival of EMS, the resident was thought to have spontaneous breathing. He was hypertensive (elevated blood pressure) and tachypneic (abnormal rapid breathing) on route to the ER. He was poorly responsive upon arrival to the ER, and would appear to open his eyes when his name was called. Due to the tachypnea and wheezing, R25 was immediately intubated. R25 did have a urinary tract infection prior to that day and was being treated by antibiotics previously. The assessment/plan indicated he had suffered cardiopulmonary arrest requiring mechanical ventilation R/T [MEDICAL CONDITION] and suspected [MEDICAL CONDITION] exacerbation. Further review of R25's [DATE] at 11:08 a.m., ER documentation history and physical revealed R25 had suffered an unwitnessed arrest that a.m., and was successfully resuscitated at the nursing home. Staff were trying to deduce the origin of the arrest, but it was likely primarily respiratory, given his recent history and mounting respiratory complaints. Other considerations could be a massive stroke, which was not suggested by clinical exam. R25 was being paced with an underlying rhythm of [MEDICAL CONDITION]. Staff were treating for [MEDICAL CONDITION] exacerbation and covering broadly with antibiotic (R/T his known bladder infection). Staff plan on providing lung protective mechanical ventilation, assessing his mental status by minimizing sedation required for ventilation, and a head CT as the resident was found down. Review R25's [DATE] 1:44 p.m. emergency room documentation revealed R25 was diagnosed with [REDACTED]. For the past several weeks, R25 was noted to be suffering from worsening respiratory symptoms, though the hospital was unaware of documentation from those visits. Previously that a.m., R25 was found unresponsive and cyanotic. No pulse was detected and CPR was initiated. Upon arrival by EMS, it appeared R25 was spontaneously breathing, but the receiving hospital had no information on R25's heart rhythm. Nursing home staff administered basic Life support at that time. It is the hospital's understanding R25 was hypertensive and tachypneic on route to the ER. Upon arrival to the ER, R25 was poorly responsive but had appeared to open his eyes when his name was called. His rapid breathing and wheezing required intubation and mechanical ventilation. Reason for visit was listed as respiratory arrest. The assessment and plan problems for admission list cardiopulmonary arrest and suspected [MEDICAL CONDITION] exacerbation, heart failure, and obstructive sleep apnea on [MEDICAL CONDITION]. Interview on [DATE] at 3:06 p.m., with the administrator regarding the above incident and care for R25 received from [DATE] to [DATE] indicated she was unaware if nurses were trained on the use of [MEDICAL CONDITION] equipment. LPN-A had made them aware of the investigation into the events surrounding R25's respiratory arrest recently, and the director of nursing (DON) was checking into available education on the [MEDICAL CONDITION] machines. The administrator had started her role at the facility 2 weeks prior and was unable to determine if staff were trained on abnormal vital signs, use of [MEDICAL CONDITION] machines, and appropriate assessment. At approximately 3:45 p.m., the director of nursing notified surveyors she was leaving for the day and would be unavailable for interview. Interview on [DATE] at 5:02 p.m. with the director of operations (DOO) and the administrator of the immediate jeopardy; it was their expectation nursing should not have left R25 alone with the above-mentioned symptoms on [DATE]. Furthermore, they agreed staff had not been trained on the use of the [MEDICAL CONDITION] machine. They were unaware the (MONTH) (YEAR) facility assessment, completed after R25 was admitted , made no mention of residents who required [MEDICAL CONDITION] or Bi-PAP's for breathing. They were also unaware the facility had no professional standards guide or policies for assessment of residents with critically low O2 sats. They were unaware R283 had no mention of his [MEDICAL CONDITION] machine, or [MEDICAL CONDITION] interventions in his physician's orders [REDACTED]. Interview on [DATE] at 9:40 a.m. with the medical director indicated he was unaware of the events surrounding the immediate jeopardy called on [DATE]. He was at the facility, seeing patients. His expectations were staff are to notify him immediately or serious or sentinel events, deaths, and hospice and comfort care concerns. Staff need to improve on their monitoring of significant changes. A resident in respiratory distress, oxygen saturations that are severely below their norm, and level of consciousness (L[NAME]) changes would warrant immediate notification to the provider and/or EMS. Staff should have stayed with R25 and appropriately assessed and intervened. The medical director thought staff were trained on use of [MEDICAL CONDITION], however, was unfamiliar with any training the facility provides to its staff. Interview on [DATE] at 10:15 a.m. with the DON revealed when discussing the events regarding R25, she indicated staff should have stayed with the resident, performed a complete assessment, and intervened to prevent the potential respiratory arrest that followed later that day. She agreed staff should have notified EMS and the provider of R25's decline in health that day. Staff should have called the number located on a sticker on R25's machine when they thought it was potentially malfunctioning. Interview on [DATE] at 10:50 a.m.with the DOO indicated it was her expectation staff should have stayed with R25, performed a complete assessment and contacted the MD and/or EMS at that time it was discovered R25 had critically low oxygen and L[NAME] changes. She agreed staff had not been appropriately trained on [MEDICAL CONDITION] usage prior to the admission of R25 and R283. Review of R283's medical record indicated he was admitted to the facility o [DATE] with [DIAGNOSES REDACTED]. R283 had no assessment performed related to his [MEDICAL CONDITION] machine to determine if he was capable of knowing if the machine would be working or malfunctioning, since staff had no knowledge and looked to the resident to be in charge of the device. R283's [DATE], MDS assessment indicated a cognitive score of 8, showing he had moderate cognitive impairment. Review of R283's physician's orders [REDACTED]. Review of R283's current care plan indicated he had an ADL self-care deficit r/t impaired cognition with short-term memory loss. He was known to be resistive to cares. R283 had problems with sleep disturbance and complaints of feeling tired, dozing during activities, and statements regarding inability to sleep. R283 used oxygen therapy with his Trilogy ([MEDICAL CONDITION]) brand machine whenever lying down R/T [DIAGNOSES REDACTED]. Staff were to monitor for signs and symptoms of respiratory distress and report the MD as needed. R283 was to be on 2 LPM of oxygen while connected to his [MEDICAL CONDITION] mask. Review of R283's current Treatment Administration Record indicated no mention of how often staff should check R283's vital signs, including pulse oximetry. There was also no mention of staff applying the [MEDICAL CONDITION] mask for R283, who had known cognition issues and was resistive to cares. Review of R283's (MONTH) (YEAR), Documentation Survey Report indicated his O2 sat was only recorded once on [DATE]. All other dates noted: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] were marked N/A for all vitals except pain. Review of R283's [DATE], Medication Self Administration Safety Screen revealed he was deemed competent to self-administer medications and use the Trilogy C-Pap machine, although there is no mention he could identify if there were a malfunction. R283 was deemed competent based on his ability to put on and take off his mask while in bed. There was no factors/situations noted of what staff were to do to ensure R283's mask had not come off in the night, his O2 sat levels remained at acceptable parameters, or how staff were to ensure he would not become hypoxic if the mask were off, or the machine malfunctioned. Review of R283's [DATE], CAA indicated he had behavior symptoms identified with respiratory disease, [MEDICAL CONDITION], and a history [MEDICAL CONDITION]. R283's cognitive abilities were impaired by disruptive behaviors, poor memory, and resisting care. R283 triggered for difficulty with ADL's due to physical limitations and depression and had the inability to perform ADLs without significant physical assistance. R283 was identified with risk for falls related to agitation behavior and cognitive impairment. Review of the (MONTH) (YEAR), Admissions Criteria policy indicated the facility was to admit residents who can be cared for adequately by the facility. Residents including those with [MEDICAL CONDITION] would be admitted as long as their nursing and medical needs can be met adequately. Review of the (MONTH) (YEAR) Oxygen Therapy Delivered via C-PAP Machine Procedure policy revealed residents would be accepted into the facility who were dependent upon [MEDICAL CONDITION] machines for oxygen delivery. It was the nursing care team member's responsibility to assess the resident for signs and symptoms of [MEDICAL CONDITION], such as restlessness, decreased L[NAME], increased heart rate, dyspnea, cyanosis, etc. and obtain vital signs as needed. If abnormalities are present, they were to be reported to the MD. Review of the (MONTH) 2014 First Aid Treatment policy indicated in addition to providing basic first aid intervention, staff were to contact EMS or advanced medical personnel immediately for altered consciousness, difficulty or absence of breathing, or a condition that was not clear or is worsening. Regardless of the nature or severity, a residents condition was to be reported to the residents physician and family and documented in the medical record. Review of the (MONTH) (YEAR) Abnormal Vital Signs or Acute Change in Resident Condition policy indicated abnormal resdient condition would include decreased L[NAME], change in skin color, and change in behavior. The charge nurse was to assess the resident and refer to the Change in a Resident's Condition or Status policy. Review of the (MONTH) (YEAR), Change in a Resident's Condition or Status policy indicated Staff were to promptly notify the resdient, his MD, and representative of a change in condition. The nurse was to notify the MD when: (1) A significant change in the resident's health had occurred. (2) There was a need to alter the resident's treatment significantly. (3) Staff needed to transfer the resident to a hospital or treatment center. (4) there were changes in a resdient's condition. A significant change of condition was noted as a major decline or improvement in the resident's status that would not normally resolve itself without staff intervention, and impacted more than one area of a resident's health status. It was ultimately based on clinical judgement and standard disease related interventions. Prior to notification, nursing staff were to make detailed observations and gather relevant data for the MD unless instructed by the resident, staff were to notify the residents representative when there was a significant change in the resident's physical, mental or psychosocial status. The nurse was to record in the resident's medical record information relevant to the changes in the resident's condition. The immediate jeopardy that began on [DATE] and identified on [DATE], was removed on [DATE] at 7:15 p.m. when the facility had educated staff on proper assessment of residents with respiratory issues, how to utilize respiratory equipment, had implemented parameters for monitoring oxygen levels, and had revised facility policies and procedures related to respiratory care and significant change in a resident's condition. However, non-compliance remained at the lower scope and severity of (G), actual harm which is isolated that is not Immediate Jeopardy.

Based on interview and document review, the facility failed to ensure staff appropriately monitored, assessed and intervened, for 1 of 2 residents (R25) reviewed for respiratory care, who displayed significantly reduced oxygen saturations with a decline in physical condition requiring emergency care. The facility's lack of assessment, staff education and failure to implement appropriate interventions, resulted in an Immediate Jeopardy (IJ) with the potential for serious harm, injury or death. In addition to R25, 1 other resident (R283) who currently resided in the facility at the time of the revisit survey was identified as at risk due to respiratory issues requiring a [MEDICAL CONDITION] (continuous positive air pressure) equipment to be used to assist with breathing. The Immediate Jeopardy (IJ) began on [DATE], when R25 was sent to the emergency room by ambulance due to respiratory distress, low oxygen saturation, related to potential malfunctioning equipment, lack of nursing assessment and intervention. The administrator and director of nursing (DON) were notified of the IJ situation on [DATE], at 5:10 p.m. The IJ was removed on [DATE], at 7:15 p.m. however, non-compliance remained at the lower scope and severity of (G) isolated with actual harm that is not Immediate Jeopardy. Findings include: Review of R25's medical record indicated he was admitted on [DATE], with [DIAGNOSES REDACTED]. airway pressure machine, a device used to prevent the airways closing during sleep). There was no mention of an assessment involving R25's knowledge or capability of using his [MEDICAL CONDITION]. R25's physician's orders [REDACTED]. Staff were to clean the [MEDICAL CONDITION] mask weekly and check the reservoir tank for the [MEDICAL CONDITION] every HS shift. R25 was ordered to have Oxygen delivered via nasal cannula at 2 liters per minute (LPM) continually every day and night shift. Review of R25's progress notes indicated: (1) [DATE] at 11:07 a.m., a nurse was called to the therapy department after a fall. R25 was sitting on his buttocks on the floor at the time the nurse arrived. R25 denied he had any discomfort or pain. His blood pressure (BP) was ,[DATE], pulse was 84, respiratory rate was 22, and O2 sats were 88% off oxygen. R25 was assisted to his wheelchair by a mechanical lift, and O2 was placed back on. Vital signs were to be monitored for 72 hours along with any changes the resident may have. There was no documentation in the nurses notes to indicate vitals were monitored for 72 hours as indicated to be or therapy staff were interviewed to the cause of the fall, or injuries that may have happened. (2) [DATE] at 3:14 p.m., R25's Medical doctor (MD) called to see how R25 was doing after the fall. The MD asked staff to advise him of R25's condition. Nursing staff told MD R25 was doing ok with no pain or bruising. Nursing staff would continue to monitor and report changes. (3) [DATE] at 11:50 a.m., R25 was having increased shortness of breath (SOB) and was much more lethargic. His O2 sats were between ,[DATE]%. R25 was now using his [MEDICAL CONDITION] between meals while in his room. His color remained pale. There was no documentation or notes related to (r/t) R25's respiratory status or notification to the doctor of his decline in health. (4) [DATE] at 11:48 a.m., R25 continued to be lethargic. His oxygen saturations (O2 sats) were anywhere from ,[DATE]%. Staff were unable to maintain his O2 sat at 90%. R25's MD was called and R25 was sent to the emergency room . (5) [DATE] at 2:26 p.m., R25 returned from the emergency room (ER) with orders to have his [MEDICAL CONDITION] machine checked and to ensure there was good wave form when checking oxygen saturation. R25 was to return to the ER for new or worsening symptoms. (6) [DATE] at 2:40 p.m., a call was placed to R25's family member, informing her of his [MEDICAL CONDITION] machine needing to be checked. (7) [DATE] at 6:11 p.m., R25 was having a hard time staying awake at supper. R25's tablemate was concerned and asked the nurse to check R25. The nurse had to wake R25 up several times over the course of his meal. There is no mention of any vital signs taken to include O2 sats at that time. (8) [DATE] at 10:59 p.m., staff noted R25's machine not working. There was no mention staff checked R25's vitals or completed a thorough assessment of his condition, to ensure he had no signs or symptoms of respiratory distress. (9) [DATE] at 9:50 a.m., R25 needed assistance of 2 with transfers related to health decline. There was no mention of any vitals being taken at that time, nor any further respiratory assessment being completed. (10) [DATE] at 8:24 a.m., the MD was called to notify R25 had coded that a.m. and was being sent to the ER via ambulance. (11) [DATE] at 8:35 a.m., family was notified of R25's ER transfer. (12) [DATE] at 9:54 a.m., the ambulance service called to inform R25 was being airlifted to another larger hospital in Rochester, MN. (13) [DATE], at 10:11 a.m., nursing staff entered documentation surrounding the events from earlier that a.m The documentation indicated that when the licensed practical nurse (LPN)-A was entering the room that morning, she found R25 in bed without O2 or his [MEDICAL CONDITION] on. When she asked R25 why he did not have his O2 and [MEDICAL CONDITION] on he mumbled incoherently. LPN-A placed his O2 on at 2 LPM and elevated his head to 30 degrees. LPN-A checked his O2 sat and found it to be 60%, which was significantly below R25's expected 90%. Earlier that a.m., nursing assistant (NA)-A assisted R25 to his wheelchair (W/C) with the mechanical stand lift. NA-A stated R25 was able to assist and was speaking to her. NA-A then noticed R25 had stopped speaking and his head fell back. NA-A called for help. R25 became cyanotic (blue color of skin caused by lack of oxygen). Chest compressions were started while the resident was in his W/C and staff called 911. An automated external defibrillator (AED) was applied, but no shock was advised. Compressions continued. A femoral pulse was noted as present. The ambulance (EMS) and sheriff's department arrived. An ambu bag was used to assist with breathing and R25's O2 was at 85%. R25 was able to move all extremities. EMS transported R25 to the ER in Fairmont. Fairmont ER called and stated R25 was being transferred to a hospital in Rochester via helicopter. (14) [DATE] at 4:04 p.m., nursing staff called for an update from the hospital on R25's condition. R25 was intubated (tube into the lungs to assist with breathing). Hospital staff were continuing medical exams and were going to check a head computerized tomography (CT) and an ultrasound. R25's O2 sats were 90%. Family was present. (15) [DATE] at 10:35 a.m., R25's family member called. R25 was now off sedation with hopes of removing his breathing tube. The family member asked if R25 had fallen during his respiratory arrest, as the CT showed a brain bleed, she was told was consistent with a fall. Nursing advised R25 had not fallen during the event, nor was he on the floor at that time. If R25 had fallen prior to the [DATE] event, he would not be able to get himself back up. R25 was unresponsive with some eye movement. The family member was quoted as saying Things do not look that good. (16) [DATE] at 2:00 p.m., R25 was off the ventilator and would now be entering hospice end-of-life care. During interview with LPN-A on [DATE] at 12:30 p.m., LPN-A stated she had started her shift the morning of [DATE] at 6:00 a.m Sometime shortly after receiving report, LPN-A went to R25's room (at approximately 7:00 a.m.). LPN-A found R25 without his O2 or [MEDICAL CONDITION] on. R25's sats were at 60% (normal oxygen saturations typically are 90% or above, 60% would indicate severe hypoxemia). R25 was mumbling incoherently at the time. After applying oxygen to R25, LPN-A left the room and did not return. LPN-A stated she thought since R25's O2 saturations were starting to climb back up into the middle 60's he was ok to be left alone. LPN-A verified she had not performed a respiratory assessment or checked vitals at that time. LPN-A stated because she was sure R25's O2 sats would come up, she did not return to R25's room until notified of his [MEDICAL CONDITION] later that morning at approximately 8:00 a.m. LPN-A said she did not call R25's physician, or procure emergency services at that time despite the critically low oxygen saturation value and change in R25's mentation. LPN- A stated if a resident's O2 sats were low, she should recheck in 1 hr. LPN-A was unaware what O2 sats level were considered critical. LPN-A stated R25's normal sats were in the low 90's. LPN-A was unaware when to assess or reassess a resident for safety in critical situations, or when to call emergency medical services (EMS) when a resident had critically low oxygen sats and/or level of conscious changes. LPN-A stated staff check R25's oxygen at night prior to going to bed, but acknowledged she was unaware of any other routine checks. LPN-A also said she felt it was useless to send R25 to the ER (on [DATE]) as they would just say he was fine after he arrived like they had done previously on [DATE]. During further interview on [DATE] at 12:30 p.m., LPN-A stated on [DATE], R25 was sent to the ER because of low O2 sats and they (the ER) did nothing. ER staff reportedly asked her what they were to do about his low O2, as by the time R25 arrived on [DATE], his oxygen was in the high 80's. LPN-A again explained the resident's tablemate had called her over to see what was the matter with R25. LPN-A said she'd asked R25 how he was doing but added, He kept falling asleep .He complained something was wrong, and continued to keep falling asleep. LPN-A said she'd called the MD and obtained orders to send R25 to the ER and sent R25's [MEDICAL CONDITION] machine along with R25. LPN-A said, Staff thought it was malfunctioning R/T (related to) R25's low oxygen levels. R25 was known to have mumbled speech when his oxygen got low. LPN-A stated she was unsure whether R25's machine was or was not functioning, and said, I don't know how to run them. LPN-A said the ER had reported the facility needed to get it checked so she called the family member and told her to come get the [MEDICAL CONDITION] machine, and instructed the family member to take it to the supplier. LPN-A said since it was not the facility's equipment, it was the family's responsibility to get the equipment checked for working order. During the same interview, LPN-A stated she felt R25 was able to properly apply the mask and use the machine on his own. She said she thought he did so because he was known to independently remove his mask during the night. She was unsure exactly how to place the mask or operate the [MEDICAL CONDITION] machine herself. LPN-A said she had looked at the instructions for the [MEDICAL CONDITION] at the time staff thought it was malfunctioning on [DATE], and had not understood what to do. LPN-A stated R25's [MEDICAL CONDITION] was still at the facility. Review of the record revealed there was no assessment performed on R25 to ensure he knew how to operate the [MEDICAL CONDITION], nor was he capable to do so. LPN-A stated staff had no professional references or policies to follow for abnormal vital signs or critical events. She said the DON and administrator are notified by nursing staff of every hospital transfer. During interview on [DATE] at 12:45 p.m., LPN-A was observed in R25's room. R25 stated the breathing machine was not identified directly as either a [MEDICAL CONDITION], but had a sticker on the machine stating to call with questions. LPN-A said she had never called the number on the machine for concerns related to potential malfunctioning of the equipment. LPN-A said since the equipment had not been supplied by the facility, but rather by a government agency, she (LPN-A) had called R25's family to come get the machine and have it fixed. LPN-A was unable to state how staff ensured R25 was safe with a malfunctioning machine. LPN-A confirmed staff had not had education on the use or maintenance of R25's [MEDICAL CONDITION] machine. Further, LPN-A identified one other resident, R283, as a current resident who also utilized a [MEDICAL CONDITION] even though staff were unaware how to ensure [MEDICAL CONDITION] equipment was placed or working properly. Nursing assistant (NA)-A was interviewed on [DATE] at 1:05 p.m. NA-A stated she'd been told by LPN-A, immediately after report on [DATE], between approximately 6:15 and 6:30 a.m. not to get R25 up for the day because his oxygen was low. NA-A stated she'd gone into R25's room to get him up at approximately 7:45 a.m. without receiving notification it was ok to do so by LPN-A. NA-A said R25 had been mumbling but was awake, so NA-A thought it was ok to take R25 over to the main bathing room to shower. NA-A explained she had used the mechanical lift on R25 to transfer him out of bed and into his wheelchair. She then proceeded to wheel him across the hall into the bathing room. NA-A said she began readying R25's shower when she noticed he was not speaking anymore. NA-A said she'd looked over at R25, and noticed his eyes were rolled back into his head with his head hung back, and he was gray in color. NA-A said she then called for help and when the nurse arrived she began cardio [MEDICAL CONDITION] resuscitation (CPR). Review of R25's (MONTH) (YEAR) Documentation Survey report indicated Vitals (Blood pressure, temperature, pulse, respirations and pain) from (MONTH) 21-[DATE]th, (YEAR), showed on: (1) [DATE], during the hours of 2:00 p.m. to 10 p.m., all vitals were marked N/A (not applicable). (2) [DATE], during the time of 6:00 a.m. to 2:00 p.m., there is 1 notation of his respiratory rate being assessed. The score was 22 breaths per minute (BPM) (normal ,[DATE] PM), meaning R25 experienced shortness of breath. (3) [DATE], during the hours of 2:00 p.m. to 10 p.m., all vitals except pain were marked NA. Pain was assessed as N meaning R25 had no pain. (4) [DATE], [DATE], and [DATE]. during the hours of 10:00 p.m. to 6:00 a.m. all vitals except pain were marked NA. R25's pain was assessed on those 3 days. There is no mention of R25's oxygen saturation having been checked by staff during the month of (MONTH) on the report. R25's [DATE] care plan revealed he had an advanced directive for Full Code. R25 had a Physician order [REDACTED]. R25 had a self-care deficit related to (R/T) his [MEDICAL CONDITION] and required extensive assist with activities of daily living (ADL). Staff were to monitor for signs of difficulty breathing. R25 was able to self-administer nebulizer medication treatments after setup by staff. R25 was at risk for neglect from others related to his nursing home placement. Staff were to identify R25's vulnerability and risk through assessment. R25 was noted use a Bi-PAP (Bi-level Positive Airway Pressure) machine HS with supplemental oxygen R/T CRF and [MEDICAL CONDITION], however, R25's current treatment sheets indicated he used a [MEDICAL CONDITION]. R25's goal was to have no signs or symptoms (SX) of poor oxygen absorption. There was no mention of how or how often staff were to monitor or assess R25 to ensure he had no complications from his [MEDICAL CONDITION] or history of CRF. Review of R25's [DATE], Minimum Data Set (MDS) indicated he had a Brief Interview for Mental Status score of 14, indicating normal cognition. R25 required extensive assist with bed mobility, transfer, dressing, and personal hygiene requiring the assistance of 1 staff. R25 weighed 380 lbs. R25 was documented as receiving oxygen but was not noted to be on a [MEDICAL CONDITION] or Bi-PAP while a resident. Review of R25's Care Area Assessments (CAA) completed on [DATE], completed by the MDS coordinator indicated he had sever [MEDICAL CONDITION] disease, but no shortness of breath. R25 had poor memory and anxiety with an inability to perform ADLs without significant physical assistance by staff. R25 's cognitive deficits included stamina, ability to express himself, and make decisions with altered mental status. R25 had a change in communication, vision, hearing, and cognition. R25's goals indicated he was to maintain his current level of functioning and physical limitations such as weakness. There was no mention of his limited visual ability from his [DIAGNOSES REDACTED]. Review of R25's [DATE] Medication Administration Record [REDACTED]. There was no mention of when staff were to check R25's oxygen levels to ensure he had no adverse effects from his [MEDICAL CONDITION] and history of CRF. Review of R25's [DATE] emergency room documentation indicated his discharge [DIAGNOSES REDACTED]. Patient instructions listed were: (1) Continue current medications. (2) Have your [MEDICAL CONDITION] machine checked. (3) Make sure there is a good waveform when checking oxygen saturation. (4) Follow-up in clinic within one week. (5) Return to the ER for new or worsening symptoms. Review of R25's [DATE] at 9:38 a.m., emergency room documentation indicated he was an inpatient at that time admitted for [MEDICAL CONDITIONS] (high potassium) [MEDICAL CONDITION], pacemaker, [MEDICAL CONDITION] (CAD), [MEDICAL CONDITION] exacerbation, heart failure, and diabetes. He was sedated and a mechanical ventilator to breathe for the resident was placed. MD progress notes revealed he was a [AGE] year-old male, admitted directly from the triaging hospital. R25 was reported to be suffering from worsening respiratory symptoms. He was reported found that day at the nursing home cyanotic and unresponsive. No pulse was detected and CPR was started. Upon arrival of EMS, the resident was thought to have spontaneous breathing. He was hypertensive (elevated blood pressure) and tachypneic (abnormal rapid breathing) on route to the ER. He was poorly responsive upon arrival to the ER, and would appear to open his eyes when his name was called. Due to the tachypnea and wheezing, R25 was immediately intubated. R25 did have a urinary tract infection prior to that day and was being treated by antibiotics previously. The assessment/plan indicated he had suffered cardiopulmonary arrest requiring mechanical ventilation R/T [MEDICAL CONDITION] and suspected [MEDICAL CONDITION] exacerbation. Further review of R25's [DATE] at 11:08 a.m., ER documentation history and physical revealed R25 had suffered an unwitnessed arrest that a.m., and was successfully resuscitated at the nursing home. Staff were trying to deduce the origin of the arrest, but it was likely primarily respiratory, given his recent history and mounting respiratory complaints. Other considerations could be a massive stroke, which was not suggested by clinical exam. R25 was being paced with an underlying rhythm of [MEDICAL CONDITION]. Staff were treating for [MEDICAL CONDITION] exacerbation and covering broadly with antibiotic (R/T his known bladder infection). Staff plan on providing lung protective mechanical ventilation, assessing his mental status by minimizing sedation required for ventilation, and a head CT as the resident was found down. Review R25's [DATE] 1:44 p.m. emergency room documentation revealed R25 was diagnosed with [REDACTED]. For the past several weeks, R25 was noted to be suffering from worsening respiratory symptoms, though the hospital was unaware of documentation from those visits. Previously that a.m., R25 was found unresponsive and cyanotic. No pulse was detected and CPR was initiated. Upon arrival by EMS, it appeared R25 was spontaneously breathing, but the receiving hospital had no information on R25's heart rhythm. Nursing home staff administered basic Life support at that time. It is the hospital's understanding R25 was hypertensive and tachypneic on route to the ER. Upon arrival to the ER, R25 was poorly responsive but had appeared to open his eyes when his name was called. His rapid breathing and wheezing required intubation and mechanical ventilation. Reason for visit was listed as respiratory arrest. The assessment and plan problems for admission list cardiopulmonary arrest and suspected [MEDICAL CONDITION] exacerbation, heart failure, and obstructive sleep apnea on [MEDICAL CONDITION]. Interview on [DATE] at 3:06 p.m., with the administrator regarding the above incident and care for R25 received from [DATE] to [DATE] indicated she was unaware if nurses were trained on the use of [MEDICAL CONDITION] equipment. LPN-A had made them aware of the investigation into the events surrounding R25's respiratory arrest recently, and the director of nursing (DON) was checking into available education on the [MEDICAL CONDITION] machines. The administrator had started her role at the facility 2 weeks prior and was unable to determine if staff were trained on abnormal vital signs, use of [MEDICAL CONDITION] machines, and appropriate assessment. At approximately 3:45 p.m., the director of nursing notified surveyors she was leaving for the day and would be unavailable for interview. Interview on [DATE] at 5:02 p.m. with the director of operations (DOO) and the administrator of the immediate jeopardy; it was their expectation nursing should not have left R25 alone with the above-mentioned symptoms on [DATE]. Furthermore, they agreed staff had not been trained on the use of the [MEDICAL CONDITION] machine. They were unaware the (MONTH) (YEAR) facility assessment, completed after R25 was admitted , made no mention of residents who required [MEDICAL CONDITION] or Bi-PAP's for breathing. They were also unaware the facility had no professional standards guide or policies for assessment of residents with critically low O2 sats. They were unaware R283 had no mention of his [MEDICAL CONDITION] machine, or [MEDICAL CONDITION] interventions in his physician's orders [REDACTED]. Interview on [DATE] at 9:40 a.m. with the medical director indicated he was unaware of the events surrounding the immediate jeopardy called on [DATE]. He was at the facility, seeing patients. His expectations were staff are to notify him immediately or serious or sentinel events, deaths, and hospice and comfort care concerns. Staff need to improve on their monitoring of significant changes. A resident in respiratory distress, oxygen saturations that are severely below their norm, and level of consciousness (L[NAME]) changes would warrant immediate notification to the provider and/or EMS. Staff should have stayed with R25 and appropriately assessed and intervened. The medical director thought staff were trained on use of [MEDICAL CONDITION], however, was unfamiliar with any training the facility provides to its staff. Interview on [DATE] at 10:15 a.m. with the DON revealed when discussing the events regarding R25, she indicated staff should have stayed with the resident, performed a complete assessment, and intervened to prevent the potential respiratory arrest that followed later that day. She agreed staff should have notified EMS and the provider of R25's decline in health that day. Staff should have called the number located on a sticker on R25's machine when they thought it was potentially malfunctioning. Interview on [DATE] at 10:50 a.m.with the DOO indicated it was her expectation staff should have stayed with R25, performed a complete assessment and contacted the MD and/or EMS at that time it was discovered R25 had critically low oxygen and L[NAME] changes. She agreed staff had not been appropriately trained on [MEDICAL CONDITION] usage prior to the admission of R25 and R283. Review of R283's medical record indicated he was admitted to the facility o [DATE] with [DIAGNOSES REDACTED]. R283 had no assessment performed related to his [MEDICAL CONDITION] machine to determine if he was capable of knowing if the machine would be working or malfunctioning, since staff had no knowledge and looked to the resident to be in charge of the device. R283's [DATE], MDS assessment indicated a cognitive score of 8, showing he had moderate cognitive impairment. Review of R283's physician's orders [REDACTED]. Review of R283's current care plan indicated he had an ADL self-care deficit r/t impaired cognition with short-term memory loss. He was known to be resistive to cares. R283 had problems with sleep disturbance and complaints of feeling tired, dozing during activities, and statements regarding inability to sleep. R283 used oxygen therapy with his Trilogy ([MEDICAL CONDITION]) brand machine whenever lying down R/T [DIAGNOSES REDACTED]. Staff were to monitor for signs and symptoms of respiratory distress and report the MD as needed. R283 was to be on 2 LPM of oxygen while connected to his [MEDICAL CONDITION] mask. Review of R283's current Treatment Administration Record indicated no mention of how often staff should check R283's vital signs, including pulse oximetry. There was also no mention of staff applying the [MEDICAL CONDITION] mask for R283, who had known cognition issues and was resistive to cares. Review of R283's (MONTH) (YEAR), Documentation Survey Report indicated his O2 sat was only recorded once on [DATE]. All other dates noted: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] were marked N/A for all vitals except pain. Review of R283's [DATE], Medication Self Administration Safety Screen revealed he was deemed competent to self-administer medications and use the Trilogy C-Pap machine, although there is no mention he could identify if there were a malfunction. R283 was deemed competent based on his ability to put on and take off his mask while in bed. There was no factors/situations noted of what staff were to do to ensure R283's mask had not come off in the night, his O2 sat levels remained at acceptable parameters, or how staff were to ensure he would not become hypoxic if the mask were off, or the machine malfunctioned. Review of R283's [DATE], CAA indicated he had behavior symptoms identified with respiratory disease, [MEDICAL CONDITION], and a history [MEDICAL CONDITION]. R283's cognitive abilities were impaired by disruptive behaviors, poor memory, and resisting care. R283 triggered for difficulty with ADL's due to physical limitations and depression and had the inability to perform ADLs without significant physical assistance. R283 was identified with risk for falls related to agitation behavior and cognitive impairment. Review of the (MONTH) (YEAR), Admissions Criteria policy indicated the facility was to admit residents who can be cared for adequately by the facility. Residents including those with [MEDICAL CONDITION] would be admitted as long as their nursing and medical needs can be met adequately. Review of the (MONTH) (YEAR) Oxygen Therapy Delivered via C-PAP Machine Procedure policy revealed residents would be accepted into the facility who were dependent upon [MEDICAL CONDITION] machines for oxygen delivery. It was the nursing care team member's responsibility to assess the resident for signs and symptoms of [MEDICAL CONDITION], such as restlessness, decreased L[NAME], increased heart rate, dyspnea, cyanosis, etc. and obtain vital signs as needed. If abnormalities are present, they were to be reported to the MD. Review of the (MONTH) 2014 First Aid Treatment policy indicated in addition to providing basic first aid intervention, staff were to contact EMS or advanced medical personnel immediately for altered consciousness, difficulty or absence of breathing, or a condition that was not clear or is worsening. Regardless of the nature or severity, a residents condition was to be reported to the residents physician and family and documented in the medical record. Review of the (MONTH) (YEAR) Abnormal Vital Signs or Acute Change in Resident Condition policy indicated abnormal resdient condition would include decreased L[NAME], change in skin color, and change in behavior. The charge nurse was to assess the resident and refer to the Change in a Resident's Condition or Status policy. Review of the (MONTH) (YEAR), Change in a Resident's Condition or Status policy indicated Staff were to promptly notify the resdient, his MD, and representative of a change in condition. The nurse was to notify the MD when: (1) A significant change in the resident's health had occurred. (2) There was a need to alter the resident's treatment significantly. (3) Staff needed to transfer the resident to a hospital or treatment center. (4) there were changes in a resdient's condition. A significant change of condition was noted as a major decline or improvement in the resident's status that would not normally resolve itself without staff intervention, and impacted more than one area of a resident's health status. It was ultimately based on clinical judgement and standard disease related interventions. Prior to notification, nursing staff were to make detailed observations and gather relevant data for the MD unless instructed by the resident, staff were to notify the residents representative when there was a significant change in the resident's physical, mental or psychosocial status. The nurse was to record in the resident's medical record information relevant to the changes in the resident's condition. The immediate jeopardy that began on [DATE] and identified on [DATE], was removed on [DATE] at 7:15 p.m. when the facility had educated staff on proper assessment of residents with respiratory issues, how to utilize respiratory equipment, had implemented parameters for monitoring oxygen levels, and had revised facility policies and procedures related to respiratory care and significant change in a resident's condition. However, non-compliance remained at the lower scope and severity of (G), actual harm which is isolated that is not Immediate Jeopardy.

Based on observation, interview and document review, the facility failed to provide adequate supervision to prevent elopement for 3 of 9 residents (R66, R24 & R39) that were identified for risk of elopement. R66, R24 and R39 had elopement from the facility and this constituted an immediate jeopardy situation. In addition, the facility failed to ensure that interventions for fall preventions were implemented for 1 of 6 residents (R61) reviewed for accidents. Findings include: R66, who was admitted with a known history of wandering, left the facility without staff knowledge and was observed walking by the road near the facility by kitchen staff on 7/27/12, at 4:00 p.m. R66 was admitted to the facility on [DATE], from an acute care hospital with [DIAGNOSES REDACTED]. An admission minimum data set (MDS) was completed on 8/1/12, and R66 was identified as severely cognitively impaired with periods of being inattentive and having disorganized thinking. The documentation identified R66 was at risk for wandering and of getting to dangerous places. He was independent with bed mobility, transferring from bed to chair, locomotion on and off the units using a walker/wheelchair. The admission care area assessments (CAAs) that were to be completed as part of the MDS had not been completed. On 8/17/12, at 11:15 a.m. the director of nurses (DON) verified this. The CAA's potentially would address cognitive loss/dementia, communication, psychosocial well-being, mood state, behavioral symptoms, falls, activities, and psychotropic drug use, all which could impact R66's wandering and elopement risk. An elopement risk assessment was completed by the social worker (SW) on 7/30/12, five days after his admission and three days after the incident on 7/27/12 where R66 eloped from the facility. The assessment noted R66 was ambulatory or self-mobile in his wheelchair. It also noted that R66 had poor decision making skills, made decisions that could jeopardize his personal safety, was a new admission, had made statements of wanting to leave, was non-compliant with facility policy regarding leaving the facility, and had a history of [REDACTED]. The assessment reported R66 had made statements of wanting to leave and "need to get out to the farm". According to the elopement risk assessment, this information was forwarded to the DON, who documented on 8/1/12, that R66's care plan needed to updated regarding elopement risk, staff were to be educated on elopement risk, charge nurse was to notify the physician of the elopement risk and all interventions were to be re-evaluated quarterly and with any new behavior related to exit seeking activity. The DON documented R66's physician had been asked for documentation as to why a secured unit placement was not appropriate. In addition, she documented "Code alert placed on right ankle" and to continue to remind resident to not go outside by himself. The fax sent to the resident's physician on 8/1/12, was noted to be a routine fax and reported to the physician that, "Resident flags as an elopement risk Need documentation as to why secured unit placement is not appropriate. Resident does have code alert placed on R (right) ankle." A nurse practitioner replied on 8/3/12; "Secured unit not necessary at this time, resident no risk to self or others. Code Alert bracelet to ankle." The plan of care, which was dated 2009, prior to the resident's admission, addressed elopement risk and identified that resident was at risk for wandering/elopement and staff were directed to check the code alert on resident's right ankle daily to ensure that it was intact and working. According to licensed practical nurse (LPN)-B, during an interview on 8/15/12, at 5:05 p.m., documentation of the code alert being intact and functioning was to be made on the Medication Administration Record (MAR). A review of August, 2012 MAR revealed no documentation that any staff had checked placement or functionality of the wander guard from 8/1/12 to 8/15/12. The DON, who verified the lack of documentation of placement and functionality, instructed LPN-B to immediately add it to the MAR. An undated Resident Care Sheet, which was used by nursing assistants as an aid to guide personal cares for residents, indicated that resident had a code alert and was an elopement risk. The admission and discharge summaries from the hospital were reviewed. The resident was referred to a higher acuity hospital from the local acute care hospital on [DATE]. He had initially been admitted to the local hospital on [DATE]. It was reported that on 7/10/12, while he was living in an assisted living facility, R66 had walked approximately 4 miles and was found in the middle of a street after suffering from a fall. He was returned to the assisted living facility and was at his baseline cognitive function. The next day, he was difficult to arouse and quite confused with significant nausea and vomiting. He was taken to the local emergency room and thought to be dehydrated and to be suffering from gastroenteritis. He also had evidence of a urinary tract infection. He was transferred to a higher acuity hospital on [DATE], due to family concern of continued decline in cognitive baseline. The resident's family informed physicians at the hospital that until recently R66 was very active and would walk up to eight miles a day from the assisted living facility to his old farm. The discharge summary from hospital neurology service, reported that R66 had recent cognitive decline and possible worsening of an underlying dementia. The decline was likely multifactorial but could be attributed to his medications and recent illness. The discharge summary recommended R66 be served at a facility that could provide close monitoring and supervision to prevent R66 from walking away from the center. According to the incident report of 7/27/12, at 4:00 p.m., R66 was observed walking by a road near the facility by a kitchen staff member. He was returned to the facility safely with no injury. The incident was not witnessed. R66 told facility staff "he wanted to go outside". The immediate intervention implemented included to: "educated res (resident) on not leaving building unattended". An analysis of the incident indicated R66 was at the assisted living prior to his admission to the facility and was "used to being able to come and go". The summary noted he had been walking outside independently and had freedom prior to his admission to the facility. The plan was to continue the code alert (wander guard) until the resident was more settled into the facility. An interview with the DON was completed on 8/15/12, at 1:33 p.m. The DON reported the R66 was referred to the facility by his physician and family as they felt it was no longer safe for the resident to be in the assisted living environment as he wandered through out the town and walked to his home farm. She reported while at the assisted living unit, R66 knew the key pad exit code and could let himself and others out the door. The DON indicated the facility was aware upon admission of the potential for the resident to elope. She reported that she was under the impression that a code alert (wander guard) had been placed on resident at the time of his admission but was unable to find documentation of this or when the code alert was actually placed on the resident. She verified that no staff person saw resident leave the building on 7/27/12, and no alarm sounded, even though he did have a wander guard on his ankle during the incident. She reported that upon his return to the facility, they tested his wander guard twice, determined that it was functional and kept the same wander guard on the resident. She reported that even though the resident was not observed exiting the building, they assumed that he had left through the front door of the facility. The DON verified on the day of the incident, the staff did not adequately supervise the resident. She did acknowledge that one nursing assistant was assigned to provide all personal cares for 12 residents on the resident's wing, which would be a tough job to do and may have prevented staff from adequately supervising the resident. An interview with the maintenance supervisor (MS) was completed on 8/15/12, at 6:05 p.m., who reported he was to ensure the wander guard system worked properly. When questioned, he reported being unaware of R66's wander guard not working during the incident of 7/27/12. MS also reported that had known R66 for many years prior to his admission to the facility. MS indicated R66 had cognitively declined but remained very fast, moving quickly from one area of the facility to another. An interview with nursing assistant (NA)-B was completed on 8/15/12, at 6:25 p.m., who reported working with resident and was aware of the resident's elopement risk. She reported having intervened several times to resident's efforts to exit the building through the main door since the incident on 7/27/12. She reported that when she saw the resident heading toward the front door, she would intervene and redirect the resident. A review of the staffing schedule on 7/27/12, revealed three nursing assistants worked from 2:30 p.m. to 11:00 p.m. and they would need to provide all personal cares to all of the residents on all four wings of the facility. An interview with the Human Resources officer (HR) of the facility on 8/15/12, at 11:05 a.m. was completed. She reported she does the scheduling for the facility and she was to ensure that a minimum of four nursing assistants worked the evening shift (2:30 p.m. to 11:00 p.m.) with the expectation that each wing has one nursing assistant assigned. A phone interview with HR was completed on 8/22/12, at 1:19 p.m. HR verified that on the evening shift on 7/27/12, only three nursing assistants were working. On 8/15/12, at 3:26 p.m., the internal door and exit door between "A" wing and the Rehabilitation Department were found standing open, unattended by any staff. No staff were in the Rehabilitation Department. "A" wing was searched and no staffs were found. Two of the three residents (R34 and R39), who had eloped resided on the "A" wing and would have direct access to leaving the facility without staff witnessing them. Licensed practical nurse (LPN)-A was found at the nursing station. She reported that these doors should never be left open and unattended. She did ask two facility staff if they knew who or why the doors were left open and neither did. The DON was interviewed at on 8/15/12, at 4:32 p.m. and acknowledged being aware that these doors were open and unattended but had not completed an investigation as to how this happened. R24, who had been identified at risk for wandering/elopement was found by staff outside the facility on 5/1/12, at 8:15 p.m. R24 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. An annual MDS was completed on 8/24/11, and identified R24 had both long and short term memory problems and was moderately cognitively impaired. The MDS indicated she was totally dependent on one staff for bed mobility and needed extensive assistance of one staff for all transfers and locomotion off the unit. R24 was independent with propelling herself in her wheelchair on the unit and eating. A quarterly MDS completed on 5/12/12, and the resident's cognition was unchanged. She did have a decline in the level of her physical status in that she needed extensive assistance of one staff for bed mobility, transfer, and locomotion on and off the unit. According to the quarterly MDS, the resident did not wander, even though she had been found outside of the facility on 5/1/12. The care area assessment (CAA) completed on 8/24/11, identified R24 as having senile dementia, Parkinson's disease, diabetes, thyroid disorder, depression and constipation, all of which could impact the resident's cognition. She also had long/ short term memory impairment and had an impairment of daily decision making. The cognitive decline had occurred slowly over time and the staff felt this was due to her dementia, The CAA indicated she was difficult to understand and had difficulty understanding others. In addition, the CAA reported R24 wandered down the hallways, looking for her room and would occasionally go towards an open door but was easily redirected. A Wander/Elopement Assessment was completed 8/12/09, and it was determined the resident was not at risk for elopement even though it reported the resident had attempted to elope from her previous living environment and wandered through out the facility. The assessment also noted other risk factors for elopement were dementia, moderately impaired decision making and long/short term memory loss. The care plan, noted R24 had decreased physical mobility with the potential for falls and was unable to ambulate, transfer, wheel self, turn and reposition self. It also noted that she did not walk and the established goal was for the resident to continue to propel herself for short distances in her wheelchair. One of the approaches was a code alert when in her wheelchair as she would take herself outside without telling staff and was unaware of her safety needs. Observations were made of R24 using her feet to self propel in her wheelchair on 8/15/12, at 4:07 p.m. and 8/16/12, at 9:15 a.m. An observation was also made on 8/14/12, at 11:47 a.m., when R24 attempted to get out of her recliner independently and was able to push the raised foot rest with her feet and legs. According to an incident report on 5/1/12, at 8:15 p.m., R24 was found sitting outside the facility. She had not been observed to exit the building. The immediate intervention implemented was "close inside door on PMs and NOC (night)" The analysis of the incident reported "Dementia, wanders frequently, cont (continue) with code alert". An interview with the DON was completed on 8/15/12, at 1:33 p.m. regarding the incident on 5/1/12. The DON reported R24 was found outside the building and verified staff had not been aware of the resident leaving the building. She was found by the exit door close to the rehabilitation department, which was not staffed at the time of the incident. She did have the code alert in place but the DON did not know if the code alert sounded when the resident left the building. The DON reported as a result of the incident, staff were instructed to lock the door but was unsure if this plan was every activated. The DON verified that staff had not provided adequate supervision for this resident related to this incident. R39, who had been identified at risk for elopement, was found outside the facility by staff on 7/26/12, at 3:30 p.m. R39 was admitted on [DATE], and had [DIAGNOSES REDACTED]. An admission minimum data set (MDS), completed 4/10/12, noted R39 was considered to be cognitive intact with no signs or symptoms of delirium, psychosis or any behavioral concerns. The MDS noted the resident had no wandering behaviors. R39 needed extensive assistance of one staff person for bed mobility, and transfers. She was totally dependent on one staff for locomotion in her wheelchair, both on and off the unit. The quarterly MDS completed on 7/10/12, indicated R39 had declined to moderate cognitive impairment and had no incidents of wandering. She was independent with locomotion on and off the unit, using a walker or wheelchair. She needed limited assistance of one staff for dressing and personal hygiene, but continued to need extensive assistance of one staff for bed mobility, transfers and toilet use. The care area assessment (CAA) completed on 4/13/12, noted R39 was at risk for falls as she had fallen and fractured her right prior to her admission to the facility. Her function status for activities of daily living was impaired as she could lift her arms but staff needed to lift her feet and legs for mobility primarily on her right side. Her cognition was not assessed. An elopement risk assessment was completed on 4/8/12, and identified resident's cognitive impairment as a risk area but R39 was not considered an elopement risk. Her plan of care, initiated on 3/28/12, (prior to her admission), identified that although resident was alert, had intermittent episodes of confusion and tended to repeat herself. The problems area also noted R39 was moderately impaired with cognition. (The MDS, completed 7 days after her admission to the facility, reported the resident to be cognitively intact) The goal was for the resident to remain alert and staffs were directed to explain all procedures, allow resident time to comprehend and document periods of confusion or changes in cognition. Elopement risk was not identified as a problem or any interventions implemented to address. According to the incident report on 7/26/12, at 3:30 p.m., R39 was seen on the sidewalk in her wheelchair with "uncertainty of where to go." She was found by a housekeeping staff person. Her exit was the facility was not witnessed. The resident reported, "I was looking for my place." The incident report noted that R39's wander guard was intact and secured to her wheelchair and resident was redirected to her room with a nursing assistant. The interventions implemented to prevent further incidents were "wander guard and assist res (resident) with destinations." The analysis of the incident reported R39 had a history of [REDACTED]. An interview with the DON was completed on 8/15/12, at 1:33 p.m. regarding the incident on 7/26/12. The DON reported R24 was found outside the building and verified staff had not been aware of the resident leaving the building. She did have wander guard in place but the DON did not know if the wander guard sounded when the resident left the building. The DON was also unable to identify when or why the wander guard had been placed on resident. The DON verified that staff had not provided adequate supervision for this resident related to this incident. A review of the staffing schedule on 7/26/12, noted three nursing assistants worked from 2:30 p.m. to 11:00 p.m. and they would need to provide all personal cares to all of the residents on all four wings of the facility. An interview with the Human Resources officer of the facility on 8/15/12, at 11:05 a.m. was completed. She reported she does the scheduling for the facility and she is to ensure that a minimum of four nursing assistants worked the evening (2:30 p.m. to 11:00 p.m.) with the expectation that each wing has one nursing assistant assigned. A phone interview with HR was completed on 8/22/12, at 1:19 p.m. HR verified that on the evening shift on 7/26/12, only three nursing assistants were working. The facility's elopement policy was requested and received. The policy Admission Elopement Assessment, copyrighted 2008, defined elopement as leaving the facility premises without following the facility's policies and procedures for leave of absence. The policy directed staff to obtain a history of diagnosis, behaviors, and wandering activity from resident, significant others, medical records and social services. A medication review was to be done by the physician to identify medication that may impact the resident's cognitive level and safety awareness. Staff were to obtain an assessment of the resident's overall mobility status, use of assistive devices were to be performed by physical therapy. Each resident was to receive a code alert, if appropriate, if determined by the nursing assessment and the status was to be checked daily. Direct care staff were to be informed of resident's risk and appropriate interventions to address the risk for elopement and if a resident was actively exhibiting exit seeking behaviors, there were to be visually monitored by staff at all times to ensure safety. On 8/15/12, at 8:30 p.m., the Administer and the Director of Nurses were notified of an immediate jeopardy situation due to the lack of supervision and elopements of R66, R24 and R39. The immediate jeopardy that began on 8/15/12, was removed on 8/17/12, when the facility took steps to review safety of the residents that were identified in the immediate jeopardy and assessed other residents that were identified as risk for elopement. The facility took step to ensure the door with the code alert system would be programmed to automatically stop the door from opening when a resident with a code alert activates the alarm. While waiting for the door to be re-programmed, R66, R24, R39 were placed on 15 minute checks and other residents identified as an elopement risk were placed on 30 minute checks. Education was provided to staff that included the procedure for the 15 or 30 minute checks and the revised elopement policy and procedure. The assessments and care plans for R66, R24 and R39 were reviewed and updated. The immediate jeopardy was removed on 8/17/12, at 1:00 p.m. but noncompliance remained at the lower scope and severity level of a pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility did not implement a chair tab alarm R61. Findings include: R61 had [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE], indicated R61 was moderately cognitively impaired, required extensive assistance from one staff member for transfers, used a wheelchair for mobility, had two or more falls since admission with no injury and one fall which resulted in injury. An incident report dated 3/27/12, at 4:00 p.m., revealed R61 was found on the floor by wheelchair. Resident says he slid to the floor, lying on back. The report indicated a fax was sent to the doctor for a chair alarm and a bed alarm as interventions implemented to prevent further incidents. An incident report dated 3/27/12, at 7:00 p.m., indicated R61 was found on the floor by the bed. Resident said he rolled out of the bed. The interventions listed to prevent further incidents included floor mats re-education on call light, trapeze over bed and faxed for alarm etc. order. An interdisciplinary note dated 3/29/12, at 2:41 a.m., indicated resident was found sitting on floor in room next to bed. Resident had some bleeding from his stitches on amputation. Reminded to use call light, will continue to monitor. No incident report was provided for this fall. An interdisciplinary note dated 3/29/12, at 3:00 a.m., as a late entry stated, "Faxed (doctor's name) to request order for placement of bed and chair alarms and black floor mat due to multiple falls. Received order from (doctor's name) Order: alarms and black mat OK." A resident incident report dated 7/25/12, at 1:15 p.m., indicated resident was back in room after dinner, did not wait for help and tried transferring himself to the recliner, slid to the floor. The report listed interventions implemented to prevent further incidents included, "wait for help" and "alarm put on resident." The post incident analysis identified R61 had impaired mobility, activity intolerance, and judgment/safety awareness deficit which were related to the fall. Review of the physician's orders [REDACTED]. Review of the care plan (updated 7/23/12) identified R61 had fallen before leaving the hospital and during nursing home stay. The care plan identified the interventions were to place the call light within easy reach and remind to use, trapeze put on bed for positioning, apply bed alarm when in bed and reposition every two hours or as needed when out of wheelchair. The nursing care plan did not identify the use of a chair tab alarm. During interview on 8/13/12, at 6:15 p.m., the director of nursing (DON) confirmed R61 had sustained a fall most recently on 7/25/12, with no injuries noted. The nursing assistant care sheet (no date) indicated R61 required one assist for transfers, needed hourly checks, and had a bed and chair alarm. During observation on 8/15/12, at 10:41 a.m., R61 was observed to be sitting in the recliner in his room with the foot rest elevated. No tab alarm was on the reclining chair or on the wheelchair. During observation on 8/15/12, at 1:39 p.m., R61 was again observed to be sitting in the recliner and no tab alarm was noted on the recliner or on the wheelchair. During interview on 8/16/12, at 10:38 a.m., licensed practical nurse (LPN)-H revealed R61 had an order to check placement of a chair alarm and confirmed R61 did indeed have a tab alarm. On 8/16/12, At 11:18 a.m., LPN-H entered R61's room where he was sitting in recliner and verified no tab alarm was currently on resident and was not still on the wheelchair. LPN-H performed a search of R61's room and found the tab alarm in the top drawer of the night stand. LPN-H then placed the tab alarm on R61 and left the room. Review of the medication administration record (MAR) on 8/16/12, at 11:20 a.m. for 7/12 and 8/12 revealed staff had initialed that placement of the tab alarm had been checked three times a day everyday including the morning of 8/16/12, by LPN-H. LPN-H was unable to verify the tab alarm had been in place when the MAR had been initialed that morning. During interview with on 8/16/12, at 3:14 p.m., NA-F indicated residents were identified as a fall risk and interventions required were listed on the nursing assistant care sheets. NA-F remembered R61 had set off the tab alarm a couple of weeks ago so R61 was a fall risk, however NA-F was unable to list specific interventions for fall precautions in place for R61. Review of the care planning policy (revised 8/06) did not reveal any guidance for care plan implementation. Review of the fall risk policy revised 4/09 revealed staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try minimize complications from falling. The policy also indicated staff would implement the identified relevant interventions.

Based on observation, interview and document review, the facility failed to provide prompt nursing services to the highest practical level including notification of the physician when there was a change in a resident's condition (R38) for 1 of 1 residents that was reviewed for a death, this resulted in harm for R38. Furthermore, the facility failed to provide the necessary care and services 1 of 1 residents (R52) reviewed for non pressure related skin conditions and pain. The pain for R52 resulted in actual harm for the resident. Findings include: Physician Notification R38 had a decline in condition identified on [DATE], at 6:50 a.m. and the physician was not notified of the resident's condition change until [DATE], at approximately 6:00 a.m. R38 was transferred to the emergency roiagnom on [DATE], at 6:15 a.m. The facility was notified at 7:30 a.m. that R38 had died . R38 had been re-admitted to the facility on [DATE], following hospitalization for [MEDICAL CONDITIONS], diabetes mellitus, [MEDICAL CONDITION] and hypertension. The resident had been hospitalized [DATE], with increased shortness of breath, [MEDICAL CONDITION], and low oxygenation as measured by O2 (oxygenation) saturations. The resident utilized oxygen at ,[DATE] liters per face mask following readmission. The hospital discharge summary indicated the resident was "stable with O2 sats now in the high 80's and at times even going up to 95. Will continue with oxygen that is continuous." The resident had been readmitted with physician orders [REDACTED]. Nurses' notes (NN) were reviewed. NN indicated the resident had experienced shortness of breath during the evening or night shift on [DATE], [DATE], and [DATE] with relief obtained by the use of a physician prescribed nebulizer treatment. None of those incidents had been documented as accompanied by wheezing, complaints of air hunger, nor were lung sounds documented. On [DATE], a NN included, "Resident at 0650 (6:50 a.m.) appeared to be air hungry. Respirations at 28 with O2 mask with 3 L on. O2 sats at 94%. Lung sounds appear diminished in lower lobes otherwise clear in upper lobes. Resident reports coughing through the noc (night). Phelgm (sic) brown in color. Temp 98.2 [MEDICAL CONDITION] noted in lower legs and feet at 3+. Denies any pain or discomfort. Medication and treatment compliant. Assisted with one for ADLs (activities of daily living). Ate 100% of meal and approximately 600 cc (cubic centimeters) in fluids. Re-educated on importance of watching his fluid intake. Currently resting in room with call light in place." No further notes were documented regarding the resident's air hunger, [MEDICAL CONDITION], or cough on [DATE], until 9:02 p.m. when a note indicated, "Resident received 10 cc of geri-[MEDICATION NAME] (cough medication) and PRN (as needed) [MEDICATION NAME] (an anti-anxiety medication) at 8 pm per his request for cough and anxiety, currently sleeping, will continue to monitor." At 10:17 p.m. on [DATE], a NN entry included, "Alert this shift. Washes face and hands with set up, oral and peri cares done with assist of one. Assist of one for dressing. Transfers with assist of one. Eats independently in MDR (main dining room). LS (lung sounds)- wheezing. O2 on 2 L. Currently sleeping, will continue to monitor." Although these entries indicated the resident's condition had changed, with increased [MEDICAL CONDITION], and diminished or wheezing lung sounds, the resident's physician was not notified. A NN dated [DATE], at 6:20 a.m. included: "Writer alerted to this residents room at 0555 (5:55 a.m.) by noc nurse. Resident noted lying supine in bed, head elevated with face mask on. O2 on concentrator at 3.5 L. Residents pallor blue. O2 sats at 40, CBG (capillary blood glucose) 247, B/P (blood pressure) ,[DATE], P (pulse) 68, R (respirations) 28, unable to respond to voice or sternal rub/painful stimuli. Order obtained from (local hospital) ER (emergency room ) to transport...EMS (emergency medical system) activated. Girlfriend (name) contacted to update. EMS arrived at 0615 (6:15 a.m.) was updated of vitals ...to transport to ER in (a larger neighboring hospital) d/t (due to) condition and code status. ..." The NN further documented the resident had subsequently died at the hospital at approximately 0730 (7:30 a.m.). The current physician orders [REDACTED]. There was no evidence found that staff monitored R38's oxygen saturations or followed up with R38 through out the day to assess his condition when the nurse noted R38 was experiencing "air hunger". The resident's care plan dated [DATE], indicated the resident had been hospitalized for [REDACTED]. The care plan also indicated staff were to monitor R38 for side effects of any medications and report any concerns to the primary doctor stat (immediately). The care plan was not updated to include information about R38 being on continuous oxygen and interventions for staff to follow as directed by the physician orders. During interview with the Director of Nursing on [DATE], at 8:30 a.m., she stated she would have expected the nursing staff to have contacted the resident's physician when the resident made the complaints of having air hunger and was noted to have diminished lung sounds. Non-pressure skin condition R52 reported she had a chronic skin disorder and there was no evidence found of the skin condition being assessed, interventions implemented or monitored. R52 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. No [DIAGNOSES REDACTED]. An admission minimum data set (MDS), completed on [DATE], indicated that R52 was cognitively intact. The MDS indicated R52 was independent with bed mobility, locomotion on the unit and eating. The MDS indicated R52 did have a skin condition, which was not a pressure ulcer, rash or cut. The care area assessments (CAA), which were done on [DATE], did not include an assessment of the skin condition. Upon R52's admission to the facility on [DATE], a skin assessment was completed by nursing staff, which noted, "Many scratches and scabs from [MEDICAL CONDITION], red area on arms from [MEDICAL CONDITION], light purple discoloration on bilateral shins, dark purple discolorations on bilateral inner thighs, heels intact and no open areas on coccyx." R52 was discharged and readmitted on [DATE], and a second admission skin assessment was completed, which noted bruising by left eye, left side of abdomen, right skin, top of right foot, left arm, three bruised areas on right arm, left forearm, and left wrist. The nurse also noted psoriasis areas on elbows, hands, upper arms, left arm and feet and reddened areas under breasts, buttock and left leg. The resident's care plan, created on [DATE], did not address skin problems or any specific interventions. R52 was interviewed on [DATE], at 11:45 a.m. and reported that she had "a skin break down area under her breast which was very painful" She rated the pain a "10", on a scale of 0 (no pain) to 10 (excruciating pain-the worse she had experience). She also reported that she had a "raw area" on her buttocks and it hurt to sit a long time in her wheelchair. She rated the pain to the buttock at a "4". She also indicated that she was recently hospitalized for [REDACTED]." A review of the medical record revealed a note from a nurse practitioner from the clinic on [DATE], that indicated: "her (R52) psoriasis, she states is much worse." The [DATE], progress noted also reported "Has multiple bruises and quite severe psoriasis at this time" The nurse practitioner documented the staff were asked to shower the resident daily due to her skin condition and underneath her breast but the nurse practitioner was told that the facility could not accommodate this as they were not staffed accordingly but would try to shower the resident twice a week. On [DATE], at 7:44 a.m. licensed practical nurse (LPN)-A applied an ointment to R52's legs, which had scattered areas that were dark brown from knee to ankle. The LPN, then applied ace wraps from ankle to upper thigh on both legs. Morning cares were observed and skin examined on [DATE], at 8:15 a.m. R52 was assisted by nursing assistant (NA)-A. Both breast skin folds was reddened, which radiated up the under breast areas and down the upper chest area approximately 2 ,[DATE] inches. The reddened area had jagged edges. The left breast had 2 openings, that were linear and approximately 2 cm (centimeters) in length. The openings had no obvious drainage. R52's abdominal fold had reddened areas on on both sides of the abdomen. The abdominal fold on the right side of the body had a linear opening, approximately 2 cm in length with no obvious drainage. The abdominal fold on the left side of the body had a raised reddened rash like area, which radiated to the back. R52's buttocks had a raised fire red rash, which extended down the posterior aspect of both legs and groin area. No obvious drainage but a small amount of blood was seen on the seat of her wheelchair, when she transferred from the wheelchair to the toilet. An interview with NA-A on [DATE], at 9:14 a.m. was conducted. NA-A reported the reddened areas have been present "for an extended time". She reported the rash gets better and then gets worse. NA-A also indicated R52 was seen on a weekly basis by a dermatologist but etiology of the rashes were unknown to her. NA-A reported that the only special treatment the nursing assistants did for the resident was to wash the areas and put on the topical creams that were ordered. An interview with the director of nurses (DON) was conducted on [DATE], at 10:15 a.m. A comprehensive skin assessment and skin monitoring were requested of the DON, who reported that none had been done. She indicated that skin issues were monitored weekly by nursing assistants when they do baths. Upon review of the June and July, 2012 weekly bath/skin it was noted there was no documentation found regarding skin condition, which was verified by the DON. An undated policy labeled Pressure Ulcers/Skin Breakdown-Clinical Protocol and Care of Skin Abrasions was provided by the DON, the policy/protocols did not address skin assessment or skin monitoring. Pain R52 reported that she had chronic pain related to skin condition, which was not being treated effectively and resulted in actual harm for R52. R52 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. An admission minimum data set (MDS), completed on [DATE], indicated that R52 was cognitively intact. The MDS indicated R52 was independent with bed mobility, locomotion on the unit and eating. MDS indicated R52 did report pain and received pain medications as needed. The MDS indicated that non-medication interventions were not being done and a pain assessment was to be completed. The MDS noted that resident occasionally had pain, pain makes it hard to sleep at night and limited her daily activities and the resident described her pain as severe. The pain care area assessment (CAA), was completed [DATE], and included a notation that R52 had pain on the upper thigh. This assessment referenced referring to a pain assessment sheet for characteristics of the pain, but a pain assessment was not found in the medical record. The CAA did identify the pain disturbed R52's sleep, adversely affected her mood and limited her day to day activities The CAA summary did not address descriptors of the pain, causes and contributing factors or risk factors related to pain. According to the facility's form, these areas were to be addressed and no evidence was obtained that they were addressed. The resident's care plan, which was established on [DATE], did not identify pain as an issue for R52 and no interventions/approaches were developed to address this issue. The physician orders [REDACTED]. No documentation was found regarding the medication effectiveness. The physician order [REDACTED]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The night staff documented the resident had no pain for this entire time frame. The documentation for day shift and evening shift ranged from ,[DATE] (on a scale of ,[DATE]). 17 times during this periods of time, the resident rated her scale at a "3" and 16 times, she rated the pain at a "4". She rated her pain at a "5" twelve times and at a "5" five times. She rated her pain at an "8" six times. There was no evidence that any interventions or medication changes were made as a result of the pain monitoring. R52 was interviewed on [DATE], at 11:45 a.m. and reported she had "a skin break down area under her breast which was very painful" and rated the pain a "10", out of a scale from 0 (no pain) to 10 (excruciating pain-the worse she had experience). She also reported that she had a "raw area" on her buttocks and it hurt to sit a long time in her wheelchair. She rated the pain to the buttock at a "4" and reported that it was very uncomfortable. On [DATE], at 7:44 a.m. licensed practical nurse (LPN)-A applied an ointment to R52's legs and during the process, R52 took a very quick, sharp, intake breath to which LPN-A stated "I know this hurts you, I will try to be gentle." An interview with LPN-A was completed on [DATE], at 2:22 p.m. LPN-A reported R52 does have pain whenever anyone touches her legs or any of the areas where she had a rash but does not usually vocalize as much pain as "she did this morning." LPN-A reported the resident was given pain medication at 6:00 a.m. and that should have helped her pain, when applied the ointment was applied to her legs. On [DATE], at 8:15 a.m., during morning cares, R52 cried out in pain, when the rash under her breasts, abdominal folds, buttocks and posterior legs were washed. NA-A repeatedly said "I know that hurts. I am trying to be as gentle as possible." An interview with NA-A on [DATE], at 9:14 a.m. was completed. NA-A reported that whenever the resident has personal cares, she complains of pain and so she tries to be very gentle. An interview with the occupational therapist (OT) was completed on [DATE], at 10:02 a.m. She reported that R52 sometimes will refuse to come to therapy as is not feeling good and is having pain. The facility's policy and procedure, Pain Assessment, was obtained and reviewed. The policy directed staff to assess the resident's pain level and provide optimal comfort through a pain control plan that was mutually established with the resident and members of the health care team. The pain assessment was to be part of the initial nursing assessment and reviewed quarterly or with a significant change of status. Continuing assessment of pain was to occur daily and to focus on the effectiveness of the comfort level of the president. Evaluation of the effectiveness of the pain medication was to occur within two hours of administration of the medication. An interview with the DON on [DATE], at 1:09 p.m., verified this policy had not been followed for this resident.

Based on observation, interview and document review the facility failed to identify causative factors, implement timely interventions and monitor identified pressure areas/devices to minimize the risk for further pressure ulcer development which resulted in the development of an avoidable stage III pressure ulcer resulting in harm for 1 of 2 residents (R20) reviewed in the sample for pressure ulcers. Findings include: R20 had podiatrist visit on 5/14/12, which noted a pressure area on R20's metatarsophalangeal (MTP) joint on her left foot. No monitoring or interventions were documented related to this pressure area until the area was identified as a stage III pressure area by facility staff on 7/18/12. On 8/9/12, R20 developed a stage II coccyx pressure ulcer without appropriate interventions in place. R20's [DIAGNOSES REDACTED]. R20's quarterly minimum data set ((MDS) dated [DATE], identified she was severely cognitively impaired and required extensive assistance of one for bed mobility and transferring. The MDS identified R20 did not have any unhealed pressure ulcers. MDS identified R20 had a pressure reducing device in her wheelchair but not on her bed. A Wound Documentation monitoring form initiated 12/26/11, identified R20 developed an unstageable left heel pressure ulcer that measured 4 centimeters (cm) by 3 cm and described the area as black and mushy. On 1/3/12, it identified the left heel was measured at 4.0 cm by 3.0 cm and described it as black and hard. On 1/10/12, identified the left heel was measured 3.8 cm by 2.8 cm and described it as black and hard. On 1/17/12, it identified the left heel was measured at 3.6 cm by 2 cm and was described as black and hard. On 1/24/12, it identified the left heel was measured at 3.5 cm by 7.2 cm and was described as [DIAGNOSES REDACTED]tous (red). On 1/31/12, it identified the left heel was measured at 3.7 cm by 7.0 cm. On 2/8/12, it identified the left heel was measured at 3.6 cm by 7.0 cm. On 2/15/12, it identified the left heel was measured at 3.5 cm by 6.9 cm. On 3/1/12, R20 was seen by the podiatrist. A nursing noted dated 12/26/11, at 3:56 p.m. indicated R20 had a "Blister 4 cm by 3 cm on L) (left) heel ... " A nursing note dated 12/27/12, indicated the interdisciplinary team reviewed the report from 12/26/12, regarding R20's blister on her left heal measuring 4 cm x 3 cm eschar. It identified skin prep would be used twice a day with heel protectors on. A skin note dated 2/3/12, at 8:56 p.m. identified during bedtime cares a nursing assistant called the nurse into R20's room. The nurse noted a 1 cm by 1 cm circular pressure ulcer with blackened center on the bottom of R20's right foot below the great toe, skin prep was applied. It identified the ulcer appeared to be caused by pressure from that area of the foot rubbing on the boot, blue boots were taken off and foam yellow boots were put on to relieve pressure on area below the great toe. An interdisciplinary team note dated 2/6/12, at 11:22 a.m. indicated the team reviewed the concern regarding the "blister" on the bottom of R20's right foot measuring 1 cm by 1 cm. It noted R20 would have plastic fitted boots replaced with foam boots so her foot fits flat in the boot. A Therapy Weekly Progress report dated 2/7/12, identified R20 was being evaluated for wheelchair positioning. It indicated occupational therapy (OT) placed a foot board on the elevated foot rests at this time. This was changed from elevated foot rests which reportedly allowed R20's feet to keep falling off. No other documentation was provided regarding wheelchair evaluation related to altering foot support to relieve pressure. A nursing note dated 2/19/12, identified the necrotic tissue on the left heel pressure ulcer was beginning to separate from the healthy skin. A nursing note dated 2/25/12, at 1:18 p.m. indicated R20 was tolerating her Broda chair this shift. It noted heel boots were donned and her right heel and left metatarsal pad continue with hardened blisters. No further Wound Documentation was provided for the monitoring of these areas. A nursing note dated 2/27/12, at 10:11 a.m. indicated R20 had a left heel that has a large black area and she would be seen by doctor of podiatric medicine (DPM)-A about [MEDICATION NAME] this area. A podiatry note dated 3/1/12, signed by DMP-A indicated R20 had a full-thickness decubitus left heel ulcer with a central necrotic eschar on her left lower extremity. It identified subcutaneous tissue was exposed but there was no exposed bone or tendon. It identified R20 had a posterior contracture with the foot in a fixed plantar flexed position and hallux contracted dorsally. It noted the wound was debrided for full thickness with a tissue nipper down to healthy underlying tissue. It noted a dressing was applied. Orders were written to apply a heel suspension boot and it was to be worn at all times on left lower extremity as well as two pillows under the calf while in bed. It directed nursing staff to do a daily wound evaluation and dressing application. A correspondence clinic note dated 3/1/12, at 2:26 p.m. signed by the DPM-A noted R20 was diagnosed with [REDACTED]. It revealed the wound was debrided and R20 was put into a compression dressing. It directed to follow up with DPM-A in approximately 10 to 14 days. A podiatry note dated 3/13/12, signed by DMP-A indicated R20 was followed for the monitoring of a left heel decubitus ulcer. It noted an order was put in for continued use of the heel suspension boots and daily bandages. A podiatry note dated 4/5/12, signed by DMP-A indicated R20 was followed for the monitoring of a left heel decubitus ulcer. It identified the wound was debrided sharply. It noted a dressing was applied and heel suspension boots were put in place. The care plan last reviewed on 4/10/12, indicated R20 had a left heel unstageable pressure ulcer. The interventions included following the treatment recommended by the wound skin nurse and physician. It identified the wound skin nurse would see R20 on monthly rounds. It directed staff to apply a heel boot on continually and remove to lotion legs and observe for any further breakdown twice a day with cares. It instructed staff to float heels when R20 was in bed. It identified R20 used a Broda chair when up to help with positioning concerns. A podiatry note dated 4/26/12, signed by DMP-A indicated staff had been doing offloading with daily dressing changes and the wound has been stable and actually improving over the last few visits. It noted overall the measures were larger than the last visit and had significant malodor, with possible infection, questioning gangrene. It directed for a follow-up in one week. A podiatry note dated 5/7/12, signed by DMP-A identified R20 was being continually monitored for her left decubitus heel ulcer. It identified on the last visit it was starting to go a little downhill and so she was started on a [MEDICATION NAME] dressing. It noted R20 came in today with further slight declination in the wound itself. It identified there was slight malodor but it was not as pronounced as it was last visit. The examination indicated R20 had a plantar flexed contracture. It noted the wound was less stable now with some stringy fat at the base of the wound. The plan indicated the base of the wound was debrided full thickness down to the subcutaneous fat. It noted [MEDICATION NAME] was applied and a dressing was placed. A culture was obtained at this time and DPM-A noted that if the wound does not get better surgical intervention may be needed. A podiatry note dated 5/14/12, signed by DPM-A indicated R20 came in for continued monitoring of the left heel wound. It noted, over the past two visits, the wound has been going downhill and has had some non-viable necrotic stringy tissue. It noted the wound was extensively debrided on the last visit and the patient comes in today with the wound doing quite a bit better. DPM-A identified R20 had also developed a "blister," at the planter left first MTP joint as well as a very low-grade pressure area on her plantar right first MTP. The plan was to alter her chair so the foot plate was not causing so much pressure on the foot. There was no pressure ulcer assessment to determine the causative factors of the development of the MTP wound or further Wound Monitoring documentation for the MTP joint pressure area until 7/20/12, when it was identified as a stage III pressure area to the left metatarsal pad. A podiatry note dated 5/21/12 signed by DPM-A indicated R20 was seen today for monitoring of heel decubitus ulcer left lower extremity and pressure wounds at the first MTP joint bilateral. It noted regarding the pressure ulcers at the first MTP joint there was a small scab over both, the tissue deep to this was healing very well. It identified all three areas were healing very well and there were no signs of infections. A podiatry note dated 5/31/12, signed by DPM-A noted R20 was seen today for continued monitoring of multiple pressure wounds on her feet. It addressed staff had been aggressively offloading the left decubitus heel as well as the plantar first MTP joint ulcer bilaterally. Orders were to apply dressing to the left lower extremity with a three and four inch ACE wrap. It directed staff to change dressing daily and provide aggressive offloading. It noted to follow-up with him in two weeks. A nursing note dated 5/31/12, indicated R20 was back from her appointment with DPM-A with a plan to continue with the daily dressing changes and aggressive offloading and follow up in two weeks or sooner with acute issues. A skin note dated 6/5/12, indicated this was a late entry for skin rounds completed on 5/31/12, with licensed practical nurse (LPN)-G. It noted R20 continues to have a stage III pressure ulcer on her left heel with 50% slough (necrotic tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy at times) and red viable tissue. It directed to continue current treatment of [REDACTED]. It identified to change the dressing daily. A physician order [REDACTED]. The note did not address the ulcer on the the MTP joint. R20's tissue evaluation dated 6/25/12, indicated she had very fragile skin, swollen, multiple bruises on arms, with a small open area on right elbow/upper arm. It indicated to turn and reposition every two hours due to fragile skin, [MEDICAL CONDITION], and bruises on arm. The data collection did not indicate if there was any redness noted on bony prominence after one or two hour of laying or sitting to determine if the current repositioning plan of every two hours was effective in minimizing the risk for pressure ulcer development. A skin note dated 6/28/12, at 11:03 a.m. identified RN-D saw R20 for left heel ulcer. It indicated R20 was to have foam boots at all times. A skin note dated 7/16/12, at 12:34 p.m. identified that during bathing R20 had an open area under her left foot (ball on foot) which measured 1 cm x 1 1/2 cm. It identified a fax was sent to DPM-A asking for the okay for a standing order treatment, DPM-A' s nurse called back and stated he wanted to see R20. R20's Braden scale for predicting pressure sore risk dated 7/15/12, identified she was at high risk, with a total score of 11. The risk data identified R20 was chair fast (ability to walk was severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair). The next available podiatry note dated 7/18/12, signed by DPM-A noted R20 was followed for the monitoring of the wounds on her feet. DPM-A indicated there was a change in her mental status and there was concern about a possible new wound on her left foot. It noted "we have been aggressively offloading and doing daily dressing changes." It revealed R20 last saw him on 5/31/12, and was supposed to follow up with me in two weeks after that appointment. The patient was somnolent during the entire examination. It noted the wound on the posterior aspect of the heel was debrided. It noted this area had significantly improved over the previous presentation and there were no signs of infections. It identified she did have breakdown with surround [DIAGNOSES REDACTED] at the plantar aspect of the left first MTP joint. It noted, after debridement, it measured 2 cm by 1.5 cm. It indicated there was no exposed bone, joint or tendon but there was some surrounding redness and some serous drainage. There was also some dried eschar at the plantar aspect of the lateral left forefoot. The stable eschar was left in place. There were no wounds noted on the right lower extremity during this examination. It directed staff to apply a dressing to the left foot and placed an order for [REDACTED]. A Wound Documentation monitoring form indicated R20 developed a stage III left MTP pressure ulcer on 7/20/12. On 7/20/12, the ulcer was measured at 1.7 cm by 2.0 cm no depth was noted, the surrounding tissue was identified as intact with no undermining, odor or drainage. On 7/27/12, the ulcer was measured at 1.7 cm by 2.0 cm no depth was noted, the surrounding tissue was identified as intact with no undermining, odor or drainage. On 8/3/12, the ulcer was measured at 1.2 by 1.8 cm no depth was noted, the surrounding tissue was identified as intact with no undermining, odor or drainage. On 8/9/12, the ulcer was measured at 0.7 cm by 0.4 cm by 0.2 cm. A podiatry note dated 7/31/12, signed by DPM-A indicated he evaluated R20 for a wound on her left heel and sub first MTP joint. It noted the infection was doing better. It identified she did come in today without a dressing on her foot. It noted, "they will continue with daily dressing changes and offloading." It directed R20 will follow up with him in two weeks. A Wound Documentation monitoring form initiated 8/9/12, indicated R20 had a stage II coccyx ulcer which measured at 1.7 cm by 0.5 cm with drainage color identified as sero-sanguineous. Nursing assistant care sheet obtained on 8/14/12, identified R20 was to be turned and repositioned every one and half hours. It instructed staff to apply cushion boots to both feet and provide a REM mattress. The plan of care did not address the type of heel protectors to be used, interventions for the wheelchair foot supports, the use of a wheelchair pressure relieving cushion or the air mattress overlay. On 8/15/12, at 7:10 a.m. R20 was observed seated in a Broda in the reclined position in her room. R20's Broda chair a solid piece of vinyl material as her foot support. R20 was wearing bilateral foam boot protectors to both feet. R20's feet where flush with the foot support. R20's bed had an alternating air mattress applied. There was a ROHO cushion placed on the seat of the chair. The ROHO cushion appeared to be deflated. On 8/15/12, at 8:03 a.m. nursing assistant (NA)-C stated R20 developed an open area on coccyx last week. NA-C stated R20 cannot reposition herself and that she had a pressure relieving cushion in her wheelchair. At 1:53 p.m. NA-C stated R20 utilized the Broda chair for about six months due to positioning issues. NA-C reported R20 wears foam protector boots on both feet. NA-C verified R20 had a heel suspension boot about two months ago for a while. NA-C stated the suspension boots were discontinued; because they was causing a little pressure area by the pad of her foot by her big toe and the area had opened up. NA-C stated they "caught it before it got too big." And further stated that's when the foam protector boots were put in place. NA-C stated R20 has had the pressure relieving mattress for about six months. NA-C verified after R20's wheelchair had a "thin foam pad" on the wheelchair seat. NA-C stated after she found out R20 had a pressure ulcer on her bottom she put the ROHO cushion, in R20's wheelchair to provide more padding. NA-C stated she took it from the therapy department. During an observation on 8/15/12, at 10:43 a.m. licensed practical nurse (LPN)-D completed a dressing change to R20's pressure ulcers on her left heel and MTP joint on her left foot. LPN-D cleansed the MTP joint pressure area with normal saline and a four by four gauze and rubbed the wound for approximately five seconds. LPN-D left the heel wound open to air without a dressing, applied a gauze with [MEDICATION NAME] and wrapped the MTP joint dressing with kerlix. LPN-D then applied an ACE wrap over the entire left foot, which covered the left heel ulcer as well. On 8/16/12, at 10:20 a.m. LPN-H completed a dressing change for R20's coccyx pressure ulcer. LPN-H started by dabbing the wound with a four by four gauze and normal saline and then started to rub the area to cleanse it. On 8/15/12, at 11:01 a.m. LPN-D stated they were not sure what caused the coccyx pressure area. LPN-D stated the area was likely due to how staff were repositioning her when they needed to provide peri-care. LPN-D stated that the staff were aware of her fragile skin and knew not to pull on her skin and to be gentle. LPN-D further stated that sometimes to get residents cleaned thoroughly they may need to be turned a little more which may have caused this pressure area. LPN-D confirmed staff had not had any recent training on how to turn or reposition residents who were at risk for skin breakdown related to sheering/friction. On 8/16/12, at 10:46 a.m. director of nursing (DON) stated once a pressure area was identified she was notified through an incident report and assessed the area. DON stated this was where the facility completed a root cause analysis of the pressure area and appropriate interventions that needed to be implemented. DON confirmed the evaluation did not address pressure related areas to determine if repositioning schedule was adequate. DON stated R20 had an air mattress implemented after the breakdown started. DON confirmed R20 developed a stage III pressure ulcer on her left MTP joint. DON stated the heel suspension boots were taken off, but was not sure when this was done. DON stated she believed staff started putting pillows at the base of the wheel chair foot board to provide support, but was not sure if this was added to the care plan or nursing assistant care sheet. DON stated she was not sure if there had been monitoring of the heel suspension boot device after it was implemented. DON reported R20's skin was monitored every week on bath day. DON reported that staff stated R20 was a heavy lady and often repositioned herself back onto her back. DON verified that R20 was unable to reposition herself. DON stated she reeducated the staff that they needed to position R20 all the way on her side. DON confirmed that the pressure ulcer on the MTP joint on the left foot did have depth of 2 cm when it was identified. DON confirmed the staff should do weekly assessments on pressure areas to identify if they are healing. DON stated that staff should not be rubbing the area when cleansing it, but dabbing it with the ordered cleansing solution. At this time the incident reports were requested. No incident reports regarding R20's pressure areas were provided. On 8/16/12, at 11:28 a.m. OT-A stated therapy had not been involved with R20 regarding pressure ulcer prevention or wheelchair positioning after the 2/7/12. OT-A reported she looked at the ROHO cushion in R20's chair and it was deflated. OT-A stated staff needed to be checking the air in the cushion on a routine basis to make sure the intervention was effective. OT-A stated she inflated the cushion this morning. The Treatment Sheet for 8/1/12, through 8/30/12, indicated R20 was to have a heel suspension boot to her left foot at all times. This treatment was signed off as being completed every shift from 8/1/12, through 8/15/12. It identified the current treatment for [REDACTED]. The left foot dressing was to be changed daily with [MEDICATION NAME], 4 x 4, apply kerlix and ACE wrap. In addition, the coccyx pressure ulcer was to be cleansed with normal saline, apply Santyl and cover with foam a dressing daily until it healed The facility's Pressure Ulcer Treatment policy revised 3/05 indicated the pressure ulcer treatment program should focus on assessing the resident's and the pressure ulcers, managing tissue loads, and provide education. It identified staff should identify interventions and preventative measures which included that chair fast residents required at least every hour repositioning. In addition, it directed staff to consider the need for pressure relief/reducing devices. It instructed to refer residents to a rehabilitation program or restorative nursing program as indicated and encourage the resident to participate in active and passive range of motion exercises to improve circulation.