Every finding on record at Valley View Manor Healthcare Center

Based on interview and document review the facility failed to ensure a gradual dose reduction (GDR) was attempted, or a rationale was provided for 1 of 5 residents (R4) sampled. Findings include: R4's Minimum Data Set (MDS) assessment accepted on 7/2/26, identified his cognition was mildly impaired, he was dependent on staff to complete activities of daily living (ADL)'s and had diagnosis of dementia, traumatic brain injury, anxiety, and depression. R4 reported feeling down, depressed, or hopeless several days over past 2 weeks. R4 had no behaviors during the assessment period. Antipsychotics were received on a routine basis and a gradual dose reduction was noted to have not been attempted. R4's Medication Administration Record identified the facility was administering escitalopram (an antidepressant) 5 milligrams (MG) daily for generalized anxiety and quetiapine (an antipsychotic) 100mg at bedtime for unspecified dementia with agitation. R4's November 2025, pharmacy (RPh) medication review report identified a recommendation to the physician (MD) by the RPH to assess R4 for continued use of escitalopram and quetiapine. If the current dose is still appropriate for the patient, the RPh asked the MD to please provide the clinical rationale for continuing the current dose. The physician reviewed and accepted the report. The physician replied for R4 to continue with medication, and she would evaluate on the next nursing home rounds. His mood was noted to be stable. R4's 12/4/25, nurse practitioner (NP)-A's progress note, (completed after nursing home rounds) identified the pharmacy review was completed on 11/25/25. The quetiapine was started on 9/5/24, and the escitalopram was started on 3/28/25. NP-A noted to be questioning if the current dosing on the medications was still appropriate. A response was given to the RPh to continue as is and will continue to monitor on routine rounds, sooner if there are acute concerns. R4's mood continued to be stable. Vitals were reviewed. No changes were recommended. Interview and document review on 7/8/26 at 8:55 a.m., with the assistant director of nursing (ADON) identified she searched through R4's medical record and was unable to find documentation that a GDR had been completed or that rationale for not completing a GDR had been documented. Interview on 7/8/26 at 3:12 p.m., with the director of nursing (DON) identified that they typically will get a recommendation from the RPh alerting them when a resident was due for a GDR. They also have interdisciplinary team (IDT) meetings and behavior meetings where they talk about residents and their medication and if the IDT determines a GDR or any change in medications were needed, they notify the primary physician. The DON identified she agreed that documenting stable and was not an appropriate rationale for continued use. She discussed it with the rounding NP and determined they need to work on a better process to make the rationale clearer. She would expect the facility to follow policy and pharmacy recommendations and follow up with the physician to ensure pharmacy recommendations are acted upon. Review of the facilities current, undated Psychotropic Medication Use policy identified residents on psychotropic medications were to receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue those medications. The policy identified the process would be completed by the IDT.

Based on interview and document review the facility failed to ensure they had obtained and documented an informed consent, including an explanation of the risks and benefits of using a psychotropic medication or alternative treatment options for 1 of 5 residents (R4) sampled. Findings include: R4's Minimum Data Set (MDS) assessment, accepted on 7/2/26, identified his cognition was mildly impaired, he was dependent on staff to complete activities of daily living (ADL)'s, and had diagnoses of dementia, traumatic brain injury, anxiety, and depression. R4 reported feeling down, depressed, or hopeless several days during the look-back period. R4's Medication Administration Record identified the facility was administering escitalopram (an antidepressant) 5 milligrams (MG) daily for generalized anxiety starting on 12/30/25 and quetiapine (an antipsychotic) 100 mg at bedtime for unspecified dementia with agitation starting on 12/4/25. Interview and document review on 7/8/26 at 8:55 a.m., with the assistant director of nursing identified she was unable to find documentation in R8's medical record that a consent had been obtained, or that risks and benefits or alternative treatment options had been provided to R4 or their resident representative. Review of the facilities Antipsychotic Medication Use policy identified the facility would ensure residents only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician was to, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Residents who were admitted from the community or transferred from a hospital and who were already receiving antipsychotic medications were to be evaluated for the appropriateness and indications for use. In addition, the hospital, previous nursing home or assisted living resident record was to include the physician diagnosis, indication for use and include documentation that the resident acknowledged consent to receive prescribed psychotropic medications. Prior to starting a new psychotropic medication, the physician was to document the resident/resident representative consent in their progress notes. Medication monitoring and documentation was to include checking for side effects at least daily for the first six weeks after a resident began taking a new psychotropic medication, or a significant increase or decreased dose occurred of a currently used psychotropic medication, and at least quarterly thereafter. Minor increases or decreases in the dose of a currently used psychotropic medication did not require to be monitored as frequently as a new medication or a significant increase or decrease of a currently used psychotropic medication. In addition to appropriate physical or laboratory assessments as determined by the medically licensed person, standardized checklists or rating scales, or scales developed for a specific drug or drug class, were to be used as monitoring tools.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) for 1 of 5 residents (R8) who had new on-set of mental illness. Findings include: R8's comprehensive Minimum Data Set (MDS) assessment accepted on 4/22/26, identified he had diagnoses of bi-polar disorder, PTSD, and personality disorder. R8's cognition was intact, and he had not displayed any behaviors during the assessment period. R8's Pre admission Screen (PAS) completed on 5/24/24, had a section noting if the person had a current diagnosis of mental illness to which it was documented he had a diagnosis of bi-polar disorder. There was no mention R8 had diagnoses of personality disorder or PTSD at that time. R8's diagnosis list identified he had been diagnosed with a personality disorder on 6/24/25 and PTSD on 5/28/24, both after his admission. Interview on 7/7/26 at 2:30 p.m., with the social service designee (SSD) identified she takes a glance at the PAS when they get a new admission to see if a level II PASARR is required but does not check for new diagnoses after admission, nor was she was aware the SMHA needed to be contacted to see if mental health services would be required. A policy was requested; however nothing was provided during the survey period.

Based on interview and document review, the facility failed to ensure appropriate antibiotic use for 1 of 3 residents (R16), who were reviewed for antibiotic stewardship. Findings include: R16's 5/11/26, accepted discharge and entry Minimum Data Set (MDS) assessment identified she had severe cognitive impairment, required limited staff assistance with activities of daily living, (ADLs). She was frequently incontinent of both bowel and bladder and had diagnoses of diabetes, chronic kidney disease, and Alzheimer's disease. R16's 3/12/26 at 9:58 a.m. progress note identified the nurse practitioner (NP) had discussed the use of Macrobid (an antibiotic specifically used to treat acute, uncomplicated bladder infections (cystitis)), with R16's family member on 3/10/26 and would not recommend long-term use related to R16's age and the impact to her kidneys. R16's, 4/21/26 at 10:58 a m. NP note identified she was seen for a routine follow-up visit. The note reported she would not be ordering a chronic antibiotic for prevention of UTIs. She did provide a referral for R16 to be seen by urology if the family chose to do so, and documented R16 had only one UTI in the past 6-month period. R16's 5/4/26 at Urology consult visit note identified she was seen due to concerns with urinary incontinence, recurrent UTIs, and to be evaluated for UTIs. She had history of urinary incontinence, and difficulty with control of bladder function. The note identified UTIs were more frequent in the past and had been managed with daily antibiotics. It was noted since admission to the facility she had increased her fluid intake and reduced the frequency of UTIs. The assessment and plan identified UTIs had decreased in frequency, with recommendation for hydration and regular pad changes, to prevent infections. Recommendations were for Cranberry tablets BID, to consider the addition of vaginal estrogen cream; toilet Q2H when awake and increase water intake with a goal of 70 ounces per day. The note identified the patient's family member was going to obtain the Cranberry tablets. Urinary incontinence was reported as likely related to cognitive decline and medications. Risks and benefits of bladder medications were discussed, and a medication trial was deferred. Recommendation was to continue scheduled toileting every 2 hours and maintain adequate fluid intake. R16 and her family member voiced agreement with the discussed plan. R16's 5/17/26 at 4:39 p.m. physician visit note listed, I understand will she be able to come in to see me. I would love to give her antibiotics once a day to prevent a bladder infection. Let nursing home [facility] know Macrobid 100 mg q am q day . R16's 5/18/26 at 12:52 p.m. progress note identified R16 was hospitalized [DATE] through 5/11/26 with a principal diagnosis of Septic shock complicated secondary to acute cystitis (inflammation of the bladder) and complicated by Escherichia coli (a normal part of the gut flora, with the most common infection from a urinary tract infection(UTI), chronic kidney disease, acute kidney injury, acute cystitis with hematuria (blood in the urine), and gram-negative bacteremia (the presence of Gram-negative bacteria in the bloodstream). She was discharged back to the facility with an order for Ciprofloxacin (an antibiotic used to treat severe bacterial infections), 500 milligrams (mg) by mouth (PO) two times daily (BID) before meals, for four days. She also had an order for Cranberry 500mg BID for history of UTIs. She was to be toileted regularly and follow-up appointments were scheduled. R16's 5/21/26 physician order from physician (MD-A) identified Macrobid 100 milligrams (mg) (antibiotic) by mouth PO every (Q) morning (a.m.). No end date or date for reassessment of need for antibiotic was included. Interview on 7/8/26 at 9:08 a.m. with the infection preventionist (IP) reported the facility continued to have issues with medical staff completing antibiotic time outs and continuing to order antibiotics even if the criteria was not met. She identified R16 and had 6 months of no recurrent UTIs following admission. She had a history of recurrent UTIs when living in an assisted living situation, and it was thought the recurrent UTIs were likely a result of poor perineal hygiene after toileting. Her family wanted her to continue an antibiotic as a preventative measure even though she had no signs or symptoms. Education was provided by both nursing staff and the NP, but family continued to request orders for a prophylactic antibiotic. R16 was also seen by Urology and education was provided to both the family and patient that antibiotic was not indicated related to the potential for kidney injury. The IP reported R16's family then contacted a different MD, who agreed to order a prophylactic antibiotic for the prevention of UTIs. She reported R16 was now experiencing increased peripheral edema felt to be a side effect of the ordered antibiotic. The MD was notified of the peripheral edema but continued to order the antibiotic, even though R16 had no signs or symptoms of a UTI, and there was no identified date to stop the antibiotic for evaluation of need. The IP reported the medical director was aware of the situation, but there was no resolution at the time of interview. Attempted interview with MD-A was made on 7/8/26 at 3:50 p.m. with a request for a return call. As return call was not received. Interview on 7/9/26 at 9:11 a.m., with the pharmacist (RPh) identified R16s medical record lacked documentation to justify prophylactic antibiotic use, and confirmed the order had an order date of 5/21/26, with no end date, nor a date for re assessment of need. She reported her expectation was for Antibiotic Stewardship criteria to be followed, and she had not addressed the issue in her June review but would request documentation for a risk verses benefit to be documented every 6 months. Interview on 7/8/26 at 4:30 p.m. with the director of nursing identified her expectation for antibiotic stewardship practices to be followed according to facility policy and the identified area of concern with R16 would need to be evaluated further. Review of the 10/4/21 Antibiotic Stewardship Policy identified a concentrated effort to decrease or eliminate unnecessary use of antibiotics for resident safety and to avoid unnecessary side effects. The seven identified elements of the Antibiotic Stewardship Program included: 1. Leadership Commitment 2. Accountability: Physician, nursing and pharmacy are responsible for promoting and overseeing antibiotic stewardship. 3. Drug Expertise: Identified by the consultant pharmacist. 4. Action: Implantation of policies and procedures for antibiotic use. 5. Tracking: Monitoring of antibiotic use with outcomes documented. 6. Reporting: Feedback to medical staff, nursing, and relevant staff on antibiotic use and any resistance to antibiotic stewardship practices. 7. Education: provision of antibiotic stewardship information to medical staff, nursing, residents and families on the need for antibiotic stewardship practices related to use of antibiotics. Prescribers were to base their treatment recommendations on likely UTI site, facility-specific culture with antibiotic sensitivity data, patient-specific data including age, prior antibiotic use, allergies, concomitant drug therapy, renal function and presence of a urinary catheter. The antibiotic stewardship team was directed to monitor the use of antibiotics, identify potential inappropriate use of an antibiotic for specific syndromes or prophylactic use to guide practice changes, and track any impact to residents.

Based on observation, interview and document review, the facility failed to ensure appropriate interventions were in place to prevent elopement for 3 of 3 residents (R1, R4, R6) who were identified as an elopement risk. This resulted in immediate jeopardy (IJ) for R1 when she was able to leave the facility when it was dark and foggy outside and was able to walk 5-6 blocks away before being found, which put R1 at likelihood for serious harm or death. The IJ began on 4/13/26 when R1 was able to elope from the facility after the facility failed to complete a comprehensive assessment for individualized interventions and level of supervision after R1 removed, then refused, replacement of Wanderguard (personal alarming safety device) on 3/29/26 and continued to display exit seeking behaviors. Additionally, the facility failed to identify and implement individualized interventions to prevent and/or mitigate risk for elopement for R4 and R6. On 4/16/26 at 5:04 p.m., the administrator, director of nursing, and vice president of clinical services were notified of the IJ. The IJ was removed on 4/17/26 at 5:00 p.m., after it was verified, the facility implemented an acceptable removal plan. However, non-compliance remained at a lower scope and severity of no actual harm, with a potential for more than minimal harm. Findings include:R1's face sheet dated 4/15/26, identified diagnoses of unspecified dementia without behavioral disturbance and depression.R1's neurology note dated 3/10/26, identified R1 was seen for a follow up on cognitive changes where her neuropsychometric (a comprehensive evaluation of cognitive, behavioral, and emotional functioning) testing suggested R1 has Diffuse Lewy Body Disease (a progressive neurodegenerative disorder characterized by cognitive decline, severe, fluctuations in alertness and detailed visual hallucinations).R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, had delusions/hallucinations, no other behaviors, no rejection of care, no wandering, did not use a walker or wheelchair, was independent with transfer and ambulation, had two or more falls since admission with no injury, and used a wander/elopement alarm daily (Per Elopement Evaluation the device was not applied until 3/26/26).Review of R1's record identified hourly safety checks were initiated on 3/23/26, however the record did not include a corresponding comprehensive assessment that had determined the frequency safety checks were appropriate and individualized to R1's risks and safety needs. R1's elopement evaluation dated 3/26/26, identified R1 was at risk for elopement due to wandering behaviors that were likely to affect the safety or wellbeing of self/others. Wanderguard was applied. R1's March 2026 Medication Administration Record (MAR) included a physician order dated 3/28/26 to check Wanderguard (name brand for a personal safety device) function and placement every shift for elopement/wandering.Review of R1's care plan 3/26/26 through 4/13/26, did not identify an elopement focus care plan had been developed and implemented with interventions to prevent R1 from leaving the facility unsupervised. R1's progress note dated 3/28/26 at 5:40 a.m., R1 was up early parts of the shift wandering in hallways and finally laid down at 3:30 a.m. but was not sleeping. R1 took off bracelet (Wanderguard) from hand and bracelet replaced on right ankle. R1's progress note dated 3/28/26 at 10:48 p.m., R1 would not allow staff to check for bracelet on leg properly. R1's progress note dated 3/29/26 at 4:39 a.m., R1 was up early hours of the night and laid in bed around 1:30 a.m. R1 would not allow staff to touch ankles to check for bracelets. R1's progress note dated 3/29/26 at 10:59 a.m., R1 had cut off her alarm bracelet on the night shift and was found in the garbage can. R1's progress note dated 3/29/26 at 4:14 p.m., R1 took Wanderguard off and will not allow replacement.R1's progress note dated 3/29/26 at 8:51 p.m., identified R1 had cut off Wanderguard with a scissor at some point during the night last night and was found in her room and was found in the garbage and then placed in the medication cart.During an interview on 4/15/26 at 4:25 p.m., director of nursing (DON) stated R1 had an elopement evaluation completed on 3/26/26 because R1 had started to make exit seeking comments; based on the evaluation it was determined R1 was at risk for elopement and had a Wanderguard placed on 3/26/26 as an intervention to reduce the risk for elopement. However, R1 removed her Wanderguard on 3/28/26 and again on 3/29/26 and would not allow staff to reapply a new one. DON explained R1 had been on hourly checks since 3/23/26 but had not had any increase in supervision and/or alternate interventions to reduce the risk of R1 eloping after R1 removed her Wanderguard. DON further explained R1 did not have an elopement focus care plan that informed staff of R1's elopement risk and interventions until 4/15/26.R1's progress note dated 3/31/26 at 6:37 a.m., identified R1 no longer had Wandergaurd on. R1's progress note dated 3/31/26 at 3:11 p.m., identified R1 does not wear [Wanderguard]. R1's progress note dated 3/31/26 at 10:57 p.m., identified R1 did not have a Wandergaurd and refused to apply during room checks. R1's progress note dated 4/1/26 at 7:29 a.m., identified R1 refused to wear [Wanderguard].R1's progress note dated 4/1/26 at 5:43 p.m., identified R1 approached writer and asked, Are you going to leave me too. R1 then said, I want to get out of here for a couple weeks and they will not let me. Writer explained to R1 that she could go on a leave of absence with a responsible party. R1 stated, Yeah right, they will not let me go and go to hell.During an interview on 4/16/26 at 11:44 a.m., social service designee (SSD) stated she did not feel R1's comments on 4/1/26 were exit seeking in nature, however, SSD was not aware that R1 had been determined an elopement risk on 3/26/26 and if she had been aware of this she would have considered this exit seeking comments and R1 should have had additional interventions put in place. R1's progress note dated 4/4/26 at 2:06 p.m., identified R1 was confused and following nurse around the facility. R1 was talking about people disappearing and when she opens her mouth and talks, she gets herself in trouble. R1 wandered around the facility all day and went outside with other residents but did not attempt to leave the facility. R1's progress note dated 4/7/26 at 3:01 p.m., identified R1 was confused this morning, walking around facility, following nursing staff seeking reassurance. R1 seemed very nervous, with her bottom lip quivering. R1 mentioned she needed to get her taxes done and she thought the writer was going to do them for her. Writer told R1 she could not do her taxes, then R1 approached writer shortly after with similar concerns. Staff called R1's power of attorney (POA) to talk to R1 to let her know POA would take care of her taxes. R1 then expressed concerns about where she was going to live and told R1 she could remain at the facility. R1's progress note dated 4/9/26 at 4:43 a.m., identified R1 stood outside of door and stated her toilet smelled. No odor noted from toilet, but staff flushed toilet to content her. R1's progress note dated 4/10/26 at 1:17 p.m., identified R1 informed staff that she had groundhogs in her room. Staff told R1 there was no groundhogs in her room. R1 then got very close to staff members face and stated, If you don't get those groundhogs out of my room, I'm going to slit your throat. Suggested to social services that R1 be moved to the front of the facility where she can be around more people and easier seen by staff. R1's progress note dated 4/10/26 at 3:00 p.m., identified R1 had a room change. R1's progress note dated 4/10/26 at 9:53 p.m., identified R1 spent a lot of shift by the nursing station due to being upset that she had a room change. R1 was offered food, but intervention was ineffective. In review of R1's record between 3/26/26 through 4/13/26 it was not evident R1's Wanderguard was reapplied, not evident the care plan interventions were re-evaluated for effectiveness nor evident a comprehensive assessment completed to determine individualized interventions including the appropriate level of supervision frequency after R1 had continued wandering and exit seeking without a Wanderguard in place. R1's Hourly Safety checklist reviewed from 4/3/26 through 4/13/26, was not completed. The checklist identified no safety checks documented for the following days/times: -4/3/26 through 4/5/26: No safety checks completed.-4/6/26: 1:00 a.m. through 5:00 a.m.; 10:00 p.m. or 11:00 p.m.-4/7/26: 1:00 a.m. through 5:00 a.m.; 3:00 p.m. through 11:00 p.m.-4/8/26: 1:00 a.m. through 5:00 a.m.; 10:00 p.m. or 11:00 p.m.-4/9/26: 1:00 a.m. through 5:00 a.m.; 3:00 p.m. through 11:00 p.m.-4/10/26: 1:00 a.m. through 5:00 a.m.; 10:00 p.m. or 11:00 p.m.-4/11/26: 1:00 a.m. through 5:00 a.m.; 10:00 p.m. or 11:00 p.m.-4/12/26: 1:00 a.m. through 5:00 a.m.; 10:00 p.m. or 11:00 p.m.-4/13/26: No documentation of any hourly safety checksR1's elopement incident report dated 4/13/26, identified R1 had been brought a sandwich at 4:55 a.m., when brought R1 pudding to her room at 5:03 a.m., R1 was not in her room. Staff searched the facility and grounds, called management, and found R1 at 5:28 a.m. R1 refused to return to the facility and was sent to emergency department with law enforcement. According to the weather station in [NAME]-[NAME] Weather Station (KMNTRACY12) the temperature on 4/13/26 at 5:04 a.m., had an actual temperature of 51.4 degrees.R1's emergency department (ED) note dated 4/13/26, identified R1 had been brought to the ED after going missing at the nursing home around 5:00 a.m. and was later found in the street wandering and became combative. R1 had stated she wanted to harm herself by jumping in front of a car. R1 was orientated to name and date of birth but required orientation to place. Not oriented to date or situation. R1 stated she would never actually hurt herself. R1 was unable to provide coherent history regarding events that occurred. R1 stated she had heard and seeing things before that were not there but was unable to provide further information regarding this. R1 had a history of Lewy Body Dementia and communication with R1's behavioral health provider recommended R1 be admitted to a geriatric psychology facility for re-evaluation and stabilization.During an interview on 4/15/26 at 12:58 p.m., nursing assistant (NA)-F stated R1 had a Wanderguard put on her a few weeks prior to her elopement and was told she had removed her own bracelet on 3/29/26 and refused to have another bracelet applied. NA-F stated they were not doing any additional interventions to mitigate the risk of R1 eloping such as increase in supervision especially since she had cut off her wander bracelet. NA-F explained R1 would always wander in the hallways through the day but was unsure if she had attempted to leave the facility prior to leaving on 4/13/26, however, R1 would make comments that she wanted to leave the facility at times. NA-F stated R1 had behavior changes in the past week prior to her eloping such as hiding around corners and watching staff closely and just acting differently. NA-F explained she had been instructed to read a handout on elopement that was at the nursing station but had not had time to read it yet. NA-F could not articulate where to locate how to identify if a resident was at risk for elopement but would reference the care plan/Kardex to help her identify which resident was at risk.During a phone interview on 4/16/26 at 6:38 a.m., licensed practical nurse (LPN)-A stated R1 had been moved to a different part of the building on 4/10/26 due to her hallucinating in her old room. R1 had been seeing groundhogs in her room and by moving R1 the facility thought it might help with her hallucinations. LPN-A explained she was the night nurse on 4/13/26 and R1 had been wandering in the hallways and had been given a snack around 4:30 a.m. then R1 went back to her room. LPN-A stated at around 4:55 a.m., R1 had returned to the nursing station to ask for something to eat. LPN-A then offered to get R1 some pudding and then R1 began to walk down the hallway in the opposite direction of her room, LPN-A then redirected R1 to the direction of her room and told R1 she would bring her the pudding to her room. LPN-A did not make sure R1 went to her room, she went to the kitchen to get ice water and pudding for R1 while NA-A went to go and answer a call light for another resident. LPN-A then went to R1's room around 5:03 a.m. and noticed R1 was not in her room. LPN-A then immediately had NA-A and NA-B begin to search for the facility for R1, but they were unable to locate R1. LPN-A then called 911 and had NA-A go outside to search around the building for R1. When NA-A could not locate R1 she had NA -B take her car to begin driving around the town for R1. LPN-A stated it was still dark out and the weather was foggy that morning. LPN-A stated NA-B had called her around 5:30 a.m., to say she had found R1 about 5-6 blocks away on the street and that R1 refused to return to the facility with her. LPN-A then sent NA-A to drive to the location of NA-B to assist. LPN-A explained neither NA-A nor NA-B could get R1 to return; R1 had become combative and began striking out at staff. LPN-A then sent other staff to attempt to get R1 to return to the facility.During an interview on 4/15/26 at 3:22 p.m., NA-A stated he was aware R1 had removed her Wanderguard bracelet on 3/29/26 and had refused to allow another bracelet to be applied, however, R1 had been on hourly checks since 3/23/26, but had not been doing the checks consistently during his shifts and would but he normally just kept a close eye on R1. NA-A was unaware of any other elopement intervention in place for R1 to prevent her from eloping. NA-A stated he worked the night shift on the day that R1 eloped from the facility. R1 had been awake that night and came to the nursing station around 4:30 a.m., asking for something to eat. Licensed practical nurse (LPN)-A had given R1 a sandwich and then R1 returned to her room. At around 4:55 a.m., R1 came back to the nursing station and asked for something else to eat at which time, LPN-A asked R1 if she would like some pudding. R1 did not respond but shrugged her shoulder and began walking in the opposite direction of her room, at which time LPN-A directed R1 in the opposite direction towards R1's room. As R1 was walking in the direction of her room, LPN-A headed towards the kitchen to get ice water for another resident and pudding. NA-A answered another resident's call light before R1 was seen entering her room. When NA-A completed answering the other resident's call light he was notified by LPN-A that R1 was missing, and he began to search the building to see if R1 could be located. NA-A then searched all the room and then began looking outside around the building but could not locate R1. LPN-A had given instructions to NA-B to get in her car and begin to search the town for R1. NA-B called NA-A at around 5:30 a.m., to inform him she had located R1 but needed additional assistance because R1 refused to go with NA-B. NA-A then got in his car and went to the location where R1 and NA-B were at which was about 5-6 blocks away. R1had shoes and a zip up hoodie when he got to her and still refused to go with either NA-A and NA-B and began to strike out at NA-A. NA-B and NA-A remained close by R1 and continued to try and convince R1 to come with them back to the facility, but R1 continued to refuse. At around 5:45 a.m., LPN-B arrived and attempted to get R1 to return to the facility but R1 continued to refuse. LPN-B then directed NA-A and NA-B back to the facility.During an interview on 4/15/26 at 3:01 p.m., NA-B was aware R1 had a Wanderguard placed, however, R1 had removed it and did not allow staff to replace it. R1 wandered around the facility at night and would sit at the nursing station to visit with staff. R1's cognition had been getting worse; she had been seeing things like groundhogs so on 4/10/26 she was moved to a different room to see if that would help. NA-B was unaware if R1 was on hourly checks and had not been documenting any hourly checks. NA-B stated she was working the night shift on 4/13/26 when R1 eloped from the facility. NA-B had received a call on the walkie talkie around 5:00 a.m. from LPN-A giving her direction to search the facility for R1 because she was missing from her room. NA-B searched her wing and could not locate R1. About 5:10 a.m., she was told by licensed practical nurse (LPN)-A to get in her car and drive around town to see if she could locate R1. NA-B stated it was dark and foggy outside when she got in her car and began driving slowly around town. Around 5:30 a.m., she found R1 walking about five or six blocks from the facility. NA-B had attempted to get R1 to return to the facility with her but R1 refused, so NA-B called the nursing home and asked for another staff member to assist her. R1 continued to walk toward the main street and continued to refuse to come back to the facility. During an interview on 4/16/26 at 11:44 a.m., social services designee (SSD) stated the facility had moved R1 on 4/10/26 to a different room on a wing closer to the nursing station to keep a better eye on R1 because her cognition had begun to decline and she had been having more hallucinations in her previous room. The move had not been based on her elopement risk; nursing had been attempting to get R1 to move to her current location by the nursing station for some time. SSD stated she had been contacted on 4/13/26 around 5:34 a.m., SSD was informed R1 had eloped from the facility. SSD walked to the location where staff were at with R1. SSD stated she remained with R1 who had continued to refuse to come with staff back to the facility. SSD stated R1 had continued to walk across a railroad track and stated, she wanted to just walk in front of train and end it all. SSD explained she remained walking with R1 who then walked across a busy highway and finally sat on a bench in front of the gas station when the local police arrived and took R1 to the ED.During a phone interview on 4/16/26 at 2:42 p.m., medical director (MD) stated any resident identified at risk for wandering/elopement should have appropriate interventions in place to mitigate the risk of the resident eloping. MD explained by R1 being allowed to elope on 4/13/26 this put her at risk for serious harm, injury, or even death. During a follow up phone interview on 4/16/26 at 4:26 p.m., MD explained R1 had worsening cognition due to her Lewy Body Dementia and was not able to make safe decisions and this was why she was in the nursing home in the first place. During an interview on 4/15/26 at 4:25 p.m., DON explained that after R1 had eloped they had completed a re-assessment of all residents on 4/14/26 for elopement risk, reviewed/revised care plans, and provided began providing education to the nursing staff on elopement and what to do if a resident elopes, but did not provide any education on what to do if a resident removes a Wanderguard. Although the DON reported after R1 eloped on 4/13/26, all residents were re-assessed for elopement risk, care plans were reviewed/revised, and staff were educated, the facility failed to ensure the identified elopement risks for R4 and R6 were incorporated into individualized care plan interventions that were implemented, and clearly communicated to staff, and failed to ensure consistent monitoring. -R4's face sheet dated 4/20/26, identified diagnoses of dementia,R4's quarterly MDS dated [DATE], indicated R4 had moderate cognitive impairment, physical and verbal behaviors that occurred one to three days, no rejection of care, had no impairment on upper extremities, used a wheelchair, was dependent with wheelchair mobility, had no wandering, had falls since admission, and did not use a wander/elopement alarm.R4's Elopement/Wandering focus care plan dated 12/19/24, identified R4 was low risk for Wandering/Elopement.-Identify if there are triggers for wandering/eloping. (dated 12/20/24) R4's progress note dated 3/5/26 at 10:05 a.m., identified R4's call light was on, however R4 was headed towards the lobby and the nursing station. R4 stated he wanted to get in the recliner, staff told him they needed to get a second person for assistance. R4 stated he wanted to get out of the f----ing place.R4's progress note dated 3/22/26, identified R4 became upset when his wife went home and stated, he is stuck here, and she gets to leave.R4's Elopement Evaluation dated 3/27/26, identified R4 was at risk for elopement due to verbally expressing desire to go home, pack belongings or stayed near the exit door.R4's Elopement Evaluation dated 4/14/26, identified R4 was at risk for elopement due to verbally expressing desire to go home, pack belongings or stayed near the exit door. R4's care plan did not include individualized care plan with interventions to mitigate the risk of elopement. During an interview on 4/16/26 at 9:22 a.m., LPN-B stated R4 gets upset at times that he cannot leave the facility when his wife leaves after visiting and makes exit seeking comments after she leaves. LPN-B stated she was not aware if R4 had been determined an elopement risk, however, LPN-B stated R4 was able to propel himself in his wheelchair throughout the facility at times and could easily attempt to leave the facility unaccompanied.During an observation on 4/16/26 at 9:45 a.m., R4 was seated in his wheelchair in the day room and was seen propelling himself in his wheelchair around the room. During interview on 4/16/26 at 12:39 p.m., NA-D stated that she referred to a resident's care plan/ Kardex to identify if a resident who wanders and if they were at risk for elopement and what interventions were in place. NA-D stated R4 could wheel himself in his wheelchair and could push the handicap button and get out the door if he wanted to. NA-D stated R4 would get upset and state he wanted to go home with his wife visited and left the building. NA-D stated staff redirected R4 and reminded him why he could not go home with his wife. NA-D stated R4's mood was better, since R4 was more used to staff. NA-D reviewed R4's Kardex and confirmed the Kardex did not identify R4 as an elopement risk, no triggers, nor a listing of interventions to mitigate elopement. During an interview on 4/16/26 at 1:25 p.m., assistant director of nursing (ADON) stated R4 had been identified as a risk for elopement, however, ADON believed R4 would not be strong enough to propel himself in his wheelchair to get himself outside and did not have any additional interventions like a Wanderguard applied to alert staff if he attempted to leave. R6R6's face sheet dated 4/20/26, identified diagnoses of dementia, Parkinson's disease, and diabetes.R6's admission MDS dated [DATE], identified R6 had moderate cognitive impairment, no behaviors, no rejection of cares, no wandering, used a walker, was independent with transfers, independent with ambulation, and did not use a wheelchair.R6's Elopement Evaluation dated 3/31/26, identified R6 was at risk for elopement due to a history of elopement or an attempted elopement while in home; R6 had been admitted within the past 30 days and is not accepting the situation. Intervention selected to engage in purposeful activity.R6's Wandering/Elopement care plan dated 3/31/26, identified R6 was at risk for wandering/elopement. Goal to not leave the facility unattended with a corresponding intervention directing staff to engage resident in purposeful activity. R6's progress note dated 3/31/26, identified R6 had poor safety awareness on admission.R6's progress note dated 3/31/26, identified R6 as an elopement risk and utilized wander elopement alarm. Review of R6's record revealed no indication of Wanderguard placement until 4/15/26. R6's progress note dated 4/1/26, identified a resident preference evaluation completed. R6 identified it was very important to him to go outside to get fresh air when the weather is good. R6's progress note dated 4/1/26 at 4:30 a.m., identified R6 was up one time during shift and asking for a snack and then ambulated to the south side of the building to stretch his legs a little.R6's Elopement Evaluation dated 4/14/26, identified R6 was at risk for elopement due to verbally expressed the desire to go home, packed belongings to go home, or stayed near the exit door, recently admitted to the facility within the past 30 days and is not accepting the situation. Intervention selected to engage in purposeful activity and monitor location frequently. R6's elopement evaluation did not identify history of elopement that was identified in R6's 3/31/26 elopement evaluation. R6's care plan did not identify any revisions to his care plan to mitigate the risk of elopement.R6's progress note dated 4/14/26 at 6:18 p.m., identified R6 stated he had a home to go to/live in. Wanderguard attempted to be placed on 4/14/26, however, R6 refused. Will attempt to place Wanderguard again on 4/15/26. R6's record did not identify any additional elopement prevention interventions to R6's care plan since R6 refused to have a Wanderguard be applied.R6's progress note dated 4/15/26 at 10:00p.m., identified a Wanderguard placed on R6's left wrist.R6's wandering/elopement care plan revised on 4/15/26 to include the following: -Identify wandering/elopement de-escalation behaviors, Wanderguard placed on 4.15.26. -Identify if there are triggers for wandering/eloping -R6 does have Wanderguard in place. During an interview on 4/16/26 at 9:22 a.m., LPN-B stated R6 has wandered throughout the facility since admission and also made exit seeking comments about wanting to go home to get his back brace. LPN-B explained she was not made aware R1 was an elopement risk until she was asked to place a Wanderguard on R6 on 4/15/26. LPN-B further explained R6 could have easily eloped from the facility prior to 4/15/26 because he was independent in the facility with only his walker and staff may not have seen him leave.During interview on 4/16/26 at 12:39 p.m., NA-D stated R6 was admitted to the facility a few weeks ago and would wander in the hallways independently with a walker. NA-D explained R6 made comments about wanting to go home at times. NA-D reviewed R6's Kardex and was unsure of R6's triggers for Wandering and/or elopement.During an interview on 4/16/26 at 1:01 p.m., ADON stated R6 was identified as an elopement risk on admission because R6 had eloped from a previous facility. ADON explained she determined R6 should have a Wanderguard bracelet placed on admission, however, the facility did not have any Wanderguard bracelets at the time of admission that were not expired, and the facility was unable to place a bracelet on R6. ADON further explained the facility had not put any additional interventions in place to prevent R6 attempting to leave the facility unsupervised and should have put things in place prior to placing the Wanderguard on 4/15/26.During an interview on 4/16/26 at 12:46 p.m., NA-C stated she was aware R1 was an elopement risk but did not identify R4 nor R6 as an elopement risk and was unsure of any interventions to mitigate the risk of R4 or R6 from leaving the facility unattended. NA-C stated Wanderguards were a replacement for resident supervision and if a resident had a wander bracelet they would not need to be supervised as much. Review of the facility's Safety and Supervision of Resident's Policy undated, identified the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities.Individualized, Resident-Centered Approach to Safety-Our individualized, resident-centered approach to safety addresses safety and accident hazards for individualized residents.-The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individualized residents.-The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.-Implementing interventions to reduce accident risks and hazards shall include the following: Communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training as necessary; ensuring that interventions are implemented; documenting interventions. -Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; evaluating the effectiveness of new or revised interventions. Review of the facility's Wander Management Policy dated 6/24/22, identified a wander management alarm system may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for elopement. PROCEDURE-A nursing assessment of each resident must be done per established frequency risk for elopement.-A plan of care must be formulated with the Interdisciplinary Team (Nursing, Physical Therapy, Occupational Therapy, Dietary, Activities, Social Worker, and Resident/Family), to determine the need for the wander guard bracelet and this information will be documented in the resident care plan.-The wander management system bracelet will be applied to the resident's dominant wrist (per manufacturer instruction). The wander management bracelet should not be removed until replacement is needed and/or the resident is discharged from the unit or facility. The wander management bracelet expiration date and model # (if available) should be documented in the resident wander management physician order and care plan.-After applying the wander management system bracelet, a safety check to make sure the bracelet fit is appropriate per manufacturer instructions. This safety check must be completed and documented in the resident medical record before leaving the resident.-The wander management system bracelets are checked every shift for placement and weekly for function. The IJ was removed 4/17/26, when it was verified, the facility completed the following:-The Elopement and Safety/Supervision of Resident Policy and Procedure was reviewed with no revisions warranted.-All current residents were reassessed for elopement risk and care plan interventions put in place to mitigate the risk for elopement.-R4 was placed on 15-minute checks and then had a wanderguard placed.-R6 had a wanderguard applied.-R4 and R6 had resident centered interventions added to their care plan if they attempt to exit seek.-Facility nursing staff were in-serviced on the Safety/Supervision of Resident Policy prior to the beginning of their shift.

Based on interview and document review the facility failed to develop a comprehensive person-centered Elopement care plan that included interventions to mitigate the risk of elopement for 1 of 1 resident (R1) reviewed for accidents. Findings include:R1's face sheet dated 4/15/26, identified diagnoses of unspecified dementia without behavioral disturbance and depression.R1's Quarterly Minimum Date Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, had delusions/hallucinations, no other behaviors, no rejection of care, no wandering, did not use a walker or wheelchair, was independent with transfer and ambulation, had two or more falls since admission with no injury, and used a wander/elopement alarm daily. R1's elopement evaluation dated 3/26/26, identified R1 was at risk for elopement due to wandering behaviors that were likely to affect the safety or wellbeing of others. R1 had a personal safety device applied.During an interview on 4/15/26 at 4:25 p.m., director of nursing (DON) stated R1 had an elopement evaluation completed on 3/26/26 due to R1 making exit seeking comments and was determined to be at risk for elopement and had a wanderguard (name brand for a personal safety device) placed as an intervention. DON explained R1 had not used a wanderguard prior to that date.Review of R1's care plan 3/26/26 through 4/13/26, did not identify an elopement focus care plan had been initiated with interventions to prevent R1 from leaving the facility unsupervised.R1's elopement incident report dated 4/13/26, identified R1 had been brought a sandwich at 4:55 a.m., when brought R1 pudding to her room at 5:03 a.m., R1 was not in her room. Staff searched the facility and grounds, called management, and found R1 at 5:28 a.m. R1 refused to return to the facility.R1's record identified R1's care plan for elopement was not developed and initiated until 4/15/26 which included R1 was at risk for wandering/elopement. Goal that R1 will not leave facility unattended. Interventions dated 4/15/26 as follows:-Clearly identify resident's room and bathroom.-Identify if there are triggers for wandering/eloping. R1 is suspected to have Lewy Body type dementia; provide R1 with medications as ordered.-Identify if there is a certain time of day wandering/elopement attempts to occur.-Identify if there is a certain time of day wandering/elopement attempts occur.-Identify wandering/elopement de-escalation behaviors.-Provide care in calm and reassuring manner.-Provide clear and simple instruction. During an interview on 4/15/26 at 12:58 p.m., nursing assistant (NA)-F stated R1 had a wanderguard put on her a few weeks prior to her elopement and was told she had removed her own bracelet on 3/29/26 and refused to have another bracelet applied. NA-F stated she was not aware if R's care plan had any increased supervision since she had cut off her bracelet nor any other interventions in place to prevent her from eloping. NA-F explained R1 would always wander in the hallways through the day but was unsure if she had attempted to leave the facility prior to leaving on 4/13/26, however, R1 would make comments that she wanted to leave the facility at times. During an interview on 4/16/26 at 4:42 p.m., director of nursing (DON) stated R1 should have had a wandering/elopement care plan initiated on 3/26/26 when the elopement assessment had been completed to inform staff of needed interventions to mitigate the risk of R1 eloping, however, R1 elopement care plan was not initiated until 4/15/25 after R1 had eloped on 4/13/26. Review of the facility's Care Plans, Comprehensive Person-Centered Policy undated, identified a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: -Include measurable objectives and timeframes. -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. - Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. -Describe any specialized services to be provided as a result of PASARR recommendations. -Include the resident's stated goals upon admission and desired outcomes. -Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire. -Incorporate identified problem areas. -Incorporate risk factors associated with identified problems. -Build on the residents' strengths. -Reflect the resident's expressed wishes regarding care and treatment goals. -Reflect treatment goals, timetables, and objectives in measurable outcomes. -Identify the professional services that are responsible for each element of care. -Aid in preventing or reducing decline in the resident's functional status and/or functional levels. -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and -Reflect currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. -Care planning individual symptoms in isolation may have little, if any, benefit for the residents.

Based on observation, interview, and document review, the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and revise the care plan to prevent and/or reduce the risk for future falls for 2 of 3 residents (R2, R4) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for 2 when he sustained a head laceration following a fall and an IJ for R4 when after repeated falls sustained shoulder dislocation that had not identified since the last imaging that did not show dislocation on 7/30/25. The IJ began on 10/20/25 after R2 had a fall that resulted in head laceration, the facility failed to complete a comprehensive analysis and implement appropriate interventions which resulted in and/or could have mitigated the risk of subsequent falls. The administrator and director of nursing (DON) were notified of the IJ on 11/13/25 at 4:01p.m. The immediate jeopardy was removed on 11/17/25 at 4:45 p.m., but non-compliance remained at the lower scope and severity level D, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include:R2's face sheet dated 11/14/25, identified diagnoses of Alzheimer's disease (a progressive neurological disorder and the most common cause of dementia), congestive heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs), diabetes mellitus (the body does not produce enough insulin), and chronic obstructive respiratory failure (when the airways that carry air to the lungs become narrow or damaged). R2's fall focus care plan dated 2/3/25, identified R2 was at risk for falls as evident by scoring tool, antidepressant use, and wandering behaviors. R2's care plan goal was to be free from falls. Interventions included:-educate on the importance of maintaining a safe environment, free from potential fall hazards.-evaluate fall risk on admission and as needed; review medication for drugs that increase the risk for falls.-Intervention added on 5/12/25 to assist R2 with ambulation and transfers, utilizing therapy recommendations. R2's fall risk assessment dated [DATE], identified R2 was at risk for falls due to having 1-2 falls in the past 3 months; disorientated; balance with standing and while walking; takes 3-4 high risk medications; had a change in medication (or medication class) or change in dosage in the past five days. No interventions under risk for falls were selected on the assessment. R2's Annual Minimum Data Set (MDS) dated [DATE], indicated R2 had severe cognitive impairment. R2 used a wheelchair and needed supervision/touching assistance for transfers, had one fall with no injury, one fall with minor injury since admission and had severe cognitive impairment. R2's progress note dated 10/20/25 at 3:18 a.m., identified R2 was found on the floor sitting between bed and his chair, bed table next to the wall with blood on the floor and a laceration on the back of the head 7-8 centimeters (cm) across and had to be taken to the hospital. R2's fall incident report dated 10/20/25 at 1:46 a.m., identified R2 was found on the floor in his room with a 7-8 cm laceration on the back of his head and an abrasion on the right inner arm. R2 thought he was answering the phone. There was no indication of a comprehensive analysis to identify causal factors was completed, no immediate interventions, and no indication R2's care plan was revised. R2's emergency department (ED) note dated 10/20/25, identified R2 was seen following a fall at the nursing home and sustained a 6.0 cm laceration on the top of his head and needed to have the scalp wound closed with 8 or 9 staples and bandage applied.R2's progress note dated 10/20/25 at 4:44 a.m., identified R2 returned from the ED and was to have sutures removed in 9-10 days. R2's fall incident report dated 11/4/25 at 8:45 a.m., identified R2 was found in his room kneeling and leaning on a chair in his room. There was no indication of a comprehensive analysis to identify causal factors was completed, no immediate interventions, and no indication R2's care plan was revised. R2's progress note dated 11/5/25 at 11:10 a.m., identified a long-term care evaluation completed for R2. R2 had two falls since last evaluation and had a safety concern with a high fall potential. R2's progress note dated 11/6/25 at 11:51 p.m., identified R2 was given a wheelchair related to him being unsteady on his feet. R2 was given an as needed Seroquel. R2's care plan had not been revised to identify an intervention that R2 required a wheelchair. R2's progress note dated 11/7/25 at 10:42 a.m., identified family had been asked about getting a different chair as current chair is not safe and difficult for resident to get to standing position. Family stated they had a chair they will bring in to replace the current chair. Offered to use a chair from the facility and family stated they will bring one in. R2's fall incident report dated 11/7/25 at 6:29 p.m., identified R2 was found lying on his face in his room at 5:50 p.m. There was no indication of a comprehensive analysis to identify causal factors was completed, no immediate interventions, and no indication R2's care plan was revised. R2's fall incident report dated 11/9/25 at 4:50 p.m., identified R2 was found sitting on the floor in his room next to his chair. R2 was trying to pick up specks on the floor and had been sitting in chair which is low to ground. R2's fall incident report dated 11/10/25 at 8:30 p.m., identified R2 was found sitting between chair and bedside table. There was no indication of a comprehensive analysis to identify causal factors was completed, no immediate intervention, and no indication R2's care plan was revised. R2's fall incident report dated 11/11/25 at 8:30 p.m., identified R2 was in hall and grabbed the handrail to pull himself up to a standing position and began walking and then started going down and before staff could get to R2 he fell to the ground. There was no indication of a comprehensive analysis to identify causal factors was completed, no immediate intervention, and no indication R2's care plan was revised. During an interview on 11/13/25 at 10:23 a.m., consulting pharmacist (C-Pharm) stated normally the facility would notify her of a resident having frequent falls to perform a medication review to see if medication could be a cause of the frequent falls, however, had not been notified of R2's frequent falls. C-Pharm further indicated since R2 was administered Seroquel, an antipsychotic medication, which could increase risk for falls because of the associated side effects of drowsiness, dizziness, and orthostatic hypotension (sudden drop of systolic blood pressure with position changes). Since 10/31/25, R2 had duplicative antipsychotic therapy because Haloperidol as needed (PRN) was added in addition to Seroquel which may have caused the increase in R2's falls since 11/7/25 due to that type of medication given more frequently. R2's progress note dated 11/12/25 at 10:56 p.m., identified R2 was seen wanting to stand up from wheelchair and was unsteady on his feet. R2 then began pulling on his pants like he wanted to use the bathroom. Staff provided 1:1 with R2 in his room and after calmed down was brought to lobby for proper supervision. R2's care plan and Kardex (abbreviated care plan) were not revised to include nor define proper supervision. During an interview on 11/12/25 at 12:05 p.m., licensed practical nurse (LPN)-A stated R2 had fallen a few times since 11/7/25. however, had not been informed of any new fall prevention interventions for R2. LPN-A stated the nurses did not update the care plan nor determine a root cause of a fall and thought the DON was responsible for that but was not sure. During an interview on 11/12/25 at 10:51a.m., (Interim Assistant Director of Nursing (I-ADON) stated R2 had fallen a bunch of times this weekend, however, was not able to articulate what occurred during the falls. During a follow up interview at 3:56 p.m., I-ADON was unable to articulate fall prevention interventions for R2 and stated R2 needs One to one at times, but we are not able to provide that service. R2's falls had been discussed at the morning meetings; however, a causal analysis had not been completed, and he had not been trained on the process, so he was unsure of the facility's process on completing the causal analysis following a fall. I-ADON indicated he had not made any revisions to R2's care plan and was unsure whom in the facility would be responsible for the updates. During an interview on 11/12/25 at 5:11 p.m., director of nursing (DON) stated R2 was a high fall risk and was very impulsive due to his diagnosis of Alzheimer's. DON stated R2's fall that occurred on 10/20/25 resulted in a large laceration on the back of his head that required him to be sent to the ED to have the area sutured. R2 had falls in the facility after 10/20/25, however, had not had a comprehensive causal analysis performed for any of his falls. R2's care plan was not revised to include individualized fall prevention interventions to mitigate the risk of future falls and limit the likelihood for serious injury. DON stated, this should have been done.During an interview on 11/12/25 at 12:38 p.m., LPN-B stated following a resident's fall, the nurses needed to fill out the risk management (incident report) documenting what happened during the fall, If the nurse determined an appropriate fall intervention it would be verbally passed onto the next shift until the IDT reviewed the incident information. LPN-B stated the nurses do not update the care plan to include new fall prevention interventions and had not been instructed to do so. During an interview on 11/12/25 at 3:23 p.m., registered nurse (RN)-A stated she was working when R2 fell on [DATE]. RN-A stated she had not completed a comprehensive causal analysis of R2's fall and believed the ADON and DON would have that completed. RN-A stated she told staff R2 needed to be kept in the lobby for close supervision and normally would include this in the progress notes so the next shifts would be aware, however, she had not documented the intervention in R2's progress notes. R2's fall incident report dated 11/13/25 at 6:30 a.m., identified R2 was sitting in his swivel recliner 30 seconds prior and then was found on the floor laying on his left side. R2 sustained an abrasion to left elbow. Nurse called the daughter and asked her to bring a new chair for R2 and remove the swivel recliner. During an interview on 11/13/25 at 8:08 a.m., licensed practical nurse (LPN)-B stated R2 had fallen from his swivel recliner in his room today. LPN-B had been asking for a while for the swivel recliner to be removed, however, it had not been removed. LPN-B explained the swivel recliner was the cause of most of R2's falls because the chair was low to the ground, and it moved when he attempted to stand up. LPN-B stated she would check if there was a stationary chair in the facility until family could bring a chair from home. During an interview on 11/13/25 at 8:22 a.m., I-ADON stated R2 had fallen out of his swivel recliner around 6:30 a.m. today. The hospice aide was in R2's room, the side left R2 sitting in his recliner when she left the room, only 30-seconds later she returned to find R2 on the floor. I-ADON stated R2 could be very quick when he would self-transfer; staff tried their best to keep an eye on R2 when he was awake, but there are times when staff needed to leave him alone do other things and in that time R2 could fall and get injured.During an observation on 11/13/25 at 9:42 a.m., R2 was seated in a wheelchair next to the nursing station, When R2's family entered the facility, R2 stood up from his wheelchair with the breaks unlocked (no anti-roll back devices on the wheels) and started to walk towards his family without staff's awareness or presence. R2 was unsteady on his feet so he grabbed ahold the top of the nursing station with his left hand while he walked. R2's family informed R2 they were going to bring him a new chair. R2's family stood next to him attempting to get him to sit back in his wheelchair. At 9:50 a.m. staff came and assisted R2 back to his room with family.During an interview on 11/13/25 at 10:00 a.m., family member (FM)-D stated they brought in a new chair because today he fell out of it again. FM-A stated the facility talked to them about getting a new chair at the last care conference, however, just have not had time to bring it until today. During an interview on 11/13/25 at 9:52 a.m., nursing assistant (NA)-A could not articulate what the fall prevention interventions were for R2 and stated she would need to check the care plan/Kardex in the electronic health record (EHR), upon looking at R2's Kardex/care plan she only identified call light should be within reach. NA-A further stated we would attempt to keep R2 seated in his wheelchair because he was unsteady on his feet and been complaining of feeling dizzy at times. Staff would attempt to distract him when he was agitated. NA-A also stated if the interventions were not in the care plan/Kardex, staff would be unsure of the falls preventions interventions that were in place. During an interview on 11/12/25 at 3:02 p.m., NA-B was unable to articulate fall prevention interventions for R2 and stated if we saw him get up from his chair, we would attempt to get him to sit back down or distract him. NA-B stated she would review a resident's care plan to see what the fall interventions were, but looked on R2's EHR and did not see any specific fall prevention interventions his care plan should be updated to make sure staff were aware of what they were supposed to do to keep R2 safe.During an interview on 11/13/25 at 1:41 p.m., medical director (MD) stated the likelihood of R2 getting serious injury from a fall is pretty high and any resident with a fall from any height has the likelihood to sustain serious injury following a fall from any height.R4's face sheet dated 11/14/25, identified diagnoses of unspecified dislocation of right shoulder joint, obesity, and schizophrenia.R4's Quarterly MDS dated [DATE], indicated R4 did not have cognitive impairment. R4 had no limitation in range of motion in her upper extremities and used a walker and wheelchair. R4 was independent in transfers, continent of bowel, and frequently incontinent of urine. The MDS identified R4 had no falls since prior assessment even though R4 had documented falls on 8/2/25 and 8/7/25. R4's fall focus care plan revised on 5/21/25 identified R4 was high-risk for falls related to confusion, deconditioning, psychoactive medication drug use, and history of voices in her head telling her to fall to the floor. Goal was to not sustain serious injury. Interventions dated 11/20/24, identified as the following: -Be sure call light is within reach and encourage to use it for assistance as needed. The resident needs prompt response to all requests for assistance.-encourage the resident to participate in activities that promote exercise, physical activity for strengthening an improve mobility such as walking with staff. -Review information on past falls and attempt to determine cause of falls. Record possible root cause. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes.-the resident needs activities that minimize the potential for falls, while providing diversion and distraction, group activities, puzzles, word searches, reading materials, and coloring activities. -the resident uses grab bars on her bed to assist with repositioning and the need to feel safe. Resident has a low bed and fall mat. R4's fall incident report dated 8/2/25 at 9:30 a.m., identified R4 was getting dried off from the shower with staff assistance, then slammed her walker into the wall of the tub room and put herself on the floor and indicated this was a behavior. R4 broke her walker and had no injury. R4 was placed in a wheelchair until walker could be fixed. There was no indication of a comprehensive analysis to identify potential modifiable and non-modifiable risk factors other than R4's behavior. Although a behavior was identified as a causal factor there was no indication of immediate intervention that addressed R4's behavior of putting herself on the floor nor evident R2's care plan was revised. R4's fall incident report dated 8/6/25 at 10:30 a.m., identified R4 was heard hollering in her room and was observed lying safely on her bed. Staff reassured resident and left the room when R4 began to holler again. About one minute later was found on the floor next to her bed and over the bed table. R4 was assisted off the floor and then taken to the lobby area where she could be observed more closely/frequently. There was no indication of a comprehensive analysis to identify causal factors was completed and no indication R2's care plan was revised. R4/s fall incident report dated 8/25/25 at 11:00 a.m., identified a witnessed fall was observed in the lounge. R4 put herself on the floor and was witnessed by staff. There was no indication of a comprehensive analysis to identify causal factors was completed and no indication an immediate intervention was implemented nor evident R2's care plan was revised. During an interview on 11/13/25 at 1:32 p.m., DON reviewed R4's fall record and stated she did not interview staff to determine all potential causal factors of R4's fall on 8/2/25 and 8/25/25. R4's fall incident report dated 9/4/25 at 8:45 a.m., identified R4 was walking with her walker from common area to her room, when she started to [NAME] towards the wall, she then let go of the walker and held onto the handrail and lowered self to the floor to a sitting position. There was no indication of a comprehensive analysis and although the report identified an intervention for physical therapy to evaluate and treat, there was no indication of an immediate intervention that would prevent/mitigate the risk for falls until the therapy evaluation and treatment if applicable. R4's physical therapy (PT) evaluation note dated 9/9/25, identified R4 had pain in right shoulder. History of falls in past year, however, exact number unknown; patient was injured from fall with the current injury. R4 had a fear of falling and right upper extremity had impaired range of motion. Reason for therapy was to facilitate motor control, minimize falls and enhance rehab potential. Although R4 had reported right shoulder pain there was no indication she was evaluated by a physician. R4's fall incident report dated 10/1/25 at 1:00 p.m., identified R4 was found on the floor next to her bed with two pillows under her head. R4 stated I put the pillows down and laid on the floor and should not have done that. R4 had an incontinent stool at the time of the fall. There was no indication of a comprehensive analysis to identify causal factors was completed, no immediate intervention, and no indication R2's care plan was revised. R4's fall incident report dated 10/28/25 at 4:00 p.m., identified R4 was found sitting down on the floor. R4's bed was in the lowest position and R4 stated she slid down the bed. There was no indication of a comprehensive analysis to identify causal factors was completed, no indication of immediate intervention, and no indication R4's care plan was revised. R4's fall incident report dated 11/6/25 at 10:00 a.m., identified R4 was found on the floor face down, with the table tipped over and pants and underwear down. R4 was having pain all over and was sent to the emergency department for evaluation. R4's progress note dated 11/6/25 at 12:18 p.m., identified nurse had eyes on R4 at 9:45 a.m. during medication pass, R4 was sitting in the chair and had pants down around ankles and this nurse assisted R4 to get pants back up. R4 was compliant and redirected. Then at 10:00 a.m., R4 was found on the floor with face to the floor. R4 was having pain all over and was sent to the ED.R4's emergency department (ED) orthopedic consult note dated 11/6/25, identified reason for the consult was right shoulder dislocation. R4 fell earlier in the day and sustained an injury to her right shoulder and hip. R4 had had a right shoulder dislocation that failed closed reduction back in April and subsequently underwent open reduction. Findings on CT scan suggest that this dislocation is not acute and is chronic in nature. Patient's daughter does note that R4 has had several falls after the initial shoulder reduction in April of 2025. It is likely that shoulder dislocated with one of these falls [while a resident at the facility], but R4 was never formally evaluated. R4 had significant limitation to range of motion of the shoulder for several months now. I do not believe an attempted closed reduction would not be successful at this point as her shoulder has likely been dislocated for some time now. R4's progress note dated 11/6/25 at 5:05 p.m., R4 returned from ED and had an order that R4 may wear sling for comfort and was to follow up with orthopedics if continued shoulder pain, to discuss surgical correction. Upon return from the ED there was no indication of a comprehensive analysis to identify causal factors was completed, no indication of immediate intervention, and no indication R4's care plan was revised. R4's fall risk assessment dated [DATE], identified R4 was high-risk for falls due to three of more falls in past 3 months, ambulatory/incontinent, three or more predisposing diagnoses, and takes 3-4 medications.R4's nurse practitioner nursing home visit note dated 11/10/25, identified R4 was seen following an ED visit on 11/6/25 after a fall. Right shoulder CT showed anterior glenohumeral dislocation (when the ball of the upper arm bone is forced out of the shoulder's cup shaped socket) with the humeral head abutting the coracoid process. Was recommended to see orthopedics for a follow up, however, declined to be seen. R4 had underwent reduction right shoulder under anesthesia 4/8/25. R4 had been following orthopedics and last x-rays done 7/30/25 showed no acute fracture or dislocation of the right shoulder (indicating the dislocation happened after 7/30/25).During an interview on 11/13/25 at 12:03 p.m., nurse practitioner (NP) stated R4 was seen for an ED follow up from 11/6/25. R4 has a right shoulder dislocation and orthopedics offered her a follow up and R4 declined. R4 had had surgery to replace a right shoulder dislocation in April 2025, which could make R4's shoulder weaken and could have easily dislocated again. During an observation and interview on 11/13/25 at 9:30 a.m., R4 had her right arm in a sling and stated the last time she fell she was trying to take herself to the bathroom, lost her balance and fell on her shoulder. R4 stated her shoulder began to hurt really bad and had to be sent to the ED to have it checked out. And it sounded like it was dislocated again which may have been from one of my falls I had, but she was not sure. During an interview on 11/13/25 at 9:52 a.m., nursing assistant (NA)-A stated R4 sometimes would try to take herself to the bathroom and fall. NA-A was unaware of any fall prevention interventions that were currently in place for R4. NA-A then opened the electronic health record (EHR) and found R4's care plan and stated her fall care plan just said call light in reach and gait belt, however, was not able to find any further care plan interventions. During an interview on 11/13/25 at 1:24 p.m., director of nursing (DON) stated she was not aware of what the facility's fall prevention program consisted of nor what the facility's policies were. DON further stated she had not performed a causal analysis of any of R4's falls and was unaware she was supposed to be documenting in the resident's record and updating the care plan. DON stated she had not had any formal training on how to perform a root cause analysis and was trying to read up on how that was completed. During an interview on 11/17/25 at 11:35 a.m., DON stated the IDT team determined R2's falls had been caused by the swivel chair moved when R2 attempted to get up from the chair; the chair has been removed from R2's room and R2 had been placed on one-to-one supervision. R4 had a fall prevention intervention added to her care plan to offer toileting if R4 was observed pulling her pants down, however, had been placed under the incorrect focus in R4's care plan and would be moved under the appropriate focus. During an observation on 11/17/25 at 10:43 a.m., R4 was seated in her wheelchair in the lobby when R4 stood up and began pulling her pants and brief down. NA-E then walked up to R4 and assisted R4 to pull her pants back up, however, did not offer R4 to toilet (according to the care plan), instead rolled R4 to the DON's office. During an interview on 11/17/25 at 11:07 a.m., NA-E stated he was unaware of R2 and R4's fall prevention interventions and had not had anything passed on in report. NA-E then went to the EHR, but was unable to locate fall prevention focus care plan along with the fall interventions for R2 and R4. During an interview on 11/17/25 at 10:55 a.m., NA-C stated she was unaware of fall prevention interventions for R2 and R4 and stated she would need to check the care plan/Kardex, however, was unable to find the fall interventions for R2 or R4 in the care plan/Kardex.During an interview on 11/17/25 at 12:18 p.m., LPN-C stated if a resident had a fall she would then add a new intervention to the care plan to prevent future falls. LPN-C stated she would add an appropriate intervention based on the likely reason for the fall, however, was unsure how to make sure the intervention was added to the Kardex. The immediate jeopardy that began on 10/20/25, was removed on 11/17/25 at 4:45 p.m., when it was verified, the facility implemented the following:-The facility reviewed their fall policies, and no revisions were warranted.-R2 and R4's falls were reviewed by the interdisciplinary team (IDT) and the incident reports were updated indicating a causal analysis and care plans updated.-Fall risk assessment scoring report was run and identified residents who are high risk for falls who experienced a fall since 11/1/25 had their care plans reviewed and/or updated based on a root cause analysis of the falls. - The facility in-serviced nurses and nurse aides on the assessing causes of falls policy with emphasis on the entire policy with special focus on the steps in the procedure items, documentation, and reporting. -Interdisciplinary team (IDT) was in serviced on comprehensive care plan with emphasis on direction to develop care plan interventions after a thorough review of data and sequencing events and that assessments of residents are ongoing, and care plans need to be revised as the resident's condition changes. -IDT was in-serviced on falls and falls management with focus on the policy section entitled Monitoring subsequent falls and fall risk which instructs the team to monitor and document the resident's response to interventions to reduce falls Review of the facility's Falls and Fall Risk, Managing policy undated, identified Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Included the following: Resident-Centered Approaches to Managing Falls and Fall Risk1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once).3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc.4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period.5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.Monitoring Subsequent Falls and Fall Risk1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved.3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the facility's Assessing Falls and Their Causes procedure dated 3/1/22, identified the purposes of the procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure included: After a Fall:1. If a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs including neurological assessment and evaluate for possible injuries to the head, neck, spine, and extremities.2. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid.Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting or lying position and the staff will lift the resident via mechanical lift and will document relevant details.3. Nursing staff will notify the resident's Attending Physician and family. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone.4. Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record.5. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. A new fall and pain assessment should be completed.6. An incident report must be completed for resident falls. The incident report form should be completed by the assigned staff nurse at the time via risk management incident portal.Defining Details of Falls:1. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred.Identifying Causes of a Fall or Fall Risk:1. Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc.2. Staff will evaluate chains of events or circumstances preceding a recent fall, including:a. Time of day of the fall.b. Time of the last meal.c. What the resident was doing.d. Whether the resident was standing, walking, reaching, or transferring from one position to another.e. Whether the resident was among other persons or a[TRUNCATED]

Based on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to increase in resident falls and as needed (PRN) psychotropics being administered as a chemical restraint by developing and implementing action plans for process improvement. This had the potential to affect all 34 residents that resident in the facility. Findings include: SEE F689: Based on observation, interview, and document review, the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and revise the care plan to prevent and/or reduce the risk for future falls for 2 of 3 residents (R2, R4) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for 2 when he sustained a head laceration following a fall and an IJ for R4 when after repeated falls sustained shoulder dislocation that had not identified since the last imaging that did not show dislocation on 7/30/25.SEE F605: Based on observation, interview, and document review the facility failed ensure residents were free from chemical restraints by not identifying duplicative antipsychotic therapy without appropriate indications, failed to identify target behaviors, failed to develop individualized non-pharmacological interventions, and failed to attempt and/or offer non-pharmacological interventions prior to the administration of as needed (PRN) doses of antipsychotic medications for 1 of 1 resident (R2) who had verbal and physical behaviors towards staff reviewed for falls. Review of the facility 's QAA/QAPI minutes identified the following: 6/27/25 QAA/QAPI minutes also identified that the facility had been cited at F605 (right to be free from chemical restraints) during a May 2025 survey. The facility developed an action plan to begin audits on resident target behaviors, non-pharmacological interventions attempted will begin twice per week for two weeks, then weekly for two weeks, then monthly to ensure compliance.7/25/25 QAA/QAPI minutes dated 7/25/2, identified two F605 audits completed during the month of 6/25 and no issues noted.8/29/25 QAA/QAPI minutes dated 8/29/2, identified one F605 audit completed for month of 7/25 and no issues noted. 9/26/25 QAA/QAPI minutes, identified the following:- the facility had eight falls involving 5 residents during 8/25. Actions taken for falls were resident-specific fixes (removing gripper strips, adding anti-roll back device, antibiotics, hospice care, and behavioral counseling) and did not have evidence of a systemic/root cause analysis across all falls. Actions appear reactive and individualized rather than addressing broader facility-wide risks.-Audits for psychotropic medication audit for F605 covered 5 residents with as needed (PRN) psychotropic orders. QAA/QAPI minutes did not identify how many residents lacked documentation of non-pharmacological interventions prior to administration. Results of audits were not documented, only a note that staff were re-educated without rationale provided why re-education was necessary. 10/31/25 QAA/QAPI minutes identified the following: -the facility had four falls in 9/25. Actions taken for falls were resident-specific fixes (care planning purposeful movement, re-orientation, floor mats, wider bed). No evidence of evaluating patterns, trends, or systemic interventions. Re-orientation is noted as only effective short-term, but no alternative strategies were explored.-Audits for psychotropic medication audit for F605 Audit referenced 8/25 again, not September. Stated six residents had PRN psychotropic orders. QAA/QAPI minutes had audit results missing and did not identify rationale for re-education not documented and no evidence that an audit was completed for September.Review of the facility's October 2025 incident report listing identified that fifteen falls occurred and was an increase from four falls for the month of September 2025. 10/8/25 F605 audit for 9/25 identified 5 residents charts reviewed and identified the following:-One resident received PRN psychotropic seventeen times and did not have consistent documented of a non-pharmacological intervention attempted prior to administration. -One resident received PRN psychotropic three times and did not have any non-pharmacological interventions documented. -Comment on audit identified that this was discussed with the director of nursing about interventions not being documented and target behaviors listed on all psychotropic medications.F605 audit completed on 11/5/25 for October 2025 identified 5 residents' charts were reviewed and identified the following: -four residents used a PRN psychotropic medication, however, did not have any documentation of non-pharmacological intervention documented attempted prior to administering medication. During an interview on 11/18/25 at 2:45 p.m., administrator stated that the QAA/QAPI committee meets monthly where the previous month's data is discussed and analyzed. Administrator stated the facility had a sharp increase in falls from the month of October 2025 from the previous month of September 2025, however, the facility had not identified the increase in falls as a concern and therefore had not brought this concern to the quality committee to discuss and create and appropriate action plan to assist the facility to determine possible causes of the increase in resident falls. Administrator stated this concern should be brought to the quality committee as soon as possible to develop a plan to correct this concern and not wait until the next month to address the problem. Administrator stated with regards to the chemical restraints the facility had been cited May 2025 for concern for psychotropics being used as chemical restraints and not having a documented non-pharmacological intervention prior to administration. The QAA/QAPI committee determined an action plan to begin doing audits of residents with prescribed as needed (PRN) psychotropics to ensure documentation was being completed by licensed staff of a non-pharmacological intervention prior to administering the PRN psychotropic. The audits which began June 2025 and had not identified a concern for the months of 6/25. 7/25, however, the 8/25, 9/25 and 10/25 audits identified PRN psychotropics were being administered without a documented non-pharmacological intervention attempted prior being administered. Administrator stated the QAPI committee had not discussed the identified concern for non-compliance and had not made any amendment to the facility's action plan and should have done this when the audits completed during 8/25, 9/25, and 10/25 identified non-compliance and if the QAPI committee had done this it may have prevented this non-compliance for re-occurring for an extended period. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan policy identified the facility shall develop, implement, and maintain and ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. The objectives of the QAPI Plan are to:1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services.2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services.3. Provide structure and processes to correct identified quality and/or safety deficiencies.4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome.5. Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability.6. Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; and7. Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.

Based on observation, interview, and document review the facility failed ensure residents were free from chemical restraints by not identifying duplicative antipsychotic therapy without appropriate indications, failed to identify target behaviors, failed to develop individualized non-pharmacological interventions, and failed to attempt and/or offer non-pharmacological interventions prior to the administration of as needed (PRN) doses of antipsychotic medications for 1 of 1 resident (R2) who had verbal and physical behaviors towards staff reviewed for falls. Findings include: Antipsychotic medications are a class of drugs used to treat psychosis-conditions where a person has difficulty distinguishing reality, often involving delusions, hallucinations, paranoia, or disorganized thinkingAccording to the Food and Drug Administration (FDA) the package insert for Seroquel (quetiapine) carries boxed warnings for increased mortality in elderly patients with dementia-related psychosis and suicidal thoughts/behaviors in children, adolescents, and young adults. Seroquel (quetiapine) has a rapid onset for sedation (within hours), but its therapeutic effects on mood, psychosis, or depression typically take days to weeks to become noticeable, with full benefit often requiring several weeks. Its half-life is about 6-7 hours (immediate-release and extended-release), meaning it takes roughly 30-35 hours for full elimination from the body.According to the FDA Haldol (Haloperidol Lactate) the package insert for Haldol has a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Its half-life is about 14-37 hours orally. The onset of action varies: oral onset is 2-6 hours. Falls risk in elderly due to sedation and blood pressure changes. R2's face sheet dated 11/14/25, identified R2 had diagnoses of Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and vascular dementia severe with anxiety (an advanced stage of cognitive decline caused by blood vessel damage in the brain).R2's Annual Minimum Data Set (MDS) dated [DATE], indicated R2 had severe cognitive impairment and required supervision/touching assistance for transfers. During the assessment period R2 had physical behavior symptoms towards others 1-3 days, verbal behavior symptoms directed towards others 4-6 days, other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, sexual acts, disrobing in public, or verbal symptoms like screaming, disruptive sounds) occurred 4-6 days , and was taking an anti-psychotic (a class of psychiatric medications used to manage symptoms of psychosis, such as hallucinations, delusions, and paranoia).R2's psychotropic medication management focus care plan dated 2/3/25, identified goal will be free from medication side effects. Interventions were as followed:-Consult pharmacist to review medications-target behaviors: hallucinations, delusions, agitation, excessive worrying, pacing (anti-psychotic), insomnia, sad/depressed mood, sexual behaviors (anti-depressant).-Non-pharmacological interventions that were identified were not individualized and/or person centered. Interventions included reassure and redirect resident, engage resident in a meaningful activity, conversation, or television show of his interest, offer snack, offer restroom, one to one. R2's behavior focus care plan dated 3/18/25, identified R2 had vascular dementia with severe anxiety. Goal to have fewer episodes of socially inappropriate behaviors weekly. Interventions were as followed:-observe behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations.-provide a program of activities that is of interest and accommodates resident status or call family to come for a visit if available and other interventions fail. R2's geriatric psychiatry follow-up note dated 10/16/25, indicated the facility requested an earlier appointment for increasing behaviors. Facility and family could not identify any stressors or environmental changes that could impact R2's behaviors. Reviewed dementia and its inevitable progression to moderate to severe dementia, which may require escalation of medication to manage symptoms. Suggested initiating discussions with palliative care if R2 required medication increase. R2's record was reviewed from 6/24/25 through 11/13/25 and identified R2 had a been first prescribed scheduled Seroquel on 6/24/25; a PRN (as needed) dose was added on 7/19/25. Further review from 10/30/25 through 11/13/25 revealed R2 continued on scheduled Seroquel in addition to PRN doses available and then Haldol (Haloperidol Lactate) was prescribed for PRN doses (in addition to Serequel) when R2 was admitted to hospice which was duplicative antipsychotic therapy. During review of the R2's medication administration records (MAR), in conjunction with progress notes, and Behavior Monitoring and Intervention Reports (BMIR) there was no indication target behaviors were identified for the determination of which medication (Seroquel versus Haldol) should be used, nor evident non-pharmacological interventions were developed, offered or attempted prior to the administration of an as needed antipsychotic medication. Of mention R2's record also identified R2 had 5 falls (11/4/25, 11/7/25, 11/9/25, 11/10/25, and 11/11/25) when both medications were used on the same days. The records from 10/30/25 through 11/13/25 identified the following: R2's progress note dated 10/30/25, identified nurse practitioner attempted to remove staples to back of head, however, R2 was not having it. R2's nurse practitioner progress noted dated 10/30/25, identified R2 was seen for an acute visit for staple removal to the back of the head from a recent fall. Only able to remove one staple today and recommend contact psychiatrist today to request consideration of a PRN medication to help with aggravation and restlessness today. R2's progress note dated 11/1/25, identified R2 was admitted to hospice services on 10/31/25 and received an order for Haldol 2 mg/ml-administer 2.5 mg prior to staple removal and then ok to use every 4 hours PRN if other medications are not managing agitation. Change PRN Seroquel to 25 mg three times per day for unmanaged agitation. During an interview on 11/13/25 at 10:23 a.m., consulting pharmacist (C-Pharm) stated having a Haloperidol and Seroquel order would be considered duplicate therapy since they both are in the same drug class (anti-psychotics). This had the potential to cause increase in falls, drowsiness, orthostatic hypotension, and dizziness. C-Pharm was not aware R2 had received this duplicate drug and if she had known she would have asked for the Haloperidol to be discontinued. R2's BMIR on 11/1/25 included behaviors of agitation, restlessness, insomnia, experiencing something not there and refusing cares at 6:21 a.m. and 7:59 p.m., however, was given a PRN Seroquel at 10:32 p.m. which was 2 hours and 33 minutes after the documented behavior. R2's progress note dated 11/2/25 at 10:43 a.m., identified R2 was in a good mood and had staples removed from back of head. R2's BMIR on 11/2/25 did not identify R2 demonstrated any behaviors, however, R2's MAR identified Haldol was given 2:00 p.m. R2's BMIR on 11/3/25 did not identify R2 demonstrated any behaviors, however, R2's MAR identified Seroquel was given 12:01a.m. R2's progress note dated 11/5/25 at 3:18 p.m., identified a new order from hospice to start Haloperidol (Haldol) 2 mg/ml: 0.5 ml every 4 hours if needed for agitation or hallucinations. R2's MAR identified Haldol was given at 9:31 a.m., 1:37 p.m. and 8:37 p.m. R2's progress note dated 11/5/25 at 9:36 p.m., identified R2 was in and out of resident rooms. Is redirected and becomes aggressive towards staff. R2 grabbed this nurse arm and proceeded to shove nurse, even with Haldol on board and remains resistive with cares. R2 BMIR on 12/5/25 included behaviors of grabbing others, pushing others, cursing at others, express frustration with others, screaming at others, agitated, anxious/restless, neglecting self-care, and refusing care at 10:07 p.m. R2's MAR then identified R2 was administered Seroquel at 11:27 p.m. R2's MAR on 11/6/25 identified Haldol was given at 3:28 a.m.,11:03 a.m. and 2:34 p.m., however, R2's BMIR did not identify a behavior of being agitated, anxious/restless, experiencing something not there, refusing care until 10:23 p.m. Progress note dated 11/6/25 at 10:51 p.m., identified R2 became very loud throughout the shift, especially when staff try to assist R2. R2 was given a PRN Seroquel. R2's BMIR on 11/7/25 did not identify R2 demonstrated any behaviors, however, R2's MAR identified Haldol was given at 12:16 p.m. and Seroquel was given 3:54 p.m. R2's BMIR on 11/9/25 included behaviors of cursing and screaming, neglecting self-care and agitation observed at 3:30 a.m. R2's MAR on 11/9/25 identified Haldol was administered at 10:04 a.m., approximately 5 1/2 hours after the behaviors at 3:30 a.m. R2's BMIR also included behaviors of cursing and screaming, neglecting self-care and agitation observed at 1:59 p.m., and 9:44 p.m., however, PRN Seroquel was administered at 10:26 p.m., which was approximately 45 minutes after the last the behavior. R2's BMIR on 11/10/25 did not identify R2 demonstrated any behaviors, however, R2 was administered Haldol at 1:25 a.m.,10:07 a.m., and 11:42 p.m. and Seroquel was given at 4:50 a.m.During an interview on 11/18/25 at 11:22 a.m., registered nurse (RN)-B stated she administered R2 a PRN dose of Haldol on 11/10/25 at 11:42 p.m. R2 had been attempting to self-transfer while seated in his wheelchair. RN-B stated she instructed staff to attempt to take R2 to the bathroom. R2 used the toilet, however, R2 refused to stand up from the toilet and began striking out at staff. RN-B stated staff then attempted to use a stand-aid (a medical device that helps individuals with limited mobility to stand up and move positions) to get R2 to agree to get off the toilet, but R2 began hitting, pinching, and yelling at staff. RN-B stated she then gave R2 a dose of Haldol to get him to settle down and get him to cooperate as he was hitting the staff and not agreeing to get off the toilet. RN-B stated she had not tried any other non-pharmacological interventions or assessed if R2 was in pain and offered pain medication first instead of trying an antipsychotic first. During a interview on 11/14/25 at 10:44 a.m., C-Pharm stated Haldol could be used as a chemical restraint if used in the wrong way. Haldol can cause side effects such as lethargy and sedation in which could cause a resident to have an increase in falls. R2's PRN antipsychotic administrations records were reviewed with C-Pharm. C-Pharm stated prior to any PRN psychotropic being administered, a non-pharmacological interventions would have to be attempted and this would need to be documented in the resident's medical record. Administering a medication to have a resident to cooperate would be considered use of a chemical restraint and should not been used in that way. R2's BMIR on 11/11/25 did not identify R2 demonstrated any behaviors, however, R2's MAR identified Haldol was given at 11:05 a.m. and Seroquel was given 11:33 p.m. R2's progress notes dated 11/11/25 at 2:06 p.m., identified R2 was up and restless and was given as needed and scheduled medication to help with restlessness.During an interview on 11/12/25 at 2:11p.m., hospice registered nurse (HRN)-G stated when she performed a routine visit for R2 on 11/12/25, she discovered that R2 had both Haldol and Seroquel PRN orders. HRN-G further stated that this was a red flag because of the duplicate drugs, and she had contacted the physician to see if the Haldol PRN could be discontinued. HRN-G stated Haldol PRN is normally part of the hospice standing orders and was unsure what was the rationale it was added in addition to the Seroquel PRN. R2's hospice progress note dated 11/12/25 at 3:12p.m., identified R2 had four falls since last week and staff had been using PRN Haldol and PRN Seroquel in addition to the scheduled Seroquel and was there a reason a reason both anti-psychotics prescribed. Both medications indicated use for anxiety, agitation (Haldol also notes delirium and Seroquel indicates hallucinations).R2's hospice progress noted dated 11/13/25 at 8:45 a.m., indicated the Haldol order was to be given prior to suture removal and nursing staff stated when R2 received the Haldol, R2 responded very well and took the remainder of his medications that R2 had previously been refusing. Physician ordered to remove Haldol off R2's medication list. During a interview on 11/14/25 at 10:44 a.m., C-Pharm stated Haldol could be used as a chemical restraint if used in the wrong way. Haldol can cause side effects such as lethargy and sedation in which could cause a resident to have an increase in falls. R2's PRN antipsychotic administrations records were reviewed with C-Pharm. C-Pharm stated prior to any PRN psychotropic being administered, a non-pharmacological interventions would have to be attempted and this would need to be documented in the resident's medical record. Administering a medication to have a resident to cooperate would be considered use of a chemical restraint and should not been used in that way. During an interview on 11/12/25 at 12:34 p.m., nursing assistant (NA)-F stated when R2 got agitated with NA's, we would just get the nurse to give him some Haldol to mellow him out, so he does not yell so much.During an interview on 11/19/25 at 3:32 pm., RN-G stated a residents have the right to be treated with dignity and respect, including to be free from chemical restraints. H-RN stated if her family member had been administered a PRN anti-psychotic like Haldol to get her to cooperate or settle her down without trying some sort of non-pharmacological intervention prior she would be appalled that that happened her family member. During an interview on 11/12/25 at 10:16 a.m., licensed practical nurse (LPN)-A stated Haloperidol was ordered for R2 as a pain medication and Seroquel was ordered as an anti-anxiety medication. If R2 is having pain, we can give him the Haloperidol. LPN-A then obtained a drug reference book and identified that Haloperidol and Seroquel were both an anti-psychotic medication and that would be considered a duplicate therapy. LPN-A stated if she noted a duplicate therapy in a resident's chart, she would not contact the provider, because this would be up to the discretion of the physician to make that determination if they needed it. LPN-A did not identify a concern that R2 had this duplicate therapy of Haloperidol and Seroquel. LPN-A was unable to articulate what the possible side effects of these medications were and had to reference the drug reference book to identify drowsiness, dizziness, and increase in falls as some of the listed side effects. LPN-A stated that she was unaware if a non-pharmacological intervention needed to be tried before administering an as needed antipsychotic. R2's as needed Seroquel and Haloperidol was ordered for agitation, so if R2 was agitated we would administer this to him to settle down.During an interview on 11/12/25 at 11:47 a.m., interim assistant director of nursing (I-ADON) stated R2 had an order for Haldol and Seroquel PRN to be given for agitation, he was unaware of the drug class (a group of medications that share similar chemical structures and act through the same mechanism) that Haldol and Seroquel were in, nor the side effects of either of the medications. I-ADON then proceeded to Google Haldol and Seroquel and then stated they were both considered anti-psychotic medications and that the Haldol and Seroquel had been ordered by the hospice agency and he would not have gotten clarification to see if hospice wanted a duplicate therapy, because the doctor must have wanted it for R2. I-ADON was not aware if a non- pharmacological intervention needed to be attempted prior to administering a PRN antipsychotic or where that would be documented. I-ADON stated both Seroquel and Haloperidol could cause sedation, lethargy (a state of unusual drowsiness), and dizziness when administered and if it was used in the incorrect way it could be considered a chemical restraint. During an interview on 11/19/25 at 3:18 p.m., medical director (MD) stated R2's Haloperidol was only initially ordered as a one-time dose to give prior to the provider removing the sutures on the back of the head. The as needed every 4-hour dose was only supposed to be given as a last resort if no other medication were effective and was unaware that R2 had received multiple doses of this medication and had now discontinued the as needed Haloperidol to clean up his record. During an interview on 11/12/25 at 5:11 p.m., director of nursing (DON) stated R2 had been followed by psychiatry and had an order for Seroquel scheduled and PRN for agitation and hallucinations, however R2 was admitted to hospice on 10/31/25 when a PRN order for Haldol was also added to R2's orders. DON stated Haldol and Seroquel PRN would be a duplication of therapy since both medications are in the same drug class and should have not had both orders at the same time. DON stated the facility should have called and got clarification from the physician that ordered the PRN Haldol to see if this was supposed to be in R2's orders. DON further stated staff are supposed to document and attempt a non-pharmacological intervention prior to administering any PRN psychotropic medications. DON reviewed R2's progress notes from 11/1/25 to 11/12/25 and did not identify any documentation of a non-pharmacological intervention prior to administration of the PRN Haldol or Seroquel. During an interview on 11/18/25 at 2:45 p.m., administrator stated all PRN psychotropics should have a documented non-pharmacological intervention prior to the medication to being administered and should never be given out of convenience. Review of the facility's Anti-psychotic Medication Use policy undated, identified residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation were as follow:1. A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior.2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:a. Anti-psychotics.b. Anti-depressants.c. Anti-anxiety medications; andd. Hypnotics.3. Residents, families, and/or the representative are involved in the medication management process. Psychotropic medication management includes:a. indications for use.b. dose (including duplicate therapy);c. duration.d. adequate monitoring for efficacy and adverse consequences; ande. preventing, identifying, and responding to adverse consequences.4. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.5. Use of psychotropic medications (other than antipsychotics) are not increased when efforts to decrease antipsychotic medications are being implemented.6. Medications not classified as anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medication are not prescribed or administered as a substitution for another psychotropic medication unless there is a documented clinical indication consistent with clinical standard of practice.7. Categories of medications which affect brain activity such as antihistamines, anti-cholinergic medications, and central nervous system medications that are prescribed as a substitute for or an adjunct to a psychotropic medication are monitored and managed as psychotropic medications.8. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes.9. Use of psychotropic medications may be considered appropriate in specific circumstances. These include:a. acute or emergency situations.b. enduring conditions; and/orc. new admissions where the resident is already on a psychotropic medication. 10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.11. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications.12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. (2) For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.13. If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued and document the rationale for this decision. Review of the facility's Anti-Psychotic Medication Use Policy undated, identified antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed.Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and re-review.Antipsychotic medications will not be used if the only symptoms are one or more of the following:a. Wandering.b. Poor self-care.c. Restlessness.d. Impaired memory.e. Mild anxiety.f. Insomnia.g. Inattention or indifference to surroundings.h. Sadness or crying alone that is not related to depression or other psychiatric disorders.i. Fidgeting.j. Nervousness; ork. Uncooperativeness.

Based on interview and document review the facility failed to ensure that alleged violations involving abuse/neglect were reported to the administrator and to the State Agency (SA) timely, in accordance with established policies for 1 of 1 resident (R5) reviewed for injury of unknown origin.Findings include:R5's face sheet dated 11/19/25, identified diagnoses malignant neoplasm of the of ovary and malignant neoplasm of the thyroid gland (cancer of the thyroid gland), and morbid obesity.R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had no skin issues, was frequently incontinent of bowel, and was cognitively intact.R5's skin focus care plan dated 10/31/25, identified R5 was at risk for impaired skin integrity related to morbid obesity and lack of mobility. During an interview on 11/18/25 at 12:24 p.m., hospice registered nurse (H-RN) stated that as a hospice nurse she is a contracted staff that provided extra support to residents in the facility while under hospice care. H-RN performed a routine visit for R5 on 11/13/25 when R5 informed her she had been sitting in feces for a long time and staff would not assist her with changing her brief or clean her up, and that she had not received a shower since she was admitted to the nursing home. H-RN also observed a large open blister on R5's right lower leg with a large purple discoloration on the back of her leg, of which to her appeared to be a large bruise. H-RN stated she had asked the interim assistant director of nursing (I-ADON) if he was aware of how R5 obtained the bruise and blister, however, was told he did not know anything about it. H-RN stated normally she would report this type of concerns of neglect and injury of unknow origin to the director of nursing (DON) and/or the administrator, however, the DON was busy with another resident, so she did not report this information to her or the administrator. During an interview on 11/19/25 at 2:44p.m., the administrator stated hospice agency staff were considered contracted staff and need to follow the same policies and procedures for reporting as the staff in the facility. If any staff, including contracted staff became aware of an allegation of neglect they would report this immediately the DON or the administrator, however, had not had any reports of allegation of neglect made by any contracted staff.Review of the facility Hospice Services Agreement dated 2/24, identified that hospice should report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the facility administrator within 24 hours of the hospice becoming aware of the alleged violation.During an interview on 11/21/25 at 4:20 p.m., clinical director of hospice (CD-H) stated she was unaware if the hospice agency would follow the facility's reporting policy and was unaware if they had received the facility reporting policy. CD-H was unaware the hospice services agreement dated 2/24, identified that if hospice received an allegation this would need to be reported immediately to the facility administrator. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy undated, identified that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator, director of nursing and the other officials according to state law.

Based on interview and document review the facility failed to develop a comprehensive person-centered behavior care plan with individualized interventions for behavior management for 1 of 1resident (R2) with Alzheimer's Disease. Findings include:R2's face sheet dated 11/14/25, identified diagnoses of Alzheimer's disease( a progressive neurological disorder and the most common cause of dementia), congestive heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs), diabetes mellitus (the body does not produce enough insulin), and chronic obstructive respiratory failure (when the airways that carry air to the lungs become narrow or damaged). R2's Significant Change Minimum Data Set (MDS) dated [DATE], identified R2 needed supervision/touching assistance for transfers, had severe cognitive impairment, had physical behavior symptoms towards others 1-3 days, verbal behavior symptoms directed towards others 4-6 days, but less than daily, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, sexual acts, disrobing in public, or verbal symptoms like screaming, disruptive sounds) occurred 4-6 days, but less than daily, and was taking an anti-psychotic.R2's psychotropic medication management focus care plan dated 2/3/25, identified goal will be free from medication side effects. Interventions were as followed: -Consult pharmacist to review medications-target behaviors: hallucinations, delusions, agitation, excessive worrying, pacing (anti-psychotic), insomnia, sad/depressed mood, sexual behaviors (anti-depressant). -Non-pharmacological interventions-reassure and redirect resident, engage resident in a meaningful activity, conversation, or television show of his interest, offer snack, offer restroom, one to one. R2's behavior focus care plan dated 3/18/25, identified R2 had a behavior problem due to vascular dementia with severe anxiety. Goal to have fewer episodes of socially inappropriate socially inappropriate behaviors weekly. Interventions added 3/18/25 were as followed: -observe behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations.- provide a program of activities that is of interest and accommodates resident status or call family to come for a visit if available and other interventions fail. R2's behavior management focus care plan dated 8/12/25, identified goal to remain safe. Interventions were as followed: -ensure the safety of resident and others-evaluate elopement risk-monitor for cognitive factors that may contribute to new behavior. -monitor for environmental factors that may contribute to new behavior.-monitor for signs and symptoms of infection. -reorient resident to person, place, time, and situation. -utilize diversion techniques as needed. R2's outpatient geriatric psychiatry follow-up note dated 10/16/25, identified R2 was seen due to a requested appointment due to worsening behaviors at the skilled nursing facility. Encourage ongoing utilization of non-pharmacological interventions, such as environmental modifications, distractions, music, and relaxation activities to manage behaviors as well. R2's record did not identify a comprehensive assessment of R2's behaviors and individualized behavior interventions that are effective for R2. R2's progress note dated 11/2/25, identified R2 was agitated and would not/unable to follow directions, was sitting at the nurse's desk. R2 was given a sandwich and taken to his room and urinated on the floor in his room. R2's progress note dated 11/3/25, identified R2 was yelling and wandering into other resident's rooms, undressing in the hallways, swinging at staff and urinated on the wall in his room. Interventions attempted of redirection and family sitting with resident which was only effective for few minutes. R2's psychosocial quarterly progress note dated 11/4/25, identified R2 had dementia with behaviors and follow psychiatry. R2 does have behavioral issues including wandering, verbal and physical aggression and is resistive with taking medications and cares. R2's preferences evaluation progress note dated 11/5/25, identified R2 prefers country music, and it very important to him to be around animals such as pets, and favorite activities included watching television, visiting, looking at tractor and truck books and to go outside when the weather is nice. R2's care plan did not identify R2's preferences. R2's progress note dated 11/5/25, identified R2 was going in and out of resident rooms and when attempted redirection, R2 becomes aggressive towards staff and grabbed the nurse and attempted to shove staff. R2's progress note dated 11/9/25, identified R2 was yelling out at staff and other residents. R2's progress note dated 11/11/25, identified R2 was restless and was given as needed medication to help with restlessness. R2's progress note dated 11/12/25, identified R2 attempted to stand up from the wheelchair and as staff attempted to redirect R2 he became loud and agitated and urinated on the floor. During an interview on 11/7/25 at 3:38 p.m., nursing assistant (NA)-D) stated R2's behaviors had been getting worse over the past few weeks, however, was unable to articulate specific care plan non-pharmacological interventions for R2, that staff should be using to decrease R2's behaviors. NA-D stated that without having specific behavior interventions in his care plan would make it very difficult for unfamiliar staff to care for R2 and could make R2's behaviors worse. During an interview on 11/7/25 at 4:00 p.m., NA-E stated R2 had some good days and bad days due to his dementia, however, NA-E was unable to articulate what type of non-pharmacological interventions staff were supposed to use to help decrease R2's symptoms. NA-E was unable to identify any interventions on R2's care plan that would be effective in reducing his behaviors. During an interview on 11/7/25 at 4:13 p.m., director of nursing (DON) stated R2's care plan had not been created to include person-centered interventions to decrease his behaviors to give direction of staff to assist R2 with each identified and/or newly identified behaviors. DON stated she will be meeting with the team to add person-centered interventions on R2's care plan to reduce some of R2's behaviors. R2's behavior focus care plan had added Interventions added on 11/7/25, that included that R2's triggers include pain, having to use the bathroom, hallucinations, thinking he is working/you are an employee. R2 owned a backhoe company and farmed/worked with livestock. R2's behavior is deescalated by the following: 1) ensure that you have R2's attention by calmly but firmly saying his name-saying it multiple times may be required. 2) ensure you have eye contact 3) ask R2 is he needs to use the restroom [ROOM NUMBER]) ask if R2 is hungry 5) offer R2 something to drink 6)ask R2 questions rather that giving commands 7) alert nurse to assess if as needed medications may be needed 8) talk mechanics, horses, farming with patient/ask questions about this topic.During an interview on 11/19/25 at 1:53 p.m., social services designee (SSD) stated that the facility does not analyze R2's behaviors to determine person centered behavior reduction interventions and ensure those interventions are placed in a resident's care plan. SSD stated since R2's care plan had included individualized behavior interventions on 11/7/25, she had already noticed a decrease in R2's behaviors. Review of the facility's Care Plan, Comprehensive Person-Centered Policy undated, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation were as followed:1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.4. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.5. The comprehensive, person-centered care plan:1. includes measurable objectives and timeframes.2. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:1. services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.2. any specialized services to be provided because of PASARR recommendations; and3. which professional services are responsible for each element of care.3. includes the resident's stated goals upon admission and desired outcomes.4. builds on the resident's strengths; and5. reflects currently recognized standards of practice for problem areas and conditions. 6. Services provided for or arranged by the facility and outlined in the comprehensive care plan are:1. provided by qualified persons.2. culturally competent; and3. trauma informed.7. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.8. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.9. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.10. The interdisciplinary team reviews and updates the care plan:1. when there has been a significant change in the resident's condition.2. when the desired outcome is not met.3. when the resident has been readmitted to the facility from a hospital stay; and4. at least quarterly, in conjunction with the required quarterly MDS assessment.11. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observation, interview, and document review the facility failed to revise the care plan for 2 of 3 residents (R2, R6) who were reviewed for falls and impaired skin integrity. Findings include:R2's face sheet dated 11/14/25, identified diagnoses of Alzheimer's disease( a progressive neurological disorder and the most common cause of dementia), congestive heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs), diabetes mellitus (the body does not produce enough insulin), and chronic obstructive respiratory failure (when the airways that carry air to the lungs become narrow or damaged). R2's Annual Minimum Data Set (MDS) dated [DATE], identified R2 used a wheelchair and needed supervision/touching assistance for transfers and ambulation, had one fall with no injury, one fall with minor injury since admission and had severe cognitive impairment. R2's functional performance focus care plan dated 2/3/25, identified R2's care plan goal of to progress towards personal discharge goal during stay. Interventions were as followed:- Transfer - Independent / no set-up or physical help- Toilet use - Limited assist / two-person physical assist- Walk in corridor - Supervision / no set-up or physical help- Locomotion on Unit - Supervision / no set-up or physical- Locomotion off Unit - Supervision / no set-up or physical R2's fall focus care plan dated 2/3/25, identified R2 was at risk for falls as evident by scoring tool, antidepressant use, and wandering behaviors. R2's care plan goal was to be free from falls. Interventions included:-educate on the importance of maintaining a safe environment, free from potential fall hazards.-evaluate fall risk on admission and as needed; review medication for drugs that increase the risk for falls.-Intervention added on 5/12/25 to assist R2 with ambulation and transfers, utilizing therapy recommendations. During an observation on 11/12/25 at 10:25 a.m., R2 was seated in a wheelchair, propelling himself with his feet around the lobby. R2's care plan had not been revised to reflect R2 used a wheelchair. During an interview on 11/12/25 at 10:33 a.m., nursing assistant (NA)-A stated R2's care plan indicated R2 was independent with transfers, however, R2 had not been independent for a while due to being unsteady on his feet and had multiple falls. NA-A further stated R2 had been wheelchair while out of his room, however, R2's care plan had not been updated to reflect this change. In review of R2's care plan in conjunction with R2's fall record there was no indication R2's fall care plan goals were appropriate, and interventions were evaluated for effectiveness that would prevent or mitigate the risk for recurrent falls and/or the care plan was revised with new interventions based on R2's safety needs to prevent falls and falls with major injury. R2's fall incident report dated 10/20/25 at 1:46 a.m., identified R2 was found on the floor in his room with a 7-8 cm laceration on the back of his head and an abrasion on the right inner arm. R2 thought he was answering the phone. R2's fall incident report dated 11/4/25 at 8:45 a.m., identified R2 was found in his room kneeling and leaning on a chair in his room. R2's fall incident report dated 11/7/25 at 6:29 p.m., identified R2 was found lying on his face in his room at 5:50 p.m. R2's fall incident report dated 11/9/25 at 4:50 p.m., identified R2 was found sitting on the floor in his room next to his chair. R2 was trying to pick up specks on the floor and had been sitting in chair which is low to ground. R2's fall incident report dated 11/10/25 at 8:30 p.m., identified R2 was found sitting between chair and bedside table. R2's fall incident report dated 11/11/25 at 8:30 p.m., identified R2 was in hall and grabbed the handrail to pull himself up to a standing position and began walking and then started going down and before staff could get to R2 he fell to the ground. During an interview on 11/12/25 at 3:23 p.m., registered nurse (RN)-A stated after a resident has fallen, the nurse is supposed to initiate an immediate intervention to mitigate the risk of a resident falling again. RN-A further stated she was not aware that a resident's care plan needed to be revised to reflect the intervention and believes this would be something the director of nursing (DON) was responsible to complete. During an interview on 11/12/25 at 3:56 p.m., interim director of nursing (I-ADON) stated R2's care plan had not been revised to include any updated individualized fall prevention interventions nor R2's transfer changed to remove independent during transfers and had not had a wheelchair added to R2's care plan. I-ADON stated the DON does resident care plan revisions and not the nurses. R6's face sheet dated 11/19/25, identified diagnoses of hemiplegia (paralysis) affecting left side, diabetes mellitus (body does not make enough insulin), and heart failure (a condition where the heart does not pump enough blood to the body). R6's Annual [NAME] Data Set (MDS) dated [DATE], identified R6 was dependent for bed mobility/transfers, at risk for developing pressure ulcers, had no pressure ulcers, and was cognitively intact.R6's skin integrity focus care plan last revised on 4/29/25, identified R6 had a potential impairment to skin integrity related to bowel and bladder incontinence and impaired mobility. Goal to maintain or develop clean and intact skin. Interventions were as followed: may apply barrier cream after each incontinent episode; elevate heels off the bed; keep skin clean and dry, use lotion on dry skin, prefers to not be checked every two hours; pressure relieving/reducing cushion in wheelchair; standard pressure relieving/reducing mattress to protect skin while in bed.R6's nursing home rounding form dated 11/10/25, identified the nurse practitioner requested to check that R6's air mattress was working. During an observation and interview on 11/18/25 at 10:21 a.m., R6 was lying in bed on top of a specialty mattress in place. R6 stated she had this type of mattress on for some time due to a sore on her bottom and because she spends a lot of time in bed. NA-F stated R6 had been on an air bed for some time because she had sore on her bottom. During an interview on 11/18/25 at 10:57 a.m., director of nursing (DON) stated R6's care plan had not been revised to include the air mattress that was placed on her bed, and it should have been revised as soon as it was placed on her bed. Review of the facility's Care Plan, Comprehensive Person-Centered Policy undated, identified the interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition.b. when the desired outcome is not met.c. when the resident has been readmitted to the facility from a hospital stay; andat least quarterly, in conjunction with the required quarterly MDS assessment

Based on observation, interview, and document review the facility failed to ensure treatments were used per standards of practice and only applied with a corresponding physician order for 2 of 2 residents (R5, R7) reviewed for non-pressure related skin concerns. Findings include:Findings includeR5's face sheet dated 11/19/25, identified diagnoses of neoplasm(cancer) of the ovary and thyroid gland, morbid obesity (excessive body fat), and abdominal hernia (where abdominal organs push through a weak spot in the abdominal wall). R5's impaired skin integrity focus care plan dated 10/31/25, identified R5 was at risk for impaired skin integrity related to morbid obesity and lack of mobility with goal of skin will remain intact. Interventions included as followed: encourage resident to frequently shift weight; encourage use of lifting devices while in bed and evaluate for pitting edema. R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 was received hospice services, was dependent with bed mobility, transfers, had no pressure, venous or arterial ulcers and was cognitively intact.R5's progress note dated 11/12/25 at 11:02 p.m., identified R5 had a fluid filled blister to her right lower extremity and is covered with a transparent dressing. R5's electronic health record (EHR) did not identify that the physician had been notified of R5's blister, nor an order obtained to apply a transparent dressing to the blister. During an interview on 11/18/25 at 2:54 p.m., registered nurse (RN)-A stated on 11/12/25. she observed a fluid filled blister and discoloration on the back of R5's right leg and she had applied a clear Opsite (a transparent, waterproof adhesive film) dressing over the top of the blister, however, she did not notify the hospice agency nor the physician of the newly identified blister and did not obtain an order prior to applying the dressing to the new blister. RN-A stated she did not need to obtain an order before applying a dressing to the new blister and she would use nursing judgement to determine what type of dressing to apply. R7's face sheet dated 11/19/25, identified diagnoses of laceration to right lower leg, diabetes mellitus, and morbid obesity. R7's admission MDS dated [DATE], identified R7 had no pressure, arterial, or venous ulcers and was cognitively intact.R7's wound management focus care plan dated 10/27/25, identified R7 had a wound right thigh just above knee. Goal of wound will show signs of improvement. Interventions as followed: administer antibiotics as ordered, monitor ulcer for signs of progression or declination, provider wound care per treatment order. R7's hospital after visit summary dated 10/20/25, identified R7 had sustained a laceration on her right lower thigh on 10/15/25 in her apartment and had received fifteen sutures to the area and to be removed in 12-15 days and keep wound clean and dry, watch for signs of infection and if noted signs of infection notify the doctor right away. R7's physician orders identified an order to keep wound clean and dry and watch for signs of infection and if noted signs of infection to notify the doctor right away. Start date 10/20/25. During an observation and interview on 11/19/25 at 9:12 a.m., R7's right leg, just above the knee, had a white foam dressing attached. R7's stated she had fallen before she was admitted and got a large cut on her right leg, and it had to be stitched up and staff have been covering it up. Licensed practical nurse (LPN)-B stated R7 had the sutures removed from her right leg a while ago, however, it does not want to heal. LPN-B then removed an undated foam dressing from R7's wound and stated the dressing had a small amount of clear drainage on the bottom half of the dressing without any odor. R7 had a 8.5 cm of scabbed/scarred area and at the lateral end of the scar was a Y shaped open area that was approximately 1 cm in size. The Y shaped wound appeared macerated (softened skin due to prolonged exposure to moisture) and had two purple sutures in the bottom of the wound. LPN-B stated she had not noticed the sutures prior to today, however, these two must have been missed. LPN-B stated the sutures still in the wound could be the reason the wound is not healing. LPN-B then cleansed the wound with skin prep (a wipe that apply a protective film to the skin), applied bacitracin (a topical antibiotic) ointment, and a new foam dressing to R7's right leg wound, however, identified that R7 did not have an order for this treatment but she had been applying if for some time to R7's laceration. LPN-B then stated she will contact the physician to inform of the remaining sutures and obtain an order to cover the laceration. During an interview on 11/19/25 at 9:41 a.m., director of nursing (DON) stated R5 and R7's orders that were applied are not part of the standing orders of the facility and it would be standard of practice for a nurse to contact the physician to obtain an order prior to administering any treatment and her expectation would be for licensed staff to ensure this is done prior to initiating a treatment.Review of the facility's Medication and Treatment Orders policy dated 6/30/24, identified orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation were as followed:1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. Such orders are reviewed by the Pharmacist on a monthly basis. 4. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. 5. The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used. 6. The staff and practitioner shall use only approved abbreviations and symbols when ordering and/or charting medications. 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date, and the time of the order. 8. Verbal orders must be signed by the prescriber at their next visit. 9. Orders for medications must include: a. Name and strength of the drug.b. Quantity, parameters, or specific duration of therapy.c. Dosage and frequency of administration.d. Route of administration; ande. Reason or problem for which given. 10. Only authorized personnel shall call in orders for prescribed medications to the pharmacy. Review of the facility's Skin Care Policy and Procedure undated, identified new or ineffective skin problems will be referred to the appropriate health professional and skin treatments will be performed per medical doctor order.

Based on observation, interview, and document review the facility failed to comprehensively assess and monitor an open blister and discoloration of skin on 1 of 1 resident (R5) and in addition failed to comprehensively assess and monitor a laceration for 1 of 1 resident (R7) reviewed for non-pressure skin issues. Findings include: R5's face sheet dated 11/19/25, identified diagnoses of neoplasm(cancer) of the ovary and thyroid gland and morbid obesity (excessive body fat).R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 dependent with bed mobility and transfers, no pressure, venous or arterial ulcers, received hospice services, and was cognitively intact.R5's clinical admission assessment dated [DATE], identified R5's skin was warm, dry, and intact. R5 had an old intravenous site on her right antecubital space (the bend in arm) and the dorsum (top) of the right hand. No other skin issues noted on the clinical admission assessment. R5's hospice note dated 10/29/25, identified R5 was admitted to hospice and had no open areas on right lower calf area on admission.R5's impaired skin integrity focus care plan dated 10/31/25, identified R5 was at risk for impaired skin integrity related to morbid obesity and lack of mobility with goal of skin will remain intact. Interventions included as followed: encourage resident to frequently shift weight; encourage use of lifting devices while in bed and evaluate for pitting edema. Review of R5's electronic health record (EHR) between 10/30/25 through 11/15/25, did not include weekly skin check documentation. R5's progress note dated 11/12/25 at 11:02 p.m., identified R5 had a fluid filled blister to right lower extremity and is covered with a transparent dressing. R5's EHR did not identify a comprehensive assessment of the fluid filled blister identified on 11/12/25 that included but not limited to measurements, color, skin integrity surrounding blister, and pain. R5's hospice note dated 11/13/25, identified new wound and bruising noted on right inner calf with fluid filled blisters noted. Bruising measured 26 centimeter (cm) in length and 20 cm in width. Coordination made with facility nurses to question the new wounds and bruising and they are unsure of the origin as well. A corresponding image identified R5's right inner calf had a large purple area with a large irregular shaped fluid filled blister located in center of the calf closet to the ankle. Above the fluid filled blister, a second wound that appeared to be a small open area with the skin folded on the edges. The second wound appeared to be a blister that had opened. Both the blister and the open area were covered with a rectangular shaped transparent dressing over the top of the area. During an interview on 11/18/25 at 2:54 p.m., registered nurse (RN)-A stated on 11/12/25, she observed a large fluid filled blister and discoloration on the bottom of R5's right calf. RN-A did not measure the blister or the discoloration, nor complete a comprehensive assessment of the newly identified area and only applied an opsite (a waterproof, transparent, breathable film dressing) dressing over the top of the blister. RN-A stated that the director of nursing (DON) or assistant director of nursing (ADON) were the staff responsible for completion of comprehensive assessment of the wounds in the facility.During an interview on 11/18/25 at 1:57 p.m., interim director of nursing (I-ADON) stated in the morning of 11/13/25, he was informed of the blister and discoloration on R5's right leg, however, did not complete a comprehensive assessment to R5's right leg because the hospice nurse was going to look at it later on. I-ADON stated the DON was responsible for the weekly wound assessments, but unsure how or when they were completed. He was aware there was a clear opsite over the open blister but was unsure who put it on or when it was put on nor when it changed last. R7's face sheet dated 11/19/25, identified diagnosis of laceration (tear in the skin) to right lower leg.R7's admission MDS dated [DATE], identified R7 had no pressure, arterial, or venous ulcers and was cognitively intact.R7's hospital after visit summary dated 10/20/25, identified R7 had sustained a laceration on her right lower thigh on 10/15/25 in her apartment and had received fifteen sutures to the area and to be removed in 12-15 days and keep wound clean and dry, watch for signs of infection and if noted signs of infection notify the doctor right away. Review of R7's record did not include a comprehensive skin assessment upon admission to the facility. R7's wound management focus care plan dated 10/27/25, identified R7 had a wound to right thigh just above knee. Goal of wound will show signs of improvement. Interventions as followed: administer antibiotics as ordered, monitor ulcer for signs of progression or declination, provider wound care per treatment order. R7's physician orders identified an order to keep wound clean and dry and watch for signs of infection and if noted signs of infection to notify the doctor right away. Start date 10/20/25. R7's Medication administration record (MAR) identified the aforementioned physician order. The MAR identified between 10/20/25 through 11/19/25 this task was completed by check marked boxes with no other information included. R7's nurse practitioner note dated 10/27/25, indicated R7 was due for suture removal to right thigh, incision with expanding warmth, malodor (unpleasant odor), and drainage. Incision appears as would dehisce if sutures removed and will delay suture removal as concern area not healed. R7's nurse practitioner note dated 10/30/25, indicated R7's wound had improved, and sutures removed on right knee and steri-strips (adhesive strips that hold lacerations by holding skin edges together) applied. R7's progress note dated 11/3/25 at 7:01 p.m., identified received response to communication left for provider regarding incision continuing to look red, slightly swollen and irritated. Nurse practitioner wrote please mark around wound and update if concern of expanding. R7's progress note dated 11/3/25 at 9:51 p.m., identified R7's wound on right thigh cleaned and recovered. Drainage was brownish and odorous. R7's EHR reviewed 10/20/25 through 11/19/25 did not include completed weekly skin bath audits had been completed and not evident comprehensive assessments and routine monitoring had been completed for decline or improvement of the right leg wound. During an observation and interview on 11/19/25 at 9:12 a.m., R7's right leg, just above the knee, had a white foam dressing attached. R7's stated she had fallen before she was admitted and got a large cut on her right leg, and it had to be stitched up and staff have been covering it up. Licensed practical nurse (LPN)-B stated R7 had the sutures removed from her right leg a while ago, however, it does not want to heal. LPN-B then removed an undated foam dressing from R7's wound and stated the dressing had a small amount of clear drainage on the bottom half of the dressing without any odor. R7 had a 8.5 cm of scabbed/scarred area with the lateral end of the scar was a Y shaped open area approximately 1 cm in size. The wound appeared macerated (softened skin due to prolonged exposure to moisture) and had what two purple sutures in the bottom of the wound. LPN-B stated she had not noticed the sutures prior to today, however, R7 had the sutures removed a while ago, but these two must have been missed. LPN-B stated the sutures still in the wound could be the reason the wound is not healing. LPN-B further stated the weekly wound assessments are not getting completed and used to be done with a camera and an application in the EHR but has not been done to her knowledge. During an interview on 11/19/25 at 10:30a.m., DON stated R7 had not had a comprehensive assessment of her right leg laceration on admission, nor a weekly assessment completed to monitor the wound for healing. DON further stated R5 should have had a comprehensive assessment of the blister and discoloration of her leg and should have been done at the time the skin concern was identified. Review of the facility's Skin Care Policy and Procedure undated, identified to ensure that the skin care and wound management needs of all the residents are assessed and managed effectively to enhance the quality of life of all the residents residing in the facility the following:1. The initial skin assessment is completed within 8 hours of admission. Any identified skin care issues are documented in the resident admission assessment.2. A Braden Assessment will be completed to identify risk for skin breakdown category,3. Residents with identified skin conditions or problems are referred to the appropriate health professional i.e., NP, Wound Consultant or MD.4. Resident care plan will detail specific skin care management instructions that include but not limited to: Skin care regimens (use of barrier/emollient creams); Repositioning frequency Aids (including pressure reducing mattresses, alternating surface mattress, wedges, cushions, and other equipment as required. Moisture reduction Relevant lifting/transferring procedures.5. Resident skin will be assessed weekly and/or as resident allows.6. Skin treatments will be performed per MD order.7. New or ineffectively managed skin problems will be referred to the appropriate health professional.8. Staff receive education on skin care and wound management upon hire and as needed in response to identified knowledge deficits or incidents. or incidents.

Based on observation, interview, and document review the facility failed to comprehensively assess and monitor a pressure wound, failed to timely notify the physician of new ulcer development, and failed to provide physician ordered treatments for 1 of 1 resident (R6) reviewed for skin integrity.Findings include:R6's face sheet dated 11/19/25, identified diagnoses of hemiplegia (paralysis) affecting left side, diabetes mellitus (body does not make enough insulin), and heart failure (a condition where the heart does not pump enough blood to the body). R6's skin integrity focus care plan last revised on 4/29/25, identified R6 had a potential impairment to skin integrity related to bowel and bladder incontinence and impaired mobility. Goal to maintain or develop clean and intact skin. Interventions were as followed: may apply barrier cream after each incontinent episode; elevate heels off the bed; keep skin clean and dry, use lotion on dry skin, prefers to not be checked every two hours; pressure relieving/reducing cushion in wheelchair; standard pressure relieving/reducing mattress to protect skin while in bed.R6's physician orders identified the following:-Calmoseptine external ointment apply to bilateral buttocks topically three times per day as skin protectant. Start date 9/3/25. R6's Braden Scale for Predicting Pressure Sore Risk dated 10/21/25, identified R6 was at risk for pressure ulcers due to having slightly limited sensory perception, skin being very moist, chairfast, and being very limited with mobility.R6's Annual Minimum Data Set (MDS) dated [DATE], identified R6 was dependent for bed mobility/transfers, at risk for developing pressure ulcers, had no pressure ulcers, and was cognitively intact.R6's weekly skin audit dated 10/16/25, identified scattered open area to buttocks. The audit did not include any other information about the wound. In review of R6's record between 10/16/25 to 10/20/25 there was no indication the wound was comprehensively assessed to include but not limited, location on the buttocks, measurements, pain, wound periphery, presence of drainage and/or odor. Further the record did not indicate would care treatments had been provided nor evident the physician was notified. R6's physician communication form dated 10/21/25, identified R6 had a two-centimeter (cm) x 2.4 cm scabbed area on left buttocks and requested an order for dressing as needed. R6's record did not indicate the type of wound and/or cause of wound. R6's progress note dated 10/21/25, identified received order communication from nurse practitioner to apply Mepilex to scabbed area on buttocks, change every 72 hours and as needed (PRN).R6's physician orders identified the following:-Mepilex as needed (PRN) to scabbed area on buttocks, change every 72 hours and PRN (start date 10/21/25). The October and November treatment administration record identified the order was transcribed to direct staff to change the dressing PRN and not that it was a scheduled every 72-hour change in addition to PRN. R6's weekly skin audit dated 10/23/25, identified open area to buttocks with progressive healing and superficial in appearance. R6's wound management focus care plan initiated eight days after wound identification on 10/24/25, did not specify what type of wound R6 had nor the location. The goal identified was wound will be free of signs of symptoms of infection. Interventions were as followed: provider wound care per treatment order; Mepilex (a type of foam dressing designed to cover and protect wounds while promoting healing) to open area on left buttocks and monitor for signs and symptoms of infection.R6's Weekly bath audit dated 10/30/25, 11/6/25, and 11/13/25, identified no skin issue present. R6's electronic health record medication administration record (MAR) for 10/21/25 through 11/18/25 indicated R6's wound on her buttocks had not had the physician ordered treatment applied. During an interview on 11/18/25 at 10:05 a.m., R6 stated she had a sore on the left side of her bottom that had been there for a while and hurts her at times. R6 stated said the aides are putting some cream on my bottom and she thinks it is getting better. During an observation and interview on 11/18/25 at 10:21 a.m., nursing assistant (NA)-F was assisting R6 with peri-cares and observed an open area on R6's left buttocks at a bony prominence approximately 1 cm x 1 cm. R6's wound had a pinkish/reddish center, no maceration. (softening of skin due to prolonged exposure to moisture), no drainage, and intact edges. NA-F stated R6's wound on her left buttocks had been there for a while, however, was unsure of the exact date. Licensed practical nurse (LPN)-B then entered R6's room and measured R6's left buttocks wound at 0.4 cm x 0.8 cm and stated this wound appeared to her to be a pressure ulcer since it is at a bony prominence. LPN-B stated she knew R6 had an order for Mepilex dressing, but was unsure how long it had been applied to R6's wound. LPN-B further stated she was unaware who is responsible for the weekly comprehensive assessment of pressure ulcers to stage them and make sure they are healing properly. LPN-B stated R6 had a cushion in her wheelchair and an air mattress on her bed, but unable to articulate any additional pressure ulcer prevention measure for R6.R6's progress note dated 11/18/25, identified R6 had 0.4-centimeter (cm) x 0.8 cm stage 2 pressure ulcer on left buttocks. Received order for Mepilex dressing to area twice daily. During an interview on 11/18/25 at 10:57 a.m., director of nursing (DON) stated R6 had an order for Mepilex dressing to an open area on her left bottom identified on 10/21/25, however, was unaware that R6 had not had a dressing placed on the open area, nor that there was an open area on R6's left buttocks that had been there for a while. DON started she is responsible to track and perform the comprehensive assessments of the pressure ulcers in the facility, however, had not kept up with it. R6 had not had a comprehensive assessment of the wound on her left buttocks on 10/21/25 to determine what type of wound it was or had a weekly comprehensive assessment to determine if the wound had been healing. A follow up interview at 3:00 p.m., DON stated she assessed R6's left buttocks wound and would consider it a stage 2 pressure ulcer. Review of the facility's Pressure Ulcer/Skin Breakdown-Clinical Protocol undated, identified the following:1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s).2. In addition, the nurse shall describe and document/report the following:a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.b. Pain assessment.c. Resident's mobility status.d. Current treatments, including support surfaces; ande. All active diagnoses.3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer.5. The physician will help identify and define any complications related to pressure ulcers.Review of the facility's Skin Care Policy and Procedure undated, identified that the skin care and wound management needs of all residents are assessed and managed effectively to enhance the quality of life for all residents residing at this facility.The skin care and wound management needs and preferences of the residents will be assessed and management effectively.1. The initial skin assessment is completed within 8 hours of admission. Any identified skin care issues are documented in the resident admission assessment.2. A Braden Assessment will be completed to identify risk for skin breakdown category,3. Residents with identified skin conditions or problems are referred to the appropriate health professional i.e., NP, Wound Consultant or MD.4. Resident care plan will detail specific skin care management instructions that include but not limited to: Skin care regimens (use of barrier/emollient creams); Repositioning frequency Aids (including pressure reducing mattresses, alternating surface mattress, wedges, cushions, and other equipment as required. Moisture reduction Relevant lifting/transferring procedures.5. Resident skin will be assessed weekly and/or as resident allows.6. Skin treatments will be performed per MD order.7. New or ineffectively managed skin problems will be referred to the appropriate health professional.8. Staff receive education on skin care and wound management upon hire and as needed in response to identified knowledge deficits or incidents

Based on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R1, R4) who were noted to have missing information in their record. Findings include: R1's face sheet dated 11/13/25, identified diagnoses of atherosclerotic heart disease (plaque buildup in the arteries), morbid obesity (excess fat), depression (a mood disorder characterized by persistent sadness), and anxiety (a mental and physical state characterized by feelings of dread or worry).R1's Minimum Data Set (MDS) dated [DATE], was independent with transfers and was cognitively intact.During an interview on 11/14/25 at 2:04 p.m., health information manager (HIM) stated R1 had been seen for routine nursing home visits on 8/1/25 and 10/7/25, however, R1's physician visit dictated notes had not been placed in R1's electronic health record (EHR), due to the notes being located in the outside medical systems. HIM stated she does not have access to the outside medical system to obtain the notes, however, will have the director of nursing (DON) obtain the records.Review of R1's electronic health record (EHR) on 11/19/25, did not include the 8/1/25, nor the 10/7/25 physician visit notes were in R1's facility EHR.An email received on 11/19/25 at 8:23 a.m., from the director of nursing (DON) included a copies of R1's nursing home physician visit notes from 8/1/25 and 10/7/25.R1's physician notes dated 8/1/25, identified R1 had been seen on routine nursing home rounds. R1's nurse practitioner nursing home visit note dated 10/7/25, indicated R1 was seen for nursing home rounds.R4's face sheet dated 11/14/25, identified diagnoses of unspecified dislocation (an injury where the bone becomes dislodged from their normal place) of right shoulder joint, obesity, and schizophrenia (a chronic brain disorder that affects how a person thinks, feels and acts).During an interview on 11/14/25 at 2:04 p.m., HIM stated R4 had been seen for a physician recertification visit on 9/26/25.Review of R4's EHR on 11/14/25, identified R4's 9/26/25 recertification visit note had been uploaded however not until 11/14/25. During an interview on 11/14/25 at 2:04 p.m., HIM stated R4 had a routine nursing home visit on 9/26/25, however, the note had not been removed from the outside medical system EHR to be placed into R4's chart until 11/14/25. HIM stated she was responsible for the uploading visit notes, that were received via fax. The other notes from outside medical visits needed to be accessed prior to uploading them into the facility's EHR system which she did not have access to. HIM needed to have the director of nursing (DON) obtain the note for R1 and R4. HIM was unaware of the facility's process to ensure that the notes were placed timely in the resident's EHR. During an interview on 11/19/25 at 4:10 p.m., vice president of clinical services (VP-CS) stated the facility has a system in the electronic health record that allows staff to enter the outside electronic health record and extract dictated notes and had shown the HIM a while ago on how to perform this task but had to demonstrate this task again today. The staff would need to find the notes and download the notes and then place the note in the facility's EHR under the miscellaneous tab.During an interview on 11/19/25 at 2:20 p.m., director of nursing (DON) stated she was unaware that R1 and R4's notes had not been placed in the facility's EHR in a timely manner. DON further stated R1 and R4's notes located in the outside medical record system belong to the outside medical system and are not a part of the facility's EHR, and her expectation would be that all resident's visit notes be placed in the EHR as soon and they are available and by not having R1 and R4's notes in the facility EHR could lead to something being missed and in the event of an emergency the resident's medical record would not be complete. Requested the facility's policy on maintaining an accurate and complete medical record, however, did not receive.

Based on interview, and document review the facility failed to ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day. In addition, the facility failed to ensure a designated interdisciplinary team member (IDT) was responsible for the coordinating with hospice representative and LTC staff in the hospice care planning process for 2 of 2 residents (R2, R5) reviewed for hospice services.Findings include:Findings include:R2's face sheet dated 11/14/25, identified diagnoses of Alzheimer's disease( a progressive neurological disorder and the most common cause of dementia), congestive heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs), diabetes mellitus (the body does not produce enough insulin), and chronic obstructive respiratory failure (when the airways that carry air to the lungs become narrow or damaged). R2's Annual Minimum Data Set (MDS) dated [DATE], identified R2 received hospice care, needed supervision/touching assistance for transfers, and had severe cognitive impairment. Review of R2's care plan on 11/12/25, did not identify a hospice focus care plan had been initiated. During an interview on 11/13/25 at 8:06 a.m., licensed practical nurse (LPN)-B stated all resident's that are under hospice care have a binder at the nurse's station that has things such as hospice visit schedules, orders, and hospice care plans. LPN-B stated sometimes the hospice information is kept under the miscellaneous tab in the residents EHR, however, was unable to locate R2's hospice plan of care in the binder at the nursing station nor the electronic health record (HER). During an interview on 11/12/25 at 2:11 p.m., hospice registered nurse (HRN)-G stated she is unaware of one specific staff member that hospice will coordinate care with the facility and will just communicate with the staff nurse when they perform a visit. The hospice plan of care is normally kept in the binder at the nursing station at the facility, however, was unaware that R2's hospice plan of care was not in the binder. R2 had been admitted to hospice on 10/31/25 and a hospice plan of care had been faxed to the facility the same day, however, was unsure if it was verified if it had been received. HRN -G stated she will be faxing another copy of the hospice plan of care to the facility to ensure it is added to R2's hospice binder. R5's face sheet dated 11/19/25, identified diagnoses of neoplasm(cancer) of the ovary and thyroid gland and morbid obesity (excessive body fat).R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 dependent with bed mobility and transfers, no pressure, venous or arterial ulcers, received hospice services, and was cognitively intact.R5's hospice plan of care dated 10/29/25, identified R5 had problem of skin integrity and to prevent skin breakdown R5 was to be turned and repositioned every two hours and as needed to promote skin integrity and prevent breakdown.R5's skin integrity focus care plan dated 10/31/25, identified R5 was at risk for impaired skin integrity related to morbid obesity and lack of mobility. Goal of skin to remain intact. Interventions were as followed: Encourage Resident to frequently shift weight; encourage the use of lifting devices while in bed; Evaluate for pitting edema; evaluate skin integrity; Keep skin clean and well lubricated. R5's facility care plan had not been updated to coordinate with the 10/29/25 hospice plan of care to turn and reposition R5 every two hours.R5's physical mobility focus care plan dated 10/31/25, identified R5 has impaired physical mobility. Goal of will be able to perform activity within physical limits. Interventions were as followed: assist resident in performing movements/tasks; ensure call light is available to Resident; ensure resident is in proper position for tasks.R5's clinical admission assessment dated [DATE], identified R5's skin was warm, dry, and intact. R5 had an old intravenous site on her right antecubital space (the bend in arm) and the dorsum (top) of the right hand. No other skin issues noted on the clinical admission assessment. R5's progress note dated 11/12/25 at 11:02 p.m., identified R5 had a fluid filled blister to right lower extremity and is covered with a transparent dressing. R5's progress note did not identify the hospice agency had been notified of the blister found on R5's leg.During an interview on 11/18/25 at 2:54 p.m., registered nurse (RN)-A stated on 11/12/25, she observed a large fluid filled blister with discoloration on the bottom of R5's right calf and had applied a clear transparent dressing over the blister. RN-A further stated she did not contact the hospice agency inform of the new area of concern nor to inform of the dressing that had been placed on R5's right leg.During an interview on 11/18/25 at 12:24 p.m., hospice registered nurse (HRN)-C stated R5's hospice's plan of care and the facility's plan of care are supposed to almost mirror each other and that R5' s plan of care identified R5 was supposed to be turned and repositioned every 2 hours, however, was unsure if staff at the facility were turning and repositioning R5 as per her plan of care. During an interview on 11/19/25, director of nursing (DON) stated that the facility needs to coordinate with hospice with any change in condition of a resident to ensure hospice is aware of a change in status to ensure there is accurate coordination. [NAME] further stated, R5's hospice plan of care that reflected to turning and repositioning R5 every two hours to prevent skin breakdown should have been added to the facility care plan to make sure the care is coordinated with hospice.Review of the facility's Hospice Program Policy undated, identified the facility had not identified a member of the IDT as a designated staff in the policy to coordinate care provided to the resident by our facility staff and the hospice staff. The policy included the following: In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following:a. Twenty-four-hour room and board care.b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care.c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death.d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; ande. Reporting any alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of resident property by hospice personnel, to the hospice administrator immediately upon awareness of the alleged violation.1. The resident may choose to specify his or her attending physician, or another physician/practitioner, as the hospice attending physician.2. Our facility has designated ___________________ (Name) _________________________ (Title) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the state scope of practice act). He or she is responsible for the following:f. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services;g. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family.h. Ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians.i. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident. (2) Hospice election form. (3) Physician certification and recertification of the terminal illness specific to each resident. (4) Names and contact information for hospice personnel involved in hospice care of each resident. (5) Instructions on how to access the hospice's 24-hour on-call system. (6) Hospice medication information specific to each resident; and (7) Hospice physician and attending physician (if any) orders specific to each resident.j. Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents.3. 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 practicable physical, mental and psychosocial well-being

Based on interview and record review, the facility failed to determine whether a resident was safe to self-monitor diabetic medication treatment results (blood glucose levels) for 1 of 1 residents (R13) who had a continuous blood glucose monitoring system (FreeStyle 3 Libre). Findings include: Observation and interview on 5/14/25 at 8:15 a.m., with R13 identified she had a sensor on the back of her arm and a hand held meter. She placed the meter near the sensor and it recorded her blood glucose level. She identified the nurse would come in and ask her what her blood sugar is and she would tell them. If my blood sugar is low they give me orange juice or a snack. R13 was not aware of any time that she would need to do a manual blood sugar check and was not familiar with how the alarms worked on the device. Review of R13's Self Administration of Medications assessment did not identify R13 had been given any guidance or assessed to ensure she was knowledgeable on how to use the monitor or when she would need to complete a manual blood glucose check to ensure accuracy. Interview on 5/14/25 at 1:04 p.m., with the assistant director of nursing (ADON) identified the facility does not have a policy or process for the use of the FreeStyle Libre 3 continuous blood glucose monitoring device and had not completed any training or competencies to ensure nursing staff were knowledgeable and had an understanding of how the device worked. In addition she agreed R13's self administration assessment did not identify if R13 was knowledgeable enough to use the Libre 3 independently and did not identify that any guidance was provided. Review of the current, undated, FreeStyle Libre 3 manufacturer instructions, located at, https://www.freestyleprovider.[NAME]/us-en/patient-training.html?type=fsl3&&msclkid=137e6c7baf1615aea40e0450ecf20f55&utm_source=bing&utm_medium=cpc&utm_campaign=M%20%7C%20BR%20%7C%20FreeStyle%20Libre%203&utm_term=freestyle%20libre%203&utm_content=Libre%203&gclid=137e6c7baf1615aea40e0450ecf20f55&gclsrc=3p.ds&gad_source=7, identified prior to using the device, patients were to review all the product instructions and complete the interactive tutorials. In addition, the instructions identified there are symbols that may be displayed on the monitor screen to warn when a manual blood glucose level should be completed.

Based on observation, interview, and document review, the facility failed to ensure staff were competent to use a continuous glucose monitoring device (FreeStyle Libre 3) for 1 of 1 resident (R)13 who had a diagnosis of diabetes. Findings include: R13's admission Minimum Data Set (MDS) assessment identified her cognition was intact, she required assistance from staff to complete activities of daily living (ADL)'s, and had diagnosis of diabetes, heart failure, respiratory failure, bi-polar disorder, borderline personality disorder, and depression. R13's May 2025, administration record identified she was to have her blood glucose level monitored and recorded three times a day before meals. R13 was to be administered 40 units of insulin aspart protamine and insulin aspart (a combination of fast acting and intermediate acting insulin to keep blood sugar levels under control) subcutaneous two times a day at 8:00 a.m., and 4:00 p.m. In addition, R13 was to be administered a correction dose based on her blood sugar levels at the time of administration. R13's 4/30/25 through 5/13/25, documented blood glucose levels identified her blood sugars ranged from 70 Milligrams per deciliter (mg/dl)- 403mg/dl. Target blood glucose levels for people with diabetes is 80-130mg/dl. Interview on 5/14/25 at 8:02 a.m., with registered nurse (RN)-B identified she was familiar with these types of devices similar to what R13 used for blood glucose monitoring because she had used them at other facilities. She revealed she had not received training on the device since working at this facility and had not completed a competency. She identified she did not know where the manufacturer directions were but thought they were on the charge nurse med cart or in the medication room. Interview on 5/14/25 at 8:07 a.m., with registered nurse (RN)-A identified he was the charge nurse and had never worked with a continuous blood glucose monitoring device. He was not aware of what type of device R13 used and was not aware if the facility had manufacturer directions or where they would be located if they did. He identified they may be on the other medication cart with R13's other medications. He revealed he had not been trained how to use the device and had not completed a competency. Interview on 5/14/25 at 1:04 p.m., with the assistant director of nursing (ADON) identified the facility does not have a policy or process for the use of the FreeStyle Libre 3 continuous blood glucose monitoring device and had not completed any training or competencies to ensure nursing staff were knowledgeable and had an understanding of how the device worked. Interview on 5/14/25 at 8:15 a.m., with R13 identified she told the nurse what her blood sugar was. If R13's blood sugar was low they [nurses] gave R13 orange juice or a snack. R13 was not aware of any time that she would need to do a manual blood sugar check and was not familiar with how the alarms worked on the device. Interview on 5/14/25 at 4:11 p.m., with the administrator identified she would expect the facility would ensure nursing staff were trained and competent in the use of any medical equipment used for the treatment and medication therapy of residents who reside at the facility. Review of the FreeStyle Libre 3 manufacturer directions identified that prior to using the device, review all the product instructions and complete the interactive tutorial at www.FreeStyleLibre.com. In addition, the instruction identified there are symbols that may be displayed on the monitor screen to warn when a manual blood glucose level should be completed.

Based on observation, interview, and record review the facility failed to ensure dietary staff had appropriate training with competencies to carry out the function of monitoring the dish machine temperatures to ensure appropriate sanitation occurred. Findings include: Observation and interview on 5/13/25 at 9:30 a.m., with dietary aide (DA)-A who ran a load of dishes through the dish machine. The gauge located on the right side was at 170 degrees and did not move. The gauge, located on the left side moved during the wash and rinse cycle showing the wash cycle was to be 160 degrees and the rinse cycle was 180 degrees. DA-A reported she observed and documented temperatures once a shift. She reported the left gauge was the wash cycle, and the right gauge was the rinse cycle. When DA-A was asked if the temperature needed to reach a certain temperature, she replied there was no special temperature it had to be. Interview and observation on 5/13/25 at 10:11 a.m., with maintenance director identified one gauge read both the wash and rinse temperature. The maintenance director accompanied the surveyor to the dish machine and ran a cycle confirming that the left gauge read both the wash and rinse temperatures. He reported he did not think that the right gauge was even working. Review of the Dish Machine Temperature logs for March, April, May of 2025, identified the logs identified the rinse temperature fell below a safe sanitizing level of 180 degrees Fahrenheit (F) during the following meal services in: 1) March 2025: Breakfast 18 of 31 days, Dinner 4 of 31 days, Supper 4 of 31 days. Staff failed to document any temperature level for 11 of 31 days. 2) April 2025: Breakfast 13 of 30 days. There was no documentation sanitation had been achieved for 4 of 30 days during the breakfast meal service. During the dinner meal, 6 of 30 days fell below 180 degrees F. Further review of the dinner meal service identified 6 of the 30 days also had no documentation to support staff had monitored rinse temperatures. Supper meal service fell below safe temperatures 2 of 30 days. Staff failed to document 12 supper meal service rinse temperatures for the 30 days in April. 3) May 2025: Breakfast 8 of 13 days fell below 180 degrees F. Dinner 1 of 12 days fell below, with the Supper meal service falling below 2 of 12 days reviewed with 1 of those 12 days having no documentation to support staff had monitored temperatures. On the form, it was noted if the rinse temperature fell below 180 degrees, F, staff were to contact the dietary manager. Interview on 5/13/25 at 10:16 a.m., with dietary manager identified staff were to contact her or the maintenance director if the wash or rinse temperature was not at the correct temperature. She reported staff were to use the gauge on the left side for monitoring the wash and rinse cycles and staff had been trained on that but did not always follow directions. She confirmed monitoring the wash and rinse cycles was a problem and she reviewed the logs to monitor for a pattern. She confirmed several rinse temperatures were under 180 degrees. Additional interview on 5/13/25 at 1:40 p.m., confirmed she had not addressed the low rinse temperatures with any staff previously. She reported staff completed training on Relias, the facility online training system. Then before staff start in the kitchen, she trained staff on the cleaning dishes machine policy. Review of DA-A, DA-B, and cook-A training and competencies identified: 1) DA-A, had no competency documentation related to monitoring the dish machine wash and rinse cycle temperatures to ensure appropriate sanitation occurred. There was no documentation the dietary policies had been read or reviewed. 2) DA-B, had no documentation of competencies or the policies had been read and reviewed. 3) Cook-A, had no competency documentation related to monitoring the dish machine wash and rinse cycle temperatures to ensure appropriate sanitation occurred. She signed on 9/11/24, she read the dietary policies. Interview on 5/13/25 at 1:40 p.m., with dietary manager revealed DA-B had no competencies related to her job functions, she only had received initial training which included an overview of food service. Interview on 5/13/25 at 2:58 p.m., with maintenance director identified both gauges were working on the dish machine. He confirmed the Ecolab data plate located on the dish machine identified minimum temperature for wash was 150 and rinse was 180. The right gauge did not move unless the machine was shut off, and the left gauge bounce back and forth for the wash and rinse cycle. He confirmed if the dish machine did not reach those temperatures staff were to contact the dietary manager or him to address. Interview on 5/14/25 at 9:24 a.m., with dietician identified sometimes the dish machine needed to run a couple cycles to get up to temperature. If the dish machine was not getting to recommended temperature for the wash and rinse cycle, then the dietary manager needed to be notified, and a maintenance request needed to be made. He would expect staff would be knowledgeable about how to read the temperature gauges, daily monitoring was being completed, and staff would report any concerns of the temperatures not reaching recommended temperature for wash or rinse cycles. Interview on 5/14/25 at 12:54 p.m., with dietary manager identified maintenance confirmed both gauges are working, and the maintenance director labeled the gauges for monitoring wash and rinse temperatures. She revealed that had not been how she was trained by Ecolab, but it now made sense. Review of the undated, ECOLAB XL HT (hot water sanitizing, electrically heated dish machine) Operation Manual identified the wash temperature for 150 degrees minimum in the hot water sanitizing mode. The rinse temperature at 180 degrees minimum in the hot water sanitizing mode. A diagram in the manual identifies on the machine the left gauge as the thermometer rinse temperature and the gauge on the right as the thermometer wash temperature. Review of the undated, Dietary Aide Training list identified staff were to wash dishes and chart dishwasher temperatures. Review of the undated, Cleaning Dishes/Dish Machine policy identified prior to using the dish machine staff were to verify proper temperatures and machine function. Staff were to check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. The policy identified dish machine wash temperature should reach a minimum of 150 and the rise cycle to reach minimum of 180 degrees. Staff were to monitor temperatures and document to assure proper sanitizing of the dishes. Staff were trained to report any problems with the dish machine to the dietary manager. The dietary manager was to take immediate action to assure proper sanitation of the dishes.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R27) was free from psychosocial abuse by (activity aid (AA)-A). Findings include: R27's 6/22/23, admission Minimum Data Set (MDS) identified R27's cognition was intact, he required limited assistance with bed mobility and extensive assistance with transfers and toileting. R27 had diagnosis of depression, post-traumatic stress disorder (PTSD), developmental disorder of scholastic skills, malnutrition, heart failure, diabetes, and epilepsy. R27's medical record also identified he had recently undergone an amputation of the toes on his right foot. R27's undated care plan identified he was at risk for abuse and staff were to allow adequate time to process tasks, ensure he was safe around others that may take advantage of his confusion and remove him from potentially dangerous situations or situations that may cause distress. Interview on 8/28/23 at 5:34 p.m., R27 identified that he had been on an outing to go shopping with several other residents, activity aid AA-(A), and the activity director (AD) on 8/16/23. The trip was approximately 40 minutes each way. R27 identified he had been experiencing episodes of diarrhea that day and had to ask AA-A to stop so he could use a bathroom. After the stop they continued the trip. Near the end of the shopping trip AA-A started really rushing me R27 explained, she had grabbed his shopping cart from him and started pulling it to the checkout counter and putting his items on the counter and reported, She seemed irritated R27 told AA-A he needed to use the bathroom. AA-A continued placing his items on the counter, he then placed his billfold on the counter and stated I can't hold it anymore. AA-A looked at me and in a stern voice said 'Hurry up!'. R27 identified there were people in line behind him and stated, I was embarrassed, I felt belittled . and treated like a child. R27 identified while he was in the bathroom AA-A banged on the door and yelled What is your PIN (personal identification number)?! R27 did not give his PIN number because he did not want others to hear it. He then came out of the bathroom and went to the counter to finish paying. AA-A grabbed his cart that had his items and left the store before he had finished paying. The unidentified customer in line behind him apologized to R27 stating I'm really sorry for what you just went through. R27 said he was worried he might get in trouble because AA-A left the store with his items before he was able to finish paying. R27 identified when they arrived back at the facility, he was still really upset and embarrassed by the whole thing. I was so upset I was shaking and almost in tears. He identified he had reported the incident to the activity director (AD). She apologized for the actions of AA-A. The AD then reported the incident to the LSW that same day, who then reported the incident to the director of nursing several days later. Interview on 8/29/23 at 12:18 p.m., activity director (AD) identified she and AA-A had taken R27 and several other residents on an outing to go shopping that day. AA-A was driving the bus and assisting with residents, she identified that she had not been aware while on the trip that anything had occurred. She checked in with R27 and he had said he had a few more things to get and she had told him that was fine and to go ahead and finish shopping, she then went out to start loading residents and their purchases with AA-A. The AD identified at some point AA-A went back into the store. After some time AA-A returned to the bus. A couple minutes later, R27 came out of the store. When he got on the bus he was visibly upset. He slammed down in his seat and stated I don't know why everyone has to be in such a [expletive] hurry around here!!! The AD identified she had decided to wait until they arrived back at the facility and had some privacy to ask him what was bothering him. On the way back R27 needed to stop to use the bathroom again, he apologized several times to everyone for having to stop. The AD identified that when they arrived back at the facility, they unloaded residents and their purchases and then she went and spoke with R27 he told her he felt AA-A was rushing him and speaking to him as if he was a child. The AD identified she reported the incident immediately following their conversation to the LSW, notifying her that R27 was upset over an incident that had occurred. The AD identified she had received a phone call 8 days later on 8/24/23 from the administrator stating she needed to talk with AA-A right away. The administrator met with AA-A and then notified me she had suspended AA-A pending investigation. The administrator informed the AD she would need to review respect and dignity policies with AA-A before she could return to work following her suspension. The activity director stated, I think [AA-A] was frustrated because we had to stop so many times, she was gesturing to me like how long is this going to take? We also had a resident almost fall that day on the bus, I think things were a little chaotic. Interview on 8/29/23 at 12:49 p.m., LSW identified on 8/16/23 the AD had reported to her an incident had occurred during an outing and that R27 was upset. LSW identified that she completed an interview with R27 and that he had reported that AA-A rushed him during the trip and was impatient with him. He told her that he had tried to use the bathroom and she came and knocked on the door and asked for his PIN number through the door. The LSW had asked R27 how he would like to proceed. He told her he was not sure and would think about it. The LSW agreed she had not followed up with R27 until 8 days later on 8/24/23. R27 at that time told her that he had told the director of nursing (DON) earlier that day and she was going to do a Vulnerable Adult report. During her interview with R27, she had asked him to tell her what happened again because she stated, the first time I spoke with him he was upset and was having a hard time articulating himself. He reported he felt like AA-A had spoken to him like he was a child . We talked about different resolutions. R27 said that he did not think an apology would be genuine because this has happened before with AA-A and previously felt rushed again the last time he had been on an outing with AA-A. AA-A had went on an outing last winter with other residents and concerns were noted at that time. AA-A was in a big hurry to get back to the facility to finish her other duties. LSW identified she did not report either of those incidents. LSW had not reported the incident to the DON on 8/16/23 because She is not my supervisor. LSW identified that she never reported the incident to the administrator since R27 had told her on 8/24/23 that he had reported it to the DON. Interview on 8/29/23 at 1:11 p.m., with the DON identified she had not been aware of the above-mentioned incident until 8/24/23 at 2:00 p.m., when R27 reported it to her. She identified R27 reported he completed a grievance with the LSW on 8/16/23. The DON asked R27 to describe the incident. R27 described the incident as noted above, to the DON and reported that he felt humiliated and embarrassed. After completing the interview with R27, The DON reported the incident to the administrator. The administrator suspended AA-A on 8/24/23 at 2:55 p.m., 8 days after the incident occurred. DON identified they had completed a full internal investigation that included interviews with R27 and several other staff and residents. They determined that R27 had suffered actual psychosocial abuse from AA-A during an outing on 8/16/23. DON identified that after completing the investigation I just felt terrible for [R27]. Interview on 8/30/23 at 9:40 a.m., AA-A identified that she had been the driver for the resident outing on 8/16/23, she said it had been a big group that day. They had to make a stop on the way so that R27 could use the bathroom and that the stop took about 20 minutes and other resident were not happy about it. At at the end of the shopping trip, she went back into the store and found R27 and told him We have to go. She said she got him in line at the checkout and helped him put his items on the counter. He told her that he needed to use the bathroom. She asked him to wait because there were 4 people in line behind him. He handed me his card and said he couldn't wait and left for the bathroom. AA-A identified that she had asked the male cashier if he would go in the bathroom and ask him if he needed help. The cashier said No. She then realized R27 went to the family bathroom so she knocked on the door and asked him for his PIN number through the door. R27 would not give her the PIN number so she returned to the cashier and told him they would have to wait. R27 returned from the bathroom and paid for his items. AA-A reported that she felt like there was a lot going on that day. There were a lot of residents on the trip and she had to get back for a 4:00 p.m. activity. AA-A stated, I don't think he should have been allowed to go on the trip that day. It was very stressful. We had resident that needed colostomy (pouch used to collect feces through an opening into the intestines) bag emptied. Other residents needed to use the bathroom and it was very hot that day. The trip was about 4.5 hours long. AA-A identified that R27 asked her why she had to be in such a rush. She told R27 Well I have a 4:00 p.m., activity back at the facility. AA-A identified she had not spoken with R27 again that day. AA-A identified she finished her workday, then returned for work 5 more days, on 8/17/23 and 8/18/23, she was off for the weekend. She then worked on 8/21/23 through 8/23/23. She was not suspended until 8/24/23 (8 days after the reported incident of abuse). AA-A had worked with other residents from the time of the incident until her suspension. Review of AA-A personal file identified she had 5 disciplinary actions from 4/10/23 through 2/15/23 for insubordination, not following facility policies, and for not reporting witnessed incidents between another staff and resident to the administrator or DON. Review of 3/22/23, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy identified staff should report any suspicion of abuse to the DON and administrator immediately. Immediately was defined as within 2 hours of an allegation involving abuse. The employee who was being accused of abuse was to be suspended and not have any resident contact until the investigation was complete. When the investigation was complete and if the allegations of abuse are substantiated, the employee was to be terminated.

Based on observation, interview, and document review the facility failed to comprehensively assess and care plan safe transfers for the appropriate brand of sit-to-stand mechanical lift and accessories to ensure safe transfers for 1 of 4 residents (R1) reviewed for mechanical lift transfers. This resulted in harm when R1 re-fractued his left humerous (upper arm) during a transfer using a standing mechanical lift. Findings include: During an interview on 9/27/22, at 8:35 a.m. the Administrator indicated the facility was divided into two sections which were identified as Country Side and City Side and were in the process of moving residents from the Country Side of the building to the City Side of the building due to low census and staffing reasons. Further the administrator indicated R1 was moved from a Country Side room to a City Side room on 9/21/22. During observation on 9/27/22, at 10:00 a.m. four (4) sit-to-stand mechanical lifts were observed throughout the facility; Valaro, Arjo Sara 3000, Arjo Sara 3000 accessorized with additional black handlebars on each side, and an EZ Stand Lift. The Country Side section housed the Arjo Sara 3000 and EZ Stand Lift. The City Side section housed the Arjo Sara 3000 with the black handlebar accessory and the Valaro sit to stand lifts. R1's face sheet indicated admission diagnosis of [CONDITION(S)], dementia, and a left femur (upper leg) and left humerus (upper arm) fracture sustained 5/10/22 with routine healing. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment and required extensive assist of two staff with transfers and did not walk. R1's Therapy Transfer Recommendation Form dated 7/20/22, indicated R1 was dependent on one (1) staff assist with EZ-Stand Lift with additional notes indicating to provide verbal cues to reach/grasp handles on EZ-Stand. EZ stand on form was the only brand name selection on the assessment and did not include the other three different brand sit-to-stand lifts that the facility used for transfers. R1's Lift Mobility Status assessment dated [DATE], indicated R1 was to use the EZ stand/sit-to-stand but appropriate sling selection or use of handle bars were not identified. R1's care plan transfer status last revised on 5/12/2022 indicated therapy's recommendation was assist of two (2) staff and full mechanical lift for transfers. The care plan was not revised to reflect R1's 7/20/22 therapy recommendations or the 8/9/22 Lift Mobility Status assessment recommendations for a standing lift. R1's nursing progress note dated 9/21/22, at 7:45 p.m. indicated the nurse was called to R1's room indicating R1 was having pain to the upper left arm. The note further indicates while R1 was being raised up by the standing lift, a loud pop and crack was heard and R1 had pain and a mild deformity was noted to the left upper left arm. R1 was transported to the emergency room (ER) for further evaluation. A progress note dated 9/22/22 at 3:08 a.m. indicated R1 returned to the facility with a diagnosis of a fracture of the left humerus and was to wear a shoulder immobilizer, orders for pain medication, and future orthopedic appointments set up. R1's document titled, Nursing Home Visit dated 9/22/22, by NP-A indicated a follow-up visit was completed and noted the incident as when R1 was transferring back to bed after toileting using the EZ stand, the nursing staff heard an audible crack, pop sound when the resident had his arms holding onto the EZ stand. Further indicates prior history of left upper arm fracture on 5/5/22 after a fall. During an interview on 9/27/22, at 12:15 p.m. NA-A indicated she had worked with R1 prior to the room change but there was a different lift that they used to transfer R1 after he moved to City Side part of the building. During an interview on 9/27/22, at 1:25 p.m., NA-B indicated she transferred R1 on 9/21/22, at the time of the incident. Stated R1 usually transfers with the sit-to-stand and one person and did well but had just moved to a new room and used the Sara 3000 with the black handlebars on it and R1 grabbed onto the black handlebars instead of the lower handlebars he usually held on to. Further stated when she lifted him to a standing position off the toilet and she heard a pop and sat him back down on the toilet then he put his arms on the lower bars of the lift like he usually did and was able to stand and complete the transfer to bed. Once he was in bed, he complained of his left arm hurting so NA-B called the nurse and was sent to the hospital. NA-B further explained the lifts are different on City Side than they were on Country Side and that was the first time they used this type of lift with the black handlebars During an interview on 9/27/22, at 2:00 p.m. certified occupational therapy assistant (COTA)-A indicated he had assessed R1 on the blue Arjo Sara 3000 lift without the black handlebars because that is the lift that would be used on the Country Side where R1's room was located at the time. Further stated, the Arjo Sara 3000 lift with the black handlebars would probably not be a good fit for R1 because the black handles would raise his arms up higher than R1 was used to. During a follow-up interview on 9/28/22, at 2:10 p.m., COTA-A indicated he did not assess residents or a particular brand of lift or the accessories that had been added but rather assesses to see how well the resident stands and strength to hold on. During an interview on 9/27/22, at 2:25 p.m., NA-E stated she didn't know if they are supposed to use the black handlebars but they were never told not to use them. During an interview on 9/28/22, at 12:30 p.m. the director of nursing (DON) indicated she has been employed by the facility for a couple months. Further stated the expectation is for a lift mobility assessment to be completed upon admission, quarterly, and with change of condition and communicate it with the team and physically try it out on the residents. Further indicated she did not know if the therapy assesses the residents for a specific brand or the handlebar accessories on the sit-to-stand lifts. Stated the care plan interventions transfer to the resident Kardex and the nursing staff are to look at the resident Kardex on the computer for everything they would need to know about how to care for the resident. The DON verified R1's care plan was not updated based on the assessments. During a phone interview on 9/28/22 at 2:30 p.m., An Arjo representative indicated the Arjo Sara 3000 is no longer available but stated the black handlebar accessory is just another option for a person to hold on to as some people are taller and like the higher handlebars. During a follow-up interview on 9/28/22, at 1:00 p.m. R1's left upper arm fracture was likely a re-fracture due to incomplete healing of the fracture approximately four (4) months earlier and history of brittle bones. Indicated although R1 didn't not have any restrictions, the overreach and different arm position than what he was used to could have contributed to the fracture. Because of the previous fracture, that area would have been weaker and more prone to fractures. The facility training titled, Safe Use of Mechanical Lifts, indicates training includes learning about the different types of mechanical lifts, identifying when to use them, and how to do so safely and efficiently. You must abide by the manufacturer's specific instructions for the lift you are using. Never assume that because you used on piece of equipment for one mechanical lift that you can use it for another type of lift. Doing so may result in equipment failure or even injury, or worse, death. Check the plan of care. The facility policy titled, Care Plans, Comprehensive Person-Centered, dated 11/30/2021, indicated the care plan interventions are derived from a thorough analysis of the information gathered as a part of the comprehensive assessment. Manufacture recommendations for the Arjo Sara 3000 was not provided.

Based on interview, observation, and document review, the facility failed to provide adequate supervision and safeguards to prevent elopement for by not following manufacturer's guidelines for the use of WanderGuard bracelets for 2 of 2 residents (R1, R2) who were determined to be at risk for elopement and required the use of a WanderGuard for safety resulting in an Immediate Jeopardy. In addition, the facility failed to implement interventions to prevent future elopements and failed to update care plan interventions related to elopement/wandering behaviors for 1 of 2 residents (R1) following an elopement. The immediate jeopardy began on [DATE], when R1, who was identified as a high elopement risk, was found on the street off the premises and was identified on [DATE]. The administrator and assistant director of nursing (ADON) were notified of the immediate jeopardy at 2:10 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level D scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of dementia and had severe cognitive impairment. Further, R1 required extensive assist from staff for activities of daily living (ADLs) such as bed mobility, transfers, dressing, toileting, and locomotion off the unit. R1's Elopement Risk Evaluation dated [DATE], indicated R1 was at risk for elopement and required the use of a WanderGuard for safety. R1's care plan as of [DATE], indicated R1 was at risk for elopement related to impaired safety awareness, statements of wanting to go home and going to the door. Further, R1's care plan directed staff to distract R1 from wandering by offering pleasant diversion, structured activities, food, conversation, television and book. R1's care plan lacked resident specific interventions for these identified behaviors, implementation of current interventions and lacked evidence of implementing new interventions following R1's elopement on [DATE]. R2's quarterly MDS dated [DATE], indicated R2 had a diagnosis of dementia and R2's cognition was moderately impaired. Further, R2 required supervision by staff for locomotion on or off the unit. R2's Elopement Risk Evaluation dated [DATE], indicated R2 was at risk for elopement and required a WanderGuard for safety. Review of facility report to the State Agency (SA) dated [DATE], indicated R1 was found by nurse leaving for the day off the nursing home premises (off campus). R1 was in his wheelchair. R1 was assessed for injury upon return to the facility and no injuries were noted. R1 had a Wandergard on at the time of incident however it was checked and found to not be working properly (not sounding when entering or exiting facility doors). A new Wandergard was placed on R1. Review of facility's five-day investigation dated [DATE], indicated action taken to prevent reoccurrence was for staff to take R1 outside for a walk in the afternoon or around the facility in his wheelchair. Further, investigation indicated to prevent reoccurrence to the other residents who were identified at risk for elopement the staff were directed to check WanderGuard function three times a day each shift as well as add expiration date and model number in the medication administration record (MAR) and WanderGuard's are changed every 60 days (not a change in practice). In addition, a message was sent to family/visitors for each resident to educate them regarding not allowing a resident to follow them out of the building. On [DATE], at 2:26 p.m. registered nurse (RN)-A stated at approximately 2:45 p.m. on [DATE], RN-A finished her shift and was headed home when R1 was observed in his wheelchair on the street at the end of the block. RN-A stated she witnessed R1 standing up attempting to try and get his wheelchair unstuck. RN-A stated she stopped her car in the middle of the road and brought R1 back to the facility. Further, RN-A confirmed she was R1's nurse that morning until the next shift arrived at approximately 2:00 p.m. and RN-A was unsure the last time she observed R1 but stated R1 had went to an activity of live music that afternoon. In addition, RN-A stated R1 was at risk for eloping due to behaviors of exit seeking and confusion and she almost had a [CONDITION(S)] when R1 was observed outside. On [DATE], at 8:28 a.m. R1 was observed at the nursing station in his wheelchair and WanderGuard was placed on R1's right wrist. On [DATE], at 8:59 a.m. R2 was observed in the commons area at the front of the facility in his wheelchair. R2's WanderGuard was observed to be attached directly to the left metal handlebar. On [DATE], at 8:44 a.m. [NAME] sales representative (SSR)-A for the WanderGuard system the facility was using stated the WanderGuard bracelet will rarely malfunction, however if a bracelet does the facility should keep the bracelet and call [NAME] to run diagnostics and evaluate as to why the WanderGuard bracelet could have malfunctioned. Further, SSR-A stated a WanderGuard bracelet should never be placed directly on metal due to metal blocking the signal and the resident would be able to go right through the door. On [DATE], at 9:09 a.m. director of nursing (DON) confirmed she completed the investigation following R1's elopement. DON stated she did not contact the WanderGuard manufacturer ([NAME]) or review the [NAME] WanderGuard User Manual to determine the cause of the WanderGuard malfunction. Further, DON stated R1's WanderGuard was on R1's wheelchair on the day of the incident, [DATE]. Following the incident, R1's WanderGuard was removed from the wheelchair and a new bracelet was placed on R1's ankle. On [DATE], upon returning to the facility, DON stated she placed another new WanderGuard on R1's wrist. DON added staff are trained to ensure WanderGuard placement is on the person rather than on the wheelchair. DON was not aware R2's WanderGuard was currently on his wheelchair. DON confirmed the facility did not assess other residents at risk and no re-education was completed following the elopement on [DATE]. DON confirmed the facility increased testing WanderGuard units on every shift daily (were testing once daily before incident) and stated a letter was sent to families and guardians with friendly reminder to ensure they were not letting residents exit the building when leaving as this was the conclusion to how R1 may have left the building (despite the WanderGuard unit still not alarming). On [DATE], at 11:46 a.m. administrator stated during the investigation it was determined R1's WanderGuard was ordered to be changed on [DATE], however when the nurse was interviewed, she misunderstood the order and R1's WanderGuard was not changed since [DATE], which was still within the 90-day expiration date range for the WanderGuard. Administrator confirmed after reviewing R1 and R2's MAR a new order was not implemented as indicated as an intervention in the facility's 5-day investigation to prevent reoccurrence to include the expiration date and model number for the WanderGuard in their record. Further, administrator stated management determined two root causes for R1's incident which included R1's battery on his WanderGuard died and the other a volunteer holding the door open for R1. Administrator stated there was a message sent to each resident's family to educate on resident safety and not holding the door open for a resident to follow them out of the facility, however administrator indicated unexpected visitors did not receive this information. Administrator confirmed there was no education provided to staff following the incident of R1 eloping related to WanderGuard placement, responding to the alarms, educating visitors when they are leaving, or on the updated Wander Management policy because staff are educated as part of their new hire orientation and there had not been an issue in the past. Administrator confirmed the manufacturer for the WanderGuard was not called and updated on the bracelet malfunction because it was just the one bracelet that failed, and they do fail once in a while. In addition, administrator indicated the facility's policy for placement of WanderGuard bracelet was either the wrist or ankle however at times the WanderGuard had been placed on a wheelchair, which administrator confirmed she was not aware a WanderGuard could not be placed on a wheelchair On [DATE], at 11:08 a.m. licensed practical nurse (LPN)-A stated staff was directed to place a WanderGuard based on each resident's mobility for example, if the resident were ambulatory the bracelet would need to be on the resident but if the resident were wheelchair bound then the bracelet would be placed on the resident's wheelchair. On [DATE], at 11:21 a.m. RN-A confirmed R1's WanderGuard was on his wheelchair the day of the incident. RN-A stated staff were directed to place the WanderGuard's on the resident's wrist or ankles however if the resident had a history of removing the bracelet staff were directed to place the bracelet on the resident's wheelchair. In addition, RN-A stated R1 had a history of removing his bracelet when placed on his wrist or ankle. On [DATE], at 1:17 p.m. MDS coordinator stated R1 displayed behaviors of wandering and exit seeking in the afternoon and was not sure which interventions were in place at this time other than distractions and taking R1 for a walk for staff to use when R1 is displaying these behaviors. MDS coordinator was not aware R1's care plan was not updated following R1's elopement on [DATE], to include taking R1 for a walk outside or in the facility if he begins to show wandering or exit seeking behaviors. Further, MDS coordinator stated resident care plans were expected to be updated at least quarterly and as needed when there are changes to ensure all staff are aware of what to do to help each resident and take care of each resident. Review of [NAME] WanderGuard User and Installation Manuel dated 2010, directed for staff to read and follow these instructions carefully before using this system, failure to do so could cause an unauthorized departure resulting in injury or death. Further, WanderGuard manual directed staff the bracelets are designed to be worn only on the resident's dominant wrist and prior to alternative placement staff are direct to call WanderGuard Customer Services. In addition, WanderGuard Manual directs staff not to place bracelet on or next to metal, such as wheelchair frames as metal could interfere with the signal sent from the bracelet to the door antennas and result in an unauthorized departure. Review of facility policy titled Wander Management System updated on [DATE], directed staff the wander management system bracelet will be applied to the resident's wrist or ankle. The wander management bracelet expiration date and model number should be documented in the resident wander management physician order. In addition, facility policy directs staff to check bracelet function and placement every shift. The immediate jeopardy that began on [DATE], was removed at 12:54 p.m. on [DATE], when the facility reassessed all residents who were at a high risk for elopement, reviewed each resident's care plan and updated to include current elopement risk interventions, [NAME] WanderGuard manufacturer was contacted related to the malfunction, Wander Management Policy was reviewed and updated to comply with manufacturer's instructions for placement of WanderGuard, all staff were educated on the updated Wander Management Policy in person, phone, and prior to beginning of their next shift and WanderGuard placement was moved to only residents person.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines to prevent or minimize the transmission of COVID-19 which resulted in an ongoing facility outbreak when 7 of of 7 residents (R2, R8, R9, R14, R17, R36 and R38), who later tested positive for COVID-19 were identified with symptoms of COVID-19 with no transmission based precautions (TBP) implemented. The facility's failures resulted in an immediate jeopardy (IJ) situation for all 36 residents who were at risk. The immediate jeopardy (IJ) began on 11/7/20, when it was identified the facility failed to immediately implement TBP and isolation when symptoms of COVID-19 were identified. The facility's administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 11/25/20 at 11:51 a.m The IJ was removed on 11/25/20 at 4:45 p.m., but non-compliance remained at the lower scope and severity of F, widespread with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: Review of the current, Infection Control Program documentation, identified processes located in a binder and an infection line list stored on an electronic spreadsheet. The infection control line list electronic document included: resident name, room number, infection type, body system for infection, and surveillance definitions met such as symptoms, onset date, infection risk factors, diagnostics performed, type of test, specimen source, results, antibiotic name, type of precautions (such as whether transmission based precautions were in place), and date symptoms resolved. Additionally, residents with symptoms of COVID were documented on a 24 hour report sheet. There was no documentation to support residents with identified potential symptoms of COVID-19 were placed on precautions or monitored by the facility infection control (IC) program. Review of the facility's Resident COVID-19 Screening Tool, identified symptoms of COVID-19 to assess for included: temperature, oxygen saturation, cough, difficulty breathing, fever or chills, sore throat, new loss of taste or smell, muscle pain, nasal congestion, runny nose, diarrhea, fatigue, and headache. The Screening Tool defined a resident suspected of COVID-19 as having one or more symptoms and indicated if a resident had suspected COVID-19, staff were to immediately isolate the resident and notify the infection preventionist. Staff were to document on the Screening Tool whether a resident was placed on isolation for COVID, or if no isolation was required at the time. During interview on 11/24/20 at 4:15 p.m., licensed practical nurse (LPN)-A stated nursing staff were to document symptoms on the screening tool, and if residents presented with symptoms, staff were to notify the infection preventionist (IP). LPN-A further stated the IP was responsible to initiate TBP. LPN-A stated nursing staff were to close the door and keep the resident in their room until they were tested for COVID. She stated staff would not implement TBP and utilize additional personal protection equipment (PPE) until the infection preventionist provided direction. LPN-A verified TBP were not immediately implemented when symptoms were identified. The IP was interviewed on 11/24/20 at 4:30 p.m., wand stated the facility's infection control line list was updated on a monthly basis or when she could get to it. The IP verified the November 2020, line list was not yet updated. The IP further stated COVID-19 symptoms were documented daily in each resident's electronic medical record (EMR), and staff were also to report symptoms verbally. She reiterated, all resident COVID test results and actions tracked were documented in progress notes in the EMR, and symptoms were to be recorded on the 24 hour Report Sheets used for shift reports. Review of resident records and the infection control line listing identified the following: R2's nurses' notes identified on 11/18/20, R2 had a cough. The note further identified R2 had a history of [REDACTED]. In addition, R2's bowel record identified R2 had diarrhea that day. R2's 11/18/20, Screening Tool identified R2 had no symptoms of COVID and isolation was not required. The notes made no mention of whether R2 was placed on TBP at the onset of cough or diarrhea, both potential symptoms of COVID-19. The November 2020, infection control (IC) line list and 24 hour report sheets up until 11/19/20 did not include R2's symptoms of cough or diarrhea. On 11/19/20, R2 tested positive for COVID and was moved to the COVID unit. R8's bowel record identified between 11/9/20 and 11/10/20, R8 experienced diarrhea. R8's 11/9 and 11/10/20, Screening Tools identified R8 had no symptoms of COVID-19 therefore, isolation was not required. The November 2020, IC line list and 24 hour report sheets prior to 11/11/20, did not include R8's symptom of diarrhea. R8's progress notes did not indicate whether R8's physician was notified at the onset of diarrhea, and made no mention about whether R8 was placed on precautions at the onset of diarrhea. On 11/11/20, R8 tested positive for COVID-19. R9's bowel record identified on 11/7/20, 11/12/20, and 11/19/20, R9 experienced diarrhea. R9's progress notes identified on 11/14/20 and 11/18/20, also described R9 as more tired, indicating the resident had woke up later than usual. R9's Screenings identified between 11/7 and 11/18/20, R9 had no symptoms of COVID therefore, no isolation was required. R9's progress notes made no mention R9's medical provider having been contacted or whether R9 was placed on TBP for the potential COVID-19 symptoms of diarrhea and malaise. In addition neither the diarrhea or increased fatigue/malaise were included on the November 2020, IC line list or the 24 hour report sheets prior to 11/19/20. R9 tested positive for COVID-19 on 11/19/20. R14's bowel record identified on 11/8/20, R14 had two episodes of diarrhea. Review of R14's 11/8/20, COVID-19 Screening Tool identified R14 had no symptoms of COVID-19 and therefore, no isolation was required. R14's progress notes made no indication as to whether R14 was placed on TBP at the onset of diarrhea, a symptom of COVID-19. In addition, there was no indication R14's symptoms were reported to the medical provider when they occurred. The November 2020, IC line list and 24 hour report sheets prior to 11/13/20, made no mention R14 had experienced diarrhea or whether R14 was placed on TBP at the onset of symptoms. R14's progress notes identified on 11/13/20, R14 was tested and found positive for COVID-19, and was transferred to the facility's COVID unit. R17's bowel record identified on 11/7 and 11/10/20, R17 had episodes of diarrhea. R17's progress notes notes made no mention as to whether R17's physician was contacted, or whether TBP were implemented. R17's COVID Screenings prior to the 11/15/20 made no mention R17 was placed on TBP when symptoms of diarrhea were identified. Review of the November 2020, IC line list and 24-hour report sheets prior to 11/15/20, made no indication R17 had diarrhea prior to testing positive or TBP implemented prior to testing positive. The progress notes indicated on 11/15/20, R17 tested positive for COVID-19 and was placed into TBP. R36's bowel record identified on 11/16/20, R36 experienced an episode of diarrhea. The progress notes did not include any indication R36's provider was contacted when R36's diarrhea occurred. In addition, there was no indication whether R36 was placed on TBP at the onset of diarrhea. R36's COVID-19 Screening Tool dated 11/16/20, identified R36 had no symptoms of COVID-19 and isolation was not required. The November 2020, IC line list and 24 hour report sheets prior to 11/17/20, made no mention R36 had experienced diarrhea or required TBP at onset of diarrhea. R36's progress notes identified on 11/17/20, R36 tested positive for COVID-19 and was moved to the COVID unit. R38's progress notes identified R38 had experienced diarrhea on 11/8/20. There was no indication R38 was placed on TBP when the potential COVID-19 symptom was identified. The November 2020 IC line list and the 24 hour report sheets prior to 11/17/20, made no mention R17 had experienced diarrhea, and made no idication R38 was placed on TBP at the onset of symptoms. R36's progress notes identified on 11/17/20, R36 tested positive for COVID-19 and was moved to the COVID unit. During interview on 11/25/20 at 8:23 a.m., nurse practitioner (NP)-A identified she worked closely with the facility and was on site approximately 3 times weekly. NP-A stated charge nurses were to document symptoms in the Screening Tool in the EMR and stated, the problem with the screening tool is that it is long and cumbersome, and staff do not complete it accurately. NP-A confirmed she expected staff to implement TBP immediately when any COVID symptoms were present, and also stated she'd expect the resident's MD be notified any time TBP were implemented. She also stated she expected the facility to assess for, and identify, all symptoms of COVID-19 and provide information for underlying conditions. NP-A said underlying conditions would be used to affect her decision to implement or remove TBP. She denied being aware of any residents having symptoms of diarrhea prior to testing positive for COVID-19, and stated she was not notified of any residents placed on isolation for diarrhea. NP-A confirmed her expectation was for staff to implement TBP immediately after any COVID-19 symptoms were identified, including diarrhea. She verified rapid [MEDICATION NAME] tests were not always accurate, and PCR test results were not immediate, so she expected staff to continue precautions when residents tested negative until they were able to be thoroughly assessed. Further, NP-A stated she expected staff to complete a record review before notifying her so she could make accurate recommendations prior to removing residents from TBP. During interview on 11/25/20 at 9:03 a.m., the facility's IP identified the facility used guidance from CMS and MDH to inform their facility's COVID-19 infection practices. The IP stated residents were to be tested and quarantined immediately when any COVID-19 symptoms were present. In addition, the IP stated if a resident had a symptom, but tested negative, they were taken off precautions if there were no further symptoms for 24 hours. She clarified that if a resident had diarrhea and tested negative, the charge nurse determined whether precautions were to be implemented. The IP stated the nurse practitioner sometimes provided guidance to implement or discontinue precautions if she was notified, but stated the nurses and the IP usually made the decisions whether to remove precautions. The IP stated when the facility's nurses contacted medical providers to ask about implementation or removal of precautions, they did not always complete a record review to ensure the provider received all necessary information to make an accurate recommendation. Upon review of the above documented resident symptoms with the IP, she confirmed she was not aware of all of the symptoms, and verified she was not always notified of COVID-19 symptoms prior to residents testing positive. The IP stated she expected staff to immediately place residents on TBP when any COVID-19 symptoms were identified. Review of the facility's 1/1/2020, Infection Prevention and Control Program policy identified the program was developed to address facility-specific infection control needs and requirements identified by the facility assessment and the infection control risk assessment. The policy indicated the program was reviewed annually and updated as necessary. The infection preventionist was responsible for coordination and oversight of the infection control program. The infection control committee was responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information was used to inform the committee of potential issues and trends. The reviews were to include documented infection incidents and corrective actions taken. Surveillance tools were used to recognize occurrences of infections, recording their number and frequency, detecting outbreaks and monitoring employee infections, adherence to infection prevention and control practices and detecting unusual pathogens with infection control implications. Outbreak management was a process to determine presence of an outbreak, manage affected residents, prevent the spread to other residents, documentation of information about the outbreak, reporting information to the appropriate public health officials, education of staff and the public, monitoring for recurrences, reviewing the care after the outbreak and recommending new or revised policies to handle similar future events. Review of the 10/15/20, COVID-19 Facility Guidelines policy identified the facility was to continue surveillance of all residents using the User Data Assessment (UDA), titled Existing Resident COVID-19 Screening Tool. Staff were to immediately place residents with suspected COVID into isolation, place a mask on the resident and close their door, contact the designated State Agencies, regional clinician and local hospital, resident's guardians, physicians, and any other providers of the resident's status. Staff were to also remember to update the infection control line list and resident care plan. Review of the undated, COVID-19 Recommendations for Long Term Care Facilities, identified all residents and staff were to be tested if symptomatic. Symptoms were identified to include: fever greater than 100.0 degrees, or two or more temperatures greater than 99.0 degrees Fahrenheit (F), shortness of breath new or change in cough, chills, sore throat, muscle aches, new or worsening malaise, headache, new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, new confusion/altered mental status, and new or worsening [MEDICAL CONDITION]. The guidance indicated a negative test only indicated an individual did not have [MEDICAL CONDITION] material at the time of testing, and repeat testing may be needed, and that testing compliments existing infection prevention practices and was not a replacement of good infection prevention control practices. Review of the facility's policy Using [MEDICATION NAME]-based Point of Care Testing for COVID-19 in Long-term Care dated 8/31/20, identified [MEDICATION NAME] testing is best used to test symptomatic residents in high disease prevalence. The policy indicated residents with negative [MEDICATION NAME] testing should be considered presumptive of COVID until RT-PCR (a more highly sensitive COVID-19 test) testing confirmed a resident positive for COVID-19. Further, the policy indicated all negative [MEDICATION NAME] tests from symptomatic residents should be confirmed with a RT-PCR. Symptomatic residents should be placed on TBP while waiting for confirmatory testing. Residents who were high-risk contacts of a known COVID-19 positive individual should be placed on TBP while waiting for confirmation testing even if they were asymptomatic. The IJ that began on 11/7/20, was verified to have been corrected on 11/25/20, when the facility had appropriately implemented an acceptable IJ removal plan. The facility reviewed their policies and procedures and implemented staff education. In addition, staff reviewed all residents to identify and initiate TBP for residents who were symptomatic for COVID-19. Verification of corrective action was confirmed through interview with facility staff, observation of care, and review of residents' medical records, infection control surveillance, policies and procedures, and staff training.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R1) was free from abuse after allegations of sexual abuse were identified. The facility also failed to protect R1 from potential further abuse by advising the alleged perpetrator, licensed practical nurse (LPN)-A of the resident's identity. This caused actual psychosocial harm to R1 as LPN-A was not immediately restricted from work pending an investigation and continued to provide care to 22 of 44 residents in the facility for 2 additional days. The IJ began on 9/4/20, when the facility failed to act on allegations of abuse, report to the State Agency and implement policies and procedures to keep R1 and other residents safe from further abuse. The facility administrator was notified of the IJ on 9/15/20 at 1:00 p.m The IJ was removed on 9/16/20 at 4:45 p.m., but non-compliance remained at the lower scope and severity G, actual harm that is not immediate jeopardy. Findings include: Review of the 9/8/20 report filed to the State Agency identified the social worker (SW) filed a report identifying the director of nursing (DON) was notified on 9/4/20 of inappropriate touching by licensed practical nurse (LPN)-A to R1. R1 advised staff she had not wanted LPN-A in her room. R1 alleged LPN-A, at an unknown date, had come into R1's room during the overnight hours and picked up R1's nasal cannula off the floor. LPN-A advised R1 there was fluid directly under the nasal cannula. R1 advised LPN-A it was from the condensation from humidified oxygen (O2). LPN-A picked up R1's bedding as R1 was laying in bed, and moved his hands along her bottom. LPN-A had not advised R1 he was going to check her for alleged incontinence. Action taken by facility was identified as the DON advised LPN-A not to go into R1's room unless there was another staff person present. LPN-A was suspended per report on 9/7/20 pending an investigation. Review of the facility's investigation notes, which began on 9/8/20 per the social worker, identified R1 advised (RN-A) on 9/4/20 at 10:10 p.m. she does not want a male care giver. LPN-A (no date or time) stated he came to work on 9/4/20 at 8:00 p.m. Over a week ago (unsure of date and time), the nurse aide on duty that night of the incident, was on break. R1 had reportedly put her call light on. LPN-A stated he answered it. LPN-A asked R1 what she needed. R1 stated she wanted cold water. LPN-A went to retrieve the water and upon return, noted a puddle or urine on the floor. LPN-A gave R1 her water and was trying to figure out where it came from. He lifted R1's cover slightly to check her bed. LPN-A advised R1 he was trying to figure out where the urine came from. LPN-A patted the bed. R1 had a funny look on her face. LPN-A immediately put the covers down and cleaned up the floor. The notes identified R1 frequently refused to be changed and voids in her bed. there was no inappropriate contact. We (facility staff) will care plan no male caregivers. If he (LPN-A) needs to give medication or attend to medical tx (treatment), male nurses will take another female staff with them into the room. LPN-A was notified of his suspension on 9/8/20. Further investigation notes identified LPN-A also remarked when he finished cleaning up R1's floor, he and LPN-A were both joking when he left the room. On 9/8/20 at 8:35 a.m., R1 was interviewed by the SW. Notes of that interview identified R1 was outside smoking the evening of 9/4/20 and saw LPN-A report to work. R1 advised NA-A and NA-B not to let him come into her room since she felt uncomfortable. R1 was unclear on when the incident of inappropriate contact had occurred, but it was before 9/4/20. LPN-A had entered her room during the night, picked up her nasal cannula and said it was wet. R1 advised LPN-A it was wet from condensation. LPN-A left to get new tubing. R1 stated she was lying on her side with her back facing the doorway. When LPN-A returned, he touched her bottom inside her brief. R1 declared she had not used her call light to summon LPN-A that night. R1 declared no other staff has ever checked her for incontinence in that manner. R1 reported to the SW she felt safe. All staff were good to her except LPN-A. Both NA-A and NA-B were interviewed on 9/8/20. NA-B stated on the night of 9/4/20, R1 was outside smoking, came inside and was visibly shaking. NA-B asked if she was ok to which R1 replied Not really. Seeing (LPN-A) makes me nervous. Both NA's took R1 to her room. R1 reported she had woken up to LPN-A checking her brief by sticking his finger in the back of her brief without telling her. R1 denied she had been wet. After talking to RN-A, NA-A and NA-B were advised LPN-A was not allowed in R1's room. Other staff were interviewed, but had no knowledge of the incident. Other residents were interviewed for safety and had no issues or concerns with staff. The Ombudsman was notified on 9/8/20 and the medical director was identified as being notified on 9/9/20. It was indicated in the report, after review of interviews, the facility identified it was our belief LPN-A was not abusive, nor had intent of abuse. We believed he failed at communication . Corrective action identified were male staff were to be accompanied by a female staff per resident request. Before returning to work, LPN-A would be inserviced on the importance of explaining to residents what he is doing before hand. LPN-A was to have one-on-one supervision for 1 week. RN-A was to be inserviced on 9/14/20 on the importance of getting all the facts first hand and reporting timely. The facility was to monitor its corrective actions. There was no mention facility management had identified they failed to report the suspicion of a crime to the SA and law enforcement within 2 hours of the allegation. There was also no mention the facility had identified it failed to follow policies and procedures by immediately beginning and investigation and suspending alleged perpetrators upon notification of an allegation. There was also no mention of appropriate notification to family and or the residents representative, or primary care physician. R1's 8/17/20, admission Minimum Data Set (MDS) assessment identified she was fully cognitive and required extensive assist of 1 staff for toileting. R1's 8/18/20, progress notes identified R1 was admitted to the facility to receive rehabilitative services related to back pain and weakness and had pans to return home. Her admitting [DIAGNOSES REDACTED]. Interview on 9/14/20, with LPN-A identified the above incident occurred about a week ago to his knowledge. LPN-A was charge nurse on the night of the incident. R1 had put her call light on at approximately 3:00 a.m R1 had lost her oxygen tubing and it was laying on the floor in a puddle at the end of her bed by R1's feet. LPN-A left the room to get R1 new O2 tubing. LPN-A then proceeded to hook up R1's new tubing. R1 was laying in bed on her side, facing the wall, away from her door. R1 had a fluffy blanket. LPN-A advised her he was cleaning up the liquid found underneath her O2 tubing. R1's blanket kept falling into the liquid on the floor as he was trying to clean it up. R1 was uncomfortable with me at that point. LPN-A proceeded to touch R1's incontinence pad. LPN-A acknowledged he had not advised R1 what he was going to check her brief. LPN-A asked R1 if she wanted another staff to help her clean up, but she refused. LPN-A then stated he made a joke to which R1 laughed and he left the room. R1 had never made concerns known about not receiving assistance from male staff members. LPN-A was unsure how R1 could have leaked urine by the foot of her bed, when the area directly below her bottom, in the middle of the bed, was dry. R1 had been known to refuse cares. In hindsight, he should have been more clear during cares. On 9/4/20, registered nurse (RN)-A had advised him he was not to go into R1's room at any time. RN-A advised LPN-A he had touched R1 inappropriately. RN-A was going to call the DON and alert her to R1's allegations. The DON called back and spoke with LPN-A. He was told to keep his distance from R1 and have another staff member give R1 her medications. He was suspended on 9/8/20 pending an investigation. He had worked 9/4/20, 9/5/20, and 9/6/20. LPN-A had come to the facility on [DATE] as he was turning in his resignation effective 9/19/20. He was to work his upcoming 3 scheduled shifts on 9/17/20 through 9/19/20. LPN-A was resigning over the allegations. Review of LPN-A's August and September, 2020, staff schedules and time clock entries identified LPN-A was scheduled to work overnight shifts on 8/27/20, 8/31/20, 9/3/20, 9/4/20, 9/5/20, and 9/6/20 LPN-A's timecard identified he worked on: 1) 8/27/20, beginning at 6:00 p.m. until 6:46 a.m. 2) 8/31/20, beginning at 9:58 p.m. until 6:51 a.m. 3) 9/3/20, beginning at 10:01 p.m. until 6:40 a.m. 4) 9/4/20, beginning at 8:03 p.m. until 6:46 a.m. 5) 9/5/20, beginning at 6:02 p.m. through 6:28 a.m., 6) 9/6/20 beginning at 5:58 p.m. and finishing at 7:09 a.m. Review of LPN-A's employee file identified a performance review dated 9/14/20. 3 resident complaints were identified on 5/5/20, 6/22/20, and 9/4/20. There was no indication LPN-A received any disciplinary actions or additional training or education following those resident complaints. The review identified LPN-A was flexible, worked both units and preferred working his night shift. LPN-A was identified having conflicts with some residents. LPN-A was to watch his tone as he had made hurtful statements without realizing it. It was identified he needed to explain what you are doing, before you do it. LPN-A had a background check performed 6/3/20, which identified LPN-A had no criminal history reported. LPN-A was hired 11/18/19. There was no previous background check identified in his file. LPN-A had concern and problem resolution coaching's in his file. With regard to R3's complaint of LPN-A looking at her vagina, it was identified by the facility LPN-A had told R3 You old people, its all in your head and you imagine things. R3 reported to management he made her skin crawl and was rude when other staff weren't around. He told her in a creepy voice . I'm back when he returned to work. No disciplinary actions were included in LPN-A's file. Interview on 9/14/20 with nursing assistant (NA)-A identified she was made aware of the incident on 9/4/20 by R1. R1 had reported to NA-A and NA-B she had seen LPN-A report for his shift that day at approximately 8:00 p.m R1 was outside. Staff noted R1 was afraid to come in and was shaking. R1 stated I don't want that (expletive) working with me. R1 elaborated LPN-A had made her feel uncomfortable the last time he worked. LPN-A came into her room during the incident (unknown date) and started poking at her bottom. R1 wears an incontinence brief. R1 stated LPN-A was touching her inappropriately and did not know what to say to LPN-A at that time. R1 advised she was shocked and scared. R1 had not told anyone about the incident before 9/4/20, and she was afraid. R1 began to cry and would not go into any further detail with NA-A or NA-B. Both NA-A and NA-B left R1's room and advised RN-A immediately. RN-A went into R1's room and spoke to her about the incident. RN-A exited the room and looked to be visibly upset by the allegations R1 had advised her of. RN-A was witnessed telling LPN-A he was not to go into R1's room. R1 had never had any concerns with male staff. There was another male staff on the floor and R1 had no concerns with that male staff member. Interview on 9/14/20 at 4:41 p.m. with NA-B identified R1 was a smoker and was outside the evening of 9/4/20. LPN-A had come in early, around 8:00 p.m. that day for his shift. NA-A and NA-B had noticed R1 was outside and rang the doorbell to come back into the facility. R1 was shaking and visibly upset. She was petrified. NA-A and NA-B proceeded to ask R1 what the matter was. She was reluctant to say. R1 proceeded to tell the staff LPN-A had come into her room the other night when he worked. R1 advised LPN-A was checking her to see if she was wet. He stuck his fingers in her brief and touched her inappropriately. R1 takes care of herself and requires no assistance to toilet or put herself to bed etc. She only needed help when she was first admitted . R1 was expected to discharge soon. NA-A and NA-B left to find RN-A and advise her of the need to speak with R1 as soon as possible. RN-A was giving meds, and as soon as she was done, she would speak with R1. RN-A finished her medication pass and went to speak with R1 in her room. When RN-A came out of R1's room, she went to LPN-A who was working on that wing and advised him he was not to go into R1's room. Today on 9/14/20, when LPN-A came to work, R1 saw him come in. She began shaking. R1 kept watching the door to see if LPN-A was coming onto shift. Observation and interview on 9/14/20 at 5:00 p.m., with R1 identified LPN-A works overnight shifts. R1 goes to bed early. On the date of the incident which R1 recalled as the last time he worked but was unsure of that date. R1 stated LPN-A usually works weekends. It would have been the previous weekend night shifts to 9/4/20. R1 is awake and routinely sees the night shift report to work. R1 pointed to her calendar and identified the incident likely occurred between the dates of 8/28/20 and 8/31/20 which was the last scheduled weekend she saw him. LPN-A came into R1's room. She was sound asleep but woke up startled when she realized LPN-A was in her room. R1 wore O2 at night. Occasionally this falls off. Her tubing was laying on the floor at the foot of her bed. LPN-A picked up the tubing, gave it to R1 and she advised him it was wet. LPN-A stated it was wet on the floor where her tubing had been. LPN-A then grabbed the wet tubing, left the room, and came back with new O2 tubing. LPN-A advised her the spot of liquid on the floor at her feet looked like pee. R1 advised him that was condensation from her O2 tubing with humidified oxygen. R1 stated she had not felt wet in her brief. LPN-A showed her the rag after he wiped up the liquid on the floor and showed her it was dirty. R1 slept with the over-bed lights on at all times and would lay on her left side with her back away from the door, facing the wall. All of a sudden, R1 felt her covers being lifted and LPN-A was poking his fingers on her (expletive). R1 stated she was terrified. LPN-A had not said anything. He would start feeling her bottom, then stop. She heard clicking noises but was unsure what they were coming from. She thought it sounded like a pen light nurses use, but never saw any flash or light of any kind. R1 denied LPN-A had penetrated her in any way. His finger was on my butt check going up and down. R1 stated she had never been touched like that before. LPN-A was not touching her brief. R1 toilets herself and had no reason for LPN-A to attempt to check her brief for wetness. R1 identified she was so scared and hadn't had the nerve to talk. LPN-A finally said, Do you need to be changed? R1 was able to say No. LPN-A replied to her Alright then and left her room. R1 stated LPN-A was very intentionally touching her buttocks and was not in any way on her brief. No staff had ever touched her that way before. R1 has never had any concerns with any male staff at any health facility. R1 elaborated the wet spot on the floor was by her feet, not on the floor directly below her bottom. R1 was scared that night and again today on 9/14/20, when she saw LPN-A arrive for work. R1 was afraid LPN-A was coming back to work. R1 stated when she saw LPN-A today arrive for work, she started shaking, and got a creepy feeling in her stomach with nausea. R1 does not feel safe around LPN-A. I can talk! Others (residents) can't. R1 was going home soon and walked independently with cares. Observations during interview of R1 identified was visibly shaken was teary eyed and expressed anger throughout the interview. Interview on 9/14/20 at 6:06 p.m. with RN-A identified she was made aware of the allegation of sexual abuse from R1 by LPN-A on 9/4/20. RN-A stated NA-A and NA-B came up to her and advised her they were walking R1 to her room. R1 was shaking. R1 found out LPN-A was on duty and the staff wanted to make sure it was ok, and requested RN-A speak to R1. RN-A advised NA-A and NA-B she would speak to R1 as soon as she passed her medications. NA-A and NA-B followed up again. RN-A was almost finished with medication pass, and would be there shortly. RN-A had never met R1 before as she is an occasional staff member. On that day of 9/4/20, she was working in the back half of the facility. R1 reported she just didn't like way things went. He (LPN-A) gives me the creeps. She couldn't recall what day the incident occurred, but identified it was about 2:00 a.m or 3:00 a.m. R1 reported her O2 would come off and fall on floor occasionally during the night. LPN-A opened her door, came in, saw it, and picked it up. He said it was wet, then advised R1 the floor was wet. Without notice, LPN-A put his hand underneath her covers. That made R1 creep out. LPN-A took his finger and was touching inside her brief. RN-A asked her what she would like her to do about him. R1 said he wiped a spot by the bathroom door towards edge of bed. R1 denied being wet. R1 denied penetration, and stated he just left. RN-A assured R1 her concerns would be forwarded. R1 also advised RN-A she had been molested as a child and it felt just like that. RN-A had not included that in her written report as R1 seemed embarrassed about her past molestation. RN-A had not performed an assessment or started an investigation. RN-A stated she called the DON right away for instruction on how to proceed. The DON had advised RN-A to write a report and see if there was nay further information R1 had on the allegations. The DON had not suspended LPN-A to her knowledge. The DON had called back to the facility after she had spoken with her, but she had not talked to RN-A. The DON spoke to LPN-A. RN-A had never been educated on filing a report to the SA, nor reporting a suspicion of a crime to the police. RN-A looks for direction from the DON and does what she is told. Since RN-A was an occasional staff person, she had not worked for a while prior to 9/4/20. Upon arriving to work that day, she was handed the policy on reporting, advised to read through it and ask if she had questions. RN-A had made no attempt to physically examine R1 on 9/4/20 after allegations of sexual abuse had been made. Review of the 9/4/20, incident report written by RN-A identified R1 advised NA-A and NA-B, she did not want LPN-A in her room. Staff asked RN-A to speak with her. R1 advised RN-a LPN-A was inappropriately touching her one time but was unable to give a date. LPN-A had come into her room. R1 was unsure why LPN-A had entered her room. R1's nasal cannula had come off and was on the floor. LPN-A picked it and it was wet. R1 advised she felt it was wet from condensation (from humidified oxygen). LPN-A had picked up her bedspread and started moving his hand along her butt. LPN-A had not advised R1 what he was doing. She requested he not enter her room. Interview and document review on 9/15/20 at 9:43 a.m., with the SW identified the DON never came to the facility on [DATE], after being made aware of the incident. On 9/8/20, the SW arrived for work and saw RN-A's written report. She immediately went to the administrator (A) and advised her this was a reportable incident. In review of the staffing schedule leading up to 9/4/20, it was identified LPN-A's last scheduled shifts were 9/3/20 and 8/31/20. LPN-A. R1 would not have seen LPN-A arrive for that shift on 9/3/20, as she would have been in bed, and the incident was reported to occur the last weekend shift time-frame he worked before 9/4/20. The SW agreed the incident would have most have likely occurred on 8/31/20. The SW was in charge of the investigation, which was still ongoing. She had plans to submit the 5 day report to the SA that day. The SW concluded she couldn't prove the allegation likely occur. The SW could not corroborate there was actual urine on the floor. LPN-A advised her the location of the urine was indeed at the end of the bed by R1's feet and not directly below where her bottom was. R1 was definitely upset about it. The facility wanted to ensure LPN-A had not worked with R1 again. R1 was visibly upset, not crying, but anxious SW reported when she recalled her interview with R1. The SW believed, what went wrong was he should have told her what he was doing. In reviewing the location of the fluid found on the floor, the SW agreed, there was no way R1's urine could have deposited at the foot of her bed, rather than directly below her bottom located in the middle of the bed, approximately over 2 feet away. The SW identified the only staff that were allowed to make reports the to SA were herself, the DON and administrator. She also agreed R1 wearing a brief would have limited deposits of urine on the floor and would have saturated R1's bed first. She agreed R1 made no mention of her bedding being wet. R1 also claimed LPN-A had not touched her brief, but was touching her buttocks. The SW agreed, R1's accounts her buttocks was being stroked by LPN-A's fingers would be inconsistent if her underwear were pulled away from her body to feel a brief. The SW also agreed R1 had been independent to toilet and there was no need to physically check her for incontinence. The SW agreed the DON should have immediately suspended LPN-A upon hearing the allegation and reported to the SA. Facility procedures indicated only the SW, admin or the DON could submit a report to the SA. No other staff were allowed to submit reports of suspicions of a crime. Interview on 9/15/20 at 10:20 a.m. with nurse practitioner (NP)-A identified she was unaware of R1's allegation of sexual abuse. The SW had called her, only to ask for the medical director (MD) number last wed. She was on call on 9/4/20 covering nights and weekends. NP-A rounded at the facility on 9/8/20, and was not notified about the allegations at that time either. She would expect the facility follow all policies and procedures and notify a residents provider when any allegation of abuse or neglect is made. NP-A was made aware of the interviews and events surrounding the allegations. NP-A expected the facility keep the resident safe and suspend any staff until an investigation was completed. R1 had improved in the ability to care for herself and could walk independently, toilet independently, was fully cognitive, and was set to go home in the next few days. Interview on 9/15/20 at 10:53 a.m., with the DON identified she had received a call on 9/4/20 at approximately 10:00 p.m., RN-A had called her and advised R1 wanted to file a complaint against LPN-A. The DON stated RN-A offered no other information and she had not asked. The DON advised RN-A to find out what prompted such a complaint and to call her back. After approximately 15 minutes, the DON called the facility. LPN-A answered the phone. The DON asked him if he did anything inappropriate as R1 wanted to file a complaint against him. LPN_A denied any wrongdoing, but did advise the DON of the incident in question and stated he had done nothing wrong and advised her. The reason she asked LPN-A if he had done done anything inappropriate as he had been accused by R3 of being gruff with her with allegations He looked at my vagina. The DON had filed a report but felt after investigation it was unsubstantiated as LPN-A had been providing personal cares and would have to look at R3's private parts. The DON agreed she had knowingly disclosed the alleged victim (R1)'s identity to LPN-A. The DON was satisfied with LPN-A's answer of no wrongdoing and stated he was not allowed to provide cares to R1 unless he was accompanied by another staff. The DON agreed, advising LPN-A of the alleged victims identity and not immediately suspending LPN-A placed R1 and other residents at risk for further abuse or retaliation. The DON failed to begin an investigation immediately and had not returned to the facility until 9/8/20. At that time, she was alerted to RN-A's written report. LPN-A was suspended pending the facilities investigation. The DON agreed her resolution and actions to prevent abuse and failing to follow facility policy put all residents at risk. Interview on 9/15/20 at 12:27 p.m. with the MD identified he had not been made aware of the incident until approximately 9/8/20. He was told by the facility R1 reported LPN-A felt her bottom, maybe she had not liked that and was found very upset. MD had not known much more. MD was unaware LPN-A was notified of R1's identity by the DON, nor that LPN-A had not been suspended immediately, or that no investigation was immediately performed upon identifying the allegation. The MD agreed the facility failed to keep R1 and all other 44 residents safe from retaliation or potential further abuse. He also agreed LPN-A should have been suspended, policies implemented, and an investigation should have been immediately started. Interview on 9/15/20 at 2:45 p.m. with the SW identified she had not called local police for suspicion of a crime but would do so right away. The SW had reported the incident to the MN Board of Nursing. Review of the 9/4/20, Reporting Abuse to Facility Management policy identified it was the responsibility of employees, consultants, physicians, family members, visitors, etc, to promptly report any incident of suspected abuse. All allegations were to be reported and thoroughly investigated. All reports made were to be made without fear or retaliation from facility or its staff. Reports were to be given to the DON. In her absence, reports were to be made the the charge nurse. Staff members shall not knowingly fail to report an incident or offense, screen reports, or withhold information from reporting agencies. If incidents were discovered after hours (8:00 a.m. to 5:00 p.m.), the admin or DON must be called at home and informed of the incident. Allegations were to be reported immediately but no later than 2 hours after the allegation was made. Employees accused of abuse were to be suspended immediately pending the outcome of the investigation. For reports of physical or sexual abuse, a thorough examination was to be performed by licensed nurses. An immediate investigation was to be made and a copy provided to the administrator. Review of the 9/4/20, Abuse Investigations policy identified all reports of abuse were to be promptly reported and thoroughly investigated by the facility immediately but no later than 2 hrs after the allegation. The Ombudsman was to be notified and offered to participate in the investigation. The Ombudsman was to be notified of results of the investigation. Employees were to be suspended immediately. The administrator was to provide a written report of the results to the SA, local police. medical director and others within 5 days of the incident. There was no mention suspicions of a crime were to be reported immediately to local police, the SA, and any other licensing boards immediately but not later than 2 hours. There was also no mention investigations were to begin immediately following an accusation of abuse. The immediacy was removed when it could be verified the facility took steps to ensure staff were appropriately trained and re-educated to all abuse policies for identifying, reporting, and protecting residents, and implemented an on-call system with management assigned to specific days 24/7, to ensure reports to the SA and all other appropriate entities were made, interventions implemented to keep residents safe, and investigations begun.

Based on observation, interview and document review, the facility failed to appropriately assess, monitor, intervene, and notify the physician for 1 of 6 residents (R2) reviewed who had a pressure ulcer. R2 developed serious illness when a newly identified pressure ulcer deteriorated significantly without all appropriate intervention, resulting in an immediate jeopardy for R2. The IJ began on 8/23/20, when staff identified a new onset pressure ulcer and the facility failed to appropriately assess, monitor, and notify the physician for 1 of 1 resident (R2). R2 suffered harm, having new onset pressure ulcer leading to hospitalization , wound debridement, and admission to hospice services with terminal illness and expectation of death. The facility administrator was notified of the IJ on 9/16/20 at 3:50 p.m. The IJ was removed on 9/17/20 at 3:45 p.m. but non-compliance remained at the lower scope and severity of G-actual harm at an isolated scope that is not immediate jeopardy. Findings include: R2's 7/16/20, quarterly MDS identified R2 had intact cognition and required extensive assistance of 2 staff with bed mobility and transfers. R2 required the use of a total mechanical lift. R2 was identified at risk for pressure ulcers and had no pressure ulcers at the time of the assessment. R2 was incontinent of bowel and bladder and relied on staff to assist in toileting and wore incontinence briefs. R2's current face sheet identified [DIAGNOSES REDACTED]. R2's current care plan identified she had a self-care deficit related to impaired balance, impaired mobility, stroke, right sided paralysis, pain, [MEDICAL CONDITION], and pressure ulcer to her sacrum (tailbone). R2 required extensive assistance of 1 to 2 staff to turn and reposition in bed every 2 hours and as needed. R2 had a pressure reducing mattress in her bed and cushion in her wheelchair. Staff were to inform family and the medical provider of any new area of skin breakdown. Staff were to monitor skin issues daily until healed. Staff were to observe, report, and document as needed any changes in skin status to include appearance, color, wound healing, signs and symptoms of infection, wound size and stage. Interview on 9/16/20 at 10:18 a.m. with family member (FM)-A identified the interim infection control preventionist/wound care registered nurse (RN)-B called her at the end of August 2020. FM-A stated RN-B reported to her R2 had a new onset pressure ulcer the size of nickel. FM-A was unaware if R2's physician had evaluated the wound, or what treatments staff were providing. FM-A stated R2 went to the local hospital on [DATE] where she was evaluated and sent for higher acuity care at the regional hospital. Once admitted to the ICU at the regional hospital, the surgeon evaluated the pressure ulcer and deemed it needed to be debrided (areas of dead and infected tissue are removed). Surgery occurred on 9/9/20. FM-A stated the debridement resulted in a softball sized area of tissue being removed from R2's sacral area. FM-A stated she could see the tailbone and said the surgeon reported R2's rectum was only half an inch away and no further debridement could occur. R2 was discharged from the hospital on [DATE], and was admitted to hospice services where she was expected to die as a result of her wound. FM-A stated the facility had made no prior indication to her about the severity of the wound, or that it needed to be evaluated at any time by a physician. FM-A stated R2 had a stroke in April 2020, and became paralyzed on her right side. R2 required a total lift for transfers and was not able to reposition herself on her own. Review of R2's 8/25/20, Weekly Wound Assessment identified R2's pressure ulcer was first identified on 8/23/20. The assessment indicated the wound was a facility acquired pressure ulcer Stage III (full thickness tissue loss with some fat visible). The wound was described as beefy red with serosanguinous (clear to bloody) drainage. There was no tunneling noted. R2 reported pain during the assessment as hurts a little bit and indicated R2 had prescribed Tylenol, [MEDICATION NAME] and [MEDICATION NAME] for pain. Wound treatment was identified as: clean as ordered, pat dry, mix collagen powder with a hydrogel to form a paste and apply to the wound. Staff were to cover the wound and change the dressing daily. The medical doctor (MD), family, and registered dietician were notified on 8/25/20. There was no mention of the need to change the care plan or increase turning and repositioning or reviewing potential additional interventions. Review of R2's 8/25/20, progress notes identified no phone call was made to R2's MD to request assessment or to identify any additional treatment. Review of an 8/25/20, faxed notification to physician from facility staff to MD-B identified, Res (resident) has a new OA (open area) on her sacrum, measures 1.3 cm (centimeters) x 0.8 cm, appears to be a PI3 (pressure ulcer, Stage III). The fax also included information on R2's forehead. MD-B replied, please check with dermatologist. There was no mention staff had used appropriate medical abbreviations to identify what OA and PI3 were on the fax. In addition, there was no request for medical examination regarding the pressure ulcer. Review of an 8/26/20, faxed notification to physician from facility staff, included notation R2 had a pressure injury on sacrum- collagen mixed with hydrogel with foam dressing. Staff requested, Can we also have order for Alginaide (protein supplement used for healing) twice daily for healing?- recommended by dietary nurse. No other details were made or asked of the provider. Staff made no mention for the need for medical examination. R2's 8/23/20 through 9/8/20, progress notes made no mention staff had performed daily assessments as indicated per care plan to identify whether the wounds increased, changed, or worsened, or the need for medical evaluation and treatment. There was no mention the MD had been informed of the progression or worsening of R2's pressure ulcer after 8/25/20. R2's 9/1/20, wound assessment identified the pressure ulcer was still classified as a stage III pressure ulcer, which had increased in size to 206 cm x 1.5 cm x 0.3 cm. The pressure ulcer was described as beefy red with a black center. Per the accompanying pressure ulcer guide, a full thickness ulcer now covered with eschar (black dead tissue) in the wound, should have been identified as an unstageable ulcer. A decline was noted, pain remained the same, and orders were unchanged. There was no mention R2's MD was notified of the swift decline in the pressure ulcer, or the need to change the care plan or increase turning and repositioning or reviewing potential additional interventions. Although the assessment indicated R2's family was notified, it was unclear what the family member (FM)-A was notified of. Review of a 9/2/20, fax to the physician identified R2 had experienced weight loss. The fax indicated her current weight was 129.6 pounds (lbs), down from 140.4 lbs in 1 month, totaling a 7.4 % weight loss. Staff did not indicate this was severe. Staff noted R2 was on a protein supplement topromote wound healing. There was no mention staff of the worsening of R2's pressure ulcer, or her new onset severe weight loss as an urgent concern requiring medical evaluation and examination. The physician response to the fax noted continue as above. R2's 9/8/20, final wound assessment identified the wound continued to have a beefy red, black center, with serosanguinous drainage but now had a foul odor. There was a new lump near the ulcer measuring 3 cm x 2.2 cm. The pressure ulcer itself now measured 4.9 cm x 2.0 cm x 1.2 cm and was still classified as a Stage III ulcer rather than unstageable. The MD was notified on 9/8/20 along with family. Additional information only listed R2 had an air mattress on her bed. Review of the 9/8/20, SBAR change of condition entry identified R2 had drastically declined. R2 was noted as lethargic and would open her eyes only when staff talk to her. R2 was not eating and it was getting harder to give her oral medication. R2 had 2 wounds, 1 is surgical. Wounds are not healing. R2 had a surgical wound on her left side of her head that was not healing and a coccyx wound not healing as well. R2's vital signs were blood pressure 60/40 millimeters of mercury (mm/hg) (normal 120/80) temperature of 97.3 degrees Fahrenheit (F), respiratory 20 (normal 16-20) and oxygen saturation (SPO2) was 91% on room air. No other assessment vitals were documented as assessed. Staff identified they now called the MD on call. The MD ordered R2 be sent to the hospital. Review of R2's vital signs identified since R2's pressure ulcer was identified on 8/23/20, R2 showed signs and symptoms [MEDICAL CONDITION] as follows: 1) R2's temperature (T) was documented at or below 96.8 degrees F during 6 days from 8/23/20 through 9/8/20. Those days identified were 8/26/20, 8/27/20, 8/29/20, 8/31/20, 9/4/20, and 9/7/20 with the lowest temperature recorded as 95.9 on 9/7/20. 2) R2's HR was recorded as over 90 bpm on 9/7/20 and 9/8/20 with the highest documented rate at 98 bpm. 3) R2's SpO2, steadily declined from the normal 95-98%, 16 times from 8/31/20 through 9/8/20 and ranged from 90 % to 94%. 4) R2's systolic blood pressure started to decline on 9/1/20, when it was documented her blood pressure was 91/58, down from 120's over 60's to 60/40 on the day she was sent to the ER. Interview on 9/16/20 at 10:36 a.m., with NP-C identified she was R2's primary care provider. She was unaware of the need for an assessment on a new onset pressure ulcer. Staff never called to notify her of the need to come to the facility or identify appropriate treatment. NP-C's partner, MD-B was not made aware of the pressure ulcer due to the facility using non-approved medical abbreviation on their fax. No phone call was ever received by herself or her partner MD-B. NP-C agreed any new onset pressure ulcer needs to be called to the provider immediately, as well as any changes in size, color, depth etc. R2 should have been sent to clinic or NP-C or MD-B would have came to the facility to assess R2. There is a local wound care clinic in Redwood Falls. Staff could have requested and then made an appointment for R2 at the clinic. Had NP-C been called, she would have immediately come to the facility as she lives within 15 minutes of the facility. It was her expectation the facility follow policies and procedures as well as best practices to prevent and treat pressure ulcers. NP-C was unaware if the facility had a trained wound care nurse, or if RN-B had been appropriately trained to perform an assessment. Interview and document review on 9/16/20 at 11:24 a.m., with RN-B identified she was the interim infection control preventionist and wound nurse while the permanent staff was on a medical leave. RN-B had minimal training on wound care. She was given the book which mimicked the wound care assessment in the facility electronic medical record. She had no formal IC training and had learned that position on the job as an RN. The facility procedure was to perform assessments 1 x per week. The delay from 8/23/20 to 8/25/20 of any formal assessment was caused by floor staff not performing assessments. They had to wait for the official weekly assessment. No documentation was documented during daily dressing changes to identify changes of condition of pressure ulcers. Staff did not call providers for new onset pressure ulcers, nor did they call for worsening of pressure ulcers. Faxes were sent vs. calling the provider. RN-B identified in the fax sent to the MD on 8/25/20, OA stood for open area and PI3 was pressure ulcer, Stage 3. RN-B agreed OA and PI3 were not appropriate medical abbreviations but eluded it was short-hand. The only time providers were called was if a situation was an emergency per RN-B. RN-B reviewed the regional hospital photos of R2's wound from the ED visit and agreed she had failed to accurately assess R2's wound. RN-B was unaware of the signs and symptoms [MEDICAL CONDITION]. RN-B agreed, looking back at her vital signs, R2 was indeed septic while she remained at the facility prior to her transfer. Review of R2's 9/8/20, local hospital medical record identified R2 was sent to the ED for emergent medical evaluation for declining condition. R2 arrived at 7:11 p.m. with decreased level of consciousness and [MEDICAL CONDITION]. R2 had a gradual decline in her overall health over the last several days. She has 2 known wounds. A sacral ulcer and she is status [REDACTED]. Upon admission, R2's vital signs were 100 degrees T, HR 104, respiratory rate (RR) 24, 92% SpO2. R2 had a large deep foul-smelling wound in the coccyx area. The MD documented there appeared to be necrotic tissue and surrounding area (inability to flex the neck forward) of [DIAGNOSES REDACTED]. Blood cultures were taken. The MD determined the combination of fever, [MEDICAL CONDITION] and known wounds led to a fairly expedited evaluation [MEDICAL CONDITION]. There is very foul-smelling sacral wound is the likely cause of our [MEDICAL CONDITION]. R2 was diagnosed with [REDACTED]. R2's lab values identified severe infection. Her white blood cell count was 24.7 (normal 3.5 to 10.5). Review of R2's 9/8/20, regional hospital medical record identified she was admitted to the regional hospital on [DATE] when she was transported for higher acuity needs. R2 had [DIAGNOSES REDACTED]. and palliative care. The hospital MD identified R2 resided at the long-term care facility. Over the past couple of days she had become increasingly lethargic. She was found to [MEDICAL CONDITION] due to an infected pressure ulcer. She was transferred from the local hospital for additional care. Surgery was consulted for debridement (done 9/9) which found a necrotic full thickness ulcer, measuring 12 cm x 12 cm x 3.5 cm. A palliative care consultation was requested. R2 was transferred out of the Coronary Intensive Care Unit. (CICU). After a palliative care meeting, R2 was transferred to hospice care. On the day of discharge of 9/15/20, R2 appeared in poor state of health and terminally ill. She will be discharged on hospice. Interview on 9/16/20 at 12:03 p.m., with MD-B identified R2 had been seeing dermatology for non-healing wound. She was diagnosed with [REDACTED]. R2 had a surgical procedure to remove [MEDICAL CONDITION] and the area was left open to heal. MD-B had not seen or been aware of R2's pressure ulcer. She was faxed on 8/25/20 and thought the facility was asking her for treatment orders for her forehead. MD-B referred them to dermatology. She was unsure what OA and PI3 were as they were not standard medical abbreviations. She had called the facility related to R2's forehead wound. She was advised the facility had a wound team and treatment had been initiated. MD-B again deferred to dermatology. MD-B stated she was not made aware of R2's new onset pressure ulcer and no mention was ever made to her regarding its onset or worsening condition. Facility staff had never called and asked her to examine R2. MD-B was advised some time after R2 had been admitted to the regional hospital by the local hospital MD, R2 had become septic from a pressure ulcer. MD-B advised the hospital MD she was unaware and had never known about the gravity of the situation. MD-B expected any change of condition was to be called, not faxed to a provider to ensure accurate information was able to be conveyed to make the best treatment plan and identify if a medical examination was required. Interview and document review on 9/17/20 at 10:00 a.m. with NP-A identified she was now R2's provider while R2 currently resided at a neighboring nursing home on hospice. NP-A saw R2 yesterday on 9/16/20, and stated the pressure ulcer was completely preventable had staff appropriately and timely assessed, monitored, intervened and notified the physician via phone. That resulted in R2's decline. Had R2 had early intervention, NP-A believed she may not be terminally ill now on hospice. NP-A reviewed R2's care plan and identified other than a pressure mattress and cushion, there were no other additional interventions to prevent the pressure ulcer. R2 was to be turned and repositioned prior to discharge every 2 hours and as needed. NA-A identified that turning schedule was for a resident with normal tissue tolerance and not at risk for pressure ulcers. When R2's pressure ulcer was identified, the care plan and repositioning schedule should have been updated to ensure R2 was turned and repositioned, sacrum offloaded, and her care plan updated to reflect her higher need for care. Interview and document review on 9/17/20 at 1130 a.m with the DON identified she was unaware of R2's pressure ulcer prior to her discharge. The DON agreed, any new onset wound needed to be assessed immediately, physician called, and interventions reviewed and revised to increase levels of care to prevent further breakdown. The DON agreed staff should never fax a physician when a change of condition is identified. The DON agreed RN-B was not appropriately trained to perform pressure ulcer assessments. The DON agreed all wounds needed to be checked daily, and results of those assessments documented so staff would be able to identify worsening condition and alert the provider. The DON agreed the facility's lack of assessment, monitoring, intervention and notification led to R2's worsening pressure ulcer resulting in harm. The DON reviewed the photographs from the regional hospital record and agreed the wound would have appeared in the same condition hours earlier when facility staff had assessed it prior to transfer. The DON had not monitored RN-B's training or performance in pressure ulcer assessment, nor had she ensured policies and procedures were followed. Review of the facility's 9/1/20, Pressure Ulcer Risk Assessment policy identified the purpose of the procedure was to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy indicated pressure ulcers were usually formed when a resident remained in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. If pressure ulcers were not treated when discovered, they have the potential to become larger, painful and infected. Pressure ulcers are a serious skin condition for the resident. Staff were to routinely assess and document the condition of the resident's skin per facility wound and skin care policy for any signs and symptoms of irritation or breakdown. Staff were to immediately report any signs of a developing pressure ulcer to the supervisor. Staff were to perform routine skin inspections with daily care. Nurses were to be notified to inspect the skin if skin changes are identified. Nurses were to conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Additionally, the guidance indicated the following information was to be recorded in the resident's medical record utilizing facility forms: 1) The type of assessment conducted. 2) The date and time and type of skin care provided, if appropriate. 3) The name and title (or initials) of the individual who conducted the assessment. 4) Any change in the resident's condition. if identified tied. 5) The condition of the resident's skin like the size and location of any red or tender areas, if identified. 6) How the resident tolerated the procedure or his/her ability to participate in the procedure. 7) Any problems or complaints made by the resident related to the procedure or observations of anything unusual exhibited by the resident. 8) The signature and title (or initials) of the person recording the data. 9) Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated. 10) Documentation addressing family, guardian or resident notification if new skin alteration is noted with change of the care plan if indicated. Staff were to report other information in accordance with facility policy and professional standards of practice, notification of attending MD of skin concern, and notification should occur to the family, guardian or resident. While performing an assessment, if a new skin alteration was noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin, then staff were to proceed to care planning and interventions individualized for the resident and their particular risk factors and document the procedure. Attempts were made to contact the facility's medical director for comment without success. The immediate jeopardy was removed on 9/17/20, when it could be verified by observation, interview and document review, protocols for resident pressure ulcer assessment and documentation had been reviewed and updated. Assessments were completed for all residents with current pressure ulcers including measurement. Care plans were also reviewed and revised as appropriate. The facility also identified systems to improve assessment of newly admitted residents with risk for pressure ulcers. Finally, the facility modified protocols for family and physician notification, and provided education to staff.

Based on observation, interview and document review the facility failed to implement repositioning and floating of heels, and provide ongoing monitoring of pressure ulcers for 1 of 1 resident (R12) with current stage 2, stage 3, stage 4 pressure ulcers and deep tissue injury. This resulted in actual harm for R12 when a new stage 2 pressure ulcer on left buttock and a new deep tissue injury to the right heel developed and the current stage 3 ischium pressure ulcer worsened. Findings include: R12's 7/31/19 admission Minimum Data Set (MDS) identified [DIAGNOSES REDACTED].) The MDS listed R12 had intact cognition and required extensive assist with transfers, toileting, and bed mobility. She was frequently incontinent of both bowel and bladder and did not utilize an indwelling urinary catheter (tube which is inserted into the bladder and left in place in drain urine). Further, the MDS listed she was at risk for skin breakdown, but had no current pressure ulcers. She had a pressure relieving mattress and wheelchair cushion. R12's 10/17/19 quarterly MDS identified R12 required a mechanical lift to transfer and extensive assist of 2 with bed mobility and toileting. She had an indwelling urinary catheter and was frequently incontinent of bowel. She remained at risk for pressure ulcers and had two current stage III pressure ulcers present and received pressure ulcer care. She had a pressure relieving mattress and wheelchair cushion. R12's Care Area Assessment (CAA),8/6/19, identified she was at risk for pressure ulcers due to impaired mobility, decreased functional ability, muscle weakness, low back pain, chronic pain, [MEDICAL CONDITION] depression with use of antipsychotic medications, altered mental status, cognitive loss, obesity, [DIAGNOSES REDACTED]. She required a special mattress and wheelchair cushion. She required extensive assist of 2 with bed mobility and required turning and repositioning every 2 hours and as needed. R12's Braden Scale for Predicting Pressure Sore Risk form on 8/16/19 indicated R12 was at moderate risk for pressure ulcer development. R12's Braden Scale for Predicting Pressure Sore Risk forms dated 8/22/19, 8/30/19 and 9/13/19, 10/14/19 and 1/2/20 indicated R12 was at risk for pressure ulcer development. R12's current care plan, undated, identified her to be at risk for pressure ulcers due to impaired mobility and balance, decreased functional ability, muscle weakness, low back pain, chronic pain, [MEDICAL CONDITION] depression with use of [MEDICAL CONDITION] medication, [MEDICAL CONDITION] with use of diuretic medication, diarrhea, obesity, [MEDICAL CONDITION], and incontinence. Interventions included use of foot cradle on bed, float heels while in bed, observe and document any skin concerns as needed. R12 was to be up in wheelchair between meals in the am and up in wheelchair for all meals. The care plan failed to identify existing pressure ulcers or goals and treatments related to the ulcers. R12's Nursing Assistant Care Plan,1/3/20, identified R12 was to be repositioned every 2 hours and as needed, heels were be offloaded and use of gray boots when in bed, blue boots when in wheelchair. On 1/2/20, from 2:39 p.m. to 6:23 p.m. during continuous observation the following was observed: At 2:39 p.m., R12 was in bed, lying on her back with the head of bed elevated approximately 10 degrees and foot of bed elevated approximately 10 degrees. R12 had an air overlay on her bed, a pillow under her from knees to calves and a foot cradle on the bed. However, both heels were resting directly on the mattress of the bed, with no boots in place. At that time, R12 stated she laid down in bed at 1:30 p.m. - 3:00 pm, R12 remained in the same position, no staff entered room. - 3:29 p.m., R12 remained in the same position in bed, with both heels resting directly on the mattress. An unidentified staff member entered the room to replace her water pitcher and immediately exited the room with the used water pitcher. - 4:10 p.m., remained in the same position, no staff entered room. - 4:44 p.m., remained in the same position in bed, no staff entered room. - 4:58 p.m., remained lying on her back, with both heels resting directly on mattress. - 5:11 p.m., remained lying on her back, with both heels resting directly on mattress. - 5:14 p.m. R12 remained lying in bed, head of bed up 10 degress, and both heels resting directly on the mattress. Dietary aid (DA-A) entered R12's room, with a meal tray for her to eat. DA-A stated R12 would let staff know if she wanted her head up. - 5:23 p.m. nursing assistant (NA)-A entered R12's room and stated R12 was not to be eating like that and needs head of bed greater than 30 degrees when eating. NA-A then raised the head of the bed and left the room. NA-A did not assist her with repositioning other than elevating head of bed. - 5:44 p.m., R12 remained lying in bed, her head up, both heels resting on the mattress of the bed. Trained medication aide (TMA)-A entered room, administered medication and immediately left the room, without offering or encouraging R12 to reposition. - 6:11 p.m., R12 remained lying on her back with head of bed elevated greater than 30 degrees, pillow remained under knees. Heels remained resting on the bed. During interview at 6:11 p.m., NA-B stated R12 required repositioning every 2 hours and should be getting up for meals. NA-B stated her shift started at 2:00 p.m. and she had not repositioned her since starting her shift as she was not the staff responsible for R12. During interview at 6:18 p.m., RN-C stated R12 utilized an air mattress and was to be repositioned every 2 hours. RN-C stated she would be concerned if R12 was not repositioned greater than 3 hours. - 6:23 p.m., RN-C and NA-B entered R12's room and repositioned her on to her left side with a body pillow behind her back, with both heels floated with a pillow under her calves. During repositioning, R12 stated my rear is so sore. R12 refused to allow surveyor to visualize her skin during repositioning. NA-B stated there were some creases in the skin but no new reddened areas. R12 remained in the same position, with both heels resting directly on the mattress for the entire observation, a total of 3 hours and 44 minutes. On 1/02/20 at 6:27 p.m., NA-A stated R12 was to be repositioned every 2 hours unless she requested more often. She started her shift at 2:00 p.m., and was responsible for the care of R12 since the beginning of her shift. She was unsure why it did not get done and stated it must have slipped through the cracks. Identified R12 does have a pressure sore so she needed to be turned that often. On 1/2/20 at 6:35 p.m., R12 stated her butt and her heels hurt and rated her pain 10/10, but after being repositioned the pain had improved. She stated often she would be in one position for that long and at night staff would assist her 1-2 times a night. On 1/2/20 at 6:45 p.m., TMA-A identified R12 was to be repositioned every 2 hours. TMA-A identified she passed her medications, but she was not the staff responsible for repositioning R12. On 1/02/20 at 7:04 p.m., the MDS coordinator/assistant director of nursing (ADON) stated R12 should be repositioned every 2 hours and required extensive assist with bed mobility. She stated her expectation was R12 would be repositioned every 2 hours to prevent worsening of existing pressure ulcers, prevent further pressure ulcer development, and to maintain comfort. ADON stated wound assessments were to be completed weekly per the facility policy. Review of R12's Weekly Wound Assessment forms revealed the following: -9/3/19, R12 had developed an facility acquired pressure area, to the right heel, that measured 5 centimeters (cm) x 3.9 cm. It had the appearance of a blister and was a suspected deep tissue injury and current treatment was to use [MEDICATION NAME] wipe to heels and leave open to air. -9/12/19, right heel measured 3.4 cm x 4.2 cm and remained unstageable. Wound base 100% intact eschar. Identified no change to wound. Treatment continued as [MEDICATION NAME] paint and leave open to air. The assessment identified CNP-A, DM, and FM-A had been notified. R12's record lacked Weekly Wound Assessments from 9/12/19 to 10/2/19. -10/2/19, right heel stage III pressure area measuring 0.2 cm x 0.7 cm x 0.3 cm. Wound base 100% dried eschar. Identified improved. Current wound treatment of [REDACTED]. R12's record lacked Weekly Wound Assessment completed from 10/2/19 to 10/24/19 -10/24/19, right heel stage III pressure area 1.5 cm x 2.0 cm, wound base 100% dried eschar. Identified no change to wound. treatment of [REDACTED]. -10/29/19, right heel stage III pressure area 1.5 cm x 2.0 cm x 0.2 cm depth, wound base 100% moist eschar. This area was hard last week when measured. No drainage noted. Identified improved. treatment of [REDACTED]. R12's record lacked Weekly wound assessments completed 10/29/19 to 11/14/19. -11/14/19, right heel stage III pressure area 2.3 cm x 4.0 cm. There was an additional area of 1.5 cm by 2.5 cm to the side of the raised area that was purple in color. Wound base raised area 100% dried eschar. treatment of [REDACTED]. Identified as a decline in wound status. CNP was notified and will be coming on 11/21/19 as well. FM-A and DM were notified. Plan was to reeducate staff to make sure heels are not touching surface of the bed. Had order for AFFO boots while in bed. R12's record lacked documentation of Weekly Wound Assessments completed 11/14/19 until 11/28/19. -11/28/19, right heel stage III pressure area 1.1 cm x 1 cm by. Did not address the additional area mentioned in previous assessment. Wound base raised area 100% smooth eschar. Identified improved. treatment of [REDACTED]. FM-A, and DM notified on 11/21/19. -12/4/19, right heel stage III pressure area 1 cm x 1.1 cm x 0.3 cm. Failed to address the additional area to the side of the raised area that was purple in color. Wound base 50% slough and 50% granulation. Identified wound to have been improved. treatment of [REDACTED]. DM notified. -12/12/19, by RN-A, incorrectly listed left buttock instead of right ischium, stage III pressure area. 5 cm x 3 cm x 0.2 cm. CNP-A debrided area at this time. Continues to have 75% attached yellow/brown slough. Drainage serosanguineous. Wound had declined as it was wider and deeper. Head of bed not to be higher than 30 degrees except for eating. Showers only until wounds are healed. Keflex 500 mg by mouth every 6 hours for 7 days, cleanse with acetic acid, then dampen 4x4 with acetic acid, fold over wound bed and cover with foam, change every day. No further Weekly Wound Assessment forms were found in R12's record. On 1/3/20 at 9:38 a.m., RN-A identified she was the facility wound nurse. She indicated if a new open area was identified, the nurse was to initiate an assessment and notify her and wound assessments were to be completed weekly. She indicated she was unsure of the reason R12's pressure ulcers had not been monitored routinely and confirmed R12's right ischium pressure ulcer had been identified on 11/21/19 by CNP-A, but no further documentation of assessment or monitoring of the pressure ulcer had been done until seen by CNP-A on 12/12/19. RN-A stated the nurse finding the pressure area should have initiated an assessment and RN-A should have done weekly documentation. She indicated she had completed R12's weekly assessment on 12/26/19, however, confirmed she had not documented the assessment. On 1/3/20 at 12:44 p.m., RN-A was present in R12's room and completed wound care and assessments with the following documentation of wound evaluation: 1. Right heel-stage IV pressure area total area both open and discolored area 2 cm x 2. 5 cm x 0.3 cm with no undermining identified. The open area measured 1 cm x 1 cm x 0.3 cm and the rest of described wound base as 90% slough, 10% beefy red, with serosanguineous and brown drainage. Wound had improved, not as deep as prior. Cleanse with acetic acid, use 1/4 inch [MEDICATION NAME] ribbon, lay into wound bed and gently pack into placed. 4x4's two to three, kerlix, ace wraps from toes to below the knee change every day. 2. RN-A identified are to right lateral heel as a new pressure injury 1.0 cm x 0.8 cm. Noted to be a stage I and have spotted brown areas that did not blanch. Will notify MD and family. 3. Right gluteal fold/ischium stage 3 pressure area. 3.0 cm x 3.0 cm x 0.5 cm. 90% slough and 10% beefy red base with purple periarea approximately 2.5 cm surrounding open area. Moderate amount of brown drainage. Wound had declined because it had deepened. 4. Left buttock had a stage II pressure area. 1.0 cm length x 2.0 cm x 0 cm. Surface had dry and flaky skin and mottled brown. RN-A identified this wound was discovered 1 week ago. RN-A was unaware if any staff had observed or followed up on this area since discovered. RN-A indicated no documentation or provider notifications had occurred and confirmed documentation should have been done and provider and family should have been notified. On 1/3/20 at 1:52 p.m., RN-A identified R12 should have been repositioned every 2 hours side to side, not on her back. Her heels should have blue booties on and be floated and an air overlay mattress used. Also, a foot cradle should be in use when in bed. She confirmed R12 had developed the left buttock, stage 2 pressure ulcer last week on 12/26/19, and she had not looked at it again until today. She was unaware if any other staff had looked at it since 12/26/19. RN-A stated the usual practice was to complete an initial assessment when a new pressure ulcer developed and this had not been done for R12. She confirmed she had been unaware of the right heel pressure injury until 1/3/20 with the dressing change. RN-A stated staff not completing repositioning every 2 hours could contribute to the worsening and development of new pressure areas for R12. She also stated weekly wound monitoring was important to monitor for changes and assure proper treatment of [REDACTED]. On 1/6/20 at 11:57 a.m., the director of nursing (DON) indicated she had not been aware of the development of R12's right heel pressure injury and development of stage 2 pressure ulcer until 1/3/20. She stated she was unaware wound assessments for R12 had not been done weekly per facility policy. DON stated she expected R12 to be repositioned every 2 hours as her care plan directed. She indicated wound documentation should have been done timely for R12 to assure accurateness of the assessment. On 1/6/20 at 12:46 p.m., MD-A (who was also the facility's medical director) indicated she was unaware of the two new pressure ulcers for R12. MD-A indicated R12 should be repositioned at least every 2 hours, since she was unable to move herself. MD-A indicated staff should follow R12's care plan, physician orders, and the facility policy. MD-A indicated wound assessments should have be completed weekly and failure to complete a comprehensive assessment when changes were first identified and failure to follow the plan of care, physician orders, and policies could contribute to the development of pressure ulcers and worsening of existing pressure ulcers. On 1/6/20 at 2:00 p.m., CNP-A stated she would expect R12 to be repositioned every 2 hours or less as ordered and her heels should have been floated. She indicated failure to reposition R12 timely and to float her heels could contribute to the development of pressure ulcers and worsening of her current pressure ulcers. CNP-A stated she was unaware R12 had developed 2 new pressure areas, however staff typically would notify primary provider and would follow her direction until the next wound care visit by her. Review of R12's clinical record revealed the following : -progress note, dated 9/4/19, identified medical doctor (MD)-A had been informed of pressure injuries and had signed the order for the [MEDICATION NAME] swabs to bilateral heels and AFFO boots (pressure relief boots). -9/12/19, certified nurse practitioner(CNP)-A, listed pressure injury to the right heel measured 3.4 cm x 4.2 cm. Wound base described as 100% intact eschar. Periwound dry and boggy. Encourage offloading heels as much as possible, Recommend a foot cradle to the bed so no blankets are directly on top of the toes. Refer to occupational therapy (OT) to evaluate and treat for an offloading device to her heels when she was in bed. Treatment to paint heel with [MEDICATION NAME] every day and leave open to air. R12's 10/24/19, progress note by CNP-A, identified R12 to have a pressure injury to the right heel measured 1.5 cm x 2 cm. Wound base described as 100% intact eschar. Periwound dry and boggy. Encourage offloading heels as much as possible. Foot cradle and offloading boots are in place. Treatment to paint heel with [MEDICATION NAME] every day and leave open to air. Areas appear to be improving, with intent to heal. R12's 11/21/19 progress note by CNP-A, identified R12 to have a pressure injury to the right heel which measured 1.5 cm x 2.5 cm. Wound base described as 100% loosely attached eschar. Periwound dry and boggy 3 cm x 7 cm. New area was identified to the right ischium 1.5 cm x 4 cm. Wound base 50% slough and 50% a-granular, periwound ruddy color and dry sloughing. CNP-A debrided the right heel ulcer. Wound measurements after debridement were 1.8 x 2.5 x 0.3 cm. Encourage offloading heels as much as possible. Foot cradle and offloading boots are in place. Treatment to right heel cleanse with wound cleanser, pat dry, apply Iodosorb gel nickel thickness to wound bed, cover with foam, change every 3 days and as needed. Treatment to right ischium wound cleanser, pat dry, and apply Iodosorb gel to wound bed cover with silicone foam and change every 3 days and as needed. Place a wheelchair cushion in wheelchair. Reposition and wheelchair every 2 hours. R12's 12/12/19 progress note by CNP-A, identified R12 to have a pressure injury to the right heel measured 1 cm x 1.3 cm x 0.7 cm. Progressed to stage IV with tendon exposed. Wound base described as 100% loosely attached eschar and slough. Periwound dry and boggy 3 cm x 7 cm. Right ischium 5 cm x 3 cm x 0.2 cm. Wound base 75% yellow to black slough and 25% a-granular, periwound ruddy color and dry sloughing. CNP-A debrided the right heel ulcer. Identified areas had worsened. Encourage offloading heels as much as possible. Treatment Keflex 500 milligrams (mg) by mouth every six hours for seven days. Right heel cleanse with acetic acid, use 1/4 inch [MEDICATION NAME] ribbon and gently pack in to the wound, 4 x 4's two or three, wrap with kerlix, ace wrap from toes to below knee, change daily. Ischium cleanse with acetic acid, then dampen 4x4 with acetic acid, fold over wound and cover with foam. Reposition and wheelchair every 2 hours. Facility's undated Pressure Ulcers/Skin Breakdown policy identified the nursing staff would describe, document, and report the following. 1. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. 2. Pain assessment 3. Resident's mobility status. 4. Current treatments, including support surfaces. 5. All active diagnoses. Facilities undated Pressure Ulcer Risk Assessment policy identified a pressure ulcer risk assessment would be completed upon admission and then weekly for 3 weeks, with each additional assessment; quarterly, annually, and with significant changes. A skin assessment, to assess for the presence of developing pressure ulcers on a weekly basis or more frequently if needed. A resident can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, therefore the at risk resident needs to be identified and have interventions implemented promptly to prevent pressure ulcers. The Resident Assessment Instrument (RAI) and MDS evaluates the resident risks for developing pressure ulcers and should identify which risk factors can be removed or modified. Factors that put residents at risk include pressure, incontinence of bowel or bladder, immobility, altered mental status, incontinence, antipsychotic medications, [DIAGNOSES REDACTED]. If a new skin alteration was noted, nursing staff were to initiate a pressure or non-pressure form, proceed to care planning and interventions individualized for that resident and their risk factors. If a new skin alteration was identified staff were to document in medical record notification to MD and resident representative with a change of care plan if indicated.

Based on interview and document review, the facility failed to provide a comprehensive safety assessment for use of an electric lift chair following admission for 1 of 1 resident (R1) admitted with a history of falls. The fall resulted in serious injury or harm. Findings include: R1's 7/31/19, 5-Day Minimum Data Set (MDS) assessment identified [DIAGNOSES REDACTED]. R1's Brief Interview of Mental Status (BIMS) was scored as 13/15 indicating her cognition was intact. The activities of daily living (ADLs) were assessed as requiring extensive assistance with transfers, ambulation with a walker, dressing, grooming, toileting and personal hygiene. R1's Bed Rail/Assist Bar Evaluation dated 7/24/19 listed: Problems with balance and poor trunk control, however R1 was found to be able to maintain position when sitting in a recliner. R1 required the use of an EZ stand (a lift that raises a person from a sitting to a standing position) for transfers. There was no safety assessment on the use of a lift chair recliner made at that time. R1's Admission Care Plan dated 7/24/19 identified R1 was to be transferred using a mechanical lift. There was no mention of use of an electric lift chair. R1 was hospitalized with a [DIAGNOSES REDACTED]. According to nursing assessment at the time of readmission R1 was alert and oriented but required extensive assistance with all ADLs. There was no evaluation on safe use of the electric lift chair following R1's return on 8/9/19. The Physical Device Evaluation form to be completed at the time of admission or prior to initiation of a device, per facility protocol, contained the following areas of assessment for an electric lift chair were: 1.) Mental Status/Cognition 2.) can resident appropriately demonstrate safe use of electric lift chair. 3.) Has resident ever fallen out of electric lift chair. 4.) Is resident currently involved in therapy. There was no indication staff had used their evaluation form to identify R1 was safe to use the electric lift chair. On 8/9/19, at 6:30 p.m. the progress noted indicated R1 remained in the electric lift recliner, and according to nursing assistants (NA)-A and B on duty at the time of the incident, the electric lift control was in the pocket located on the side of the recliner. At 9:30 p.m. R1 was found lying, face down, on the ground in front of her recliner. The recliner was in the highest up position. R1 complained of pain with movement, and was transferred to the emergency department for evaluation and was admitted with [DIAGNOSES REDACTED]. Registered nurse (RN)-A was interviewed on 8/19/19, at 2:36 p.m. and identified not all residents have an electric lift chair in their rooms, but it they would choose to have one, the process is to determine cognition, provide a demonstration and then have the resident provide a return demonstration. R1 should have had this assessment completed upon admission and again upon return from the hospital on [DATE]. RN-A agreed there was no documentation that it had been completed. RN-B was interviewed on 8/19/19, at 2:56 p.m. and indicated she both performed resident assessments following admissions, readmissions, quarterly, and/or with significant changes. A physical device/safety assessment should have been completed for R1 at the time of both the initial admission on 7/24/19, and following readmission from her hospital stay on 8/9/19. No documentation was present in either the electronic or paper record of either of these assessments having been completed. The Director of Nursing (DON) was interviewed on 8/19/19 at 3:08 p.m. and indicated her expectation was for the physical device evaluation form to be completed at the time of admission/readmission/or significant change if an electric assistive device was to be utilized by a resident. If the device was to be utilized by a current resident then she would expect the evaluation to be completed prior to utilization of the device. The DON indicated she was not able to find any documentation of completion of the device assessment. She agreed the Physical Device Evaluation had not been completed at the time of R1's initial admission or following her readmission after being hospitalized . A policy/procedure was requested for the facility device assessment but not provided and the DON verified that the facility had a check off list of assessments to be completed, but there was not a written policy in place.

Based on interview and document review, the facility failed to provide adequate nursing care and services for 2 of 4 residents (R46, R21) reviewed who had been hospitalized . This resulted in actual harm for R46, who experienced prolonged discomfort, dehydration and vomiting related to delayed nursing assessment and transfer to an inpatient facility for a small bowel obstruction. In addition, the facility failed to provide appropriate interventions related to dementia care for 1 of 1 resident (R6) reviewed who had dementia and could not speak/understand English. Findings include: R46's discharge orders to the nursing home dated [DATE], identified a discharge condition of improving with orders for physical and occupational therapy. R46's physician's progress notes, dated [DATE] indicated [DIAGNOSES REDACTED]. The physician's progress note also identified a history of diverticulitis of the colon. R46's admission Minimum Data Set (MDS), dated [DATE] identified a Brief Interview for Mental Status score of ,[DATE] (cognitively intact). No care area assessments were completed with the MDS. R46's care plan, dated [DATE] identified no cognitive impairments and that R46 desired to return to the community. R46's [DATE] medication sheets revealed R46 had received [MEDICATION NAME] (an antacid) 30 cubic centimeters (cc)'s on [DATE] a total of four times on that date, as well as one dose at 2:00 a.m. on [DATE]. Notations documented by licensed practical nurse (LPN)-A, on the back of the Medication Administration Record [REDACTED]. No follow up assessment for effectiveness was completed. A subsequent entry dated [DATE], at 2:00 am. indicated R46 had received another dose of [MEDICATION NAME] for an upset stomach and emesis; the follow up result was listed as had another emesis at 4 a.m. None of the other doses administered had follow up results documented. A nursing progress note written by LPN-F on [DATE] at 8:30 a.m., indicated R46 had hiccups and complaints of not feeling well. The notes indicated R46 had been given [MEDICATION NAME] 30 cc's along with [MEDICATION NAME] and had begun retching after his morning medications. In addition, R46 had experienced a large projectile emesis all over the bed and himself, and had refused to eat anything for breakfast, stating he had consumed orange juice that had all come up. A nursing progress note documented by LPN-F on [DATE], at 1:39 p.m. indicated R46 had a large emesis, and that the resident had stated he was not feeling well. The notes indicated his hiccups had subsided for a while but had then started again. Documentation indicated R46 had received [MEDICATION NAME] and [MEDICATION NAME] (an antipsychotic medication used for antiemetic properties) with another small emesis afterward. The emesis was documented as having had food particles present and was described as having a colicky odor. R46's temperature was documented as having been elevated at 99.0 degrees Fahrenheit (F). A nursing progress note dated [DATE], at 6:00 p.m. per LPN-F indicated R46 had stayed in bed most of the evening. The note indicated R46's hiccups were better over the early evening hours but that R46 had been stated his tummy still didn't feel right and that whenever he moved he began to gag. R46 had eaten Jell-O for supper and had sips of water. Additionally, the documentation indicated a fax (facsimile) had been sent to medical doctor (MD)-A with an update on R46's condition including that R46 had an elevated temperature at 99.5 degrees F and complained of feeling chilly. A nursing progress note dated [DATE], at 11:05 p.m. per LPN-F indicated R46 had not been feeling well, and had been having brown colored emesis twice on the afternoon shift which did not appear to have a feces odor. [MEDICATION NAME] 30 cc's had been given to help with hiccups and R46's vitamins had been held due to emesis. A nursing progress note by LPN-A, dated [DATE], at 1:56 a.m. indicated R46's abdomen was distended, his bowel sounds were difficult to hear and he had been having emesis which looked like BM. R46's temp was noted to be slightly elevated at 99.1 degrees F. A nursing progress note written by LPN-A on [DATE], at 4:48 a.m. indicated R46 had 100 cc's of emesis, like soft formed/loose BM (bowel movement) with no odor. The note further indicated R46 was cool and clammy, with a slightly elevated temperature at 99.1 degrees F. R46 had a wastebasket beside him, and continued to wretch. A nursing progress note entered by LPN-B, dated [DATE], at 9:57 a.m. indicated R46 had two further emesis of greenish liquid thick with pieces of BM looking in it. In addition, the note indicated an acute care hospital had been called and an order was received to transfer R46 to their emergency room (ER) via ambulance. The note indicated R46's daughter was updated and had agreed to meet him at the hospital. R46 left the facility at 8:45 a.m. A faxed physician's orders [REDACTED]. An additional nursing progress note dated [DATE], at 2:06 p.m. indicated R46 had been admitted to the acute care hospital with a [DIAGNOSES REDACTED]. A faxed physician's orders [REDACTED]. R46 complained of feeling weak. The fax had not been signed off until on [DATE], three days later, when the nurse practitioner (NP)-A responded with a statement including, Noting telephone order to transfer toER on [DATE]. Please do NOT fax in regard to situations that need attn (attention) that day. This will be sent to (physician) - today [DATE]. Please review the faxing for response procedure. Thx (Thanks). The ER progress note dated [DATE], at 10:36 a.m. was reviewed. The ER note indicated R46 had appeared distressed when examined, had been uncomfortable, and had dry oral mucous with dried brown material on the tongue and lips. The ER note further indicated R46's abdomen was firm and diffusely distended, mildly tender with no appreciable bowel sounds. In addition, 1800 milliliters (ml) of brown liquid had been drained from R46's stomach after the insertion of a nasogastric tube. R46 had received 2000 ml of normal saline intravenous for hydration. The ER physician's note indicated R46 had appeared quite dehydrated and verified the admitting [DIAGNOSES REDACTED]. The ER registered nurse's assessment dated [DATE], at 11:17 a.m. indicated: R46 had stated he'd been vomiting for the last two days and his emesis was now brown like stool. R46 had vomited three times in the ambulance enroute to the ER and the vomit was described as dark brown liquid running out of his mouth. R46's abdomen was very firm, with no bowel sounds and the abdomen was distended. R46 complained of abdominal pain but was unable to rate the pain. R46 had his stomach drained via a nasogastric tube for ten minutes with 1400 mL of fluid output after which R46 stated he felt much better. R46 was alert and states we should do what ever we have to do. Is comfortable now. The hospital discharge summary dated [DATE], indicated R46 had undergone abdominal surgery to correct the small bowel obstruction, and had developed subsequent cardiac and anticoagulation issues as well as post-operative ileus (disruption in normal bowel motility) after the surgery. The ileus resolved with the replacement of a nasogastric tube; however, comfort cares were initiated and R46 passed away on [DATE]. During interview on [DATE], at 3:07 p.m. the director of nursing (DON) verified she would have expected staff to contact the on-call doctor immediately with the urgent clinical issues, especially when the resident was vomiting BM-type material and not feeling better. During interview on [DATE], at 3:32 p.m. the nursing home's health information coordinator/nursing scheduler (HIM) stated LPN-B was not well and was currently in a hospital intensive care unit, unavailable for interview. The HIM verified LPN-F had been a pool nursing staff. During interview on [DATE], at 3:45 p.m. the acting administrator, who had been the DON at the time of the incident stated she'd thought R46's family had indicated he was admitted to the hospital with [REDACTED]. The administrator was unable to recall specifics regarding R46's episode of illness; however, stated she would have expected staff to contact/call the on-call and/or primary physician directly with concerns that were urgent. The administrator stated she would have expected the staff to check the vital signs, bowel movement status, appetite and fever status while conducting a physical assessment. The administrator stated she thought LPN-A was a good nurse and trusted her judgment. She further verified LPN-A worked every Thursday night shift. When LPN-A was interviewed about the incident on [DATE] at 4:02 p.m., LPN-A stated she'd received report from the evening nurse (LPN-F) on [DATE], regarding R46's emesis, but had been unaware a fax had been sent. LPN-A stated she'd worked with R46 at least one time prior and was aware R46's vomiting and complaints of not feeling well was new for R46. She was aware R46 had thrown up and had not been eating well, and had subsequently administered [MEDICATION NAME] during the night. LPN-A thought the [MEDICATION NAME] had helped somewhat the first time she administered it (around 2:00 a.m.). LPN-A verified R46 had emesis of what looked like stool but there was no odor. She verified his abdomen had also seemed a little distended. LPN-A was unaware whether R46 had complained of pain. LPN-A said R46 subsequently vomited and it looked more like BM later in her shift (around 5:00 a.m.) at which time she'd become concerned that he may have something wrong with his small bowel. LPN-A said she'd proceeded to fill out all the transfer paperwork for a hospital discharge; however, did not call the RN on call nor notify the physician of her concern. LPN-A indicated she had passed along the paperwork and her concern to the day nurse, LPN-B, who arrived on duty at 6:00 a.m. on [DATE]. LPN-A stated she'd told LPN-B to do an assessment to follow up on R46's condition. During the interview, LPN-A stated she thought there had been a history of small bowel concerns she had noted when filling out the paperwork to pass along to the day shift personnel. During a follow up interview on [DATE], at 9:12 a.m. the administrator stated LPN-A should have notified the physician sooner about R46's symptoms, and that she had not been aware there had been a delay in his nursing care and physician notification of his condition. During interview on [DATE], at 2:11 p.m. the medical director was interviewed and stated she would have expected nursing staff to call when they filled out the paperwork to transfer R46 to the hospital. The medical director stated although R46 may have subsequently expired anyway, prompt medical care would have made him comfortable. The medical director stated the effect of delayed medical care/interventions related to R46's medical outcome was difficult to state since she was not his usual physician. During interview on [DATE], at 9:27 a.m. medical doctor (MD)-A (R46's usual physician) stated he would have expected staff to have called the clinic and/or the on-call physician when R46 began vomiting stool-like material. MD-A stated faxing medical staff at the clinic at 6:00 p.m. was inappropriate as the fax machine was not attended at that time of day. MD-A stated he'd been concerned about the potential for ischemic bowel when R46 arrived at the hospital, due to the delay in receipt of medical attention after his symptoms began. MD-A stated R46 had made some depressed comments prior to the hospital transfer on [DATE], but those comments were a sidebar and were not relevant to this issue. MD-A confirmed R46 would have been more comfortable if he had been examined sooner in the ER. MD-A stated, when you are vomiting brown stuff, it is probably a good idea if you are seen. The facility's policy entitled Change in Condition SBAR last revised ,[DATE], indicated immediate notification of the physician was required for any symptom, sign or apparent discomfort that was sudden in onset, a marked change (i.e. more severe) in relation to usual signs and symptoms and was unrelieved by measures already prescribed. The policy further indicated in a section related to abdominal distension that immediate notification of the physician was required when there was rapid onset, or presence of marked tenderness, fever, vomiting or GI (gastrointestinal) bleeding. Review of R21's Medication Administration Record [REDACTED]. Between the dates of ,[DATE] - [DATE] there were 44 blood sugar (BS) levels which were documented as 400 milligrams (mg)/ deciliter (dL) and above, with 25 of those documented BS level readings higher than 430 mg/dL. Although the resident's blood sugars fluctuated dramatically, there had not been physician notification of blood sugars which registered greater than 430 mg/dL. A physician's orders [REDACTED]. A physician's orders [REDACTED]. BS readings were to be faxed to the diabetic educator weekly. No parameters were listed for notification of the physician regarding hypo (low) or hyper (high) glycemia (BS). During interview on [DATE], at 3:10 p.m. a licensed practical nurse (LPN)-C indicated there were no protocols, or orders, indicating when to notify the medical doctor (MD) of BS levels. LPN-C stated she would notify the MD related to how the resident felt and if there was a high BS-which she identified as way above 400's- 500's. On [DATE], at 2:36 p.m. LPN-D stated she would notify the MD if she obtained a BS result above 600 mg/dL. LPN-D confirmed on [DATE], the supper BS check for R21 was 521 mg/dL and the MD was not updated. LPN-D further stated R21 frequently has BS readings above 400 mg/dL and the facility standing orders read to give 6 units of regular insulin if the BS was greater than 350 mg/dL. LPN-D indicated when the glucometer read high it was the result of a BS over 600 mg/dL and she would telephone the nurse on call at the hospital to report the reading. During interview on [DATE], at 2:57 p.m. the diabetic educator indicated she received weekly reports of R21's BS results. She further stated the clinic has a protocol for diabetic medication adjustments and this was what insulin changes were based upon. The diabetic educator further stated R21 had a history of [REDACTED]. The diabetic educator further indicated she thought BS parameters had been identified when R21 was recently discharged from the the hospital on [DATE]. She indicated the parameters would have been determined by the discharging MD. During interview on [DATE], at 3:12 p.m. RN-B and RN-C stated there were facility parameters for reporting BS readings. They referenced the documentation on the facility's standing orders and stated that would be the practice they followed unless individualized orders were written. RN-B indicated if a resident was symptomatic she would notify the physician based on the standing order instructions. RN -B and RN-C indicated they were not aware of the Change in Condition policy related to immediate reporting of BS readings above 430 mg/DL. RN-B stated, we will have to make certain everyone is aware of this policy. During interview on [DATE], at 8:36 a.m. LPN-E indicated she had been employed as an LPN for 3 months at the facility and had received training on BS checks which included: to test in a private area, wear gloves, and follow MD orders if the resident had orders for a sliding scale (SS), or a specific insulin order. LPN-E stated if there was a high reading she would contact the MD on call for direction. In the instance of a 400+ reading for R21 LPN-E indicated she would administer the ordered SS dose and recheck in one hour and then recheck in the following hour to determine whether the BS was responding to insulin. LPN-E stated she would probably not notify the MD in this instance as this resident has a history of BS fluctuations. LPN-E further indicated R21 did not have specific orders for follow up but this is what she would do. On [DATE], at 9:04 a.m. R21's physician, also the facility's medical director, stated typically a resident would have a specific order that comes from the hospital for sliding scale insulin. R21's physician stated R21 had been her patient even before admission to the nursing home, and had a history of [REDACTED]. However, stated if she'd received a telephone call for an elevated blood sugar level she could provide specific orders as to when staff were required to recheck the BS and call back the results. She stated, they call if the meter reads 'hi' because they have nothing to base it off. If the blood sugar is below 70 mg/dL staff would need to initiate the [DIAGNOSES REDACTED] protocol. She further indicated she would expect staff to notify the clinic and/or on-call staff to update on BS readings that were outside range. When interviewed on [DATE], at 1:00 p.m. the director of nursing (DON) reviewed the [DATE] documentation of R21's BS readings and indicated she was unaware of the wide fluctuation of BS readings for R21 which were over 430 mg/dL. She confirmed she would have expected staff to notify the attending MD and/or the on-call staff in accordance with the Change in Condition When to Report to the MD/NP/PA policy. The facility's policy related to physician notification for blood sugar fluctuations, entitled, Change in Condition When to Report to the MD/nurse practitioner(NP)/physician assistant last revised ,[DATE], included: blood sugars greater than 430 mg/dL (or machine registers high) in diabetic patients using sliding scale insulin should be immediately reported to the physician or nurse practitioner (NP). When interviewed on [DATE], at approximately 8:50 a.m. the DON confirmed R6 was unable to understand or be understood, and staff communicated using gestures and facial expressions. The facility diagnostic report indicated R6 was admitted to the facility in 2014, with [DIAGNOSES REDACTED]. R6's annual MDS assessment dated [DATE], revealed the resident had severely impaired cognition with daily wandering that significantly intruded on the privacy of others, physical behavior towards others ,[DATE] days, other behavior not directed towards others ,[DATE] days but less than daily. The MDS also indicated R6 required extensive assistance with bed mobility, transfer, locomotion on/off unit, dressing, toilet use, and personal hygiene. The MDS further indicated neither the resident nor family/significant other was able to complete the daily and activity preference portion of the assessment. R6's care plan dated [DATE], indicated a risk for falls related to (r/t) history of falls, generalized weakness, gait/balance problems, bladder incontinence, hearing and vision impairments, impaired cognition, and difficulty communicating needs. Interventions included: anticipate and meet needs, encourage activities that promoted exercise, physical activity for strengthening and improved mobility, ambulate with staff in hallway three times daily, redirect when wheeling close to wall or objects, use distraction when restless. The care plan further identified a communication problem r/t hearing deficit and head injury. Interventions included: discuss with resident/family concerns or feelings regarding communication difficulty, family reported that they were unable to communicate with resident due to the progression of his dementia, observe effectiveness of communications strategies and assistive devices. On [DATE], R6 was continuously observed from 1:16 to 4:17 p.m.: - At 1:16 p.m. R6 was observed being ambulated by two staff with a third pushing the resident's wheelchair (w/c) behind him down the west Cityside hallway. The resident was cooperative while walking and although could not be understood, spoke and smiled to the staff, who in turn talked to the resident. After walking the length of the hall, the resident was assisted back to the dayroom in front of the television (TV). R6 then propelled himself throughout the dayroom in his w/c. -At 1:27 p.m. NA-A brought R6 a sensory item that was rounded in shape and consisted of multiple-colored hollow tubes held together with a -type cord enabling the object to be stretched and manipulated. R6 accepted the item, talking out loud constantly and NA- walked away. R6 held the item but did not appear interested, nor did he attempted to manipulate the object. -At 1:34 p.m. a staff member transported R6 from the middle of the dayroom to a table with another resident. R6 continued to verbalize while the sensory object remained in his lap. No interaction with staff and R6 was observed. R6 remained at the table for a short time and then began to propel himself in w/c around the dayroom. -At 1:44 p.m. R6 started to propel behind the nurses' station. LPN-C redirected the resident away from the area and then assisted him to his room. -At 1:52 p.m. R6 propelled himself out of his room to the drinking fountain in the west hallway. R6 had a plastic mug and was attempting to obtain water from the fountain. A staff member approached R6 and assisted him with filling the mug with water then replaced the cover on the mug. R6 accepted the water mug then continued to mumble out loud and propel himself down the west hallway towards the administrative offices. Once R6 made it to the end of the hallway, staff intercepted the resident and returned him to his room. -At 2:00 p.m., R6 was lying in bed on top of covers without shoes. A sensory item the resident was holding earlier was on the resident's legs. R6 eyes were wide open. -At 2:07 p.m. R6 was sitting up on the edge of the bed with feet dangling, and the sensory item was on his lap. The resident was not touching or paying attention to the sensory object. - At 2:30 p.m. R6 was seated on the edge of his bed. His left shoe was off his foot, as he held his other shoe and pulled out the laces. -At 2:39 p.m., R6 continued to sit on the edge of bed in room attempting to pull the laces out of his left shoe. Coffee social and word games activity was being conducted in the dining room at that time. At 2:56 p.m. R6 continued to sit on edge of bed having successfully removed the laces from his shoe. At 3:10 p.m. NA-C entered R6's room and greet him. A trained medication aide (TMA)-A entered the room and asked if the resident was still working on his shoe. NA-C asked if R6 was supposed to have the shoe. TMA-A responded that if she could get it laced and on the resident, then they could put him in his chair and not worry about it. On [DATE], at 3:57 p.m. R6 seated on side of bed examining the unlaced shoe. A wellness group was scheduled to begin at 4:00 p.m. On [DATE], at 4:17 p.m. R6 was still on the edge of the bed, attempting to re-lace his shoe. This activity had been continuous since 2:30 p.m. or nearly two hours. R6 was not approached and/or involved in any significant staff to resident communication during the three hour continuous observation on [DATE]. The resident was handed a sensory object though staff failed to model how object could be used or spend time with the resident. Staff provided minimal interaction with R6 and continually redirected him to his bedroom and eventually put into bed though the resident was wide awake. R6 was observed on [DATE], during the following times: - At 7:50 a.m. R6 was seated alone at a table in the corner of the dining room eating breakfast independently. The table was pushed flush to the wall on two sides. R6's back was to the other residents as he faced the wall. - At 7:58 a.m. R6 was assisted in the w/c by staff to the Cityside dayroom and was situated at a table. Staff handed R6 a multicolored cylinder shaped sensory object that also made sound when manipulated. Staff then left the area without further interaction. R6 placed the object behind him on the seat of his w/c and proceeded to propel himself past the nurses' station towards the dining room to the medication cart where LPN-C was standing. Although R6 could not be understood, he vocalized loudly. LPN-C informed R6 he had already eaten and assisted the resident back to his room. LPN-C left the resident's room at 8:05 a.m. R6 was lying on the bare mattress and pillow without a pillowcase. The bedding was piled at the end of the bed. R6 was holding onto the grab bar, attempting to sit up in bed. -At 8:25 a.m. R6 was seated at the edge of the bed and the w/c was positioned next to bed with the brakes locked. R6's tennis shoes were located on the seat of the w/c. At 8:36 a.m. R6 was wearing shoes, and was ambulating along the side of the room as he felt the wall. The surveyor alerted the administrator who was walking by to question whether R6 was capable of independent ambulation. The administrator stated R6 did sometimes ambulate, and redirected R6 to his wheelchair. The administrator asked R6 whether he needed his oxygen (O2) as he was heavily breathing. The O2 was applied via a nasal cannula and the administrator left the room. - At 8:49 a.m. R6 removed the 02 tubing, propelled himself from the room via the w/c and entered another resident's room located across the hall. Upon entering the doorway, housekeeping (Hspkg)-A intervened and redirected R6 back to his own room. -At 10:04 a.m. a church activity was conducted in the activity room. R6 independently propelled himself down the west hallway but once he turned the corner, the administrator redirected and propelled him back down the direction of the hallway. R6 then entered the dayroom, propelling himself around the perimeter of the area, pausing to look out the window and watched the fish in the fish tank. R6 propelled himself toward the direction of the east hallway and remained seated here until 10:30 a.m. LPN-C then moved R6 from the east hallway to a table located in the dayroom. No verbal communication nor interaction was noted between staff and R6. -At 11:07 a.m. R6 was seated in w/c in dayroom by nurses station. A wellness activity in process and was identified on the plan of care as an planned intervention. At 11:27 a.m. R6 was seated in w/c in Cityside dayroom near nurses station when the activity director (AD) entered the dayroom, said Hi to R6, turned up the volume on the TV and walked away. At 11:48 a.m. R6 remained seated at the table in the corner of the dining room with his back away from the other residents. -At 2:16 p.m. NA-B and NA-A attempted to assist R6 to ambulate, however, the resident did not stand when prompted for approximately 30 seconds. The transfer belt was removed and the staff left the resident. -At 2:35 p.m. R6 was in the dining room where the men's group activity was held in the main area of the dining room. R6 was served a snack while located in the front area of the main dining room, partitioned off by a wall with two openings. R6 was offered his snack at the table where he routinely had been served meals, alone and away from the other residents who were served their snacks in the main dining area. At 2:41 p.m. when R6 finished his snack, propelled himself around the front area of the dining room near his designated table. No staff interacted with R6 until he was assisted out of the dining room towards the direction of his room at 2:44 p.m. When interviewed on [DATE], at 12:41 p.m. the AD cited a communication barrier. When interviewed on [DATE], at 3:36 p.m. TMA-A indicated they were unable to communicate with the resident and had not attempted any alternative method, and said it was unfair to R6. TMA-A said R6's family visited approximately monthly. When interviewed on [DATE], at 8:50 a.m. the licensed social worker (LSW) and DON stated they were unsure whether R6 would have been able to talk to his family on the telephone. Although they had never attempted to assist him to contact his family, they said it would be worth attempting. When interviewed on [DATE], at 1:25 p.m. the DON confirmed the R6 should not have been returned to his room or put into bed when he wandered. The DON stated, That's sad when informed the resident had been put into bed with a bare mattress, linen pushed to the end of the bed, and no pillowcase on the pillow. The DON agreed staffs' interventions and/or lack of appropriate interventions were concerning.

Based on interview and document review the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well being for 1 of 1 residents (Resident #1/R1) in the sample who experienced a [MEDICAL CONDITION] and did not receive CPR, and potential harm to 10 of 49 residents in the facility who had documented full code status. Due to the lack of a system or guidelines for staff to follow when confronted with a cardiopulmonary arrest and conflicting staff responses how to respond to a [MEDICAL CONDITION], it was determined there was an Immediate Jeopardy to patient health and safety to individuals who had elected full code status. The Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy began on [DATE] when RN(H) failed to initiate CPR on R1, who had elected a full code status in the event of a cardiopulmonary arrest. The Administrator and Director of Nursing were informed of the Immediate Jeopardy finding on [DATE] at 4:15 p.m. The Immediate Jeopardy was removed on [DATE] at 1:45 p.m. but noncompliance remained at lower scope and severity of potential for harm (H) to the 10 residents residing in the facility who have current requests for CPR in place. The immediate jeopardy was removed after confirmation of an acceptable removal plan including development of CPR guidelines and protocols, training licensed staff on the new guidelines, including a plan to train all licensed staff and monitoring of staff knowledge and response to cardiopulmonary arrest. Findings include: R1's medical record was reviewed. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 had a form titled Directives to Define Scope of Medical Care dated [DATE], signed by R1's physician and his Proxy that included his request for "Full cardiopulmonary resuscitation (CPR:forced respiration by external means, e.g. mouth to mouth breathing; closed chest compressions.)" R1's care plan with initiate date of [DATE] and review date of [DATE] indicated his code status was full code, and included a goal that his code status would be honored. Interventions included CPR as needed. Nursing notes dated [DATE] and signed by RN(H) indicated that R1 was found at approximately 1:15 a.m. not breathing and lying across his bed. No pulse was noted, mottling of lower legs was present, extremities were cool to touch. RN(H) examined the body and nothing abnormal was noted. The funeral home and family were notified and the body was removed by funeral home staff. RN(H) was interviewed on [DATE] at 11:50 a.m. and stated that she found R1 at approximately 1:15 a.m. on [DATE] and he was not breathing. RN(H) stated that R1 was cold and cyanotic. R1 stated she never even thought of starting CPR because it looked like he had been gone awhile. She stated that she had seen him approximately one hour before and he seemed fine. Although R1 had documented wishes for cardiopulmonary resuscitation she did not initiate CPR because she did not check his code status and in her opinion it would have been "futile." She further stated that the facility did not have any policy regarding CPR and that the facility never discussed CPR response but she indicated she probably should have initiated CPR. RN(H) stated that being a nurse for so long she had a "good idea" of when CPR would benefit a patient. RN(H) stated that if R1 would have been warm, she would have initiated CPR. During an observational tour of the facility on [DATE] discussions with multiple licensed nursing staff revealed that staff were unable to consistently provide how they would respond to a resident found in cardiopulmonary arrest. RN(E) was interviewed on [DATE] at 1:40 p.m. and stated that if she found a resident in [MEDICAL CONDITION] she would get vitals, check code status, then call the resident's family to see if they wanted anything further done, prior to initiating CPR. RN(G) was interviewed on [DATE] at 2:40 p.m. and stated that if she found a resident in [MEDICAL CONDITION] with no pulse, no breath sounds and cyanotic she would not start CPR. RN(G) further stated that there was currently no policy in place to guide staff response to residents found in [MEDICAL CONDITION]. RN(D) was interviewed on [DATE] at 1:00 p.m. and stated that if she found a resident in [MEDICAL CONDITION] she would check vital signs and check code status, then if the patient was obviously gone for a long time she would not start CPR. If the resident were still warm she would call 911 and then start CPR. LPN(F) was interviewed on [DATE] at 2:00 p.m. and stated that if she found a resident in [MEDICAL CONDITION] she would check vitals, check code status, call 911 and initiate CPR. RN(B)DON was interviewed on [DATE] at 11:40 a.m. and stated that she conducted an internal investigation and she identified that RN(H) failed to initiate CPR, call R1's physician or check R1's CPR status on [DATE]. RN(B) stated that after the incident she noted that there had been no CPR policy that she could find at all and her reaction was that she had to retrain staff so they would all be on the "same page" knowing what to do in a full code event. RN(B) stated that although the incident happened on [DATE], 10 days before the onsite investigation, there was currently no CPR policy in place. RN(B)further stated that RN(H) was disciplined related to the incident and her failure to initiate CPR. The facility's census at the time of the on-site investigation was 49 residents. Of these residents 10 had identified their desire to have CPR in the event of a [MEDICAL CONDITION]. R2 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R2 was interviewed on [DATE] and verified her wishes for CPR. R3 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R4 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R5 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R5 was interviewed on [DATE] and verified her wishes for CPR. R6 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R6 was interviewed on [DATE] and verified her wishes for CPR. R7 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R8 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R9 had a Directives to Define Scope of Medical Care from indicating her desire for full cardiopulmonary resuscitation signed and dated [DATE]. R2 was interviewed on [DATE] and verified her wishes for CPR. R10 had an information form, undated, indicating her decision for full code status. R11 had an information form, undated, indicating his decision for full code status.

Based on interview and record review the facility failed to ensure that each resident was free form neglect for 1 of 3 residents reviewed who was at risk for falls. Findings include: Medical record review revealed Resident #1 was admitted to the facility in December 2010 with [DIAGNOSES REDACTED]. Resident #1's fall assessment dated [DATE] indicated that Resident #1 was at risk for falls related to a history of multiple falls, unsteady gait, impaired balance, general weakness and an inability to recognize her own physical limitations. Resident #1 experienced numerous falls in 2011 Resident #1's care plan dated 3/31/2011 indicated that Resident #1 had a history of [REDACTED]. Although the care plan indicated that Resident #1 was not to be left alone in her room in the chair, on 12/20/2011 at approximately 7:45 p.m. Employee D/Trained Medication Aide/Nursing Assistant left Resident #1 alone in her room in her chair. Resident #1 fell in her room and experienced a broken hip as a result of the fall. Resident #1 required surgical intervention to repair the broken hip. Employee D was interviewed on 1/17/2012 at 10:50 a.m. and stated that on 12/20/2011 Resident #1 was restless and frequently standing up in the day area. Employee D stated that Resident #1 had been taken to the bathroom and taken for a walk, but continued to be restless. Employee D stated that she brought Resident #1 to her room, placed her in her recliner with her chair alarm on and left the room. Employee D stated that she heard the alarm and found Resident #1 had fallen in her room. Employee D stated that she was aware of the care plan and that Resident #1 should not have been left alone in her room, but did so in contradiction to the care plan. When asked why she left her alone, Employee D stated she did not know why she did it. Employee D also stated that she should have probably stayed with Resident #1. Employee D's personnel file was reviewed and revealed that the facility was aware that she had a previous history of not following facility procedure or not following the care plan including: on 6/11/2010 Employee D was given a final warning for failure to follow the care plan while utilizing a mechanical lift alone, contrary to care plans and facility policy. Employee D was re-educated. On 6/1/2011 Employee D was disciplined for not following a resident's care plan for transferring with two assist. Employee D was re-educated. On 6/11/2011 Employee D was disciplined for transferring a resident with a mechanical lift alone, contrary to care plans and the facility policy. Employee D was re-educated. On 7/7/2011 Employee D was disciplined for not using gloves for eye drops, treatments and direct patient care. "Employee has been spoken to on many occasions to comply with this policy." Employee D was re-educated. On 8/26/2011 Employee D was given another final warning for not following the care plan and making sure a resident's bed alarm was in place and functioning according to the care plan. Employee D was re-educated. On 12/20/2011 Employee D was given another final warning for not following the care plan for Resident #1, which resulted in a fall with injury. Employee D was re-educated. Although the facility was aware of a pattern of Employee D not following facility policy and care plans, and re-education had not been effective, the facility continued to allow Employee D to provide resident care.

Based on interview and record review the facility failed to provide each resident with adequate supervision to prevent accidents for 1 of 3 residents reviewed, resident #1, who experienced falls. Findings include: Medical record review revealed Resident #1 was admitted to the facility in December 2010 with [DIAGNOSES REDACTED]. Resident #1's fall assessment dated [DATE] indicated that Resident #1 was at risk for falls related to a history of multiple falls, unsteady gait, impaired balance, general weakness and an inability to recognize her own physical limitations. Employees C, E and F/Nursing Assistants were interviewed on 1/10/2012 and stated that staff members are made aware of resident's care plans through the nursing assistant sheets and that changes to the care plans are communicated effectively. Resident #1 experienced falls on 10/1/2011 when she stood from her chair independently there was no injury, 10/26/2011 when she turned off her chair alarm and stood there was no injury, 11/1/2011 when she stood from a chair in the lounge there was no injury, 11/5/2011 when she stood from a chair in the lounge there was no injury, 11/11/2011 when she was walking with an aide and her toe caught on a chair there was no injury, 11/20/2011 when she stood from a chair in the lounge there was no injury, 12/2/2011 when she was observed to stand independently there was no injury and 12/13/2011 when she observed to stand up independently there was no injury. Resident #1's care plan dated 3/31/2011 indicated that Resident #1 had a history of [REDACTED]. Although the care plan indicated that Resident #1 was not to be left alone in her room in the chair, on 12/20/2011 at approximately 7:45 p.m. Employee D/Trained Medication Aide/Nursing Assistant left Resident #1 alone in her room in her chair. Resident #1 fell in her room and experienced a broken hip as a result of the fall. Resident #1 required surgical intervention to repair the broken hip. Nursing notes dated 12/20/2011 were reviewed and revealed that when Resident #1 was assessed after the fall. Resident #1 was on the floor in her room, her right foot was externally rotated and she complained of right hip pain. 911 was called. Employee D was interviewed on 1/17/2012 at 10:50 a.m. and stated that on 12/20/2011 Resident #1 was restless and frequently standing up in the day area. Employee D stated that Resident #1 had been taken to the bathroom and taken for a walk, but continued to be restless. Employee D stated that she brought Resident #1 to her room, placed her in her recliner with her chair alarm on and left the room. Employee D stated that she heard the alarm and found Resident #1 had fallen in her room. Employee D stated that she was aware of the care plan and that Resident #1 should not have been left alone in her room, but did so in contradiction to the care plan. When asked why she left her alone, Employee D stated she did not know why she did it. Employee D's personnel file was reviewed and revealed that the facility was aware that she had a previous history of not following facility procedure or not following the care plan on numerous occasions including 6/11/2010, 6/1/2010, 6/11/2011, 7/7/2011, 8/26/2011 and 12/20/2011. Although the facility was aware of a pattern of Employee D not following facility policy and care plans, and re-education had not been effective, the facility continued to allow Employee D to provide resident care.

Based on interview and record review the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for resident's needs as described in the plan of care for 1 of 1 nursing assistants reviewed. Findings include: Medical record review revealed Resident #1 was admitted to the facility in December 2010 with [DIAGNOSES REDACTED]. Resident #1's fall assessment dated [DATE] indicated that Resident #1 was at risk for falls related to a history of multiple falls, unsteady gait, impaired balance, general weakness and an inability to recognize her own physical limitations. Resident #1's care plan dated 3/31/2011 indicated that Resident #1 had a history of [REDACTED]. Although the care plan indicated that Resident #1 was not to be left alone in her room in the chair, on 12/20/2011 at approximately 7:45 p.m. Employee D/Trained Medication Aide/Nursing Assistant left Resident #1 alone in her room in her chair. Resident #1 fell in her room and experienced a broken hip as a result of the fall. Resident #1 required surgical intervention to repair the broken hip. Employee D was interviewed on 1/17/2012 at 10:50 a.m. and stated that on 12/20/2011 Resident #1 was restless and frequently standing up in the day area. Employee D stated that Resident #1 had been taken to the bathroom and taken for a walk, but continued to be restless. Employee D stated that she brought Resident #1 to her room, placed her in her recliner with her chair alarm on and left the room. Employee D stated that she heard the alarm and found Resident #1 had fallen in her room. Employee D stated that she was aware of the care plan and that Resident #1 should not have been left alone in her room, but did so in contradiction to the care plan. When asked why she left her alone, Employee D stated she did know why she did it. Employee D also stated that she should have probably stayed with Resident #1. Employee D's personnel file was reviewed and revealed that the facility was aware that she had a previous history of not following facility procedure or not following the care plan including: on 6/11/2010 Employee D was given a final warning for failure to follow the care plan while utilizing a mechanical lift alone, contrary to care plans and facility policy. Employee D was re-educated. On 6/1/2011 Employee D was disciplined for not following a resident's care plan for transferring with two assist. Employee D was re-educated. On 6/11/2011 Employee D was disciplined for transferring a resident with a mechanical lift alone, contrary to care plans and the facility policy. Employee D was re-educated. On 7/7/2011 Employee D was disciplined for not using gloves for eye drops, treatments and direct patient care. "Employee has been spoken to on many occasions to comply with this policy." Employee D was re-educated. On 8/26/2011 Employee D was given another final warning for not following the care plan and making sure a resident's bed alarm was in place and functioning according to the care plan. Employee D was re-educated. On 12/20/2011 Employee D was given another final warning for not following the care plan for Resident #1, which resulted in a fall with injury. Employee D was re-educated. Although the facility was aware of a pattern of Employee D not following facility policy and care plans, and re-education had not been effective, the facility continued to allow Employee D to provide resident care.