Every finding on record at Viewcrest Health Center

Based on observation, interview, and document review, the facility failed to ensure interventions for safety and the prevention of elopement were consistently completed and recorded in the record to help prevent future elopements for 1 of 3 residents (R2) reviewed. R2 had a history of exit-seeking behavior and wore a wanderguard device (alarms if someone with one tries to exit) for safety; however, this was not checked for placement and function everyday as directed by the plan of care. Findings include: A facility-submitted Vulnerable Adult Maltreatment Report (FRI), dated 7/25/26, identified R2 was found outside of the care center by staff unattended on 7/25/26. R2 was brought back inside the care center and was uninjured.On 8/4/26 at 10:06 AM, a tour of the care center was completed. The main entry doors consisted of two double doors with magnetic locks present on the inner doors along the top. The doors had a white-colored keypad on the wall next to them which had a status, READY. The device was a [NAME] Healthcare wander management system and was working correctly at this time. Later, at 12:56 p.m., R2 was observed seated in a standard wheelchair in the commons area of the Island Lake unit. R2 was unable to answer how long she'd lived at the care center and responded to many questions with, I don't know. R2's wheelchair had a white-colored wanderguard bracelet attached to the rear frame. R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had severe cognitive impairment and demonstrated wandering behavior(s) during the review period.R2's care plan, revised 7/31/26, identified R2 had an ADL self-care deficit but was able to reposition in bed without help and used only a standby assist (SBA) for transfers. R1 had a history of self-transfers and was able to propel her wheelchair by herself. The care plan identified R1 as an elopement risk due to disorientation and a history of attempts to leave the campus. A goal was listed, My safety will be maintained through the review date, along with multiple interventions including treating pain promptly, conducting frequent visual checks of R2, and use of a wanderguard bracelet on her wheelchair. The plan outlined R2's family member would, at times, cut off the bracelet and discard it. Further, R2's Order Summary Report, signed 5/12/26, identified an order which read, Wanderguard check function & placement at bedtime . under wheelchair on right side. A start date of 3/6/25 was listed and nurse practitioner (NP)-A signed the report. R2's Treatment Administration Records (TAR), dated 7/2026 and 8/2026, identified the intervention to check placement and function of R2's wanderguard bracelet every day along with spacing for staff to record the task as completed. However, multiple dates were left blank and had no recorded evidence that the device had been checked to ensure it was present still or working. The dates left blank were: 7/9/26, 7/22/26, 7/27/26, 7/31/26, and 8/1/26. Further, R2's entire medical record lacked evidence that the wanderguard bracelet had been checked on those dates to show it remained present and working correctly, including on multiple dates after R2 had been found outside unsupervised (7/25/26). When interviewed on 8/4/26 at 12:59 p.m., nursing assistant (NA)-B stated R2 had several behaviors and was resistive to care at times. R2 was able to self-propel in her wheelchair and would, at times, try to leave the unit and head down other hallways. R2 was also able to walk by herself although unsafely. NA-B stated the white-colored bracelet on R2's wheelchair was the wanderguard system used to alert staff if she tried to leave the building by alarming at the doorway. R2 didn't wear it on her physical body as the family member didn't like it placed there and would remove it. NA-B stated R2 had just recently been found outside, and the door apparently had not alarmed as R2 had somehow got seated in a wheelchair which was not hers, so there was no bracelet to activate the alarm system. NA-B stated the night shift was responsible for checking to ensure the bracelets were on the person or wheelchair but was unsure where or if that process was recorded in the medical record or not. NA-B confirmed R2 did not sustain any injuries from being found outside on 7/25/26.When interviewed on 8/4/26 at 1:14 p.m., registered nurse (RN)-D stated they were the floor nurse covering R2's unit and had worked with R2 multiple times prior. RN-D explained wandering and elopement risk were evaluated upon admission and quarterly thereafter, and if the person was at risk, then a wanderguard bracelet would be applied to them. The night shift then checked the bracelets every day to ensure they were present and working correctly; with those checks being recorded on the TAR. RN-D stated they were unsure anywhere else in the record such checks would be recorded. RN-D reviewed R2's TAR (dated 7/2026, 8/2026) and verified the blank spaces. RN-D stated the spaces being blank either meant nobody completed the task or didn't document it. RN-D stated it should be completed adding, I don't understand why it wouldn't be done, they [nurses] can delegate it. RN-D stated it was important to check the wanderguard bracelets every day to ensure resident safety. When interviewed on 8/4/26 at 2:23 p.m., registered nurse manager (RN)-A stated R2 had worn a wanderguard bracelet long term as she was very, very exit-seeking. RN-A verified the TAR intervention was the facility's process to ensure the bracelet was present and working each day and acknowledged the multiple missing dates of data on the TAR. RN-A stated they were unsure if that meant the task wasn't completed or just not documented. RN-A agreed the signed Order Summary Report would be considered part of R2's plan of care and reiterated they were unsure why staff were not recording that intervention on the TAR for those dates. However, RN-A stated it was important to ensure a wanderguard bracelet was checked every day as it helped to keep the residents, including R2, safe from elopement. RN-A added, Safety is number one.The director of nursing (DON) was away from the campus on 8/4/26 and unavailable for interview. The facility Elopement policy, dated 6/2026, identified an elopement was considered to have occurred when a resident who is impaired left the care center unsupervised and/or unnoticed. Each resident would be assessed for risk of elopement and wandering and, if a wanderguard was used, then nursing staff would test the notification bracelet daily for proper function.

Based on observation, interview, and record review the facility failed to follow its policy to adequately supervise 1 of 3 residents (R1) prior to a successful elopement who was reviewed for accidents. R1 eloped from the facility wearing a WanderGuard system, was found four blocks away and was hospitalized with abrasions.Findings include:Upon observation on 6/2/26 at 8:30 a.m. the facilities camera recording revealed at 3:52 p.m. on 5/19/26 the maintenance director checked the WanderGuard that was going to be placed on R1. The WanderGuard set off the door alarm, a staff member in the front office heard the alarm and ran to the door. At 5:35 p.m. R1 walked up to the front door and the magnetic light came on. R1 turned around and walked away. The footage had no audio so it could not be confirmed if the alarm sounded. No staff arrived at the door. At 5:42 p.m. R1 walked up to the door, no staff or visitors were in sight of the [NAME]. R1 opened the door and walked through it taking a left turn and proceeded down the sidewalk outside the door. The magnetic light came on. The footage had no audio so it could not be confirmed if the alarm sounded. No staff arrived at the door.R1's elopement risk dated 5/6/26 indicated R1 was not physically mobile, was new to the facility, and had no history of elopement. Analysis of the risk and interventions indicated R1 was in the facility for respite with her husband, sitting with her husband all day as he is the primary caregiver. R1 was not an elopement risk at the time of assessment.R1's care plan dated 5/6/26 - 5/19/26 lacked any interventions of staff supervision for R1.R1's progress note dated 5/6/26 indicated R1 was chronically confused and disoriented. R1 had severe cognitive impairment (affecting all areas of judgement). She was coherent with clear speech and no language barrier and was able to make herself understood. R1 was at the facility as a respite resident due to her husband who was admitted for rehabilitation, and he was her primary caregiver. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was a six indicating severe cognitive impairment. R1 was independent with dressing, hygiene, and transferring. R1's pertinent diagnosis was dementia. R1's admission assessment dated [DATE] indicated R1 had cognitive concerns that could affect her ability to leave the facility independently. She did not have physical concerns that could affect her ability to leave the facility independently. She was unable to identify where she was going or with whom she was going. R1 did not have the ability to utilize the call pendant or cellphone if she needed assistance outside the facility. R1 needed staff or family with her to leave the facility as her dementia had progressively made her more confused.R1's nursing progress note dated 5/15/26 at 11:25 a.m. indicated R1 was walking in and out of her room wanting to know where her husband was. R1 was redirected and told he was in the hospital. R1 was redirectable and asked if she could walk up and down the unit. The effectiveness of the intervention and follow-up was R1 was calm and redirectable, walking the unit and did not leave the unit area.R1's nursing progress note dated 5/15/26 at 3:40 p.m. indicated R1 was repeatedly asking where her husband was and would forget in a few seconds and asked again. R1 was redirected with activities, meals, and visitors.R1's nursing progress note dated 5/19/26 at 12:52 a.m. indicated R1 had lots of anxiety that shift. She had been wandering the halls looking for her husband. Staff verbally redirected her as able. She was assured her husband was safe. R1 had wandered into other resident rooms to look for her husband.R1's nursing progress note dated 5/19/26 at 4:48 a.m. indicated R1 was confused about where her husband was. She stated she wanted to go home and packed her and her husband's room. Staff tried to keep her from hauling it out into the hallway. She was offered snacks and encouraged to go to bed. She had been up all night and refused to lay down. R1's nursing progress note dated 5/19/26 at 2:26 p.m. indicated R1 had been wandering up most of the shift looking for her husband and a ride home. R1's son had visited that morning and had explained to her she had to stay at the facility. Staff continued to redirect R1 and attempted to engage her in activities which she would attend for a very short time.R1's nursing progress note dated 5/19/26 at 4:00 p.m. indicated R1 had a WanderGuard placed on her right ankle due to increased statements of wanting to leave the facility. R1 was agreeable and chose the location of the placement. R1's nursing progress note dated 5/19/26 at 11:59 p.m. indicated R1's morning nurse, licensed practical nurse (LPN)-A stated she had placed a WanderGuard on R1 in the afternoon due to her persistent exit seeking behaviors. R1 was last seen walking by the nursing station at around 6:00 p.m. All staff were looking for R1 after 6:00 p.m. and were unable to locate her within the facility. The director of nurse (DON) called 911 at 6:20 p.m. and reported R1 could not be located in the facility and a description of her was given to the officer. The facility staff within the facility and the nearby vicinity outside the facility and a nearby church. R1's family member (FM)-A was called, and he stated R1 would try to walk home. The DON received a call from the police at 7:00 p.m. saying R1 had been found several blocks away and ambulance personnel had assessed R1 and had taken her to the emergency department (ED) for evaluation. At 11:47 p.m. the DON was updated that R1 had been admitted to the hospital.R1's admission hospital note dated 5/19/26 indicated R1 resided at a nursing facility where she walked out the door. R1 had a tracker/device that would monitor her. Somehow the alarm did not go off or alert the facility. R1 was found to be missing and found approximately four blocks away on a gravel road and had fallen on the ground. She had numerous abrasions and bruising. R1 was given pain medication and admitted to the hospital. R1's assessment and plan indicated R1 had a fall with numerous abrasions, most notable on her right forehead and knee. She did not have any fractures. She would continue to be reassessed as she was at a high risk for fractures. Her plan was to have physical therapy (PT), occupation therapy (OT), pain control, and a social worker for her unclear disposition for a new facility vs. home vs. other arrangements.R1's care plan revised dated 5/20/26 indicated R1 was an elopement risk with goal not to elope from the facility. Interventions included changing the WanderGuard device per manufacture recommendations, performing WanderGuard checks per facility policy, using distraction from wandering, offering diversions, structured activity such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, food, television, books. Staff observe for wandering and redirecting if attempting to enter another resident's room without permission. Identified wander alert and elopement risk.Upon interview on 6/1/26 at 1:59 p.m., nursing assistant, (NA)-A stated she worked with R1 the morning she eloped, and it was difficult to redirect her that day and ever since her husband went to the hospital a few days prior to that. NA-A denied any formal supervision of R1. She stated she was not aware that a WanderGuard had been placed on R1.Upon interview on 6/1/26 at 2:15 p.m. (NA)-B stated 5-6 days before R1 was admitted to the hospital she was hard to contain, she would pack her bags. She would look for and ask about her husband and stated she was going home. NA-B stated she tried to redirect R1 or give her a snack but had never been told any specific interventions by the nursing staff.Upon interview on 6/1/26 at 2:41 p.m. registered nurse, (RN)-A stated when R1's husband was at the facility she was fine; she barely left his side. When he went to the hospital her exit seeking behavior got worse by the day. RN-A stated she gave R1 reassurance that her husband was alright and returning. On the day R1 eloped the facility placed a WanderGuard on her hours before the elopement happened, and the alarm failed.Upon interview on 6/1/26 at 4:10 p.m. LPN-A stated she worked the evening R1 eloped. She was the nurse who initiated the WanderGuard after attempting visiting one-on-one with her, calling her husband to the hospital, and giving her activities. She stated around 4:00 p.m. she reached out to maintenance and had a WanderGuard placed on R1. LPN-A stated R1 had tried to get out the back doors of the facility, but the alarm sounded and R1 was redirected back to her room. She last saw R1 at 5:45 p.m. in the dining room. LPN-A stated she went to give medications to another resident and around 6:00 p.m. she asked staff where R1 was. The staff searched the unit. The facility called (FM)-A to see if he had taken her out and forgot to sign the book. When she realized he did not take her out she called the DON and reported R1 as missing. LPN-A stated she did not check the WanderGuard when it was placed on R1, however maintenance had checked it prior to giving it to her. She denied telling other staff to supervise R1 due to her exit seeking behaviors since she had placed the alarm on her.Upon interview on 6/1/26 at 4:38 p.m. registered nurse (RN)-B stated R1 was completely fine at the facility until her husband was hospitalized . On 5/19 at around 4:00 p.m. (LPN)-A requested R1 to have a WanderGuard because R1 was attempting to leave the facility. A WanderGuard was placed on her immediately. RN-A was not certain of any supervisory interventions for R1 from the time the behaviors started until the elopement. Upon interview on 6/1/26 at 6:30 p.m. R1's family member (FM)-B stated she was aware R1 had been packing her bags at the facility and threatening to leave ever since her husband was in the hospital. The family visited her often to tell her where her husband was, and she had to stay at the facility until he returned. She was not aware the facility had placed a WanderGuard on R1. FM-B started on the night R1 eloped (FM)-A called her and told her, so she met R1 at the hospital. She described R1 as being banged up. Her face was a mess, one of her eyes could not been seen due to the swelling and R1 was complaining about knee pain. She had to use a walker while in the hospital which she had never used prior.Upon interview on 6/2/26 at 11:49 a.m. the director or nursing (DON) stated R1 required a lot of redirection and activities. R1 liked movies. The DON was aware the staff had to reiterate again that her husband was in the hospital, and she could not leave the facility. Her family visited often. She stated she was updated that staff had placed a WanderGuard on R1 that failed at the time of the elopement. The DON denied any supervision interventions on R1's care plan.Upon interview on 6/2/26 at 12:55 p.m. the Administrator stated he was aware R1 had been packing her bags, wandering with exit seeking. He stated his expectation was that staff reassess with any changes and update the care plan as needed to keep residents safe. He was not certain whether R1 had supervision on her care plan or not. A facility policy titled Elopement with a revision date of 7/29/25 indicated that when a resident is determined at risk for elopement, an elopement risk assessment will be performed (see electronic health record (EHR)) and a corresponding care plan developed that addresses the following:Cognitive statusAmbulation and Mobility Status: Includes evaluation of ambulation or wheelchair use, as well as their ability to open doors independently, since greater independence may increase risk.History of wandering and/or attempts to leave the building.Wandering patterns: Frequency, specific locations, time(s) of day, and duration of wandering episodes.Supervision: The level of oversight required when leaving the building. Prevention strategies may involve measures such as:Placing the resident's room in proximity to the nursing station or in an area farther from exit doors.Incorporating activity-based programs during peak wandering periods.Conducting more frequent checks or scheduling them at times when the resident is most likely to wander.Equipping the residents and/or their mobility aid (e.g., walker or wheelchair) with a WanderGuard bracelet that alerts staff if the resident attempts to leave.The nurse will document this plan into the resident's care plan in the EHR. Findings include:R1's care plan dated 5/6/26 - 5/19/26 lacked any interventions of staff supervision for R1.R1's progress note dated 5/6/26 indicated R1 was chronically confused and disoriented. R1 had severe cognitive impairment (affecting all areas of judgement). She was coherent with clear speech and no language barrier and was able to make herself understood. R1 was at the facility as a respite resident due to her husband who was admitted for rehabilitation, and he was her primary caregiver. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was a 6 indicating severe cognitive impairment. R1 was independent with dressing, hygiene, and transferring. R1's pertinent diagnosis was dementia. R1's admission assessment dated [DATE] indicated R1 had cognitive concerns that could affect her ability to leave the facility independently. She did not have physical concerns that could affect her ability to leave the facility independently. She was unable to identify where she was going or who she was going with. R1 did not have the ability to utilize the call pendant or cellphone if she needed assistance outside the facility. R1 needed staff or family with her to leave the facility as her dementia had progressively made her more confused.R1's nursing progress note dated 5/15/26 at 11:25 a.m. indicated R1 was walking in and out of her room wanting to know where her husband was. R1 was redirected and told he was in the hospital. R1 was redirectable and asked if she could walk up and down the unit. The effectiveness of the intervention and follow-up was R1 was calm and redirectable, walking the unit and did not leave the unit area.R1's nursing progress note dated 5/15/26 at 3:40 p.m. indicated R1 was repeatedly asking where her husband was and would forget in a few seconds and asked again. R1 was redirected with activities, meals and visitors.R1's nursing progress note dated 5/19/26 at 12:52 a.m. indicated R1 had lots of anxiety that shift. She had been wandering the halls looking for her husband. Staff verbally redirected her as able. She was assured her husband was safe. R1 had wandered into other resident rooms to look for her husband.R1's nursing progress note dated 5/19/26 at 4:48 a.m. indicated R1 was confused about where her husband was. She stated she wanted to go home and packed her and her husband's room. Staff tried to keep her from hauling it out into the hallway. She was offered snacks and encouraged to go to bed. She had been up all night and refused to lay down. R1's nursing progress note dated 5/19/26 at 2:26 p.m. indicated R1 had been up wandering most of the shift looking for her husband and a ride home. R1's son had visited that morning and had explained to her she had to stay at the facility. Staff continued to redirect R1 and attempted to engage her in activities which she would attend for a very short time.R1's nursing progress note dated 5/19/26 at 4:00 p.m. indicated R1 had a wander guard placed on her right ankle due to increased statements of wanting to leave the facility. R1 was agreeable and chose the location of the placement. R1's nursing progress note dated 5/19/26 at 11:59 p.m. indicated R1's a.m. nurse, licensed practical nurse (LPN)-A stated she had placed a wander guard on R1 in the afternoon due to her persistent exit seeking behaviors. R1 was last seen walking by the nursing station at around 6:00 p.m. All staff were looking for R1 after 6:00 p.m. and were unable to locate her within the facility. The director of nurse (DON) called 911 at 6:20 p.m. and reported R1 could not be located in the facility and a description of her was given to the officer. The facility staff within the facility and the nearby vicinity outside the facility and a nearby church. R1's family member (FM)-A was called, and he stated R1 would try to walk home. The DON received a call from the police at 7:00 p.m. saying R1 had been found several blocks away and ambulance personnel had assessed R1 and had taken her to the emergency department (ED) for evaluation. At 11:47 p.m. the DON was updated that R1 had been admitted to the hospital.R1's admission hospital note dated 5/19/26 indicated R1 resided at a nursing facility where she walked out the door. R1 reportedly had a tracker/device that would monitored her. Somehow the alarm did not go off or alert the facility. R1 was found to be missing and found approximately four blocks away on a gravel road and had fallen on the ground. She had numerous abrasions and bruising. R1 was given pain medications and admitted to the hospital. R1's assessment and plan indicated R1 had a fall with numerous abrasions, most notable on her right forehead and knee. She did not have any fractures. She would continue to be reassessed as she was at a high risk for fractures. Her plan was to have physical therapy (PT), occupation therapy (OT), pain control, and a social worker for her unclear disposition for a new facility vs. home vs. other arrangements.Upon interview on 6/1/26 at 1:59 p.m., nursing assistant, (NA)-A stated she worked with R1 the morning she eloped, and it was difficult to redirect her that day and ever since her husband went to the hospital a few days prior to that. NA-A denied any formal supervision of R1. She stated she was not aware that a wander guard had been on placed on R1.Upon interview on 6/1/26 at 2:15 p.m. (NA)-B stated 5-6 days before R1 was admitted to the hospital she was hard to contain, she would pack her bags. She would look for and ask about her husband and stated she was going home. NA-B stated she tried to redirect R1 or give her a snack but had never been told any specific interventions by the nursing staff.Upon interview on 6/1/26 at 2:41 p.m. registered nurse, (RN)-A stated when R1's husband was at the facility she was fine; she barely left his side. When he went to the hospital her exit seeking behaviors got worse by the day. RN-A stated she mainly gave R1 reassurance that her husband was alright and returning. On the day R1 eloped the facility placed a wander guard on her hours before the elopement happened, and the alarm failed.Upon interview on 6/1/26 at 6:30 p.m. R1's family member (FM)-B stated she was aware R1 had been packing her bags at the facility and threatening to leave ever since her husband was in the hospital. The family visited her often to tell her where her husband was, and she had to stay at the facility until he returned. She was not aware the facility had placed a wander guard on R1. FM-B stated on the night R1 eloped (FM)-A called her and told her, so she met R1 at the hospital. She described R1 as being banged up. Her face was a mess, one of her eyes could not been seen due to the swelling and R1 was complaining about knee pain. She had to use a walker while in the hospital which she had never used prior.Upon interview on 6/1/26 at 4:10 p.m. LPN-A stated she worked the evening R1 eloped. She was the nurse who initiated the wander guard after attempting visiting one-on-one with her, calling her husband in the hospital, and giving her activities. She stated around 4:00 p.m. she reached out to maintenance and had a wander guard placed on R1. LPN-A stated R1 had tried to get out the back doors of the facility, but the alarm sounded and R1 was redirected back to her room. She last saw R1 at 5:45 p.m. in the dining room. LPN-A stated she went to give medications to another resident and around 6:00 p.m. she asked staff where R1 was. The staff searched the unit. The facility called (FM)-A to see if he had taken her out and forgot to sign the sign out book. When she realized he did not take her out she called the DON and reported R1 as missing. LPN-A stated she did not check the wander guard when it was placed on R1, however maintenance had checked it prior to giving it to her. She denied telling other staff to supervise R1 due to her exit seeking behaviors since she had the placed the alarm on her.Upon interview on 6/1/26 at 4:38 p.m. registered nurse (RN)-B stated R1 was completely fine at the facility until her husband was hospitalized . On 5/19 at around 4:00 p.m. (LPN)-A requested R1 have a wander guard because R1 was attempting to leave the facility. A wander guard was placed on her immediately. RN-A was not certain of any supervisory interventions for R1 from the time the behaviors started until the elopement. Upon observation on 6/2/26 at 8:30 a.m. the facilities camera recording revealed at 3:52 p.m. on 5/19/26 the maintenance director checked the wander guard that was going to be placed on R1. The wander guard set off the door alarm, a staff member in the front office heard the alarm and ran to the door. At 5:35 p.m. R1 walked up to the front door and the magnetic light came on. R1 turned around and walked away. The footage had no audio so it could not be confirmed if the alarm sounded. No staff arrived at the door due to hearing an alarm sound. At 5:42 p.m. R1 walked up to the door, no staff or visitors were in sight. R1 opened the door and walked through it taking a left turn and proceeded down the side walk outside the door. The same small magnetic light was visualized as it was 5:35 p.m., again no staff arrived at the door due to hearing an alarm.Upon interview on 6/2/26 at 11:49 a.m. the director or nursing (DON) stated R1 required a lot of redirection and activities. R1 liked movies. The DON was aware the staff had to reiterate over and over that her husband was in the hospital, and she could not leave the facility. Her family visited often. She stated she was updated that staff had placed a wander guard on R1 that failed at the time of the elopement. The DON denied any supervision interventions on R1's care plan.Upon interview on 6/2/26 at 12:55 p.m. the Administrator stated he was aware R1 had been packing her bags, wandering with exit seeking. He stated his expectation was that staff reassess with any changes and update the care plan as needed to keep residents safe. He was not certain if R1 had supervision on her care plan or not. A facility policy titled Elopement with a revision date of 7/29/25 indicated that when a resident is determined at risk for elopement, an elopement risk assessment will be performed (see electronic health record (EHR)) and a corresponding care plan developed that addresses the following:Cognitive statusAmbulation and Mobility Status: Includes evaluation of ambulation or wheelchair use, as well as their ability to open doors independently, since greater independence may increase risk.History of wandering and/or attempts to leave the building.Wandering patterns: Frequency, specific locations, time(s) of day, and duration of wandering episodes.Supervision: The level of oversight required when leaving the building. Prevention strategies may involve measures such as:Placing the resident's room in proximity to the nursing station or in an area farther from exit doors.Incorporating activity-based programs during peak wandering periods.Conducting more frequent checks or scheduling them at times when the resident is most likely to wander.Equipping the resident and/or their mobility aid (e.g., walker or wheelchair) with a wander guard bracelet that alerts staff if the resident attempts to leave.The nurse will document this plan into the resident's care plan in the EHR.

Based on interview and document review, the facility failed to follow manufacturer's recommendation on EZ Way sling usage, facility policy, and transfer care plan for 1 of 3 (R1) residents reviewed for mechanical lift transfers. Additionally, the facility lacked a system to assess and document appropriate resident sling size. R1 fell out of the sling, sustained a laceration to the back of her head and was sent to the Emergency Department (ED). The IJ began on 3/13/25 at 11:00 p.m., when R1 fell from a mechanical lift causing a laceration to her head and the liklihood for potnetial serious harm. The administrator and director of nursing (DON) were informed of the IJ on 3/21/25 at 10:30 a.m. The facility had implemented corrective action on 3/14/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: R1's Face Sheet dated 2/4/25, indicated R1 had cerebral palsy, abnormal posture, functional quadriplegia, and scoliosis. R1's annual minimum data set (MDS) dated [DATE], indicated R1 was cognitively intact, needed extensive assistance with two people for transfers. R1's care plan dated 2/26/25, indicated R1 needed a mechanical lift with two staff assistance for transfers. R1 used a size small sling. R1's weight on 3/12/25, was 115.5 lbs. R1's medical record did not have evidence that a sling assessment had been completed. R1's encounter summary dated 3/14/25, indicated R1 fell roughly 4-5 feet. R1 had a contusion noted to the lower back of head. R1's progress note dated 3/14/25 at 8:33 a.m., written by registered nurse (RN) -B indicated R1 was being transfers with an EZ Way smart lift from her wheelchair to her bed. R1 had an inappropriate sling on and was transferred with assist of one staff instead of two staff. R1 had laceration to the back of R1s head and was sent to the ED. During an interview on 3/20/25 at 9:35 a.m., R1 stated nursing assistant (NA)-A was transferring her with the EZ Way smart lift from her wheelchair to her bed and R1 slid out of the sling when it was in the air and hit her back and head on the floor. R1 stated NA-A was the only staff in the room. During an interview on 3/20/25 at 12:24 p.m., NA-A stated on 3/13/25 at around 11:00 p.m., NA-A transferred R1 by herself with a green sling. NA-A was not aware the sling was not appropriate or that two staff were needed to assist with an EZ Way smart lift. NA-A placed the sling on R1 correctly and attached the sling correctly to the lift. NA-A lifted R1 into the air and she started to move the EZ Way lift towards R1's bed when R1 started to slide out of the opening where R1's buttocks were. NA-A left R1 and ran to get help as R1 was falling out of the sling. When NA-A got back to the room R1 was on the floor bleeding from her head. NA-A stated she asked other nursing assistants how R1 transfers but did not look at the care plan. NA-A also indicated that she received safe-transfer training but denied knowing she should have transferred R1 with two people. During an interview on 3/20/25 at 12:42 p.m., RN- A stated on 3/13/25 around 11:40 p.m., NA-A came running down the hall stating R1 was falling out of her sling. RN-A stated she went to R1's room and found her on the floor bleeding for her head. RN-A stated the sling was green in color and straps were still attached to the lift correctly but R1 was no longer in the sling. RN-A indicated she was unsure if that's how the straps were attached at the time of the fall. During an interview on 3/20/25 at 1:14 p.m., EZ Way representative stated EZ Way had never made a completely green sling for any lifts. EZ Way lifts should have only been used with EZ Way brand slings as no other brand would have been safe to use. During an interview on 3/20/25 at 1:54 p.m., certified nurse practitioner (CNP)-A stated she would have excepted the facility staff to have followed the policies and care plans put in place for R1. During an interview on 3/20/25 at 2:06 p.m., the director or nursing (DON) stated the green sling used on R1 was not an EZ Way brand and should not have been used and R1 should have been transferred per policy and care plan with two staff. DON further stated on 3/21/25 at 8:01 a.m., since her time at the facility, starting in May of 2023, the facility has not had a process for assessing appropriate sling type and size until following R1's incident on 3/13/25. During an interview on 3/21/25 at 8:36 a.m., RN-B stated a week and a half ago RN-B started overseeing R1's care at the facility. RN-B stated she was not sure why R1's sling was not an EZ Way brand and was unaware of the sling issue until R1 had fallen. The only slings that should've been used were EZ Way brand slings. During an interview on 3/21/25 at 9:14 a.m., medical director (MD)-A stated he would have expected the facility staff to follow facility policy and manufactures instructions for EZ Way products. EZ Way Smart Life Operator's Instructions revised 6/13/2011, indicated EZ Way slings were made specifically for EZ Way Smart Lifts. For the safety of the patient and the caregiver, only EZ Way slings should be used with EZ Way lifts. EZ Way Sling Sizing Chart undated, indicated a small sling should've been used for residents who weighed 70 to 100 pounds. Residents who weighed 90-220 pounds should've use a medium sling. R1's recorded weight at the time of the incident was 115.5lbs. Mechanical Lift Policy revised 9/11/23, indicated two staff would assist with all full body mechanical lift transfers, nursing and therapy staff would assess residents' needs for transfer assistance on an on going basis, and the mechanical lift assessment would identify the type and size of sling to use. The past noncompliance immediate jeopardy began on 3/13/25. The immediate jeopardy was removed, and the deficient practice was corrected by 3/14/25, after the facility implemented a systemic plan that included the following actions: Reviewed their policies on use of mechanical lifts, including the assessment and size of the slings. The facility has re-assessed all residents who utilize a mechanical lift to ensure they have the proper brand and size sling. Resident care plans had been updated. Sling assessments would be completed at least quarterly and with significant change. Non EZ Way brand slings had been removed from the facility so that they were not inadvertently used. The facility has re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing. The facility completed audits three times weekly observing staff transferring residents with mechanical lifts results will then be brought to QAPI committee. Verification of corrective action was confirmed by observation, interview, and document review on 3/20/25 and 3/21/25.

Based on observation, interview and document review, the facility failed to ensure proper glove use and hand hygiene was performed during incontinence care and wound care for 2 of 3 residents (R3, R4) reviewed for infection control. In addition, the facility failed to use proper personal protective equipment (PPE) for 1 of 3 (R4) residents reviewed for infection control. Findings include: R3's Face Sheet dated 3/15/24 indicated R3 had orders for wound care to his left lower extremity every three days. On 8/27/24 at 1:11 p.m., registered nurse (RN)-A entered R3's room with a gown and gloves on. RN-A told R3 he was going to change the dressing on his left leg. RN-A used wound cleanser and gauze to cleanse R3's left leg which had multiple open areas. RN-A then removed his soiled gloves, and without performing hand hygiene donned clean gloves. RN-A grabbed calcium alginate (a wound dressing) and cut it to size for the wound on the top of R3's left foot, and applied it to the wound bed. RN-A repeated cutting the calcium alginate and applied to three other wounds on R3's left shin and calf area. RN-A applied zinc oxide paste (a protestant) on the skin around the wounds. RN-A removed his soiled gloves, and without performing hand hygiene, donned clean gloves. RN-A applied Alevyn dressings (a wound dressing) to all four wounds on R3's left lower leg and left foot. RN-A applied Aquaphor ointment (moisturizing ointment) to the dry areas on R3's left leg and right leg. RN-A removed his soiled gloves, and without performing hand hygiene, donned clean gloves. On 8/27/24 at 2:03 p.m., RN-A stated he was nervous, and forgot to wash his hands between glove changes. RN-A stated staff should wash their hands before removing soiled gloves and donning clean gloves. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 needed extensive assistance with toilet use. R4's care plan dated 1/12/24, indicated R4 was on enhanced barrier precautions (EBP) due to chronic wounds. On 8/27/24 at 11:35 a.m., nursing assistant (NA)-A was observed entering R4's room sanitizing hands and placing on gloves. NA-A told R4 she was going to check her incontinent brief. NA-A was not wearing proper PPE which would have included a gown. NA-A removed R4's incontinent brief straps, and cleansed R4's peri-area with a washcloth and soap. NA-A assisted R4 to turn onto her right side. NA-A used toilet paper to wipe feces off of R4's buttocks. NA-A removed the soiled incontinent brief. Without changing gloves, NA-A placed a clean incontinent brief under R4. NA-A removed her soiled gloves, and without performing hand hygiene, donned clean gloves. NA-A applied the incontinent brief on R4, then removed her gloves and performed hand hygiene. On 8/27/24 at 11:54 a.m., NA-A stated she forgot to wear the right PPE when caring for R4. She should have worn a gown along with her gloves when providing cares for R4. She should have sanitized her hands after taking her gloves off, but she was nervous. On 8/29/24 at 10:35 a.m., the director of nursing (DON) stated staff were expected to follow the EBP and hand hygiene policy. On 8/29/24 at 12:18 p.m., the administrator stated staff were expected to follow the hand hygiene and EBP policy. The facility policy Hand Hygiene dated 5/8/17 directed staff will perform hand hygiene when moving from a contaminated body site to a clean body site during cares and after removing gloves. The facility policy Enhanced Barrier Precautions (EBPs) revised 6/25/24 directed staff will use EBPs for all resident with chronic wound and when performing peri care activities.

Based on interview and document review, the facility failed to consistently offer and provide a nutrient and/or calorie substantive snack after the dinner meal and before bedtime, leaving 15 hours between the evening and morning meals. This had the potential to affect 93 out of 94 residents who take in sustenance orally. Findings include: During interview on 7/08/24 at 5:19 p.m., R47 stated it has been months since a snack was offered after the dinner meal and before bedtime. R47's quarterly Minimum Data Set (MDS) date 4/16/24, identified intact cognition and a diagnosis of diabetes mellitus. During interview on 7/08/24 at 12:14 p.m., dietary manager (DM) stated mealtimes are 7:30 a.m., 11:30 a.m., and 4:30 p.m. with snacks offered at 2:30 p.m. (siesta snack pass) and 7:30 p.m. (bedtime snack pass). Snack carts are prepared and delivered to the units by kitchen staff. Kitchen staff complete the 2:30 p.m. snack pass and nursing staff complete the 7:30 p.m. snack pass. DM used a snack sheet log to ensure each resident was offered a snack twice a day. During interview on 7/09/24 at 3:05 p.m., nursing assistant (NA)-A confirmed working afternoon's on R47's unit. NA-A stated kitchen staff do not deliver a snack cart to the unit in the evenings and a bedtime snack pass never occurs. During interview on 7/09/24 at 3:17 p.m., NA-B confirmed working afternoons on a unit other than R47's unit. NA-B stated a bedtime snack pass sometimes occurred on this unit. If snacks were distributed/offered, it would be by kitchen staff, not nursing staff. During interview on 7/09/24 at 3:23 p.m., NA-C confirmed working afternoons on a unit other than R47's and NA-B's unit. NA-C stated kitchen staff will sometimes provide a snack cart in the evenings. A bedtime snack was not offered to each resident. The snack cart remained next to the nurse's station and if a resident wanted a snack, they would have to ask for one. During interview on 7/10/24 at 1:38 p.m., the director of nursing (DON) explained a bedtime snack pass was required at the facility because there was too many hours between dinner and breakfast. The DON stated it would be her expectation kitchen staff deliver an evening snack cart to each unit and nursing staff brought the cart room to room, offering a snack to each resident. DON stated it was important to offer a bedtime snack for medical and quality of care purposes. During interview on 7/11/24 at 8:29 a.m., the administrator stated having the expectation a bedtime snack was offered to each resident every evening. A bedtime snack was important for medical and quality of care purposes. June and July 2024 snack sheet logs were requested, but not provided. The last documented snack pass occurred on May 4th, 2024. A policy, Weight Monitoring Program dated 1/18/21, identified the care center will ensure there are no more than 14 hours between a substantial evening meal/snack and breakfast the following day, expect when a nourishing snack is served at bedtime.

Based on observation, interview, and document review, the facility failed to ensure cold beverage items were stored at temperature to prevent foodborne illness. This had the potential to affect 16 out of 94 residents who were served beverages from the dining room beverage cart. Findings Include: On 7/10/24 at 7:28 a.m., dietary aid (AD)-A was preparing five cold beverage carts. Each cart had a bin on the top shelf which contained half gallon containers of assorted milk and juice. One of the five carts also contained milk and juice containers on the second shelf which was not in a bin. Ice was added to all 5 bins containing milk and juice and no ice or other cooling source was applied to the milk or juice on the cart which contained milk and juice on the second shelf. Items on the second shelf included following: -opened whole milk -opened and unopened 2% milk -unopened chocolate milk -opened and unopened almond milk -opened cranberry, pineapple, prune, and orange juice Each juice container stated to refrigerate after opening. On 7/10/24 08:05 a.m., the beverage cart was brought to the dining room. All 16 residents in the dining room received milk or juice from the beverage cart. All milk or juice served to the resident's during meal service was held on ice. On 7/10/24 at 8:49 a.m., meal service concluded. DA-A removed the beverage cart from the dining room and returned it to the kitchen. During interview on 7/10/24 at 8:50 a.m., DA-A stated she was planning to return the beverage cart items to the refrigerator so they could be served tomorrow. DA-A stated she always stocked the second shelf of the dining room beverage cart with extra beverages and these extra beverages are never held on ice. DA-A did not express any awareness of the hazards related to this practice. On 7/10/24 at 8:51 a.m., dietary manager (DM) obtained the temperatures of the beverage items stored on the second shelf of the dining room beverage cart. The temperatures ranged from 48 to 54 degrees Fahrenheit (F). DM stated it was not safe to serve these items and threw each item away. DM stated she has educated staff on the importance of keeping cold beverages ice and plans to re-educate staff. During interview on 7/11/24 at 8:27 a.m., the administrator stated having the expectation cold beverages were stored and served at safe temperatures. This was important to prevent the risk of illness. A facility policy, Food Temperature dated 7/9/11, identified all cold items must be served at a temperature of 40 degrees F or below. The United States Food and Drug Administration (FDA) Food Code dated 2022, identified milk as a temperature control for safety food and foods requiring refrigeration should be maintained at or below 41 degrees F to prevent foodborne illness.

Based on observation, interview, and record review the facility failed to properly care for oxygen and nebulizer equipment for 1 of 2 residents (R8) reviewed for respiratory equipment to help prevent the potential for infection. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of spastic quadriplegic cerebral palsy (CP), asthma, chronic cough, and shortness of breath. R8's care plan dated 4/2/24, identified an alteration in respiratory status related to asthma and spastic CP with interventions for a nurse to administer inhalers and nebulizers as ordered as R8 was unable to do so for herself, monitor lung sounds, report concerns, keep head of bed elevated when in bed, and observe for the need for oxygen. R8's provider orders dated 9/1/22, identified orders for albuterol sulfate (a medication used to treat and prevent breathing problems) three milliliters (mL) two times daily to be administered via inhalation with a nebulizer (a machine used to directly administer medications into the lungs), oxygen via mask or cannula at one to four liters per minute (LPM) as needed, to change the nebulizer mouthpiece and tubing every week on Friday, and daily at bedtime to wash nebulizer mask, mouthpiece, and reservoir and leave out to dry overnight. The orders did not contain an order set to change the oxygen tubing, cannula, or bubbler (a bottle used for water to help humidify the oxygen). On 7/8/24 at 2:13 p.m., R8's nebulizer machine was sitting on a table near her bed with the tubing hooked up to the chamber (the piece the liquid medication is placed in), and the chamber attached to the mouthpiece. There was a small amount of clear liquid in the bottom of the chamber and clear droplets of liquid covering the upper portions of the chamber. Oxygen tubing was draped over the table and did not contain a date. R8 confirmed she used the oxygen at night and the nebulizer two times a day. On 7/10/24 at 1:08 p.m., R8 was wearing oxygen and her nebulizer machine was sitting on a table near her bed with the tubing hooked up to the chamber and mouthpiece with a small amount of clear liquid in the bottom of the chamber and clear droplets of liquid covering the upper portions of the chamber. R8 confirmed she used the nebulizer twice a day. During an interview on 7/10/24 at 1:12 p.m., LPN-A stated oxygen tubing was to be changed every Friday night for everyone, it was the same for nebulizer mouthpiece and tubing. LPN-A confirmed she did not disassemble and rinse out the nebulizer chamber and mouthpiece after R8's treatment this morning. During an interview on 7/11/24 at 9:42 a.m., RN-A stated the oxygen and nebulizer tubing, and mouthpieces were changed out weekly on the overnight shift and were to be dated when changed. RN-A also stated the nebulizer mouthpiece and chamber should be disassembled, rinsed out, and left to air dry after use. During an interview on 7/11/24 at 11:01 a.m., the director of nursing (DON) stated her expectation was for tubing to be dated when replaced weekly, and for a nebulizer mouthpiece and chamber to be taken apart and rinsed out after use. These items were important for infection control and medication safety. A document, Viewcrest Health Care Nebulizer Cleaning dated 2/15/23, identified the purpose was to provide guidelines for the cleaning of a nebulizer. After each use, disassemble the nebulizer, rinse each piece with warm water, and let air dry on a clean paper or cloth towel. Daily the pieces were to be washed with warm soapy water and let air dry on a clean paper or cloth towel. A document, Viewcrest Health Care Oxygen dated 9/23/23, identified oxygen tubing and cannula would be replaced and marked with the date weekly.

Based on observation, interview, and record review the facility failed to ensure nebulized medications were administered safely for 1 of 1 resident (R8) who was observed to self-administer a nebulizer and had not been assessed as safe to do so. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of spastic quadriplegic cerebral palsy (CP), asthma, chronic cough, and shortness of breath. R8 had functional limitations in range of motion of both upper extremities, needed substantial assistance with oral care, and was dependent for hygiene and transfers. R8's care plan dated 4/2/24, identified an alteration in respiratory status related to asthma and spastic CP with interventions for a nurse to administer inhalers and nebulizer's as ordered as R8 was unable to do so for herself. It further identified nursing staff to monitor lung sounds, report concerns, keep head of bed elevated when in bed, and observe for the need for oxygen. An assessment for self-administration of medication dated 1/4/24, identified R8 was unable to self-administer medication. R8's provider orders dated 9/1/22, identified orders for albuterol sulfate (a medication used to treat and prevent breathing problems) three milliliters (mL) two times daily to be administered via inhalation with a nebulizer (a machine used to directly administer medications into the lungs). During an observation on 7/10/24 at 7:30 a.m., R8 was observed in her bed with the head of bed elevated to about 45 degrees, her eyes were closed, and head was bent to the left and forward. There was a nebulizer machine running and the pipe (the mouthpiece for the medication delivery) was near the left side of her face. It could not be seen how much medication was left in the chamber of the device, if any. At 7:48 a.m., licensed practical nurse (LPN)-A was observed to go into R8's room, wake resident and remove the mouthpiece and tubing from her and set it on the table to the left of the bed and went back to the medication cart. During an interview on 7/10/24 at 1:08 p.m., R8 confirmed she uses the nebulizer two times a day and the nurse would set it up and hand it to her. During an interview on 7/10/24 at 1:12 p.m., LPN-A confirmed setting up R8's nebulizer treatment that morning. The medication administration record did not reflect an order to self-administer nebulizer treatments, which LPN-A thought she had. During an interview on 7/11/24 at 9:42 a.m., registered nurse (RN)-A confirmed the self-administration of medication assessment for R8 indicated she could not administer her own medications. During an interview on 7/11/24 at 11:01 a.m., the director of nursing (DON) stated it would be her expectation that residents who are self-administering medication would be assessed and have an order to do so. The DON further stated this was important for safety. A policy, Self-Administration of Medication by Residents dated 5/1/24, identified the purpose was to provide guidance to staff for assessing and accommodating resident's wish to self-administer their medications. All residents would be asked their preference for self-administration and an assessment would be done on those wishing to do so. An assessment would be performed based on the resident's cognitive status, physical status, and which medication to evaluate if they were clinically appropriate to self-administer medication.

Based on interview and document review, the facility failed to ensure a Level I Pre-Admission Screening and Resident Review (a requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care (PASSAR)) was completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 resident's (R30) reviewed for PASARR. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of anxiety, depression, and manic depression (bipolar disease). R30's undated face sheet, received on 7/11/24, identified R30 was admitted to the facility on [DATE], and diagnoses included bipolar disorder, major depressive disorder, and panic disorder. During interview on 7/10/24 1:43 p.m., the director of social services (DSS) reviewed the document labeled PAS in R30's medical record. The PAS document dated 1/8/18, identified Senior LinkAge Line did not complete the PAS and forwarded the PAS request to a county/managed care organization for PAS processing. DSS confirmed the document did not identify if a PASSAR level 1 was completed or if a PASSAR level II was recommended. During interview on 7/10/24 at 3:15 p.m., the director of nursing (DON) stated the director of social services was responsible for the PASARR and would expect them to complete the task. A policy, Pre-Admission Screening dated 3/7/22, identified the care center will ensure all individuals seeking admission will receive a Pre-Admission Screening (PAS) and the PAS notice indicating he/she has been screened will be retained by the care center.

Based on interview and document review, the facility failed follow medication administration policy for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an immediate jeopardy (IJ) for R1 when LPN-B administered R2's medications to R1, which resulted in severe bradycardia (slower than normal heart rate) for R1 leading to hospitalization and a surgical intervention of a temporary pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 5/7/24, when the facility failed follow medication administration policy when LPN-B administered R2's medications to R1, which resulted in severe bradycardia leading to hospitalization and a surgical intervention of a temporary pacemaker. R1 had previously received her a.m. medications and received all of R2's a.m. medications. The facility had implemented corrective action to prevent recurrence by 5/10/24, prior to the start of the survey and was therefore Past Noncompliance. Findings included: R1's Face Sheet printed 5/14/24 indicated R1's diagnoses included longstanding persistent atrial fibrillation (irregular heart beat), history of transient ischemic attack (blockage of blood flow to the brain), and cerebral infarction (stroke). R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. On 5/7/24, a progress note indicated at approximately 10:00 a.m. R1 was administered her roommate's (R2) prescribed medications. The note indicated licensed practical nurse (LPN)-A had dispensed R2's medications and gave them to LPN-B with instructions to go down the hall, take a left and then a right and go into the shared room. LPN-B then gave R1 R2's a.m. medications which included diltiazem (lowers blood pressure), metoprolol (anti- hypertensive- beta blocker), Cardizem (anti-hypertensive), allopurinol (gout), Cymbalta (antidepressant), doxycycline (antibiotic), famotidine (anti-indigestion), Keppra (anti-seizure), metformin (lowers blood sugar), Wellbutrin (anti-depressant), aspirin (blood thinner), methanamine (treats recurrent urinary tract infections), iron, and gabapentin (anti-seizure). At the time of the medication error, nurse practitioner (NP)-A was in the facility. Nursing staff informed her of the medication error, she completed a bedside assessment on R1, and ordered R1 be sent to the hospital to be monitored. R1's hospital record dated 5/7/24, indicated R1 arrived via ambulance to the emergency department (ED) after she was inadvertently administered another patient's medications which included a beta blocker and calcium channel blocker. R1's hospital admission diagnoses included accidental overdose, drug induced bradycardia, and atrial fibrillation with slow ventricle response. On 5/8/24, a progress note indicated R1 received a temporary pacemaker which was placed on 5/8/24, at approximately 7:00 p.m. On 5/13/24, at 2:19 p.m. LPN-B stated she was still in her orientation phase on 5/7/24. LPN-A had handed her a medication cup full of medications, and instructed her to go down the hall, take a left and then a right and go into R1 and R2's shared room. She stated she was not given the name of the resident, nor was she shown a picture of the resident. LPN-B stated when she returned to the medication cart, she saw a picture of R2 and told LPN-A she had given the medications to R1, and not R2. On 5/13/24, at 2:52 p.m. registered nurse (RN)-A stated to ensure the resident is receiving the correctly prescribed medications there was a picture of each resident on the medication administration record, along with the room and bed number. She stated the nurse administering medications was to ask the resident's name, and if they were not sure they should ask another staff member prior to administering any medications. The nurse who dispensed medications should be the one who administered the medications. This had not occurred, and led to a medication error in which R1 received multiple incorrect medications, resulting in R1 being sent to the emergency department on 5/7/24, requiring a temporary pacemaker. R1 remained hospitalized . On 5/13/24, at 3:12 p.m. the director of nursing (DON) verified the facility medication administration policy had not been followed. This resulted in a significant medication error in which R1 was hospitalized . After the medication error involving R1 was identified, leadership had added the medication administration policy to be included in the staff meeting scheduled for the afternoon of 5/7/24. The facility also sent out a facility wide text requiring all staff who administer medication to complete computer-based education related to medication administration. The facility also performed medication administration audits. On 5/14/24, at 8:31 a.m. LPN-A verified she had dispensed the medications for R2, handed LPN-B the medications, and instructed LPN-B to go down the hall, take a left and then a right, and go into R1 and R2's shared room. She stated she did not show LPN-B a picture of R2, nor had she given LPN-A the name of the resident. She verified proper procedure for medication administration had not been followed, which led to the medication error. She further verifed she had given R1 all of her prescribed morning medications which included Eloquis (blood thinner), iron, folic acid. Fosamax, gabapentin (anti-seizure), Keppra (anti- seizure), Norvasc (anti-hypertensive), and pantoprazole (anti-indigestion). On 5/13/24, at 1:17 p.m. the hospital cardiology physician assistant (PA)-C stated receiving diltiazem and metoprolol led to R1's to severe bradycardia, resulting in placement of a temporary pacemaker. R1 remained hospitalized . On 5/14/24, at 8:50 a.m. the pharmacist consultant (P)-A stated nurses who are dispensing mediations should verify they are giving the medication to the correct resident. He stated only the nurse who dispensed the medications should be administering medications to ensure the resident is receiving the correct mediations. On 5/14/24, at 10:55 a.m. the medical director (MD)-A stated he had been made aware of the medication error. He stated nursing staff should follow the policy and procedure which included verifying the correct resident to ensure residents are receiving the correct medications prior to administering any medication. The facility's Medication Administration policy dated 8/7/23 directed the facility will ensure all medications will be administered safely according to current standards of practice and regulatory requirements. The policy further directed staff will approach and identify the resident by the eMAR (electronic medication administration record) photograph or if still in doubt, question the identification of a resident with another staff member. The facility document titled The Six Rights of Medication Administration undated, directed staff as follows: 1. Right Individual 2. Right Drug 3. Right Dose 4. Right Time 5. Right Route 6. Right Documentation The facility implemented corrective action to prevent recurrence by 5/10/24. The facility provided education to all staff members responsible for medication administration, which included administration of medications and ensuring the 6 rights of medication administration was being followed. The facility also completed medication administration audits. The corrective actions were verified by observation, interview with staff, audit review and policy review.

Based on observation, interview, and document review, the facility failed to ensure the care plan was followed to prevent and/or reduce the risk of burns from hot liquid for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained three 2nd degree burns (damage to outer and second layers of skin) to both thighs. This deficient practice is being cited at past non-compliance related to corrective action taken prior to survey to ensure use of assistive devices/adaptive equipment when dining. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had indicated R1 had Alzheimer's disease, dementia, and severe stage of open angle glaucoma to bilateral eyes. R1 was cognitively intact and needed supervision with eating. R1's care plan revised 6/9/23 indicated R1 needed sippy cups with screw tops to prevent spills. R1's Covered Cup assessment dated [DATE], indicated R1 needed covered mugs for hot liquids due to spilling. R1's meal ticket dated 2/13/24 indicated R1 needed two sippy cups with lids. R1's Recommended Plan of Treatment dated 2/9/24 indicated R1 had second degree burns on her left and right thigh/groin areas. Left medial thigh measured 3 centimeters (cm) x 3cm x 1cm with partial thickness skin loss involving epidermis (outer layer of skin) and/or dermis (middle layer of skin). Left and right groin areas had no measurements, with partial thickness skin loss involving epidermis and/or dermis. On 2/13/24 at 12:45 p.m., cook (C)-A stated on 2/9/24 dietary aide (DA)-A had given R1 hot coffee or tea without a lid. C-A stated he told DA-A she should have looked at the meal ticket for R1 to see what assistive devices were required for R1, prior to giving R1 liquids. C-A stated the water temperature on the hot water machine was 205 degrees Fahrenheit (F) according to the machine reader. C-A stated the facility was unable to regulate the temperature of the machine. C-A stated they started taking temperatures of the hot liquids on the morning of 2/13/24. On 2/13/24 at 1:09 p.m., nursing assistant (NA)-A stated R1 needed sippy cups with lids for a long time because she had gotten burned in the past. NA-A stated on each resident's meal ticket would indicate if a resident needed assistive devices for meals. On 2/13/24 at 3:48 p.m., R1 stated her hot tea didn't have a lid on it and it fell in her lap. R1 stated she screamed for her parents as it hurt a lot on her legs. On 2/13/24 at 4:13 p.m., the director of nursing (DON) stated the facility did not have any prior audits of hot liquid temperatures or completed hot liquid assessments prior to the current ones being completed. On 2/14/24 at 8:46 a.m., C-B stated they did not take temperatures of any hot liquids until recently. On 2/14/24 at 9:56 a.m., licensed practical nurse (LPN)-A was observed to complete a dressing change on R1's burns. R1's left medial thigh burn measured 4cm x 2.7cm, her left groin burn measured 8.5cm x 2.7cm, and her right inner thigh burn measured 7.4cm x 2.7cm. All burns had beefy red wound bases with scant sanguineous drainage (red blood and clear yellow liquid). On 2/14/24 at 11:08 a.m., R1's nurse practitioner (NP)-A stated if the facility staff would have followed the care plan, R1 would not have received the burns to her legs. On 2/14/24 at 12:11 p.m., the DON stated staff were to ensure hot liquids were safe to serve by following the policy. The DON stated staff should provide assistive devices as care planned. The DON stated if the staff member would have followed the care plan, R1 would not have been burned. On 2/14/24 at 12:16 p.m., the administrator stated staff were expected to follow the care plan and facility policy when it comes to assistive devices. The administrator stated R1's care plan was not followed. The facility policy Hot Beverage Serving Temperatures reviewed 6/5/23 directed hot beverages will be served at temperatures between 130 degrees Fahrenheit and 150 degrees Fahrenheit. Residents who are unable to handle hot beverage cups will be assessed for appropriate adaptive beverage container to maintain independence and safety. Dietary staff will perform monthly temperature audits to maintain policy compliance. The facility implemented a systemic plan that included the following actions: All staff were reeducated on the Hot Beverage Serving Temperatures policy, and on assistive devices/adaptive equipment per care plans on 2/12/24. Kitchen staff were educated on temping hot liquids prior to serving on 2/9/24. The policy on hot liquids was reviewed with the dietary manger on 2/9/24. Verbal notice was provided to DA-A on 2/9/24. Automatic hot water dispensers were decreased to 190 degrees Fahrenheit on 2/12/24. Audits were completed on all resident care plans for accident prevention on 2/13/24. Audits for correct assistive devices and temps of hot liquids was completed on 2/13/24. All resident's hot liquid assessment started on 2/9/24 and were completed on 2/14/24. This was verified through observation, interview, and document review on 2/13/24 through 2/14/24.

Based on observation, interview and document review, the facility failed to utilize proper hand sanitization after topical medication administration for 1 of 5 residents (R226) observed for medication administration; failed to ensure staff completed proper hand hygiene and glove use during distribution of snacks and meals. This had the ability to affect all 69 residents as well as staff and visitors who consumed food in the facility. Findings include: MEDICATION PASS During an observation on 9/19/23 at 6:39 p.m., licensed practical nurse (LPN)-B entered R226's room and administered three medications orally. LPN-B then applied gloves and administered a topical medication to R226's left calf. When done, LPN-B removed her gloves, did not complete hand hygiene, walked to the medication cart in the hallway, documented the medication administration, and then returned R226's medication tube to the medication cart after placing the tube in a zip lock bag. Without completing hand hygiene, LPN-B placed a medication cup on the cart and began to touch other resident medication cards in the cart. During an interview on 9/19/23 at 6:47 p.m., LPN-B stated they had not complted hand hygiene since they had removed their gloves in R226's room. Normally they would sanitize their hands after they performed a treatment that required gloves, then LPN-B continued to touch the medication cards without performing hand hygeine. LPN-B confirmed they still had not sanitized their hands, and stated they were going to wash their hands now because it was important to sanitize hands after wearing gloves and between residents for infection prevention. LPN-B then sanitized their hands. During an interview on 9/21/23 at 12:58 p.m., the infection preventionist (IP) stated gloves should be removed immediately after the application of topical medicine and hand sanitization should occur as soon as possible, and before other tasks are performed or other items are touched. Proper glove use and hand sanitization was required to prevent the spread of infection. 49036 MEAL SERVICE: On 9/19/23 at 3:35 p.m., activities aide (AA)-A was observed handling cupcakes and administering them to residents on the Hawk Ridge unit. AA-A was wearing the same gloves when entering multiple resident rooms, did not once remove their gloves or complete hand hygiene, and then wiped their nose with their gloved left hand. Prior to continuing to pass cupcakes, AA-A was stopped by the survey team before entering another resident room. AA-A stated that staff was to wear gloves whenever they have contact with residents, handle food or drink, or clean up after a resident. AA-A should not have worn the same gloves between resident rooms. AA-A not aware that they had wiped their nose with a gloved hand. If they had noticed, they would have taken off her gloves and washed their hands. During continuous observation 9/20/23 at 11:42 a.m., dietary manager (DM)-E was assisting with meal preparation by placing silverware on resident trays and loading each individual tray into food warming carts. -11:50 a.m., DM-E changed gloves for a second time and failed to complete hand hygiene between glove changes. Dietary aide (DA)-A was plating food with gloved hands, including bread rolls from a plastic bag. DA-A touched the outside of the bread bag and opened a cooler door with gloved hands and failed to change gloves or complete hand hygiene prior to continuing to plate food. -11:58 a.m., DA-A opened a cabinet door and moved plates on the counter with the same gloved hands and failed to change gloves or complete hand hygiene. Directly following the observation DM-E identified that she touched a door and other items and removed her gloves, failed to completed hand hygiene, and donned a new pair of gloves. The undated facility Hand Hygiene policy identified staff would routinely perform hand hygiene to control the spread of infection. Hands should be washed before and after direct contract with a client, if moving from a contaminated body site to a clean body site during client care, after contact with environmental surfaces or equipment in the immediate vicinity of the client, after removing gloves or gowns, before eating, after using a restroom, and prior to preparing food. The Viewcrest Health Center Infection Control Preventing the Spread of Infections - Hand Washing dated 6/13/12, identified gloves did not replace hand washing and hands should be washed immediately after gloves were removed.

Based on interview and document review the facility failed to ensure the dietary manager was certified and credentialed to oversee food services. This had potential to affect all 69 residents, staff, and visitors who consumed food from the ktichen. Findings include: During interview on 9/21/23 at 9:53 a.m. dietary manager (DM)-E stated they had not completed the certified dietary manager course, but was working toward becoming enrolled. The facility was helping to enroll them in the course, but was unsure when that would be. The corporate dietary manager was available by email daily. During interview on 9/21/23 at 10:32 a.m., administrator confirmed DM-E did not have their dietary manager certification or state equivalent and DM-E would start the online program for the dietary manager certification on October 1st. The adminstrator wasnted the dietary manager to get settled in before adding extra work as they are a newer employee. The qualifications of DM-E were requested, but not received.

Based on interview and document review, the facility failed to ensure the surety bond was equal to or greater than the funds entrusted to the facility. This had the potential to impact all 52 current and 47 discharged residents identified as having a trust fund account at the facility. Finding include: The facility Trust Fund Monthly Summary, dated 9/1/23 to 9/20/23, identified the beginning balance on 9/1/23 was16,195.63 and the ending balance for the time period was 15,735.63. The balances were calculated based on account balances for 52 current residents and 47 discharged residents. The Nationwide Mutual Insurance Company dated 9/30/22, identified the facility had a surety bond in the amount of $15,000.00 that went into effect on 10/1/22. During an interview on 9/20/23 at 2:43 p.m., the accountant stated the total account trust balance on 9/20/23, was $15,735.63. The balance was made up of 52 current residents and 47 discharged residents. The facility surety bond to cover resident funds at the facility was for $15,000.00 and the current trust account balance had an excess of 735.63 that was not covered by the surety bond. During an interview on 9/21/23 at 12:42 p.m., the administrator stated the resident fund amount should not exceed the surety bond, and the facility should have a surety bond that covered the amount they had in the resident fund account at any given time.

Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 3 of 5 residents (R9, R10, R60) reviewed for immunizations. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of cerebral palsy(A group of disorders that affect movement, muscle tone, balance, and posture). R9's undated immunization record, identified R9 received PPSV23 on 7/26/21, and the PCV13 on 3/31/15. R9's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R9/R9's representative. R10's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of vascular dementia. R10's undated immunization record, identified R10 received the pneumococcal 23 (PPSV23) on 6/25/22 and the pneumococcal conjugate vaccine 13 variant (PCV13) on 1/04/16. R10's medical record failed to provide evidence the pneumococcal conjugate vaccine 13 variant (PCV13) and the PCV20 (pneumonia immunization) was offered and/or education was provided in conjunction with the provider to R1/R10's representative. R60's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of dementia and diabetes. R60's undated immunization record, identified R18 received PPSV23 on 10/6/99, and the PCV13 on 10/1/15. R60's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R60/R60's representative. During an interview on 9/19/23 at 2:10 p.m., registered nurse (RN)-C stated the MDS coordinator sent out a list of what immunizations should be offered to each resident and filled out a declination form. The clinical manager was responsible to order the immunizations the resident was agreeable to receive and administer the vaccine. The clinical manager then notified RN-C of the vaccine administration and RN-C entered it into each residents record. During interview on 9/19/23, at 3:00 p.m. RN-F stated the facility just received information related to the PCV20 vaccine. RN-F had not offered P9, P10 or P60 the vaccine yet. During an interview on 9/19/23 at 3:15 p.m., the director of nursing (DON) stated the facility was just starting to update residents pneumococcal vaccinations and have developed a plan to accomplish that. The facility sent out requests to the residents medical providers regarding which residents they wished to have the PCV15 or PCV20 vaccines. They have not offered to any residents at this time as they were just getting started on the necessary steps needed prior to offering the vaccine. The facility policy Resident Immunizations dated 7/18/23, indicated pneumococcal vaccines would be offered to each resident according to the current recommendations from the CDC. The CDC guidance dated 2/9/23, identified adults 65 and older have the option to get PCV20.

Based on interview and document review the facility failed to ensure residents had reasonable access to their personal funds after hours and on weekends for 2 of 2 residents (R13, R227) reviewed for personal funds. This had the potential to affect all 52 residents who had personal accounts managed by the facility. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R13 was cognitively intact. During an interview on 9/18/23 at 8:34 a.m., R13 stated they went to accounting when they needed money, but it was difficult to get their money and the facility did not have anyone they could get money from on the weekend. R227's annual MDS assessment dated [DATE], identified R227 was cognitively intact. During an interview on 9/18/23 at 9:23 a.m., R227 stated they kept money in a facility account and indicated they could not get money on the weekend, and if they wanted money on a Saturday, they would have to ask for it on Friday, or wait until Monday. During an interview on 9/20/23 at 2:08 p.m., nursing assistant (NA)-A stated social services could assist a resident with getting money from their personal facility account, but residents could not get money during the weekend. During an interview on 9/20/23 at 2:40 p.m., licensed practical nurse (LPN)-C stated during the week they would bring a resident to the accountant to get money, but they did not know if residents could get money during evenings or weekends. During an interview on 9/20/23 at 2:43 p.m., the accountant stated she has been in her position since 6/12/23. Residents knew she left at 4:00 p.m. and that they could access their funds anytime when she was there. The administrator could also disperse money from the resident fund cash box locked in her office. The charge nurse had access to the cash box to get residents money after hours and on weekends, but since she had been at the facility nurses had not accessed the cash box. She could also be called in to get money for a resident, but that had not happened since she started. If a resident wanted money for the weekend, they would get it on Friday. The facility kept $300.00 to $500.00 in cash on hand in the accountant office for residents with personal accounts. During an interview on 9/21/23 at 9:27 a.m., registered nurse (RN)-B stated residents cannot get money in the evening or the weekend. Those that get cash know to ask before the weekend or before the end of the business day. There was petty cash at one time, but they were not sure if there was any anywhere anymore. During an interview on 9/21/23 at 8:49 a.m., RN-E stated normally residents cannot get money in the evening, so they try to have them plan ahead. The money was kept locked in the accountant office and they were not sure if anyone had access to the money on weekends or evenings. On 9/21/23 at 9:31 a.m., RN-D stated the green valley medication cart had 75 dollars of petty cash in it. RN-D opened the narcotic box and showed a bank bag with a ledger and withdrawal slips for residents to take money out of the petty cash. The resident ledger indicated the last time money had been counted was 3/31/23. RN-D counted a total of 75 dollars in the petty cash bag. The Trust Fund Tally Sheet in the petty cash bag identified the last withdrawal occurred on 3/31/23, and the balance was 75.00 dollars. During a follow-up interview on 9/21/23 at 10:22 a.m., the accountant stated she was not aware the Green Valley medication cart had resident funds petty cash in it and must have been something previously in place. The petty cash was off since she started and indicated the money in the medication cart was not being included in the count and that explained the discrepancy. On 9/21/23 at 10:32 a.m., the accountant reported she spoke with the administrator and found out the money in the medication cart was kept in the cart for the weekend needs of residents. During an interview on 9/21/23 at 12:38 p.m., the director of nursing (DON) stated in the past the facility had had a petty cash box for after hours and weekends and it should contain 100 dollars for residents to access. The cash box should be counted each day to ensure it is balanced. Information about the petty cash would be reviewed with staff and residents at the next resident council meeting to ensure everyone knew resident funds could be accessed outside of business hours and on weekends. During an interview on 9/21/23 at 12:42 p.m., the administrator was unaware there was an issue with residents not being able to get money on the weekends or after hours. The issue likely developed during the transition of an accountant leaving, an interim and a replacement being hired and trained. There will need to be staff and resident education provided so that all are aware residents can access their funds at any time. The facility Trust Fund Monthly Summary, dated 9/1/23 to 9/20/23, identified there were 52 current residents with accounts.

Based on interview and document review the facility failed to ensure residents with trust accounts received quarterly accounting statements for 2 of 2 residents (R227, R13) reviewed for resident funds. This had the potential to affect all 52 residents who had personal accounts managed by the facility. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R13 was cognitively intact. During an interview on 9/18/23 at 8:34 a.m., R13 they handled their own finances and had not received a quarterly account balance statement from the facility. R227's annual MDS assessment dated [DATE], identified R227 was cognitively intact. During an interview on 9/20/23 at 9:17 a.m., R227 stated they did not know how much money they had in their account, but since they didn't think it was very much. R227 did not identify if they received a quarterly statement. During an interview on 9/20/23 at 2:43 p.m., the accountant recently stated and had not sent out resident trust account statements since she was hired and did not know when they were last sent out. During an interview on 9/21/23 at 12:42 p.m., the administrator stated residents should get quarterly trust account statements if the accountant didn't send residents a trust account statement, then the residents had not received one. It was facility practice to send out regular statements to residents and indicated the gap in sending statements was likely due to the position transitions and orienting processes that were occurring within the accounting department. The facility Trust Fund Monthly Summary, dated 9/1/23 to 9/20/23, identified there were 52 current residents with accounts.

Based on observation, interview and document review, the facility failed to ensure the care plan was revised to reflect newly assessed needs and services for 1 of 4 residents (R10) reviewed for changes in activities of daily living (ADL); 1 of 2 residents (R61) reviewed for pressure ulcers. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment. Diagnoses included dementia, kidney disease, history of stroke and anxiety. R10 required limited assistance with bed mobility, transfers, and toileting. Ambulation and dressing did not occur. R10 was frequently incontinent of bowel and always incontinent of urine. R10's care plan dated 8/23, identified staff were to ambulate R10 daily with assist of one and a full wheeled walker. R10's care plan did not address her assessed need for assistance with bed mobility and dressing. During continuous observation on 9/20/23, from 8:20 a.m. to 11:45 a.m. R20 was observed dressed in a hospital gown lying in bed on her back. R20 did not make any attempt to turn or reposition herself during the 3 hours and 15 minute observation and no staff were observed to offer assistance with bed mobility. During subsequent observations on 9/19/23, and 9/21/23, at various times, R20 was observed lying on her back in bed, dressed in a hospital gown. During interview on 9/19/23, at 11:30 a.m. nursing assistant (NA)-G stated they offer to assist R10 to dress but she preferred to remain in a hospital gown. The staff changed the gown and bedding when needed. When interviewed on 9/19/23, at 11:45 a.m. NA-F stated she assisted R10 with her morning cares and R10 refused to dress. R10 preferred to wear her hospital gown and NA-A assisted R10 to put a fresh one on that morning. R10 did not ambulate and only stood and pivoted to the commode at bedside. R10 was able to assist staff with turning and reposition when she was prompted by grabbing onto the bed rail. During interview on 9/20/23, at 2:40 p.m. registered nurse (RN)-F stated R10's care plan did not address dressing because R10 refused to dress. RN-F confirmed bed mobility and dressing were not on the plan of care and should have been. RN-F was aware R10 had not ambulated in over a year as she frequently refused. R10's family member (FM)-F wanted to keep her on the ambulation restorative program, despite her constant refusals. RN-F was responsible to update the care plan and R10's care plan should have been updated as a result of the changes that had occurred with her MDS assessments. Part of the problem was the facility had recently changed their care plan program from one system to another, and he was still struggling with learning the new system. When interviewed on 9/21/23, at 1:30 p.m. the director of nursing (DON) stated R10's care plan should have been revised to reflect R10's increased care needs. The care plan needed to reflect that R10 refused to dress and preferred to remain in a hospital gown, as she still needed assistance to change the gown daily and bed mobility should be on the care plan as well. R10's refusal to ambulate should be re-evaluated and other interventions attempted and care planned to prevent range of motion decline. 45842 R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 had moderate cognitive impairment, was an extensive assist of one staff member for bed mobility and was on hospice services. Diagnoses included coronary artery disease, dementia, and cancer. R61's undated care plan identified R61 was independent with bed mobility which included turning and repositioning. During an interview on 9/20/23 at 9:56 a.m., nurse assistant (NA)-B stated R61 was unable to reposition himself and new staff would not be aware based on the care plan. During an interview on 9/21/23 at 10:14 a.m., registered nurse (RN)-C stated once the MDS nurse performed the assessments they would email RN-C to update the care plan if needed. RN-C never received an email to let them know to update the care plan. During an interview on 9/21/23 at 10:30 a.m., the MDS assistant (MDSA) stated the MDS coordinator would complete the resident MDS based on observations, interviews with staff and medical record review. After the MDS was completed, the nurse manager was responsible for updating the care plan if there were any changes. MDSA stated she would send emails occasionally letting them know when the MDS assessment was completed to help but it was not a requirement. During an interview on 9/21/23 at 10:37 a.m., the DON stated it was the responsibility of the nurse manager to update the care plan based on the MDS assessment, even if the MDS did not notify them there needed to be changes. The DON stated she expected all nurse managers reviewed every resident MDS when completed to see if changes to the care plan were needed. The care plan needed to be updated to match the MDS so the staff new what needed to be done to provide the best care possible to our residents.

Based on observation, interview and document review, the facility failed to ensure the facility provided a home like environment for 1 of 1 residents (R47) reviewed for home like environment. Findings include: During an observation on 9/18/23 at 8:17 a.m., R47 was laying on a bare mattress on her bed. The bed was unplugged and in a low position. During an observation on 9/19/23 at 2:42 p.m., R47 was laying across the foot of the bed and the bed had a flat sheet and incontinence pad and there was not pillow or blanket. The room contained two chairs, and an end table and a call light cord hanging from the wall. There was a stuffed animal on the bed and several others on the floor next to the bed. R47's room lacked any personal clothing or items and the bathroom room was locked. During an interview on 9/19/23 at 3:20 p.m., RN-A identified R47 was at the facility for six months. The facility was concerned about hoarding, but R47 had a history of eating things like incontinence briefs and gloves, the facility did not keep things in R47's room. RN-A didn't know why R47 did not have a pillow or a blanket in her room, as many things were put in to place before RN-A started at the facility. On 9/20/23 at 9:02 a.m., nursing assistant (NA)-J assisted R47 with cares. NA-J explained R47 did not have personal care items or clothes in her room because if she did, R47 would put everything in the toilet and flood the room. NA-J indicated R47's clothes were kept in the laundry room and all of her personal care items were kept in the tub room bathroom they used for R47. During an interview on 9/20/23 at 3:15 p.m. regiatered nurse (RN)-A confirmed R47's room was very sparse and identified all items were removed from her room based on her past behaviors and safety needs, even though R10 did not have any currently identfied behaviors. During an interview on 9/21/23 at 9:14 a.m., NA-K stated R47's clothing had been kept in the laundry room for at least a year or more. When R47's needed clothes, they get them from the laundry room. NA-K stated it was not in her scope to determine if R47's room was homelike. During an interview on 9/21/23 at 12:38 p.m. the director of nursing (DON) acknowledged that R47 did not have much of a home like environment and identified an attempt had been made to put some decorative paper items in her room but they were removed. The facility Person Centered Care Planning policy dated 3/7/22, identified the care plan should allow for resident choice, honor home like environment, enhance dignity, allow for treatment refusal, and help support achievement of highest practicable level of well-being for the resident.

Based on observation, interview and document review, the facility failed to provide assistance with toileting for 1 of 2 residents (R10) reviewed for activities of daily living and who were dependent on staff for their care. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment, required limited assistance with toileting, and was always incontinent of bladder. R10's care plan dated 8/23, identified R10 required assistance to change her brief and provide peri cares after each incontinent episode. Interventiions included: staff to remind and assist R10 to the toilet on arising at 6:00 a.m. and every two to three hours during the day, as well as at bedtime; assist R10 to the commode every day around 9:00 a.m., and after breakfast to promote continent bowel movements. On 9/20/23, R10 was continuously observed from 8:20 a.m. until 11:30 a.m. R10 was lying in her bed with the head of her bed elevated, watching her television. R10 remained lying in her bed watching television and sleeping off and on until nursing assistant (NA)-F offered assistance to the commode and provided assistance with incontinence care at 11:45 a.m. R10's brief was saturated with a large amount of urine R10 was observed for 3 hours and 15 minutes and was not offered assistance with toileting or incontinence care during that time. On 9/20/23, at 11:45 a.m. NA-F stated she was assigned R10's care and R10 required assistance to check and change her brief and provide incontinence care. NA-F had not checked R10 since her morning cares at 6:00 a.m. and confirmed R10's brief was saturated with urine. When interviewed on 9/20/23, at 2:40 p.m. registered nurse (RN)-F stated he was not aware R10 was always incontinent of urine. R10 was care planned to be assisted to the commode every two to three hours and he would expect staff to check and change R10 or offer toileting assistance in a timely manner. During interview on 9/21/23, at 1:33 p.m. the director of nursing (DON) stated it was her expectation that residents who were incontinent of bladder and needed assistance with toileting be checked and changed every two hours and if increase in incontinence were noted, the nurse should initiate a bowel and bladder assessment. The policy Urinary Incontinence Program dated 4/16/15, indicated each resident who was incontinent would be identified, assessed, and provided appropriate care and services to prevent incontinence related complications to the extent possible.

Based on interview and document review, the facility failed to effectively provide pain management for 1 of 1 residents (R1) reviewed for acute post surgical pain. This resulted in actual harm to R1, when R1's narcotic pain medication was not administered per orders resulting in uncontrolled pain. Findings include: R1's Admission Record printed on 6/10/21, indicated she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 48 Hour Baseline Care Plan initiated on 6/4/21, indicated R1's reason for admission was related to recent pacemaker and Coronary Artery Bypass Graft (CABG). R1 was to have assist of 1 staff for toileting, ambulation, toileting, bathing, and bed mobility. Pain interventions included ice, medications, distraction, massage, and conversation. R1's baseline care plan also indicated R1 was a fall risk. R1's mental status was listed as alert and orientated. R1's hospital discharge and facility admitting orders dated 6/4/21, included acetaminophen (Tylenol) tablet 325 milligrams (mg), take 1-2 tablets by mouth every 6 hours as needed for pain, and [MEDICATION(S)] ([MEDICATION(S)], narcotic medication called an opioid for use with moderate to moderately severe pain) 50 mg tablet every 6 hours as needed for pain. R1's hospital discharge paperwork indicated R1 had last received Tylenol 1000 mg dose at 9:50 a.m. and [MEDICATION(S)] 50 mg dose at 8:12 a.m. prior to being admitted to the facility. R1's PRN (as needed medication) Report dated 6/4/21, indicated the following: -6/4/21, at 4:53 p.m. acetaminophen 325 mg, 2 tablets by mouth was administered to R1 for verbalized pain. The result was documented at 9:43 p.m. as unrelieved by medication. -6/4/21, at 9:47 p.m. acetaminophen 325 mg, 2 tablets by mouth administered to R1 for verbalized acute pain at a level of 10/10. At 12:06 a.m. the result was documented as unrelieved by medication. -6/4/21, at 10:16 p.m. [MEDICATION(S)] 50 mg tablet administered to R1 for verbalized acute pain at a level 10/10. The result was documented by RN-A as unknown, as R1 had left the facility against medical advice (AMA). R1's Vital Sign record reviewed from the electronic health record (EHR) dated 6/4/21, indicated R1's pain level on 6/4/21, at 9:42 p.m. was 9/10 (on a scale of 1-10 with 1 being mild pain and 10 being excruciating pain), at 9:47 p.m. 10/10, and at 10:16 p.m. 10/10. On 6/10/21, at 12:02 p.m. R1 was interviewed and stated she had left the faciity on [DATE], and went home. R1 stated she went to the hospital the following morning and had been readmitted . R1 stated she did not believe the facility had been prepared to take a patient post coronary care. R1 stated she arrived at the facility on 6/4/21, around 11:00 a.m. and RN-B had completed the admission paperwork with her. R1 stated after she arrived, her parents and husband had come to see her. R1 stated at the entrance, an office staff had stopped her husband and requested to make a copy of her insurance card for her medications. R1 stated RN-C had come to her room early in the evening stating that the facility needed another copy of her insurance card because they lost the first copy that was made. R1 stated she contacted her husband who sent her a photo of the card, and she forwarded an email to RN-C with the information. R1 stated she was asked if she had more than one insurance card, R1 stated they had one insurance card for everything, including prescriptions. R1 stated she had never felt so scared and vulnerable as she had at the facility. R1 stated she did not see any staff after her supper tray had been brought to her room, even though she had placed her call light on numerous times for assistance with toileting and pain management. R1 stated at one point, her call light had been on for over 90 minutes at which time an unidentified female staff came in, shut her call light off. R1 asked her for her pain medications. R1 stated the staff said she would check, but she never saw her again. R1 stated a little before 10:00 p.m. one of the staff did come and administer Tylenol, but by that time she was crying in pain. R1 stated she had told the staff no one had been to her room, and she felt like she was all alone. R1 stated at that time she called FM-A to tell him to come and get her. R1 stated FM-A arrived around 10:30 p.m. and around that time, RN-A brought her the [MEDICATION(S)] pain medication with her other bedtime medications. R1 stated she had been in pain throughout her entire stay. R1 further stated when her call light was not being answered, she had called the other facility numbers she was given at the time of admission on the telephone, however, the staff had not answered any of those calls. A facility pharmacy delivery Packing Slip dated 6/4/21, indicated at 11:04 p.m. medications were delivered to the facility from the pharmacy. R1's medication was included in the delivery which included her [MEDICATION(S)] ([MEDICATION(S)]) 50 mg tablet pain medication. Registered nurse (RN)-A was noted to have signed for the medication delivery. On 6/9/21, at 3:56 p.m. a progress note by the facility administrator indicated on 6/4/21, at 10:16 p.m. RN-A had received a phone call around 10:30 p.m. that FM-A had shown up to the facility and wanted to take R1 home. RN-A educated R1 regarding the risk verse benefit of leaving the facility, and the R1 still decided to leave the facility. On 6/9/21, at 4:12 p.m. a progress note by RN-B indicated on 6/4/21, per RN-A, R1 was given 650 mg of Tylenol per her request at 4:45 p.m. Staff reported to RN-A at 9:45 p.m. that R1 was having a panic attack, was hyperventilating, and was speaking with FM-A via telephone regarding leaving the facility. R1 stated that she did not think she should have left the hospital. R1 was then offered another dose of Tylenol which R1 agreed to take. Upon returning to the cart to prepare the Tylenol, it was noted R1's medications had just been delivered by the pharmacy. At that time, RN-A reported she prepared the ordered [MEDICATION(S)] and other bedtime mediations for administration. An ice pack was also provided to R1. R1 continued to panic and hyperventilate. RN-A discussed with R1 the option of leaving AMA, and encouraged R1 to remain in the facility to recover from her surgery. Per RN-A, R1 stated she had not been using her call light as she did not want to be a bother. Per RN-A, R1 stated she was scared and she was too young to be in the facility, This is all too much for me. Staff notified the facility administrator. FM-A arrived at the facility around 12:03 a.m. to pick up R1 in his personal vehicle. R1 was encouraged to go to the emergency room (ER) with any increase in pain, or if she started to feel worse or did not feel as though she was improving. On 6/10/21, at 9:30 a.m. RN-B was interviewed and stated he completed R1's admission assessment on 6/4/21. RN-B stated earlier that day, R1 had been noted to be grimacing and rated her pain at a 5/10. RN-B stated he had offered Tylenol because the [MEDICATION(S)] had not been delivered from the pharmacy at that time. RN-B stated R1 declined the Tylenol, but did accept an ice pack. RN-B confirmed the facility had available an stock emergency(Ekit) supply of medications which included a supply of [MEDICATION(S)]. RN-B stated a pain level of 5/10 in addition to showing nonverbal signs of pain such as grimacing should have signaled a reason to access medications out of the emergency kit (Ekit). RN-B confirmed he did not offer the [MEDICATION(S)] pain medication to R1 from the Ekit at that time, nor did he reassess R1 for pain relief. RN-B further stated he felt if R1 had been rating her pain at 9/10 staff should have accessed the [MEDICATION(S)] from the facility Ekit. On 6/10/21, at 10:21 a.m. the administrator was interviewed and stated FM-A had left her a message detailing his concerns on the night of 6/4/21. The administrator stated the facility's investigation had not yet been completed. The administrator stated they had not pulled the call light logs to verify if R1 had long call light wait times. On 6/10/21, at 10:41 a.m. RN-A stated she was working the night R1 was admitted and left AMA. RN-A stated she was alerted to R1 being anxious and hyperventilating. RN-A stated there had been discussion with another nurse about getting R1 her pain medications from the Ekit, however, the decision was made to wait until R1's medications were delivered from the pharmacy. RN-A stated her shift started around 7:00 p.m., but she had not seen or assessed R1 until around 9:45 p.m. On 6/10/21, at 10:25 a.m. during follow up interview the administrator stated if a resident reported pain at a level of 5/10, 9/10, or 10/10 to a nurse, she would expect the nurse to offer pain medication effective to control the pain. The administrator stated if no pain relief was obtained or reached, she would expect the staff to contact the resident's physician or pharmacy. The administrator stated uncontrolled pain could cause anxiety and increase heart rate, and put a resident at risk. The administrator stated it was her understanding R1's medication had not been included with the first pharmacy medication delivery because FM-A had given the facility the wrong insurance card. On 6/10/21, at 1:26 p.m. RN-D verified the first copy of R1's insurance card had been lost or misplaced. RN-D stated they needed another copy from R1 and sent it to the pharmacy. RN-D stated this was some time after 4:00 p.m. RN-D stated it was the responsibility of SW-A to send the insurance card to the pharmacy at the time of admission. RN-D stated it may or may not have affected the timely delivery of R1's medications. On 6/10/21, at 2:29 p.m. the DON stated she was unable to pull R1's call light logs to review. The DON further stated the voice mail FM-A left on 6/4/21, at 9:30 p.m. with his concerns had not been saved. The DON stated, Call logs had been pulled automatically on 6/9/21, so there would be no ability to review (R1's) call logs unfortunately. A facility document titled Voluntary Discharge Against Medical Advice(AMA) Release dated 6/4/21, at 10:32 p.m. indicated per R1, I should not have been admitted if you were not prepared to care for me. No medications or continuous care was provided per my stay. I tried to reach someone. R1's family member (FM)-A and RN-A both signed the document as witnesses. The facility administrator signed on 6/7/21. On 6/10/21, at 2:42 p.m. during further follow up, the administrator stated R1 should have received her ordered pain medications to manage her pain and had not. The administrator stated staff should have contacted the on-call physician to obtain additional medication orders, and/or use mediation available in the facility Ekit. On 6/10/21, at 4:18 p.m. the facility medical director (MD)-A stated pain medications were to be given timely and as ordered to control resident's pain. MD-A stated if a pain medication or any medication was needed and not available, he would expect the facility to contact the on-call physician to get further instructions which may include obtaining an alternative medication or using the supply of medication from the facility Ekit. MD-A stated it was not acceptable to have a resident rate pain at 5/10, 9/10 or 10/10 and not seek alternative medications. The facility policy Pain Management Policy undated, directed the facility will provide care and services that will recognize and manage a resident's pain to support his or her highest practicable level of wellbeing. Both pharmacological and non-pharmacological interventions assessed as appropriate will be utilized to provide maximum pain relief. If a pain scaled of 1-10 is used, it will be interrupted as follows: 0 is No pain, 1-4 Mild pain, 5-7 is Moderate, 8-9 is Severe and 10 is Excruciating pain. The Physician will be notified of pain levels on the Pain Evaluation, as appropriate. The Physician will also be notified when pain persists or reoccurs despite treatment or if suspected adverse consequence are noted.

Based on observation, interview, and document review, the facility failed to ensure the correct diet texture was served to 1 of 4 residents (R1) reviewed for diet texture. This resulted in an immediate jeopardy for R1, who received the wrong diet texture, and had choking episode. R1 required medical intervention, the [MEDICATION NAME] manuever, to remove the food. The immediate jeopardy began 9/1/20, when R1 was served the wrong textured diet, which resulted in R1 choking. Staff did not follow R1's dietary orders for a pureed diet, and R1 was served a mechanical soft diet (foods that are soft and easy to chew). R1 ate the food, and had a choking episode which lasted 10 minutes. The administrator, director of nursing (DON), assistant director of nursing (ADON), and the facility's quality assurance nurse were notified of the immediate jeopardy at 4:31 p.m. on 9/10/20. The immediate jeopardy was removed on 9/11/20, at 1:00 p.m. but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Face Sheet dated 9/1/20, indicated R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 was cognitively intact, on a mechanically altered diet, and required supervision with eating. R1's Active Orders dated 9/10/20, indicated R1's diet was a pureed diet (texture of a pudding or mousse) and nectar liquids (consistency of apricot nectar) effective 4/30/20. R1's care plan dated 6/8/17, indicated R1 was on a pureed textured diet with nectar fluids. R1's pocket care guide (nursing assistant care guide) undated, lacked identification of R1's diet texture. On 8/20/20, the NP initiated the following order: SLP-A to evaluate, treat, and make recommendations. On 9/1/20, at 11:10 a.m. a progress note indicated R1 was brought to her room from the dining room by the activities director (AD)-A. R1 had aspirated on her food, turned a gray dusky color, and could barely inhale. R1 was encouraged to continue and try to cough up, spit up, or vomit anything she could. The ADON and the speech language pathologist (SLP)-A arrived to R1's room. After approximately 10 minutes of coughing, R1 coughed/vomited up a moderate amount of thick, frothy like phlegm, mixed with light brown food particles. R1's color returned, and R1 was able to breath more easily. R1's lung sounds presented crackles and wheezes. After R1 was administered an [MEDICATION NAME] (liquid medication that is inhaled to treat/prevent difficulty breathing) nebulizer treatment, R1's lungs had slight audible wheezes. The progress note further indicated R1 had a chest x-ray. On 9/1/20, at 1:49 p.m. the facility submitted a report to the State Agency (SA). The facility indicated R1 was served the incorrect diet consistency at lunch, which resulted in a choking episode and possible aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airways). On 9/1/20, a note from R1's nurse practitioner (NP) indicated R1 was requested to be seen by the NP due to a choking episode during lunch earlier that day. The note further indicated R1 was served a mechanical soft diet which was the wrong textured diet, and resulted in R2 choking and needing the [MEDICATION NAME] maneuver to provide relief. R1 was immediately in respiratory distress with low oxygen saturation, and had a raspy voice. The note further indicated R1 had possible aspiration pneumonia, was ordered [MEDICATION NAME] (medication used to treat narrowing of the airway), and a chest X-ray. R1 was to continue on a pureed diet with supervision of meals. The note indicated R1 was tired and scared after her choking episode, and refused to eat the rest of her second portion of lunch. On 9/2/20, R1's chest X-ray impression indicated R1 had no acute infiltration (filling of air spaces in the lungs) or pneumothorax (a collapsed lung). R1's dietary ticket dated 9/9/20, indicated R1 was to receive a puree diet, no restrictions with small portions with nectar liquids. On 9/9/20, the facility's Incident Details investigative report indicated on 9/1/20, at 11:10 a.m. R1 had aspirated on her food. R1 became a dusky gray color, sounded raspy and congested, and was barely able to breathe. The speech language pathologist (SLP)-A was summoned, and after approximately 10 minutes, R1 coughed/vomited up a moderate amount of phlegm mixed with light brown food particles. R1's color started to return, and she was able to breathe more easily. R1's lungs were documented to have crackles and wheezes in the bases of the lungs. On 9/1/20, a speech therapy (ST) note indicated SLP-A saw R1 after the meal due to a choking episode. R1's lungs presented crackles with wet vocal quality and breathing. The SLP-A educated R1 on diet level and risks of aspiration and pneumonia. The note indicated staff served R1 a mechanical soft diet for lunch despite R1 being on a puree textured diet unless with the SLP-A for trials. The note further indicated staff was to be re-educated on the importance of following diet orders. On 9/9/20, at 11:09 a.m. the dining room was observed. Each resident's dietary ticket was setting at their table. Dietary staff went to each resident, took their food and beverage orders, and told the cook the resident's food choices. The cook plated the food, and the dietary staff delivered the meal to the residents. Some staff were observed taking the dietary tickets up with them when ordering the resident's lunch, and some staff left the dietary tickets at the resident's table when ordering the resident's meal. On 9/10/20, observation of dietary staff plating and serving in the dining room started at 10:07 a.m. -10:08 a.m. Cook (C)-A took the temperature of the meat, and began to make mashed potatoes. -10:16 a.m. C-A prepared the dietary tickets, gathered plates and plate covers. The dietary aide (D)-A made coffee and was setting the tables with placemats, napkins and silverware. The D-A asked C-A the names of residents who required special utensils, and put in place. Surveyor noticed C-A had a scratch piece of paper hand written with a resident name, room number, and breakfast. C-A stated they ran out of dietary tickets that morning for breakfast, so some of the resident's dietary tickets had to be hand written on paper. -10:23 a.m. C-C set the dining tables with cups. -10:29 a.m. C-A showed a blank dietary ticket with only the date, meal time, name, diet, and allergies [REDACTED]. C-A stated blank dietary tickets were common and often times were not printed the night before. -10:29 a.m. C-C and C-A were in the serving kitchen assisting with getting room trays ready. C-A took the diet tickets from the pile, dished up the food, handed the plate and dietary ticket to D-A. C-C put the cover on the plate and put the tray of food in the warming cart. -A dietary ticket indicated Extra gravy. C-A did not add extra gravy. -11:07 a.m. a dietary ticket which indicated No gravy was observed. C-A viewed the dietary ticket, dished up meat, mashed potatoes, and poured gravy over the mashed potatoes and meat. D-A finished plating the food, put a cover on the plate, and the meal tray was placed into the warming cart. When asked for the residents name of the lunch that had just been plated, C-A looked at the dietary ticket and stated, Oh, she doesn't like gravy, and dished up another plate of food without gravy. -11:24 a.m. The last room tray was plated. C-C and D-A left the serving kitchen area, and C-A started plating food for residents eating in the dining room. DA-A went around to the residents in the dining room and asked residents what they would like for lunch, took their order, picked up the dietary ticket and verbally read the dietary ticket to C-A. C-A did not view the resident's dietary ticket before plating the food. The AD-A assisted serving in the dining room. The AD-A took the resident's food order, took the dietary slip to the serving counter, placed it on the meal tray and read the diet order to C-A. C-A did not look at the dietary ticket prior to plating the food, but looked at the dietary ticket when the plated food was put on the serving tray. Dining Observations completed at 11:34 a.m. after all residents were served. On 9/9/20, at 1:18 p.m. the administrator was interviewed and stated she completed the investigation after R1 received the wrong textured diet. The administrator stated per her investigation, R1 told C-A her diet was changed to mechanical soft, and no longer needed the pureed diet. The DON further stated C-A did not see the dietary ticket and took R1's word, and served R1 a mechanical soft diet which consisted of ground meat and soft foods instead of pureed foods. The administrator stated the cooks should be looking and following the diets on the dietary tickets. The administrator confirmed R1's diet was never upgraded to mechanical soft from puree. The administrator stated she and the dietary manager (DM)-A talked to the cook who served the incorrect diet, and information about R1's incident was put in the weekly newsletter for the rest of the staff to read. The administrator verified no formal education or re-training was completed for the entire dietary, nursing or activity staff related to the importance of following the diets on the dietary tickets. On 9/9/20, at 1:32 p.m. DM-A was interviewed and stated the dining room had been open for residents for about a week, with 10 residents eating in the dining room. DM-A stated the resident tables were set up prior to the resident arriving to the dining area with place settings, and the dietary tickets. Once the resident arrived at the table, the dietary staff verified the correct resident and dietary ticket, and took their food and beverage order. DM-A stated the cooks did not see the dietary ticket prior to plating the food in the dining room. DM-A stated the cooks received the dietary order verbally from the staff taking the residents order. DM-A stated she was working the day R1 was served the wrong textured diet. DM-A stated R1 had been working with SLP-A on a trial of mechanical soft textured foods. DM-A verified she never received diet order changes for R1's diet and R1 was supposed to receive a pureed diet. DM-A stated after talking with dietary staff, C-C told C-A, R1 was on a mechanically soft diet and did not have the dietary slip to support the diet. DM-A stated there were only a few residents on special diets, and the cooks were familiar with those residents, and DM-A stated she did not understand how R1 received the wrong diet. DM-A stated she talked to the staff that were directly involved in the incident about the importance of following the resident's dietary tickets. DM-A stated she educated the dietary staff by putting up an updated list of resident diets in the kitchen, and gave an updated list to the DON. DM-A stated she did not have a formal meeting or training with the dietary staff, but talked amongst the kitchen staff that day of R1's choking incident. DM-A stated she thought about changing the serving process, and have the cooks look at the dietary tickets, and staff who pass room trays double check the dietary tickets before delivering the meal trays, but had not done that yet. DM-A further stated she also thought about having the dietary staff watch training videos, and develop a policy for the dietary staff to read and sign. DM-A stated she had not implemented those practices. On 9/9/20, at 2:14 p.m. C-C was interviewed and stated she worked the day R1 was served the incorrect diet and choked. C-C stated during lunch on 9/1/20, R1 first was served a regular textured diet which C-C caught, the plate of food was removed, and R1 was given a mechanical soft diet. C-C stated she ordered R1 a mechanical soft diet instead of a pureed diet because R1 had been working with SLP-A, and she thought R1's diet had changed to mechanical soft. C-C stated she did not look at R1's dietary slip before ordering R1's mechanical soft diet. C-C stated R1 ate the entire meal and requested to have another plate of food. DA-A stated she ordered R1 another plate of mechanical soft food. C-C stated ideally, staff should bring the resident's dietary ticket to the cook, and the cook should read the dietary ticket before plating the food. C-C further stated the cooks were familiar the resident's diet, and could plate the food without looking at the dietary tickets. C-C stated because the cooks knew the resident's diets, they were not asking for the dietary tickets. C-C stated resident's dietary tickets were placed at each table, and when the residents arrived in the dining room, the staff were supposed to bring the dietary ticket to the cook to read before plating the food. C-C stated the dietary ticket should be checked again by the server before delivering the resident their food. C-C stated this was not being done. C-C stated she was not bringing the dietary ticket to the cooks when she worked in the dining room. On 9/9/20, at 2:25 p.m. DA-A was interviewed and stated she was sitting with R1 the day R1 was served the incorrect diet and choked. DA-A stated R1 arrived at the dining table, which was already set up with place settings and R1's dietary ticket. DA-A stated no one never came and picked up R1's dietary ticket to bring to the cook. DA-A stated R1's dietary ticket indicated puree diet with nectar liquids. DA-A stated R1 was served a mechanical soft diet, and DA-A did not question the diet because R1 had been working with SLP-A with mechanical soft foods. DA-A stated R1 ate the entire plate of food, and requested more food. DA-A stated she ordered another mechanical soft plate of food for R1. DA-A was eating fast and started to choke on her food, and started to change colors. DA-A stated the AD-A came into the dining room and rushed R1 to the nurse's station. DA-A stated she did not know what to do or how to help R1, and was scared. DA-A stated she was concerned there were no nursing staff present during meal times. DA-A stated it was the first week the dining opened for residents, and some staff were unaware dietary tickets needed to be brought to the cook. DA-A stated she had not received education or training after R1's incident of being served the incorrect diet. DA-A stated the DM-A was responsible for printing the dietary tickets the night before for the next day. DA-A stated often times the dietary tickets were not printed, or were printed but were blank, and staff had to remember each resident's food preferences. On 9/10/20, at 8:55 a.m. C-A stated dietary tickets were printed the night before, and were reviewed and organized by the cooks before each meal. C-A stated the cooks should look at the dietary tickets for diet type, allergies [REDACTED]. C-A stated she plated R1's food the day R1 choked. C-A stated DA-B requested a regular tray for R1, and C-A did not know who the regular meal tray was for. C-A found out DA-B delivered the regular meal tray to R1. C-C saw R1 had a regular diet, and before R1 ate any food, the plate was removed. C-C then ordered R1 a mechanical soft diet. C-A stated she knew R1's diet was supposed to be a pureed diet, but she continued to plate a mechanical soft diet for R1. C-A stated she should have asked to see R1's dietary ticket. C-A stated the only time R1 had a mechanical soft diet was when R1 was working directly with SLP-A. C-A stated R1 choked because she received a mechanical soft diet. C-A stated the administrator and the DM-A had spoken with her. C-A stated she did not receive any re-education, and was told by the DM-A to make sure dietary slips were being followed. C-A further stated it was the responsibility of the DM-A to update the dietary slips, and print them the night before to have ready for the next day. C-A stated sometimes the dietary slips were not printed, were blank, and it took weeks to get the dietary tickets updated with new information. On 9/10/20, at 9:29 a.m. SLP-A was interviewed. SLP-A stated she worked with R1 a few different times to see if R1 would be able to progress from a pureed diet to a mechanical soft diet. SLP-A stated R1 started speech therapy (ST) on 8/24/20, and was being discharged from ST on 9/10/20. SLP-A stated R1 had unsafe feeding behaviors that consisted of shoveling food into her mouth, and taking too big of bites, putting her at a high risk of choking. SLP-A stated R1 was not appropriate to upgrade to a mechanical soft diet. SLP-A stated she did not make any dietary changes to R1's diet, and R1 was only to have a mechanical soft diet when SLP-A was sitting with her during ST sessions. SLP-A further stated dietary staff should be following the resident's dietary tickets, and never accept verbal orders from other staff. SLP-A stated dietary changes were made on a dietary communication slip that was given to all department heads, and it was the responsibility of the dietary manager to make the changes on the dietary slips. SLP-A stated she was summoned to R1's room the day she choked. SLP-A stated she coached R1 to continue and try to cough up the foods. SLP-A stated R1 finally coughed up some ground meat and carrots, her color started to return to normal, but her lungs had audible gurgles. SLP-A stated if a resident received the wrong textured diet, the could choke, aspirate, or possible die. On 9/10/20, at 2:01 p.m. the snack tray observed being passed on Green Valley unit by C-B and DA-B. C-B was interviewed and stated he had the resident's diets memorized. C-B stated there was a clipboard with the list of the resident diets, but had been unable to find it, so he went by memory. C-B stated he was aware R1 had a choking episode after being served the incorrect texture diet. C-B stated he did not receive any education or training after R1's choking incident. On 9/10/20, at 2:13 p.m. DA-B was interviewed and stated he would ask the cook or look at the dietary ticket to know a resident's diet. DA-B stated he worked the day R1 had her choking episode. DA-B stated he asked R1 what she wanted for lunch, and ordered R1 a regular lunch tray from the cook. DA-B stated he brought R1 a regular textured diet, and immediately was told by C-C that R1 could not have regular textured foods, and needed a mechanical soft diet. DA-B stated a mechanical soft diet was requested from the cook, and although he had R1's dietary ticket, he did not read it, nor did he show C-A the dietary ticket. DA-B stated serving in the dining room was new, and there had not been any training on the process. DA-B stated there had been no training or education provided after R1 was served the incorrect texture diet. On 9/10/20, at 3:21 p.m. the DON was interviewed. The DON stated if a resident's diet changed, a communication form was completed, and given to the DM-A to make the dietary changes. The DON stated verbal diet orders were not acceptable, and she would expect staff to follow the correct process. The DON stated she did not work the day R1 was served the wrong textured diet. The DON stated she was not involved in investigating the choking incident, and she was unaware if all staff were re-educated. The DON further stated the DM-A was responsible for the dietary staff, and the DON was responsible for the nursing staff, and the DON did not retrain nursing staff. The DON stated the nurse managers were told to check the dietary tickets before the meal trays were delivered to resident rooms. The DON stated all staff should check the resident's dietary ticket before delivering a meal tray. The DON confirmed R1 was supposed to receive a pureed diet, and R1's diet orders had not been changed to mechanical soft. On 9/10/20, at 3:38 p.m. AD-A stated he was present the day of R1's choking episode. The AD-A further stated he noticed R1 was having a difficult time breathing, and brought R1 to the nurse's station right away. The AD stated he was directed by the nurse to get the SLP. The AD-A stated he assisted with passing lunch trays in the dining room, and did not hand the cooks the dietary tickets, and instead read the diet order to the cook. The AD-A stated he felt the cook should not be touching the dietary tickets and dishing up the food. The AD-A stated he had not received any education or training after R1's choking episode. On 9/10/20, at 3:45 p.m. C-D stated he was aware R1 was served a mechanical soft diet instead of a pureed diet, which resulted in R1's choking episode. C-D stated he did not receive any education or training after R1's incident. C-D stated the cooks were supposed to look at the resident's dietary ticket before plating the food, and stated not everyone followed the process. C-D stated it was concerning there were no nursing staff in the dining room during meals. The facility policy Dining and Nutritional Services dated 9/11/20, directed direct care staff providing meal service will ensure the correct diet is provided to the resident by verifying the diet order on the meal ticket with the dietary server. The staff requesting a resident's tray will be responsible for communicating to the dietary server the resident's diet, adaptive equipment and any other considerations utilizing the resident's meal ticket. The policy further directed residents will be served diets per their order, and mechanically Altered Diets, such as mechanical soft diet and/or pureed, will be served to residents who require this texture due to problems with chewing or swallowing and may be at risk for choking. Diet orders may also include fluid consistency changes, including nectar, honey, or pudding consistency. The immediate jeopardy that began on 9/10/10, at 11:10 a.m. was removed on 9/10/20, at 1:00 p.m. when it was verified by observation, interview, and document review, the facility trained dietary aides, nursing staff, and activity staff on the need to ensure dietary tickets were checked prior to a resident being served food. The facility revised and implemented new dietary policies on Dining and Nutritional Services. Implementations included: All dietary, nursing, and activity staff working were immediately re-educated on meal textures, and to ensure meal tickets were checked prior serving food to residents. All other staff reporting to work were required to receive training prior to their next shift. A list of residents diets were updated and placed on each nursing unit. The interdisciplinary team (IDT) reviewed and revised dietary policies and procedures on serving food on Dining and Nutrition Services. New hires that assisted with food service would be educated on the updated Dining and Nutritional Services policy and procedure upon hire, and would be required to complete the training course Dining, Nutrition and Food Safety. The administrator, DON, ADON, and DM-A provided training on the need to ensure meal tickets were checked prior to a resident being served food. Auditing of the Dining and Nutritional Services policy and procedure would occur, and results will be reported to the facility Quality Assurance and Performance Improvement Committee.

Based on observation, interview, and document review, the facility failed to ensure development of a comprehensive care plan, and implement interventions to address suicidal ideation that included behavioral health services, provision of a safe environment, and meaningful activities and social interactions to promote psychosocial well-being and prevent a suicide attempt for 1 of 1 residents (R201) reviewed for [MEDICAL CONDITION] and suicide attempt. This resulted in actual psychosocial and physical harm for R201 when she attempted suicide by strangulation. Findings include: R201's Face Sheet printed 8/13/20, indicated R201's [DIAGNOSES REDACTED]. R201's quarterly Minimum Data Set ((MDS) dated [DATE], identified R201's was cognitively intact, and was mildly depressed. R201's care plan dated 7/21/20, identified R201 was at risk for alteration in psychosocial well-being related to restriction on visitation due to COVID-19. The care plan dated further indicated R201 preferred activities in her room, and directed activity staff/volunteers to visit during daily rounds to provide socialization. R201's care plan lacked identification of suicidal ideation. R201's nursing assistant care sheet printed 8/10/20, lacked identification of R201's suicidal ideation, and lacked staff direction on what to do when R201 expressed thoughts of self-harm. R201's Quarterly assessment completed by the social service director (SS)-A dated 4/27/20, indicated R201 was cognitively intact, Patient Health Questionnaire (PHQ-9, a screening for the presence and severity of depression) indicated R201's mood was normal and further indicated R201 stated during the past week she felt more depressed due to her family being unable to visit. The assessment identification of R201's recent suicidal ideation. On 6/8/20, an Incident Details report revealed R201 was in her room when she attempted to strangle herself with a stretch band (Theraband) that was attached to the mobility bar on her bed. The report indicated the Theraband was removed from R201's neck, and R201 was taken to the hospital by ambulance. The incident report revealed R201 was placed on 15 minute checks. On 6/18/20, a hospital Behavioral Health Discharge Summary indicated R201 was seen in the emergency room after being found with a Theraband around her neck in attempt to kill herself. The summary further indicated nursing home staff noted R201 had been making suicidal statements two weeks prior to her attempt, and felt they could not keep R201 safe after being found with the Theraband around her neck. R201 was admitted to a mental health unit for stabilization, medication management, and assessment. The hospital Discharge Summary indicated at the time of discharge, R201's condition had improved and was stable and discharge to nursing home and instructed to follow up with primary care provider within 5 days. On 6/24/20, a provider note indicated R201 had a physician visit via Zoom visit. The note indicated R201 was tearful through much of the visit, and expressed a lot of sadness. R201 expressed she was being quarantined, and would rather be back in her old familiar room. R201 stated, I've missed so much, everything is gone. R201 expressed a friend of hers health had deteriorated, and he was in a nursing home, and she was unable to communicate with him. The note further indicated R201's distress reached a point earlier in the month that lead to an attempt of self-harm with a Theraband around her neck, and lead to an inpatient stay on the psychiatry unit from June 11-19, 20. During that stay, R201 received psychotherapy, and had medication adjustments. The note indicated R201 was emotionally distressed, and she struggled to compose herself, but was able to carry on a conversation. R201's physician discussed with the director of nursing (DON), and the facility's plan was R201 would return to her room after quarantine period ended, and R201 would have outdoor visits with her family. On 8/10/20, at 3:52 p.m. family member (FM)-A was interviewed and stated R201 was having a difficult time being isolated to her room, and the lack of contact from the outside also was difficult for her. FM-A stated R201 had a history of [REDACTED]. FM-A expressed concern of R201's mental health, and stated R201 recently attempted suicide by trying to strangle herself with an exercise stretch band. FM-A stated R201 started making comments of suicidal ideation about six weeks prior to her attempt. FM-A stated the facility removed dangerous items from R201's room and placed R201 on 15 minute checks when R201 expressed self-harm. FM-A stated the nurse practitioner (NP) made medication changes, and the facility talked about setting up an appointment with a mental health provider for R201, but it never happened. FM-A stated R201 refused to go out to appointments, and feared R201 would have to go to a different room to quarantine for 14 days. FM-A stated R201 had to quarantine after her last hospitalization which was a difficult time for R201 mentally. R201 was unable to see family during this quarantine, and was not surrounded by her personal items. FM-A was unaware if the facility attempted to arrange a video visit for mental health services. FM-A stated she thought if R201 would attempt to commit suicide it would have been when R201 lived in the community, and FM-A never thought it would be at her age in a nursing home. FM-A stated she felt R201 would attempt to end her life again. On 8/11/20, at 3:47 p.m. R201 was interviewed and stated she had been awake from 1:00 a.m. until 4:00 a.m., and thought she was having a [MEDICAL CONDITION]. R201 stated the doctor was called, and was told R201 was having an anxiety attack. R201 stated it was upsetting that she had not been able to see her significant other since he was admitted to a nursing home. R201 stated staff were going to try and arrange an outside visit with R201's significant other sometime next week. R201 expressed feeling lonely and isolated since no one could leave their rooms, and all activities had stopped. R201 stated she was very close with her family, and talked with her daughter daily. R201 stated she video chatted with her daughter a couple of times, and they had two outdoor visits. R201 became teary eyed, and stated she felt like she had missed so much, and the summer was gone. R201 stated she struggled with depression for many years, and now she had so much time on her hands to think and stare at the four walls within her room. R201 stated no one came to her room to visit anymore, staff walked in, did what they had to do and walked out. R201 stated she had [MEDICAL CONDITION] and could no longer crochet or knit, but could still make snowflakes from paper. R201 stated she was unable to make the snowflakes because staff took her scissors away. R201 further explained she had tried to strangle herself with the exercise band she received from therapy a couple of months ago. R201 stated she told staff she was going to kill herself, but would not tell them how. R201 stated staff took her scissors away and removed her cordless phone base, because of the cords. R201 further stated if she wanted to strangle herself she would use the cords from the desk phone staff gave her, and proceeded to point at the desk phone on the side table between her recliner chair and bed. R201 stated she was currently not seeing a mental health provider, and she would not leave the facility in fear she would have to go to the isolation unit and quarantine for 14 days. R201 stated she could not handle that. R201 stated she had a psychiatric appointment scheduled for September, and she was told since she was in a private room with a private bath, she would not have to go to the isolation unit. R201 stated she visited with the NP via video chat, and expressed her concern of feeling anxious, depressed and lonely. R201 stated she was told a meeting was going to be scheduled to see if she could have her personal items returned, and stated the meeting had not been scheduled as of date. R201 stated the day she attempted to strangle herself she was feeling very alone and isolated, and stated staff bought in her lunch that day around 11:00 a.m. and did not come in her room again until the nursing assistant (NA) found her with the Theraband around her neck at 4:00 p.m. R201 stated her family bought her an IPad after hospitalization to stay connected, play Scrabble, and go on the internet, otherwise she had nothing to occupy her time. Review of R201's progress notes from 4/19/20, to 7/29/20, revealed the following: - 4/19/20, R201 verbalized she was suicidal and had a plan, but would not elaborate further and stated, You'll take it away from me. The NP was notified, [MEDICATION NAME] (tranquilizer) was increased for a one time dose, and R201 was placed on 15 minute checks. The note further indicated R201's family was updated, and R201 safety checks were decreased to 30 minute checks for the rest of the shift. -4/20/20, SS-A spoke with R201's daughter regarding a room change. The note lacked indication SS-A had a conversation with R201's daughter regarding R201's suicidal thoughts or her current state of mental health. - 4/21/20, SS-A spoke with R201 and followed up on room change. The note lacked any indication SS-A had a conversation with R201 regarding suicidal thoughts, or her current state of mental health. - 4/30/20, R201 expressed to the nurse of feeling sad all of the time. The note further indicated the NP was contacted to address R201 blood sugars and her non-compliance with dietary choices. The note lacked indication R201's mood was addressed. - 5/27/20, R201 was very depressed that morning due to hearing her house was cleared out and was being sold, and her boyfriend moved to an assisted living facility. R201 expressed to registered nurse (RN)-C she felt hopeless, and did not want to live anymore. RN-C asked R201 if she had a plan to hurt herself, and R201 stated she had nothing to hurt herself, with otherwise she may do it. R201 was put on 15 minute safety checks and R201's daughter was updated. R201's daughter planned a window visit for that afternoon. - 5/28/20, SS-A met with R201 and discussed recent days of feeling down. R201 denied any suicidal thoughts at that time and stated she cannot live like this. R201 expressed increased anxiety of not being able to see her significant other. SS-A discussed arranging a Zoom visit with R201's significant other. -5/28/20, R201 was taken off of 15 minute safety checks, had spoken with family, and had a Zoom visit with the NP which addressed blood sugars, and her depression. The note lacked any indication if R201's NP changed any medications, addressed any [MEDICAL CONDITION], or added any new interventions. - 6/8/20, R201 was found by a NA with a stretch band around her neck which was attached to the mobility bar. R201 was pulling the stretch band tightly trying to strangle herself. The note further indicated the stretch band was removed, R201 had a reddened mark all around her neck, and R201 stated she was trying to kill herself. Potential harmful items were removed from R201's room, family was notified, and the NP ordered R201 to be sent to emergency department. R201 was placed on 15 minute checks until the ambulance arrived. - 6/9/20, SS-A spoke with R201's daughter regarding R201's recent suicidal attempt, and having her bed held. The note indicated R201's daughter stated she talked to R201 daily, and felt R201 had been in a better mood, and R201 had not made any recent comments about wanting to hurt herself. - 6/9/20, the hospital social worker stated R201 still had thoughts of harming herself, and the hospital was looking for in-house placement. -6/19/20, R201 was readmitted to the nursing home. R201 stated the two new medications were helping with her depression, she denied thoughts of self-harm, and stated did not plan on going down that road again. -6/25/20, R201's progress notes lacked any follow up from SS-A upon return to the facility from the hospital, until six days later. - 6/25/20, Interdisciplinary Team (IDT) reviewed R201's medications and blood glucose levels, weight, non-compliance with dietary choices and indicated no MDS concerns. The IDT lacked any information on R201's mental health. -7/4/20, R201 was crying and stated she was sick of being alone in her room. The note further indicated R201 requested the nurse to sit and talk with her for a while. The nurse sat with R201 and talked until R201 felt better. -7/7/20, R201 stated the new medications she was taking were making her fell more depressed, more tired than usual, and gave her a loss of appetite. The note further indicated the nurse explained R201 was not on any new medications, but had an increase dosages and she would update the physician. -7/10/20, IDT reviewed and discussed R201's pain medications. The IDT did not address R201's mental health. -7/10/20, a progress note indicated FM-A called the facility and left a voice mail message for the nurse manager. FM-A stated R201 called and stated her anxiety medications were not effective. The note further indicated the NP changed R201's medications two weeks prior, and wanted to give the medications a chance to work. -7/15/20, R201 had been crying all day, and told staff she needed a mental health doctor. The note further indicated R201 stated she did not want to live anymore, then denied that statement to the nurse manager and assistant director of nursing (ADON). R201's bed remote was removed due to it having a cord and R201 having [MEDICAL CONDITION]. The NP was notified and requested R201 to be seen by her that next day. -7/16/20, NP ordered to continue to monitor and document R201's behaviors and sleep patterns for 14 days, and ordered [MEDICATION NAME] for nausea. -7/27/20, the Spiritual Director (SP) visited with R201. -7/29/20, R201's quarterly care conference with IDT and FM-A via phone included a review of medications, diet, activities, and R201 recently received a new IPad. On 7/7/20, R201's [MEDICAL CONDITION] medication review indicated on 4/3/20, R201's had a onetime dose increase in a medication (unnamed) related to suicidal thoughts. Review further indicated R201 was noted to be crying and depressed on 7/4, 7/7, 7/10, 7/15, and 7/16. R201's medical record lacked evidence of mental health service, suicide prevention evaluation and assessments, and documentation of supporting activity interactions and participation. On 8/12/20, at 10:17 a.m. activities aide (AA)-A stated the only in-house activity for residents was Bingo. Bingo consisted of activities staff going from room to room marking the Bingo cards on the resident's door. AA-A verified activity staff were not interacting with the residents during Bingo except to let the residents know if they won something. AA-A stated activity staff were not allowed to go into the resident's rooms for activities due to COVID-19. AA-A stated the first month activities stopped was terrible, the residents were very upset and had a hard time without activities, and now they do not say anything. AA-A stated activity staff were busy screening staff and visitors at the front door, and bringing residents on outside visits. AA-A stated staff were being hired to do the screening at the front door which would allow more time for activities with residents. On 8/12/20, at 10:19 a.m. registered nurse (RN)-D stated she was aware of R201's depression and attempt to end her life. RN-D further stated R201 had never made suicidal comments to her. RN-D stated R201 safety interventions included removal of unsafe items with cords from R201's room. RN-D then placed R201's desk phone down to the floor, out of R201's reach. On 8/12/20, at 10:46 p.m. the DON stated R201 she was unsure how R201 got the desk phone. The DON stated there was no formal assessment to determine when it would be appropriate to return items that had been removed for safety, and stated R201 was doing better. The DON stated R201 had not been making comments about harming herself, and staff were able to recognize when R201 felt depressed and teary-eyed. The DON stated staff visited with R201 frequently, provided one-on-one activities, and R201 had Zoom and outdoor visits. The DON stated staff visits were documented on the room visit logs outside of the resident's doors. The DON stated anytime anyone enters a resident's room, they were to sign in and out. The DON stated R201 didn't start complaining about not being able to make snowflakes until her scissors were taken away. On 8/12/20, at 11:19 a.m. the DON stated R201's phone was put out of R201's reach, and maintenance did not give R201 the desk phone. The DON further started the NP did a Zoom visit with R201 recently, and the NP stated R201 could have all of her items returned to her. The DON further stated she could try plastic scissors or rounded scissors for R201, if making snowflakes was important to her. The DON stated an assessment had not been completed to determine R201's mental health status or risks of self-harm. On 8/12/20, at 12:06 p.m. SS-A stated she was aware R201's history of depression and suicidal ideation. SS-A stated she met with R201 frequently, but did not chart her visits or conversations in R201's medical record. SS-A stated she did not conduct any formal assessment to assess R201's suicide risk level, or complete a depression assessment after R201 verbalized [MEDICAL CONDITION]. SS-A was unsure if R201 was receiving any outside mental health services, and stated she did not make any mental health referrals. On 8/13/20, at 9:54 a.m. activities director (AD)-A stated it had been very frustrating for staff and residents since COVID-19 restrictions of stopping group activities, and residents being restricted to their rooms. AD-A stated activity staff had taken on additional responsibilities like delivering mail and packages to residents, and screening staff and visitors at the front door. AD-A stated all group activities had stopped since COVID-19, and there were no hallway activities occurring. AD-A stated resident activities included delivering packages to resident rooms, putting items away, dropping off puzzles, books, crossword puzzles, and crafts the residents could do independently in their rooms. AD-A stated activity staff were not allowed to go into resident rooms until recently. AD-A stated Zoom visits and outdoor visits were the main focus for activities due to the high requests from families. AD-A stated the activity department currently had two IPads for Zoom visits, and more were on order. AD stated residents had complained about not having activities like they were used to, and staff tried to accommodate residents, but it was difficult due to the restrictions set by the facility. AD-A stated R201 used to play dice, paint, attend Bingo, and had expressed frustrations of not being able to have regular Bingo or see her significant other. AD-A stated activity staff could visit with R201 more if requested. AD-A stated activity staff could provide one-on-one visits doing crafts or just talking if that would help with R201's feelings of depression and isolation. AD-A stated more staff were being hired, which would allow more time and opportunities for resident activities. AD-A stated activity staff don't chart or keep records on resident's participation in an activity. AD-A stated R201 has had window visits, two or three outdoor visits, and Zoom visits with family. On 8/12/20, at 4:02 p.m. RN-D was interviewed again. RN-D stated she noticed a decline in R201's ambulatory status and being weepier since COVID-19. RN-D stated R201 used to see her family every day, and now she only talked with them daily, but recently started outdoor visits which seemed to help with R201's mood. On 8/13/20, at 10:44 p.m. housekeeper (H)-A stated R201 had made comments to her about wanting to die, which she reported to nursing. H-A stated when R201 made those comments, H-A would talk with R201 about positive things like her family, which seemed to help. H-A stated R201 stated she missed going to Bingo, socializing with other residents, and was going stir crazy. On 8/13/20, at 1:48 p.m. the spiritual coordinator (SC)-A stated she worked 3 days a week, not full days, and visited with residents. SP-A stated she recently had a leave. SP-A stated she tried to check on R201 at least once a week, but had not seen her for a while because she had been on leave. SP-A stated she did not always chart her visits with the residents because a lot of the time she was just stopping by to say hi. SP-A stated she had seen more depression in the residents since COVID-19. SP-A stated the focus was on nursing for the residents, and more focus needed to be on the mental health of the residents, and taking a holistic approach. SP-A further stated she tried to help out the activity department as much as she could, the activities department were shorthanded, and had additional responsibilities added to their day that did not involve activities with the residents. SP-A stated there were a few residents that really struggled with depression, and identified R201 as being one of them. SP-A stated she wanted to get those residents together wearing masks, and social distancing for their mental health. SP-A further stated groups of any kind were not permitted in the facility. On 8/13/20, at 4:06 p.m. the ADON stated she was working the day R201 attempted to strangle herself. The ADON stated staff stayed with R201 until the ambulance arrived, family was notified, and R201 was transported to the hospital. The ADON stated she was aware of R201's previous suicidal ideation, but R201 had no plan. The ADON stated residents were to stay in their rooms and all hallway activities were canceled per corporate office policy. The ADON stated staff rotated and took a few residents outside for activities. The ADON stated isolation could impact a resident's depression, and it was difficult to balance keeping the residents safe from COVID-19 and socialization. The ADON stated residents that went out to appointments were put on contact precautions due to the risk of exposure outside of the facility. On 8/13/20, at 4:40 p.m. another interview was conducted with the DON. The DON stated she was notified immediately by the ADON of R201's suicidal attempt. The DON stated she instructed staff to call 911, notified R201's medical provider and family, and placed R201 on 15 minute checks until R201 left the building. The DON stated the plan when R201 returned to the facility was to remove potentially harmful items from R201's room, and replace the call light with a call box without cords. The DON stated she would expect a comprehensive assessment to be completed within a week of R201's hospital return. The DON verified R201 was not seen by SS-A until 6/25/20, nor had a comprehensive assessment completed to determine R201's new baseline after readmission. The DON stated R201's nurse manager visited with her every day, and SS-A saw R201 frequently after R201's hospital return, although documentation in R201's electronic medical record (EMR) did not support that. The DON stated back in April 2020, R201 verbalized wanting to harm herself. The DON stated R201's medical provider was notified, and R201's care plan directed staff to watch for signs and symptoms of depression, and to allow R201 to talk. The DON further stated R201 did not have a plan to end her life, and no updates were made to R201's care plan at that time. The DON stated R201's care plan should have been updated in April after R201 expressed suicidal ideation. The DON stated updating R201's care plan and nursing assistant care sheets were important so staff knew what was going on with R201, and to ensure R201's safety. The DON verified R201's care plan was not updated following her suicide attempt, and stated it should have been updated. The DON stated upon R201's return from the hospital, staff were informally educated on R201 suicide attempt by memo and meetings. The DON stated R201 had not been seen by a mental health provider since R201 returned from the mental health unit, and further stated R201 had an appointment scheduled in September (three months after R201's suicide attempt). The DON stated group and hallway activities were canceled, and further stated resident's received socialization by activity staff delivering packages to resident rooms, offering snacks, and Zoom and outside visits. The DON stated R201's activities included one-on-one visits, outdoor and Zoom visits with family, and R201 recently received her own IPad. The DON verified IDT notes from 6/25/20, did not address R201's suicidal ideation, depression, or overall mental health status. The DON stated the facility did not have an assessment to determine resident's suicidal ideation risks, and recently found a suicide contract on-line. On 8/13/20, at 5:48 p.m. the administrator stated if a resident verbalized wanting to harm themselves, she would expect the nurse to talk with the resident, and find out if the resident had a plan. The administer further stated an assessment would be completed to determine the level of seriousness, safety checks would be initiated, harmful objects would be removed from the room, and the medical provider and family would be notified. The administrator stated safety checks would be removed after the nurse or SS-A talked with the resident to determine if there was a need to continue, or if the resident needed to be sent to the hospital. The administrator stated SS-A could have completed a depression assessment to identify if there were other areas of concern after R201 expressed suicidal ideation. The administrator stated she would expect a comprehensive assessment to be completed upon R201's return from the hospital right away, within a day, by SS-A to create a new baseline and identify any concerns. The administrator stated she expected care plans to be updated with any resident changes, and verified R201's care plan should have been updated after R201 verbalized suicidal thoughts back in April 2020. The administrator stated they had never experienced a resident attempt to commit suicide, and did not have any formal assessment or tools to assess a resident's risk level that expressed suicidal ideation. The administrator stated staff were not formally educated on what to do if a resident verbalized suicidal ideation. The administrator stated staff were informed on reporting the smaller things like watching a resident's mood closely with medication changes. The administrator stated R201 had been offered mental health services in the past, and R201 declined. The administrator was unable to provide documentation to support the facility made referrals for mental health services for R201. The administrator verified R201 was not receiving mental health services at that time, and had an appointment scheduled for September. The administrator stated there was a mental health practitioner who made in-house visits for another resident, and the facility could have requested R201 to be seen. The administrator stated the facility was in the process of hiring more staff so the activity staff had more time for resident activities instead of using activities for screening staff and visitors. The administrator stated activity staff were allowed in resident rooms for one-on-one activities, and activity staff passed out mail, art projects, and books to the residents. The administrator stated the focus for the activities department had been on Zoom meetings and outdoor visits. The administrator stated residents were allowed out of their rooms as long as they wore a mask, and were social distancing. The administrator further stated staff had been used to keeping residents in their rooms, and need to be re-educated. The facility provided the following on education provided to staff for residents that expressed suicidal ideation: Memo From The Desk Of The Administrator dated 6/22/20, and 6/29/20, reminded staff after an incident with a resident, exercise bands would no longer be stored in the residents rooms. The memo also reminded staff if a resident had a medication change to watch for adverse side effects including but not limited to changes in sleep/eating habits, depression, anxiety, mania, panic attacks, restlessness, or suicidal thoughts/ideation to notify the nurse. The facility policy Suicide Precaution Policy revised date 4/17, directed: 1. Residents observed attempting suicide call 911 2. Any employee hearing or observing any suicidal talk or behavior of a resident must report such to the nurse in charge immediately. 3. Employee to remain with the resident until the charge nurse assess. Determine if resident has a plan, remove all equipment that could be used and/cause harm, i.e. sharps, cords, belts, etc., and begin 15 minute visual checks on resident. 4. Charge nurse to contact resident's Physician, Administrator, Director of Nursing, Social Services, and Clergy (if appropriate). 5. Nursing personnel will be informed of the suicide threat and to report changes in the resident's behavior immediately. 6. Resident's may be temporarily secluded if there is a potential of danger to him/herself or others. 7. An assessment of the resident's behavior will be made by the interdisciplinary care plan team within 24-48 hours of such incident to determine interventions that may be necessary to prevent the recurrence of such threats. Revised care plans will be developed to reflect such interventions. 8. Document all the above and update the care plan. The facility policy Comprehensive Care Planning Process undated, was to ensure each resident's status is properly assessed and that the highest practicable functional status can be attained and maintained. The policy directed the following: -Nursing Department will be responsible for modifying, adding, updating the following focuses: Additional Vulnerability Areas (if applicable), Behavior, and Safety. -Activity Department in collaboration with Social Service will be responsible for modifying, updating the following focus: Psycho-Social/Activities. -Nursing, Dietary, Social Service, Activity Departments will schedule new interventions or link interventions previously scheduled to improve resident's functioning or minimize decline as needed on the care plan. The Director of Social Services Job description undated, indicated the responsibilities and standard of the DSS for resident services were to provide individual, family, and group services designed to improve social functioning and reduce the psychosocial problems of residents. The facility policy on Behavioral Health Services and Activities were requested and not provided by the facility.

Based on observation, interview, and document review, the facility failed to thoroughly assess and implement interventions to prevent the development and worsening of pressure ulcers for 1 of 3 residents (R33) reviewed for pressure ulcers. This resulted in actual harm for R33, who developed a pressure ulcer that worsened. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. R33's Face Sheet printed 4/26/18, indicated R33's [DIAGNOSES REDACTED]. R33's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R33 had severe cognitive impairment, and had no rejection of cares during the assessment period. The MDS further identified R33 required extensive assistance of two staff for bed mobility, and total assist of two staff for transfers. R33's MDS further indicated R33 was frequently incontinent of bladder and always incontinent of bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, and had moisture associated skin damage. The MDS indicated R33 had a pressure reducing device in the chair and in bed, and was treated with ointments. R33's Care Area Assessment (CAA) for a significant change MDS dated [DATE], indicated R33 was at low risk for skin breakdown per a 12/4/17, Braden Score (tool used to assist in identifying risk for pressure ulcers). R33's Tissue Tolerance Test (TTT, a tool used to assist in determining the ability of the skin and tissues to endure the effects of pressure without adverse effects) indicated R33 tolerated repositioning every 4 hours in the wheelchair, and every 3 hours when lying. R33's most current TTT was dated 11/29/17, through 11/30/17. R33's CAA indicated R33 had impaired mobility and functional ability. The CAA noted R33 had a pressure injury to the gluteus when in the hospital that was healed upon admission to the facility on [DATE]. The CAA indicated R33 required staff assist with toileting and repositioning, had a problem for friction and shearing, but used a Hoyer (mechanical) lift for transfers, and a pad was used to assist with boosting to avoid shearing. The CAA further indicated R33 was exposed to incontinence of bowel and bladder, but wore an incontinent brief to wick excess moisture away from the skin, and was checked and changed or toileted every two hours, and as needed. The CAA indicated R33 was at risk for diarrhea related to medications, and R33 was noted to refuse cares at times. The CAA also indicated R33 had a pressure reduction cushion on the chair, and pressure redistributing/relieving mattress on the bed, was repositioned per the TTT results, and was toileted every two hours to help keep her dry. R33 was to have a barrier cream applied with any noted redness after incontinent episodes, an adult incontinent brief to wick excess moisture away from the skin, Prafo boots (a pressure-relief boot for patients with compromised mobility and at risk of developing pressure sores at the heel) to feet. R33's care plan initiated 9/15/17, indicated R33 was at risk for skin breakdown related to impaired mobility and refusals of turning and repositioning, and incontinence. The goal was for R33 to remain free of pressure ulcers. R33's care plan directed staff to inspect skin weekly and observe daily with cares, provide Prafo boots on feet when up in chair, and a pressure reducing cushion on the chair. On 4/4/18, R33's care plan was updated to include: reapproach when R33 refused or was resistive to turning and repositioning. R33's care plan directed staff to turn and reposition per the tissue tolerance results to help prevent skin breakdown. In addition, R33's care plan was updated on 3/13/18, identified shearing to the coccyx, and directed the use of an alternating pressure mattress, turn side to side with repositioning, and position with a pillow, and ensure the head of the bed was not elevated beyond 45 degrees unless eating or drinking, and treat per physician orders. R33 was to be toileted or checked and changed every two hours and as needed. R33's current undated Care Card (nursing assistant care guide) directed staff to turn and reposition R33 every two hours, position side to side with pillows when in bed, and Prafo boots were to be on when up in the wheelchair. The Care Card further directed staff to check and change every two hours and ensure the head of the bed was no higher than 45 degrees unless eating or drinking. On 4/25/18, during continuous observations beginning at 7:41 a.m. when staff exited R33's room, R33 had been lying quietly in bed, tilted slightly to the right with the head of the bed at approximately 30 degrees. At 8:31 a.m. registered nurse (RN)-B entered R33's room to give oral medications, and raised the head of the bed up to approximately 90 degrees. RN-B administered medications, then returned the head of the bed to approximately 30 degrees. R33 continued to lay in her bed tilted slightly to the right with the head of her bed at approximately 30 degrees until 10:30 a.m. (2 hours and 49 minutes without repositioning) when surveyor stopped a nursing assistant to ask about R33's repositioning time. Nursing assistant (NA)-G stated she thought R33 had been repositioned about 8:30 a.m. when NA-E had changed her and washed her up. When informed R33 was last repositioned at 7:40 a.m. NA-G stated she would reposition her, and called a nurse to meet her in the room. On 4/25/18, at 10:36 a.m. RN-B and NA-E entered R33's room to reposition her. R33's incontinent brief was wet, and was opened by NA-E. NA-E cleansed R33's perineal area with a cleansing wipe. R33's right hip had no redness. R33 was turned to the right, and RN-B removed the dressing from R33's coccyx. The dressing had a small amount of clear pink drainage without odor. RN-B cleansed R33's ulcer with wound cleanser, and measured the ulcer at 0.5 cm x 0.5 cm x 0.3 cm. The wound edges were regular, except from 6 o'clock to 10 o'clock, and the wound bed was circular with yellow/white stringy slough covering it. RN-B stated the pressure ulcer would be a Stage 3. RN-B packed the wound with [MEDICATION NAME] packing strip, and covered with an Allevyn dressing. NA-E finished dressing R33 and got her up in the wheelchair. R33 had an alternating pressure mattress on her bed. On 4/25/18, at 11:07 a.m. NA-E brought R33 out of her room in her high back reclining Broda (brand name) wheelchair, reclined at approximately 45 degrees. NA-E stated she had changed and repositioned R33 at 7:40 a.m. that morning, and stated R33 should be repositioned every two hours. NA-E verified she had not repositioned R33 timely. On 4/25/18, at 10:51 a.m. RN-B stated her previous statement regarding the staging of R33's pressure ulcer was incorrect, and stated it would be Unstageable pressure ulcer with the slough covering the wound bed. RN-B verified R33 should be repositioned every two hours, and stated she had not repositioned R33 when she had given her medications earlier. RN-B stated she thought R33 received the alternating pressure mattress, but was not sure. On 12/28/17, at 2:30 a.m. a progress note indicated R33 had been up in the wheelchair at the beginning of the nurse's shift at 6:00 p.m. R33 was agitated and yelling at other people. Resident yelled out, Ow, ow, ow, and when asked where she hurt, replied, My butt! Resident was laid down in bed per her preference, and once in bed, R33's behaviors ended and she rested. The progress note lacked indication if R33's skin had been observed at that time. On 1/10/18, a physician progress notes [REDACTED]. On 1/18/18, R33's progress notes and Skin Condition/Wound Progression note indicated R33 had multiple areas of blanchable redness on the buttocks and perineal area, and a small open area on the coccyx. R33's open area was identified as an abrasion. The progress note indicated R33 was incontinent of bowel and bladder, and frequently refused cares and repositioning. A note was left in the rounding book for the physician. On 1/19/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx open area was changed to a moisture lesion in the anal cleft. R33's wound measured 0.5 centimeters (cm) x 0.3 cm and was very superficial, and wound base was shiny granulation tissue (new connective tissue that forms when the wound is healing) with white surrounding skin. R33 was noted to be frequently incontinent of bowel and bladder, had loose stools at times, and refused cares at times, which Could have contributed to an increase of moisture on the skin and lead to skin breakdown. An [MEDICATION NAME] barrier cream was initiated with incontinent cares, and R33 was to be checked and changed every 2 hours and as needed. On 1/23/18, R33's Skin Condition/Wound Progression note indicated R33's moisture lesion was more irregularly shaped, and measured 0.5 cm x 0.8 cm, was very superficial, and had shiny granulation tissue. The wound edges had no white tissue and were normal skin colored. On 1/23/18, R33's nurse practitioner progress note indicated R33 was up sitting in the dining room, and was waiting for lunch. The note lacked any skin concerns. On 2/1/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx wound was irregularly shaped, very superficial, and measured 0.8 cm x 0.7 cm. The coccyx wound base continued to be shiny granulation tissue, with white tissue surrounding the wound, though wound edges were normal skin color and blanchable. On 2/5/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx wound was circular shaped and very superficial measuring 0.6 cm x 0.6 cm with yellow slough tissue (yellow devitalized tissue, that can be stringy or thick, and adherent on the tissue bed) in the wound base. Wound edges were normal skin color and blanchable. R33's treatment continued to be the same. On 2/16/18, R33's Skin Condition/Wound Progression note indicated 33's coccyx wound was circular shaped, measured 0.8 cm x 1.0 cm, was very superficial, though it had white slough tissue on the wound bed. The wound edges were normal skin color, and blanchable. On 2/16/18, R33's progress notes indicated R33's coccyx wound was larger in size with some depth noted to 75% of the wound bed, and had slough. R33's progress note indicated there were two purple linear areas noted to the right buttock, but were not open. The provider was updated through the rounding book. Staff were instructed to provide side to side positioning for R33, and to lay her down after meals. An addendum to the note, indicated an occupational therapy evaluation of the wheelchair cushion was requested. On 2/19/18, R33's Braden Scale score indicated R33's risk for pressure injuries had increased to a moderate risk with increased moisture. On 2/19/18, R33's progress note referencing the quarterly MDS assessment, indicated R33 required extensive to total assist of two staff for toileting, and was frequently incontinent of bowel and bladder. The note indicated R33 had a moisture associated lesion to her coccyx, and she was checked and changed every two hours and as necessary, which was determined to remain appropriate. R33's documentation noted, After speaking with the RN (registered nurse) MGR (manager) she had re-educated staff on the importance of following the care card/care plan of every 2 hrs (hours) toileting and lesion had then improved with staff compliance (when looking again after the re-education completed). No changes were made to R33's care plan at that time. On 2/22/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx wound had some depth, and measured 1 cm x 1.2 cm x 0.2 cm, and appeared as Kissing ulcers. These had a pink/red and moist wound base, and the wound edges were normal skin colored and blanchable. R33's buttocks were noted to have areas of very dry and peeling skin along with pin-point macerated areas. The wound care nurse assessed R33's skin on that date, and suggested application of 50/50 [MEDICATION NAME] (helps treat and prevent diaper rash, wet and cracked skin) and Vaseline cream to the buttocks with incontinent cares. The note further indicated the nurse practitioner was to be updated with requests of new orders the following day. On 3/1/18, R33's Skin Condition/Wound Progression note indicated R33's, Moisture lesion appeared as one open area and measured 1 cm x 1.2 cm x 0.1 cm. R33's wound base was pink and red and moist, with white and macerated looking irregular edges. R33's other macerated areas were healed. The same treatment was continued. On 3/7/18, R33's physician progress notes [REDACTED]. The note lacked any other skin concerns. On 3/15/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx wound measured 1.1 cm x 0.8 cm x 0.1 cm, and appeared less moist with a pink-red sound base. R33's wound edges were white or pink, macerated and irregular. On 3/20/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx wound measured 1.1 cm x 0.8 cm and the depth from 12 o'clock to 6 o'clock measured 0.1 cm, and the remainder measured 0.3 cm. R33's wound base was pink and dry, and wound edges were pink, irregular, and slightly firm to touch. R33's care plan was updated to turn and reposition R33 from side to side only. On 3/28/18, an occupational therapy (OT) discharge summary indicated R33 had been treated from 3/1/18, through 3/28/18, for positioning equipment. R33's goals included: R33 would be provided with a specialized wheelchair cushion that would provide optimal weight distribution, off loading ability, encourage upright posture, and pressure relief to reduce the chance of further skin integrity issues. It was noted that R33 had a moisture lesion on the coccyx that had worsened, and R33 refused to lay on side for pressure relief. R33 was non-ambulatory, and sat on a gel/foam cushion on the wheelchair. R33 was provided with an appropriate cushion to provide pressure relief, and improve skin integrity and weight distribution. On 4/6/18, R33's Skin Condition/Wound Progression note indicated R33's Moisture lesion measured 1 cm x 0.7 cm x 0.2 cm with a pink wound base and irregular, firm, pink edges. R33's treatment remained the same. On 4/10/18, R33's nurse practitioner progress notes indicated R33 was seen for follow up of nutritional assessment to support wound healing. R33's progress note indicated she was up in the dining room waiting for brunch. The note indicated R33 had a Moisture associated wound on her coccyx that has been slowly healing, possible cause is abrasion secondary to shearing. It was noted that barrier cream had been used over the last two weeks, nursing was attempting to keep resident as dry as possible with incontinence, and the wound had areas of maceration. R33's progress note indicated a supplement had been initiated to support healing. R33's progress note documented a Decubitus coccyx ulcer (pressure ulcer), unspecified staging, and directed the nurse manager to initiate follow up if skin breakdown worsened. On 4/11/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx wound measured 0.8 cm x 0.7 cm x 0.2 cm, with a pink, dry wound base, and pink, irregular, firm edges, that appeared as scar tissue. R33's treatment remained the same. On 4/16/18, R33's Skin Condition/Wound Progression note indicated R33's coccyx Moisture lesion measured 0.8 cm x 0.7 cm x 0.5 cm with a pink, dry base, with white, firm, irregular, macerated appearing edges, that appeared to be scar tissue. On 4/20/18, R33's Skin Condition/Wound Progression note indicated R33's Moisture lesion measured 0.8 cm x 0.7 cm x 0.5 cm with a pink wound base that was not moist, and had white, macerated and irregular, slightly firm edges. R33's note indicated the physician was updated with a request to change the wound care orders. The physician was noted to have ordered, Cleanse wound with wound cleanser and pat dry. Pack wound with [MEDICATION NAME] packing strips (used to absorb drainage in draining open and/or infected wounds). Cover with Allevyn boardered (sic) (foam) dressing. Change BID (twice daily) & prn (as necessary) if soiled or falls off. On 4/23/18, R33's Skin Condition/Wound Progression note indicated the moisture lesion was changed to a shearing injury. R33's coccyx wound measured 1.2 cm x 1.2 cm x 0.6 cm with undermining present to the wound of 0.2 cm around the entire circumference. R33's wound base was pink with scant amount of serosanguinous drainage noted on the dressing and wound base. Wound edges were white, macerated, and irregular from 6 o'clock to 11 o'clock, and were less firm. The note indicated R33 had been compliant with repositioning and changing of incontinent brief every 2 hours. It was noted at that time, R33's head of the bed had been elevated beyond 45 degrees, and R33 was not eating or drinking at that time, so the change in the wound appeared to be related to shearing. R33 had been observed to be scooting herself down in bed, and attempting to swing her legs over to the right side. R33's Care Card and care plan were updated to direct staff to not elevate the head of the bed beyond 45 degrees unless she was eating or drinking. All other interventions remained the same. R33's progress notes lacked documentation of R33's resistance to cares and repositioning. On 4/25/18, at 12:47 p.m. RN-B stated R33's ulcer was moisture related, and developed into a shearing injury. RN-B agreed that a shearing injury was a pressure related injury. On 4/25/18, at 2:14 p.m. RN-G confirmed she had looked at R33's pressure ulcer because it had gotten worse, so she recommended a change in treatment. RN-G stated it was now getting better. RN-G stated she questioned whether staff had been rubbing the barrier cream off, and then noticed undermining of the wound. RN-G stated the head of R33's bed had been elevated too high, and the pressure ulcer had developed more depth. RN-G stated R33 initially had moisture associated skin damage (MASD), rather then shearing. RN-G stated that undermining of a pressure ulcer was classic shearing. RN-G stated R33 had an alternating pressure mattress, and a turning and repositioning program, and it had been determined that R33 did not have unsustained pressure. RN-G verified R33 should be turned and repositioned every 2 hours, and stated the facility had been doing audits on repositioning about three to four weeks ago, and all the audits on that unit had come back showing no concerns. RN-G stated the facility did assessments with a root cause analysis, and the doctor signed off on them, and R33's MD had signed off on hers. RN-G stated the facility does measurements, documents appearance, drainage, treatment, and faxes the information to the physician. The physician group takes pictures of the wounds. On 4/26/18, at 11:32 a.m. the nurse practitioner (NP)-E was interviewed and verified she had not looked at R33's pressure ulcer, and stated she had not been notified of the worsening and the depth of the pressure ulcer. NP-E stated she was unaware that it was a, Hole and an ulcer, and stated she went by the information provided by the nurses. NP-E verified shearing can cause a pressure injury. NP-E stated if there is slough, the pressure ulcer would be considered unstageable. NP-E stated she expected to be informed of the worsening and condition of the pressure ulcer, and verified she would need to look at it, and the pressure ulcer would need to be identified correctly, so it can be treated appropriately. NP-E stated she was unaware that a physician had ordered the packing of the wound, and did not know if the physician had looked at the wound. On 4/26/18, at 11:34 a.m. RN-G stated R33 had moisture, was incontinent, and her bed had been at 45 degrees, so R33's pressure ulcer was determined to be from moisture and shearing. On 4/26/18, at 11:45 p.m. NP-E verified barrier ointments would not treat the inside or the base of the pressure ulcer. NP-E stated the wound needed to heal from the inside out. On 4/26/18, at 2:00 p.m. the director of nursing (DON) was interviewed and stated the nurse manager does a root cause analysis of skin impairments, and determines what the injury could be caused from. It was determined R33's coccyx wound was from moisture, and then on 4/23/18, it had gotten worse. R33's Braden score had changed, and the head of her bed was noted at 90 degrees, causing shearing and undermining. When asked about the increased depth and slough noted in R33's wound in February, the DON stated it was not pressure related, but was from sliding down in bed. The DON said at that time it was noted R33's Braden score had changed, and an alternating pressure mattress was implemented. The DON stated audits were done on R33's repositioning, and indicated repositioning had been done on time. That was how the facility determined R33's wound was a shearing injury. The DON stated also, the head of R33's bed was elevated at 90 degrees and she was sliding down. The DON stated the facility did not feel R33's pressure ulcer was pressure related. The DON was asked about the treatment of [REDACTED]. The DON replied the nurse manager noted the treatment needed to be changed, and new orders were obtained. Their wound nurse looked at it, and made recommendations. When asked about the slough, and if the barrier cream was appropriate to treat that, the DON replied the physician and nurse practitioner addressed it and agreed to the treatment, and the NP stated it had been addressed. The DON stated they have nurses who are wound certified and are trained annually. The DON stated the staff are to follow the Care Cards, as that is what they have access to. The DON stated skin assessments should be done when there is a new open area. The DON stated R33 had been resistive to reposition and cares in the past, but was less resistive now. The DON stated resistive behaviors should be documented, and followed up on. The Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/17, indicated pressure ulcers occur when tissue is compressed between a bony prominence and an external surface. In addition to pressure, shear force, and friction are important contributors to pressure ulcer development. The underlying health of a resident's soft tissue affects how much pressure, shear force, or friction is needed to damage tissue. Skin and soft tissue changes associated with aging, illness, small blood vessel disease, and malnutrition increase vulnerability to pressure ulcers. Additional external factors, such as excess moisture, and tissue exposure to urine or feces, can increase risk. Key areas for pressure ulcer development include the sacrum, coccyx, trochanters, ischial tuberosities, and heels. Other areas, such as bony deformities, skin under braces, and skin subjected to excess pressure, shear or friction, are also at risk for pressure ulcers. The facility policy and procedure for Skin Documentation dated 6/30/17, directed a resident who enters the facility without a pressure sore will not develop a pressure sore unless their clinical condition demonstrates that it was unavoidable and a resident who had a pressure sore would receive necessary treatment and services to promote healing. The policy and procedure directed nursing to complete a Braden Scale and Tissue Tolerance Test lying and sitting upon admission, quarterly, and annually and with any significant changes, and the Braden would also be done for the first four weeks after admission. The nurse manager would assess risk factors for impaired skin integrity and/or delayed wound healing and would document the identified risk factors, and implement appropriate interventions to prevent skin alterations and/or promote wound healing. The nurse manager was to would update all necessary departments of any risk factors associated with that department. The primary care physician would be notified within 24 hours of any new skin alterations, except when the physician requests to be notified on routine rounds only. The All wound would be reviewed and discussed with the interdisciplinary team weekly and as necessary, wound nurse or nurse manager would assess all pressure ulcers, venous ulcers, and other wounds of concern weekly, and if no improvement with wounds within 2 to 4 weeks, a new treatment would be tried if necessary. Nursing staff to document any non-compliance by the resident with the recommended interventions and education provided to the resident. The facility policy and procedure for Care Planning revised 10/17, directed that it is the expectation that staff would follow the resident's comprehensive care plan.