Every finding on record at Waverly Gardens

The facility failed to ensure 1 of 3 residents (R1) reviewed for abuse, was free from abuse during cares on 5/16/26, when licensed practical nurse (LPN)-A performed a manual removal of impacted feces from the rectum without consent and continued after R1 asked LPN-A to stop. The immediate jeopardy began on 5/16/26, when the facility failed to ensure R1 was free from abuse during cares when licensed practical nurse (LPN)-A performed a manual removal of impacted feces from the rectum without consent and continued after R1 requested he stop. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 5/27/26 at 5:00 p.m. The immediate jeopardy was removed on 5/28/26, but noncompliance remained at the lower scope and severity level D (isolated, scope and severity level) which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility on [DATE], from the hospital. R1 had moderately impaired cognition and no behaviors. R1 had functional limitations in range of motion (ROM) in upper and lower extremities on one side. R1 required substantial/maximal assistance with personal hygiene, was dependent on staff for all transfers, repositioning in bed, toileting hygiene, and lower body dressing. R1 was frequently incontinent of bladder and occasionally incontinent of bowel with constipation. R1's diagnoses included: stroke, atrial fibrillation, hemiplegia or hemiparesis (weakness or paralysis on one side of the body), adjustment disorder, mixed anxiety and depressed mood. R1's care plan dated 6/14/26, identified: Limited physical mobility and unable to ambulate. Staff were directed to transfer R1 with assist of two with a stand lift and support right arm, unable to hold (Should this be fold) her hand but able to bend elbow slight. R1 was at risk for abuse and/or neglect. Staff were directed to follow the facility Vulnerable Adult (VA) policy. Keep her safe and refer to resident services as needed (PRN). R1's physician orders identified: May use house standing orders. Order date: 5/13/26. Hydroxyzine HCL (hydrochloride) (given for anxiety) 25 milligrams (mg) every four hours by mouth (po) as needed (PRN) for anxiety or insomnia. Senna (laxative used to relieve constipation) 8.6 mg give two tablets po every 24 hours as needed for constipation times two daily (no stool in the last day). Start dated 5/13/26. Polyethylene Glycol (MiraLAX) (laxative) 3350 oral powder 17 gm (Grams)/scoop po one time a day for constipation. Order date: 5/15/26. Discontinue date: 5/21/26. Behavioral Expression: every shift for clinical monitoring for seven days. Start dated 5/19/26. End dated 5/26/26. Buddy Cares at all times. Nurses and aides, every shift. Start date: 5/19/26. R1's electronic medication administration (EMAR) reviewed 5/15/26 through 5/22/26, identified: Polyethylene Glycol 3350 oral powder 17 gm/scoop one time a day po for constipation for three days. Administered 5/16/26, 5/17/26, and 5/18/26. Bisacodyl rectal suppository 10 mg insert rectally every 24 hours as needed for constipation, no stool in the last three days. Administered on 5/16/26 at 7:26 p.m. Hydroxyzine HCL give 25 mg po every four hours PRN for anxiety or insomnia. Administered on 5/21/26 at 9:02 p.m. Hydroxyzine Pamoate capsule 50 mg every four hours PRN po for anxiety or insomnia. Administered on 5/13/26, 5/15/26, and 5/17/26. Senna 8.6 mg give two tablets po every 24 hours PRN for constipation times two daily as needed (no stool in last day). Administered on 5/16/26 at 3:02 p.m. Behavior Expression: refer to progress note template for assessment and documentation requirements every shift for clinical monitoring for seven days all three shifts and Buddy cares at all times (nurses and aides) every shift. Start date: 5/19/26 at 3:00 p.m. Check marks noted on 5/19/26, evening and night shift, 5/20/26 and 5/21/26, for all three shifts, and 5/22/26, for day shift. Polyethylene Glycol (MiraLAX) (laxative) 3350 oral powder 17 gm/scoop po one time a day for constipation. Administered on 5/22/26. R1's nursing assistant (NA) bowel movement (BM) documentation reviewed 5/14/26 through 5/17/26, identified: 5/14/26, no BM 5/15/26, no BM 5/16/26 at 4:42 a.m. no BM and 9:42 p.m., large BM. 5/17/26 at 4:19 a.m.,12:40 p.m., and 7:58 p.m., medium BMs. R1's NA Target Behavior documentation reviewed 5/14/26 through 5/27/26, target behaviors 1. Crying/sad and 2. Anxiety/Agitation occurred. Intervention attempted. Intervention effective/ineffective. Documentation identified: Target behaviors were documented as did not occur or not applicable from 5/14/26 through 5/18/26, 5/20/26, and 5/27/26 (7 days). 5/19/26 at 1:38 p.m., anxiety/agitation, other, intervention ineffective. 5/21/26 at 10:59 p.m., anxiety/agitation, crying/sad, reassure, intervention effective. 5/22/26 at 2:50 p.m., anxiety/agitation, crying/sad, conversation, intervention ineffective. 5/23/26 at 5:36 a.m., anxiety/agitation, other, intervention effective. 5/24/26 at 11:08 p.m., anxiety/agitation, reassure, intervention effective. 5/25/26 at 8:55 p.m., anxiety/agitation, reassure, intervention effective. 5/26/26 at 9:55 p.m., anxiety/agitation, reassure, intervention effective. Provider initial visit/assessment to establish a plan of care dated 5/14/26 at 5:16 p.m., R1 was hospitalized on [DATE] through 4/22/26 for acute ischemic stroke. While at a transitional care unit (TCU) occupational therapy (OT) was working with R1, and had a very large stool (bowel movement) (BM) after some prolonged constipation, dizziness leaving the bathroom, syncope (fainting or passing out), most likely a vasovagal event (the vagus nerve was stimulated typically from straining or discomfort during defecation leading to a sudden drop in heart rate and blood pressure which may result in fainting), loss consciousness, and pulselessness (lack of flow of circulation). A code blue (a medical emergency that required resuscitation) was called and R1 received 15 compressions with return of spontaneous circulation. R1's progress notes from 5/16/26 through 5/22/26, identified: 5/16/26 at 11:22 p.m., R1's daughter complained her mother had no bowel movements for the last three days. Senna was given per orders, rectal check was done and hard stool noted, suppository administered without results. Manual evacuation of stool was performed with removal of large amounts of stool. R1 expressed discomfort during the removal but was relieved at the end. 5/17/26 at 12:16 p.m., Alert and orientated to self with some confusion, increased anxiety observed upon rising this morning. Assist of two with stand lift transfer. 5/17/26 at 12:41 p.m., Family expressed concerns to staff regarding bowel habits, digital removal, policies regarding procedure. Family concerned that digital removal was painful, and she [R1] called family distressed after procedure was performed. Family expressed dissatisfaction with nurse who performed procedure. 5/17/26 at 11:56 p.m., Family wished to stay the night, staff prepared air mattress and bedding for family. Family changed mind later and went home to prepare for early morning appointment. Staff reported they would call family if any concerns arose during the night 5/18/26 at 1:00 p.m., Writer entered R1's room and daughter was present and brought up some concerns that she had been having. Writer reassured R1 and daughter that she would bring concerns to superiors. Writer immediately brought concerns to supervisor and director of nursing (DON) upon leaving room. 5/19/26 at 5:50 a.m., Overnight staff reported went to change R1, but she refused cares stating she was dry. Staff stated they just needed to change her brief, was a little wet from overnight, R1 was not pleased with that but let them. 5/19/26 at 7:16 a.m., R1's daughter called writer and reported her mother called crying and needed help immediately. Writer went into R1's room and she observed her sitting on bedside on the verge of tears. R1 stated I haven't slept since 5:00 a.m., because I do not know why people have to come in here and change people at 5:00 a.m. when they are supposed to be sleeping. Writer apologized, reassured her care plan will be updated. R1 stated I am sorry to bother you with my complaints, but I am in pain. Writer offered medication, accepted, and administered. 5/19/26 at 2:36 p.m., R1 alert, oriented to self, family, place with forgetfulness and confusion within her baseline. R1 refused therapy this morning due to fatigue per resident, slept in per request and cares were done as allowed by R1. 5/19/26 at 4:07 p.m., Email message sent to Pastor, daughter requested a visit for R1, thought it benefit her mom. 5/21/26 at 10:58 a.m., Pastor visit made. 5/21/26 at 4:30 p.m., DON checked in on R1. Daughter and ex-husband were both in R1's room. Daughter inquired about the possibility of rectal bleeding following recent stool removal procedure, expressed concern related to potential rectal tearing. DON informed daughter if any tissue injury had occurred symptoms would likely have presented by this time and no observed or reported signs/symptoms identified. 5/22/26 at 2:21 p.m., R1 refused toileting, bed bath, and scheduled weekly shower, requested to be able to go back to sleep, stated not now, later, and reapproached with no success. R1's Bowel, Bladder, and Skin Risk assessment dated [DATE], identified areas affecting elimination patterns: decreased mobility, chair bound, and poor fluid intake. Bowel movement frequency was identified as: more than three days since admission and constipation. PRN or routine bowel medications: senna PRN and MiraLAX daily. Suspected type of incontinence (due to) decreased mental awareness, decreased loss of mobility or personal unwillingness. Ability of skin and underlying tissue to tolerate exposure to pressure: no new skin integrity issues reported or observed. R1's Body Audit completed on 5/22/26 at 6:25 p.m., by registered nurse (RN)-C identified current alterations in skin integrity: other type of alternations. Scattered bruising on belly and near both elbows/antecubital spaces. R1 had an old/healing scratch mark on her left shin, daughter said she thought it was from the lift machine in the hospital. All other areas of skin are clean, dry and intact. R1's Body Audit completed on 5/27/26 at 9:11 p.m., by DON identified overall skin is clean, dry and intact. All bruises are in the healing stage, and the scratch continues to heal without issues. The peri-anal area was assessed and unremarkable. The anus is clean, intact, without visible cuts, tears, or lumps and is normal in size and shape. Psychology visit dated 5/22/26, identified R1, recently had an incident during caretaking where she felt violated by a staff member. It had been reported and investigated appropriately by the facility/regulatory officials. Appointment was made to follow up to evaluate distress and provide additional support. R1's mental status exam identified oriented to general situation, short term memory mildly impaired, thought process linear, goal directed, and thought blocking (sudden interruptions in a person's thought process often associated with various mental health conditions), depressed and anxious mood, and quality of mood: anxious and dysphoric ( hard to bear characterized by feelings of sadness, irritability, restlessness, and general discomfort). R1's symptoms identified: moderate depressed mood and low self-worthlessness/guilt moderate, and mild crying spells. Regarding the recent incident, R1 stated she remained emotionally impacted but felt she continued to process and gained some emotional distance from it. R1 reported she felt increasingly supported and reassured by the facility response and identified several individuals she can reach out to if needed. She currently felt safe, heard and comfortable with the environment. Treatment recommendations: paired-care approaches, as she had identified this as reassuring and emotionally regulating for both herself and staff and trauma-informed and emotionally validating approaches emphasizing predictability, reassurance, and collaborative communication (knocking before entering, announcing presence with name and role, extra attention to explaining cares, going slow and allowing her input). During an interview on 5/22/26 at 11:38 a.m., NA-F stated she saw R1 cry on 5/18/26. R1 stated the nurse abused her on 5/16/26, he placed his finger in her, and she begged him to stop. R1 told NA-F, he was smiling when she looked at him and every time she talked about it, she cried. Monday was a very difficult day for R1. When R1 cried on 5/18/26, it was different that day versus days prior to the incident since admission to the facility, R1 had more emotion and seemed completely upset with what happened to her. R1's daughter informed NA-F the incident happened on 5/16/26 around 6:00 p.m. A male nurse (LPN-A) administered a rectal suppository. R1 told NA-F, at approximately 8:30 p.m., LPN-A put his finger her rectum to pull out the BM and hurt R1. R1 stated she just wanted him to stop, it was so painful. NA-F reported this incident right away to the DON on 5/18/26. NA-F stated when R1 requested the nurse to stop he should have stopped. LPN-A seemed to always smile. When NA-F asked LPN-A why he smiled all the time he told her why should I be angry? NA-F stated LPN-A had the kindest expression and did not think he would intentionally hurt anyone. NA-F stated she had not received education regarding abuse since this incident. During an interview on 5/22/26 at 12:37 p.m., R1 stated she had no concerns about staff until 5/16/26, when she was constipated and unable to have a BM. R1 felt the nurse was in a hurry, and one or two other female staff were in the room with him. The nurse inserted his finger into her anus, started to circle it around and informed her he had to do that to make the stool come out. R1 stated the male nurse kept circling his finger, Over and over, and she started to cry and begged him to stop. LPN-A told R1, We need to get it out of here, just relax. R1 told LPN-A, Oh please stop you are hurting me. When R1 looked at LPN-A, He smiled at me and I felt he was laughing at me. R1 stated she begged him to stop, it made her vulnerable, embarrassed, and felt he was making a mockery for her. You can ask the other staff when I begged him to stop, they were standing right there. During a follow-up interview on 5/22/26 at 4:55 p.m., R1 stated the nurse kept digging with his finger, It felt like it was in the vaginal area but hard to say for sure, he was doing it so fast. It was very painful. I told him he was hurting me. He grinned at me. It was awful. It made me feel like a piece of dirt. R1 stated she tried to let it go but it continued to bother her and felt it was horribly demeaning. R1 stated she cried when it came to mind. R1 was sad that someone could treat her that way. R1 stated she wondered what the repercussions were for the nurse, Will he be upset and come back and hurt me? Does he expect me to be submissive and let him hurt me? It was very unprofessional. I do not want to believe he treated other people like that but if he came back to work, would he retaliate? R1 stated it was perplexing for her. During an interview on 5/22/26 at 1:45 p.m., NA-D stated R1 had some difficulty with memory. Since admission on [DATE] through today, R1 had increased behaviors such as refused therapy, refused to participate in activities of daily living (ADLs), and did not want to get up until 12:00 p.m. today. R1 did not say why she refused these things, but nothing seemed to be working for her. NA-D thought R1 seemed sad with her stroke and talked about how it impacted her. NA-D had not worked with LPN-A. Last time she had received education on abuse was one month ago. During an interview on 5/22/26 at 2:04 p.m., NA-E stated today had been a hard day for R1, she refused breakfast, only ate four bites of toast, and refused her shower. R1 seemed to not focus or pay attention when NA-E talked with her and overwhelmed with many staff in the room at one time. Yesterday, R1 informed NA-E at the end of the day, a nurse assisted her with constipation and how she had not liked his approach. NA-E stated she planned on reporting it to the DON but forgot and told her today instead. NA-E received abuse education one month ago. Staff were expected to approach R1 with two staff now and she was unaware of why. During an interview on 5/22/26 at 2:42 p.m., LPN-D stated on 5/18/26 at approximately 1:00 p.m., she entered R1's room and R1's daughter reported she had concerns about the care her mother received. Daughter indicated specifically the name of the nurse [LPN-A] administered a rectal suppository, dug out stool from R1's rectum with possible vaginal penetration, and R1 experienced quite a bit of pain. LPN-D informed R1 and daughter she would bring this information immediately to her supervisor. LPN-D left R1's room, went directly to DON and reported the incident. LPN-D stated she was unaware of who was responsible for completing the assessment on R1 after an allegation of abuse. LPN-D did not complete an assessment. LPN-D stated the nurse would be expected to listen to the resident if they indicated they were in pain, stop what they were doing, and contact provider if needed. LPN-D had not received education on abuse since orientation in 1/2026. During an interview on 5/22/26 at 3:15 p.m., LPN-C stated a suppository and/or manual stool removal can be uncomfortable but should not be painful. When a resident asked a nurse to stop, the nurse should stop. Pain tolerance was different for everyone. If the resident complained of pain, the nurse should stop, respect the resident, find a different way to get the results, and contact a provider for further orders. Any allegation of abuse should have been reported immediately to the supervisor. Staff involved in the allegation should be removed from work to protect the residents. A physical assessment, including the area of concern, should be completed right away to provide a clear picture of what may have happened. The assessment should also include a behavior assessment with changes from baseline noted and documented. If a resident was scared, they would be more anxious and possibly crying. LPN-C verified documentation of a physical or behavior assessment was not identified in R1's medical record. R1's care plan was changed with direction for two staff go into R1's together for all needs and cares. This was done to make sure R1 was safe. LPN-C stated they had not received any additional education on abuse or removal of impaction of stool since 5/16/26, following the incident. During an interview on 4/22/26 at 4:15 p.m., NA-A stated R1 had a change in her behavior since the incident on 5/16/26. On 5/16/26, R1 was having trouble with a BM that wouldn't come out and requested to go to the bathroom every 15 minutes. NA-A asked LPN-A to take a look at R1. LPN-A offered a suppository, R1 agreed. NA-A was in R1's room when LPN-A gave R1 a suppository, NA-A felt it went well. R1 did not have any results from the suppository. LPN-A offered to remove the BM. NA-A was unsure if R1 gave consent but remembered LPN-A explained to R1 what he was going to do. R1 was transferred into the bathroom with a stand lift. LPN-A attempted to scoop the BM out of R1's rectal area with a gloved hand. NA-A was unable to see specifically where LPN-A's hands were placed. NA-A heard R1 state, Stop, stop, stop. while she cried. NA-A asked LPN-A, Are you done yet, she doesn't want to do this anymore, can we be done? LPN-A did not respond right away then stated he was almost done and continued to remove hard stool for one to two minutes. R1 screamed out while crying, asking LPN-A, Stop! Please stop! LPN-A continued for another minute to remove stool manually with his hand. R1 was lowered down onto the toilet. NA-A could see in R1's face, she was shaken up. R1 stated, That was the most terrible thing I have ever went through. NA-A stated it was scary. R1 stopped crying around 7:30 p.m. NA-A stated she saw manual bowel removal done before but had never seen a resident have this much pain or discomfort during the procedure. NA-A did not see any blood. NA-A stated she should have reported this incident to the supervisor. NA-A's feeling about this was not good, and thought LPN-A knew what he was doing. Today, R1 refused her bath, didn't want to get out of bed, was anxious, and cried a few times. R1 had anxiety prior to this incident but it seemed to be really sinking in for her now and that was why she had increased anxiety, refused to shower, get out of bed, and did not eat much. NA-A stated she should have told another nurse when it happened, she was in shock at the time. NA-A stated R1 told NA-A today, LPN-A had placed his finger in her vagina, R1 had not said this on 5/16/26. NA-A was interviewed on 5/18/26 and again on 5/22/26 by DON and received education on VA reporting. NA-A did not notice anything different with R1's skin the day of the incident. During an interview on 5/26/26 at 2:15 p.m., R1's primary provider nurse practitioner (NP) stated R1 had concerns with constipation while in the hospital with a Vaso Vagal response. NP stated she had seen R1 on 5/16/26 and noted R1 had not had a BM since admission. 5/16/26 was R1's fourth day without a BM. NP stated standing orders for constipation should have been initiated prior to 5/16/26. The nurse would have been expected to follow the protocol, listen to bowel sounds, note if R1 was eating, drinking, and document findings. Once the standing orders are implemented, senna should have been given as ordered, waited 24 hours, if no BM then administered a suppository, then a fleets enema. The nurse was expected to not do all the steps one after another. If the resident is doing ok, the nurse is expected to follow orders. The nurse would be expected to complete assessments to guide them on the next step taken. When a resident does not have bowel sounds it could be a bad sign, and an x-ray may be needed. If additional orders are needed, the on-call provider should have been contacted. NP stated she had never given orders for manual removal of stool, and the standing order indicated rectal checks. There was no standing order for bowel impaction and was unsure if an order was needed for disimpaction. The nurse would be expected to check for the presence of stool. This may have resulted in disimpaction of stools due to stimulation, without the need for manual removal. The rectal check could have felt invasive, painful and uncomfortable. A resident may cry and complain of pain during manual removal of hard stool; the nurse should have listened to the resident and stopped. The NP stated three minutes seemed like a long time in general for manual removal of stool. The nurse would be expected to assist with stool coming out but if the resident is distressed and in pain, the nurse would be expected stop as soon as they can. There are risks with manual removal of stool such as bleeding, pain, or a rectal tear, depending on how big and hard the stool was. The NP verified there was no documentation in R1's medical record to indicate the on-call provider was contacted on 5/16/26. The NP stated she was made aware of the incident on 5/17/26. It would have been helpful for her or the on-call provider to know about R1's constipation due to this specific situation. If R1 was that constipated, a provider could have provided further direction regarding what to do next. A physical exam would not have been needed after the incident as would not have shown. R1 did not have vaginal or rectal bleeding that NP was aware of. NP stated she was not aware of changes in behaviors with R1. R1 seemed calm, cooperative, was anxious and did not like to be alone due to previous deaths in family, and more depressed over the stroke situation. During an interview on 5/26/26 at 3:03 p.m., RN-D stated nurses are expected to follow the facility standing orders for constipation, administer the medications as ordered, and allow time for medications to work. A physical assessment should have been completed which included listening for bowel sounds and examine the abdomen (hard, soft, or distended). The assessment should have been completed at least every shift if the resident had no BM for three days. The assessment results were used to determine how the resident was responding. The provider should be contacted if additional orders were needed. RN-D stated manual stool removal was an invasive procedure, could be traumatizing to the resident, and could have had a history in which it would not be appropriate, therefore an order would have been needed. Manual stool removal would have been uncomfortable but should not have been painful. R1 should have been positioned on her left side in a Sims position (due to the anatomy/ position of the intestine helps promote evacuation of the stool) and made comfortable. This process should not have been completed while R1 stood up. RN-D stated, Given the population we work with, it would have placed the resident at risk for a fall, being uncomfortable, and the nurse would have been unable to see what they are doing, which increased the risk for harm to the resident such as rectal tear and/or bleeding. If a resident stated they were in pain and requested the nurse to stop, the nurse would be expected to stop immediately. This type of situation could have caused harm to the resident, it was a sign something wasn't going well, and there was a need to come up with a different intervention and/or plan. On 5/17/26 at 3:45 p.m., R1's family voiced concern to her about digital removal of stool, pain, and dissatisfaction with how the nurse performed the procedure. RN-D stated she listened to the daughter and looked at the standing orders. RN-D now realized she should have asked more questions and reported the daughter's concerns to the supervisor right away. RN-D completed a neurological assessment on 5/17/26, assisted R1 to the bathroom, but did not assess her skin on her bottom or rectal area. RN-D stated she documented in R1's progress notes, the concerns the family had but should have taken action to keep R1 safe, assess and follow up in case the procedure caused harm. RN-D stated it could have been abuse and caused harm. RN-D stated she was not interviewed and had not received abuse education since the incident. During an interview on 5/26/26 at 4:04 p.m., LPN-A stated the facility protocol for constipation and/or impacted stool included the night nurse was responsible to check in the computer and see how many days each resident had gone without a BM. After three days without a BM, the night nurse entered the standing orders for Senna twice a day to be administered on day four. The nurse completed rectal check on day five and administered a suppository. If no results from the suppository, then the nurse administered an enema. LPN-A stated, usually after the suppository, stool can be felt. If the resident had poor cognition, then LPN-A would contact the on-call provider and ask for orders. LPN-A stated when a resident indicated they were constipated; the nurse was expected to give the resident options and ask what they would prefer. LPN-A stated that was how he completed the assessment. LPN-A would document results of the assessment in the medical record so that other staff can see what has been done so far. On 5/16/26, R1 agreed to manual removal of the stool. LPN-A stated it was his first time taking care of R1, he did not know how long it had been since R1 had a stool and was unaware if she had a history of constipation other than what her daughter told him. R1's daughter approached LPN-A and indicated she had not had a stool for five days and requested something be given. LPN-A stated R1 had already received MiraLAX, so LPN-A administered senna. One hour later, R1's daughter informed LPN-A, R1 had not had a bowel movement yet. Twenty minutes later, while R1 laid in bed, he completed a rectal check, placed his finger R1's in rectum, felt stool, and administered a suppository. R1's daughter left the facility at 6:30 p.m. Approximately 40 minutes later, R1 requested to go to the bathroom and NA-A asked him if he could help R1. While R1 stood in bathroom by the toilet, LPN-A placed gloves on and asked R1 if she could push stool out, R1 stated, No. LPN-A informed R1 he planned on pulling it out. R1 told LPN-A, It's hurting me. LPN-A informed R1, It's going to hurt because it's hard. LPN-A placed his finger inside her rectal area and pushed on the hard stool with his finger. LPN-A stated he did not swirl his finger around, nor did he enter the vaginal area, and NA-A was there as a witness. R1 told LPN-A, It's hurting me, but was not crying. LPN-A did not remember R1 asking him to stop, If she had, I would have stopped and reported to the nurse practitioner. The stool was giving her [R1] pain, not me. I just needed to get it out, it was so hard, and she was very uncomfortable. There was quite a big piece of stool that came out. LPN-A stated a physical assessment of R1's abdomen was not completed, The stool was just hanging there. I am unsure how long the removal took. [NA-A] did not ask me to stop. LPN-A stated in his nursing career he usually took the resident to the bathroom; he never manually removed stool while laying down. In nursing school, LPN-A was not taught to use a certain position, only how to get the stool out. LPN-A stated it was his process to manually remove R1's stool in the bathroom, he made a nursing judgement to get it out. LPN-A did not feel he could go back and call the provider, I helped [R1], and documented what I did. LPN-A stated the manual removal of R1's stool was not completed according to the facility policy/protocol. The enema was not administered, R1's provider was not updated for further directions. LPN-A stated, following the protocol would have been important to him as a nurse, They would have helped the resident, and then they couldn't say, 'You did not call the provider. LPN-A stated he did not typically follow facility protocol for constipation, however he would next time. LPN- A stated facility protocol included directions to administer the enema, call the provider if there were not results, and send resident to emergency room if ordered. LPN-A stated he was a smiling person; he was not smiling during the time he assisted R1 with stool removal and was not sure why R1 reported that. He returned to work on 5/18/126 at 2:30 p.m., assigned to the same area he had worked on 5/16/26, worked until almost 5:00 p.m. when approached, was told something happened on Saturday and sent home. LPN-A stated he was placed on leave, had not worked since, and interviewed regarding the incident for the first time on 5/19/26. During an interview on 5/27/26 at 8:15 a.m., DON stated staff were expected follow the facility process/policy/protocol for constipation. The nurse would be expected to complete initial and ongoing physical assessments which included listening to bowel sounds, checking for abdominal tenderness, distention, nausea, review BM log, and document findings. DON stated R1 was impacted with stool when she came to their facility, staff were not informed R1 had not had a BM when admitted to the facility. R1 had a vaso vagal episode in the hospital that was determined it was due to bearing down during a BM. When a resident failed to have a BM for three days, nurses were expected to have completed a rectal check to determine impaction. Once impaction was confirmed, nurses were expected to follow the protocol and start with administration of senna. DON stated LPN-A would have been expected to complete basic abdominal assessment and document. LPN-A should have followed the facility protocol and administered an enema prior to manual removal of the stool. When family voiced concerns related to a resident's bowel pattern, the nurse would have been expected to provide education, explain what and why he was doing to lower anxiety, bring trust and provide a clear picture of the next steps so that they would have been aware of what to expect. LPN-A administered two senna (takes up to 24 hours to work), on the same day a suppository was administered (takes more than a few hours and up to 12 hours to have results depending on the severity of the

Based on interview and document review, the facility failed to report an allegation of abuse to the State Agency (SA) within two hours for 1 of 1 resident (R1) who was witnessed being abused by a staff member. Findings include: Facility Vulnerable Adult (VA) Maltreatment Report filed with State Agency (SA) dated 5/18/26 at 5:36 p.m., identified estimated date and time of most recent occurrence was 5/16/26 at 8:00 p.m. in resident bathroom. Description of incident: Allegation of sexual contact by daughter today on 5/18/26. VA complained of rectal pain before, during, and after administration of bowel evacuation regime. Daughter stated VA called her crying around 8:30 p.m. on 5/16/26 stated he hurt me! He hurt me! He put his fingers in my rectum and vagina. VA interviewed in room today 5/18/26 and she wept, I looked back at him while he was behind me and was smiling at me while he hurt me, digging around in my anus. Allegation: sexual abuse.Facility 5-day report dated 5/22/26 at 8:13 p.m., identified on 5/18/26, R1's daughter reported an allegation of inappropriate sexual contact involving facility staff. R1 had a history of constipation and rectal pain due to bowel management interventions. R1 complained of pain following administration of a rectal suppository during manual removal of stool and documented by a nurse on 5/16/26 prior to allegation made on 5/18/26. On 5/16/26 at approximately 8:30 p.m. R1 called daughter in a distressed stated crying and stating, he hurt me, he hurt me and put his fingers in my rectum and vagina. On 5/18/26, R1 was interviewed in presence of daughter and appeared tearful and stated I looked back at alleged perpetrator while he was behind me and he was smiling while he is hurting me, digging around in my anus. At the time the allegation was disclosed on 5/18/26, R1 appeared tearful, covered her mouth and stated, I don't want to get him or anyone into trouble, or anyone to lose their job, but he hurt me. R1 had received a rectal suppository and reported pain during insertion without results and later assisted to the bathroom by nursing assistant NA-A and licensed practical nurse LPN-A. R1 stated during this time LPN-A placed his fingers in her rectum and vagina and she kept saying you're hurting me, you're hurting me. NA-A stated she observed R1 stood in a stand lift while LPN-A performed manual stool removal from her rectum. During that process R1 had significant discomfort, tearful, appeared shaken and stated stop but LPN-A continued attempting to remove the stool. NA-A stated she asked LPN-A if we could be done now and did not stop and procedure took approximately two to three minutes. When done R1 stated glad it's one it was terrible. LPN-A stated manual removal of stool was done with a gloved hand and R1 appeared uncomfortable during the process, did not insert his finger as the hard stool was right there, hard as a rock, difficult to remove, and just needed to pull it out. LPN-A did not pause when R1 was in pain during removal of the stool because it was coming in pieces. When R1 said stop he stopped three times, told her if it was going to hurt, she tried to push it out, and he was finally able to pull it out. LPN-A stated was aware of the of the facility policy on removal of impactions and if there was pain to stop and pause the procedure.R1's Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility on [DATE], from the hospital. R1 had moderately impaired cognition and no behaviors. R1 had functional limitations in range of motion (ROM) in upper and lower extremity on one side. She required substantial/maximal assistance with personal hygiene and lying to sit on bed, dependent for all transfers, repositioning in bed, toileting hygiene, and lower body dressing, and used a manual wheelchair for mobility. R1 was frequently incontinent of bladder and occasionally incontinent of bowel with constipation. R1's diagnoses included: stroke, atrial fibrillation, hemiplegia or hemiparesis (weakness or paralysis on one side of the body), adjustment disorder with mixed anxiety and depressed mood.R1's care plan dated 5/14/26, identified:-R1 was at risk for abuse and/or neglect. Staff were directed to follow the facility Vulnerable Adult (VA) policy. Keep her safe and refer to resident services as needed (PRN).R1's physician orders identified:- Behavioral Expression: every shift for clinical monitoring for seven days. Start dated 5/19/26. End dated 5/26/26. -Buddy Cares at all times. Nurses and aides, every shift. Start date: 5/19/26.R1's nursing assistant (NA) BM documentation from 5/14/26 through 5/17/26, identified:-5/14/26, no BM -5/15/26, no BM -5/16/26 at 4:42 a.m. no BM and 9:42 p.m., large BM. -5/17/26 at 4:19 a.m.,12:40 p.m., and 7:58 p.m., medium BMs.R1's NA Target Behavior documentation from 5/14/26 through 5/26/26, target behaviors 1. Crying/sad and 2. Anxiety/Agitation occurred. Intervention attempted. Intervention effective/ineffective. -5/19/26 at 1:38 p.m., anxiety/agitation, other, no. -5/21/26 at 10:59 p.m., anxiety/agitation, crying/sad, reassure, yes. -5/22/26 at 2:50 p.m., anxiety/agitation, crying/sad, conversation, no. -5/23/26 at 5:36 a.m., anxiety/agitation, other, yes. -5/24/26 at 11:08 p.m., anxiety/agitation, reassure, yes.-5/25/26 at 8:55 p.m., anxiety/agitation, reassure, yes.-5/26/26 at 9:55 p.m., anxiety/agitation, reassure, yes.Target behaviors were documented as did not occur or not applicable from 5/14/26 through 5/18/26, 5/20/26, and 5/27/26 (7 days).R1's progress notes from 5/16/26 through 5/22/26, identified: -5/16/26 at 11:22 p.m., R1's daughter complained her mother had no bowel movements for the last three days. Senna was given per orders, rectal check was done and hard stool noted, suppository administered without results. Manual evacuation of stool was performed with removal of large amounts of stool. R1 expressed discomfort during the removal but relieved at the end. -5/17/26 at 12:16 p.m., Alert and orientated to self with some confusion, increased anxiety observed upon rising this morning. Assist of two with stand lift transfer. -5/17/26 at 12:41 p.m., Family expressed concerns to staff regarding bowel habits, digital removal, policies regarding procedure. Family concerned that digital removal was painful, and she called family distressed after procedure was performed. Family expressed dissatisfaction with nurse who performed procedure. -5/17/26 at 11:56 p.m. Family wished to stay the night, staff prepared air mattress and bedding for family. Family changed mind later and went home to prepare for early morning appointment. Staff reported they would call family if any concerns arose during the night -5/18/26 at 1:00 p.m. Writer entered R1's room and daughter was present and brought up some concerns that she had been having. Writer reassured R1 and daughter that she would bring concerns to superiors. Writer immediately brought concerns to supervisor and director of nursing (DON) upon leaving room. -5/19/26 at 5:50 am. Overnight staff reported went to change R1, but she refused cares stating she was dry. Staff stated they just needed to change her brief, was a little wet from overnight, R1 was not pleased with that but let them. -5/19/26 at 7:16 a.m., R1's daughter called writer and reported her mother called crying and needed help immediately. Writer went into R1's room and she observed her sitting on bedside on the verge of tears. R1 stated I haven't slept since 5:00 a.m., because do not know why people have to come in here and change people at 5:00 am when they supposed to be sleeping. Writer apologized, reassured her care plan will be updated. R1 stated I am sorry to bother you with my complaints, but I am in pain. Writer offered medication, accepted, and administered. -5/19/26 at 2:36 p.m. R1 alert oriented to self, family, place with forgetfulness and confusion within her baseline. R1 refused therapy this morning due to fatigue per resident, slept in per request and cares were done as allowed by R1. -5/19/26 at 4:07 p.m., Email message sent to Pastor, daughter requested a visit for R1, thought it benefit her mom. -5/21/26 at 10:58 a.m. Pastor visit made. -5/21/26 at 4:30 p.m. DON checked in on R1. Daughter and ex-husband were both in R1's room. Daughter inquired about the possibility of rectal bleeding following recent stool removal procedure, expressed concern related to potential rectal tearing. DON informed daughter if any tissue injury had occurred symptoms would likely have presented by this time and no observed or reported signs/symptoms identified. -5/22/26 at 2:21 p.m., R1 refused toileting, bed bath, and scheduled weekly shower, requested to be able to go back to sleep, stated not now, later, and reapproached with no success.Psychology visit dated 5/22/26, identified R1, recently had an incident during caretaking where she felt violated by a staff member. It had been reported and investigated appropriately by the facility/regulatory officials. Appointment was made to follow up to evaluate distress and provide additional support. R1's mental status exam identified oriented to general situation, short term memory mildly impaired, through process linear, goal directed, and thought blocking (sudden interruptions in a person's thought process often associated with various mental health conditions), depressed and anxious mood, and quality of mood: anxious and dysphoric (means hard to bear characterized by feelings of sadness, irritability, restlessness, and general discomfort). R1's symptoms identified: moderate depressed mood and low self-worthlessness/guilt moderate, and mild crying spells. Regarding the recent incident, R1 stated she remained emotionally impacted but felt she continued to process and gained some emotional distance from it. R1 reported she felt increasingly supported and reassured by the facility response and identified several individuals she can reach out to if needed. She currently felt safe, heard and comfortable with the environment. Treatment recommendations: paired-care approaches, as she had identified this as reassuring and emotionally regulating for both herself and staff and trauma-informed and emotionally validating approaches emphasizing predictability, reassurance, and collaborative communication (knocking before entering, announcing presence with name and role, extra attention to explaining cares, going slow and allowing her input).During an interview on 5/22/26 at 11:38 a.m. NA-F stated she saw R1 cry on 5/18/26. R1 stated the nurse abused her on 5/16/26, he placed his finger in her, and she begged him to stop. R1 told her he was smiling when she looked at him and every time she talked about it, she cried, Monday was a very difficult day for R1. When R1 cried on 5/18/26, it was different that day versus days prior to the incident since admission to the facility, she had more emotion and seemed completely upset with what happened to her. R1's daughter informed her the incident happened on 5/16/26 around 6:00 p.m. when a male nurse LPN-A administered a rectal suppository. At approximately 8:30 p.m., LPN-A placed his finger in to pull out the BM and hurt R1. R1 stated she just wanted him to stop, it was so painful. NA-F reported this incident right away to the DON on 5/18/26. NA-F stated when R1 requested the nurse to stop he should have stopped.During an interview on 5/22/26 at 12:37 p.m., R1 stated she had no concerns about staff until 5/16/26, when she was constipated and unable to have a BM. There was a male nurse, she felt he was in a hurry, and one or two other female staff were in the room with him. The nurse inserted his finger into my anus, started to circle it around and informed her he had to do that to make the stool come out. R1 stated the male nurse kept circling his finger over and over and she started to cry with tears and begged him to stop. He stated we need to get it out of here, just relax. She told him Oh please stop you are hurting me and turned around, he smiled at her and felt like he laughed at her. She begged him to stop, it made her vulnerable, embarrassed, and felt he was making a mockery for her. R1 stated you can ask the other staff when she begged him to stop, they were standing right there.During a follow-up interview on 5/22/26 at 4:55 p.m. R1 stated the nurse kept digging with his finger, felt like it was in the vaginal area but hard to say for sure, he was doing it so fast, very painful, felt like she was going through the roof told him you are hurting me, he grinned at her, it was awful, and made her feel like a piece of dirt. R1 stated she tried to let it go but still bothered her and felt it was horribly demeaning. R1 stated she cried and when it came to mind, she became sad that someone could treat her that way. Observation during the interview identfied R1 became teary eyed. R1 stated she wondered what the repercussion were for the nurse, would he be upset and come back and hurt her? Did he expect her to be submissive and let him hurt her, it was very unprofessional. She did not want to believe he treated other people like that but if he came back to work, would he retaliate? R1 stated she did not know him, but you never know, and he seemed humiliated afterwards, but did he think it was the right way to act? It was perplexing for her.During an interview on 5/22/26 at 2:04 p.m. NA-E stated today had been a hard day for R1, she refused breakfast, offered toast, accepted and ate only 4 bits, refused shower, accepted a bed bath instead but was unable to complete a bed bath before end of day, and passed it onto the next shift. R1 seemed a bit more absent when she conversed with her and overwhelmed with many staff in the room at one time. Yesterday, R1 informed her at the end of the day something about a nurse assisting her with constipation and how she had not liked his approach. NA-E stated she planned on reporting it to the DON but forgot and told her today instead. Staff were expected to approach R1 with two staff now and she was unaware of why.During an interview on 5/22/26 at 2:42 p.m., LPN-D stated on 5/18/26 at approximately 1:00 p.m. she entered R1's and daughter indicated she had concerns about the care her mother received. Daughter indicated specifically the name of the nurse [LPN-A] administered a rectal suppository, dug out stool from her rectum with possible vaginal penetration, and R1 experienced quite a bit of pain. LPN-D informed R1 and daughter she would bring this information immediately to her supervisor. LPN-N left R1's room, went directly to DON and reported the incident. The nurse would be expected to listen to the resident if they indicated they were in pain, stop what they are doing, and contact provider if needed. During an interview on 5/22/26 at 3:15 p.m. LPN-C stated a suppository and/or manual stool removal could have been uncomfortable but not painful. When a resident asked a nurse to stop, stop and go by what they said. Pain tolerance was different for everyone, if painful stop, respect the resident, find a different way to get the results, and contact a provider for further orders. Any allegation of abuse should have been reported immediately to the supervisor, removal of staff involved to protect the residents, and a physical assessment including the area of concern, should have been completed right away to provide a clear picture of what may have happened, if anything, and make sure it did not happen againDuring an interview on 4/22/26 at 4:15 p.m. NA-A stated R1 had a change in her behaviors since the incident on 5/16/26. Today (4/22/26) she had refused her bath, didn't want to get out of bed, anxious, and cried a few times. On 5/16/26, R1 had a BM that wouldn't come out and had to go to the bathroom every 15 minutes, tried to get her comfortable in any way we could, then she started to cry. The past week she was constipated and on Friday (5/14/26) NA-A asked another nurse if he could look at it and not be sure if that happened. On 5/16/26, she asked LPN-A to look at R1 and when he did state yes there is a problem here, offered a suppository, R1 agreed, and suppository was given and went well. R1 did not have any results from the suppository and aske LPN-A what can he do, and he stated maybe we can take it out. Unsure if R1 gave consent but remembered LPN-A explained to R1 what he was going to do. R1 was transferred into the bathroom with a stand lift and LPN-A stood by the wall, looking down at R1's buttocks. LPN-A placed gloved on and attempted to scoop the BM out of her rectal area. NA-A was unable to see where his hands were placed. R1 stated stop, stop, stop, while she cried. NA-A asked LPN-A are you done yet, she doesn't want to do this anymore, can we be done? LPN-A did not respond right away then stated he was almost done and continued to remove hard compacted stool for one to two minutes. R1 screamed out while crying to LPN-A stop please stop and LPN-A continued for one more minute to remove stool manually with his hand. R1 was lowered down onto the toilet and was shook up, could see it in her face, and she stated that was the most terrible thing I have ever went through. NA-A stated it was scary, and she felt bad seeing R1 being treated like that and her crying stopped around 7:30 p.m. NA-A stated she had seen this done before but never did the resident have this much pain or discomfort. NA-A did not see any blood. NA-A stated she should have most likely reported this to the supervisor, her feeling about this was not good, and thought LPN-A knew what he was doing. R1 had anxiety prior to this incident but really sinking in for her now and that was why she had increased anxiety, refused to shower, get out of bed, and did not eat much. NA-A stated she should have told another nurse when it happened, she was in shock and getting the gravity of the situation. NA-A stated today R1 stated LPN-A had placed his finger in her vagina, that was not said on 5/16/26. NA-A stated last time she worked with LPN-A on 5/18/26, he left the facility in the middle of this shift.During an interview on 5/26/26 at 2:15 p.m., primary provider nurse practitioner (NP) stated R1 had concerns with constipation while in the hospital with a Vaso Vagal response. NP stated she had seen R1 on 5/16/26, had not had a BM since admission, which was the fourth day, and standing orders should have been initiated for constipation. The nurse would have been expected to follow the protocol when R1 had not had a BM in three days, concerns with constipation, listed to bowel sounds, note if she was eating, drinking, and document findings. The rectal check could have felt invasive, painful and uncomfortable. A resident may cry and complain of pain during manual removal of hard stool; the nurse should have listened to the resident to guide him and stopped. Three minutes seemed like a long time in general for something like that to be done, manual removal of stool. The staff would be expected to assist with stool coming out but if the resident is distressed and in pain stop as soon as they can. There are risks with manual removal of stool such as bleeding, pain, or a rectal tear depending on how big and hard the stool was. NP verified there was no documentation in R1's medical record the on-call provider was contacted on 5/16/26. NP stated she was made aware of the incident on 5/17/26. It would have been helpful for her or the on-call provider to know about R1's constipation due to this specific situation, the family is really involved and if she was that constipated a provider could have provided further direction as to what to do next so that something could be done about it. R1 was cognitively impaired and unable to describe anything to her.During an interview on 5/26/26 at 3:03 p.m. RN-D stated staff nurse would be expected to follow the facility standing orders for constipation, administer the medications as ordered, and allow them to work. RN-D stated manual stool removal was an invasive procedure, can be traumatizing to the resident, and could have had a history in which it would not be appropriate, therefore an order would have been needed. This process should not have been completed while the resident stood up, given the population we work with, it would have placed the resident at risk for a fall, uncomfortable, and the nurse would have been unable to see what they are doing, which increased the risk for harm to the resident such as rectal tear and/or bleeding. If a resident stated they were in pain and requested the nurse to stop, the nurse would be expected to stop immediately. That type of situation would have caused harm to the resident, it was a sign something wasn't going well, and there was a need to come up with a different intervention and/or plan. On 5/17/26 at 3:45 p.m. R1's family voiced concern to her about digital removal of stool, pain, and dissatisfaction with how the nurse performed procedure. RN-D stated she listened to the daughter and looked at the standing orders and now realized she should have asked more questions and reported this to the supervisor right away. RN-D completed a neurological assessment that day, assisted R1 to the bathroom, did not assess her skin on her boom or rectal area. RN-D documented in R1's progress notes the concerns the family had that day, should have taken action to keep her safe, assess and follow up in case it could have caused harm or just being uncomfortable due to digital removal of stool. RN-D stated she did not put it all together at the time and could have been abuse and caused harm. During an interview on 5/26/26 at 4:04 p.m., LPN-A stated R1's daughter approached him and indicated she had not had a stool for five days and requested something be given. LPN-A stated R1 had already received MiraLAX, he administered Senna, one hour later daughter informed him she had not gone yet. Twenty minutes later while R1 laid in bed, he completed a rectal check, placed his finger in the rectal area, felt stool, and administered the suppository. R1's daughter left the facility at 6:30 p.m. Approximately 40 minutes later, R1 requested to go to the bathroom and NA-A asked him if he could help R1. While R1 stood in bathroom by the toilet, LPN-A placed gloves on and asked R1 if the stool could be pushed out and she stated no, informed her he planned on pulling it out. R1 stated it's hurting me, and he informed her it's going to hurt because it's hard. LPN-A placed his finger inside her rectal area and pushed on the hard stool with his finger. LPN-A stated he did not swirl his finger around, nor did he enter the vaginal area, and NA-A was there as a witness. R1 stated it's hurting me, was not crying, did not remember her asking him to stop, but if she had, he would have stopped and reported to the NP. The stool was giving R1 pain, not him, just needed to get the stool out, it was so hard, and she was very uncomfortable. There was quite a big piece of stool that came out. LPN-A stated a physical assessment of R1's abdomen was not completed; the stool was just hanging there. and unsure how long the removal took. The NA-A did not ask him to stop. LPN-A stated in his nursing career he usually took the resident to the bathroom, never manually removed stool while laying down. In nursing school, they did not teach us to use a certain position only just how to get the stool out. LPN-A stated, it was his process to manually remove R1's stool in the bathroom, he made a nursing judgement to get it out, could not go back and call the provider, helped R1, and documented what he did. LPN-A stated the manual removal of R1's stool was not completed according to the facility policy/protocol, that was not his practice or how he did things. LPN-A stated next time he would follow the facility protocol, administer the enema per order not given, call provider if there were no results, and send them to emergency room. Those steps would have been important to him as a nurse, helped the resident, and then they couldn't say you did not call the provider. LPN-A stated he was a smiling person, and he was not smiling during the time he assisted R1 with stool removal, not sure why R1 said that. LPN-A stated he provided report to the oncoming shift at approximaelty 12:00 a.m. and went home. He returned to work on 5/18/126 at 2:30 p.m., was assigned to the same area he had worked on 5/16/26, worked until almost 5:00 p.m. when approached, was told something happened on Saturday and sent home. LPN-A stated he was placed on leave, had not worked since, and interviewed regarding the incident for the first time on 5/19/26.During an interview on 5/27/26 at 8:15 a.m., DON stated staff were expected follow the facility process/policy/protocol for constipation. DON stated R1 was impacted with stool when she came to their facility, staff were not informed. During LPN-A's interview he identified R1 stated stop during the manual removal of stool, she was given a break, sat down on toilet a few times, stool was right there, never placed his finger in the rectal area, and continued with manually removing the stool. DON stated this was an invasive procedure, depending on the size of the stool, there was potential to cause harm to R1 especially when standing there was potentially a higher risk of a rectal tear and should have been assessed and monitored after the incident. Staff were expected to assess and monitor R1's abdomen, bottom area, bowel sounds by 5/17/26, to make sure there were not any issues such as skin integrity and alterations in the peri/anal area. DON stated in this type of environment, impaction of stool can occur, and the provider should have been updated when the steps in the policy had not worked prior to the manual removal of stool to provide direction to what the nurse should have done next. DON stated if resident states stop it would never be appropriate to not stop. LPN-A should have given the R1 a break, explain what is happening, and proceed only if she said yes and try again. R1 had the right to say no/stop and LPN-A should have stopped. R1 reported she told LPN-A to stop, NA-A stated can we be done now, LPN-A stated it's almost out and did not stop per NA-A's and R1's requests. DON stated NA-A was a witness to the incident and would have been expected to share concerns with her and/or another nurse as soon after it happened. DON was unsure if that happened and would have been important for the safety and well-being of the resident, started investigation to determine what the complaint was, clarified it had occurred and prevented it from occurring again. Bottom line was the allegation of abuse should have been reported within two hours of the allegation to make sure residents were safe and felt safe with the care they were receiving. DON stated she was not made aware of the incident until 5/18/26 (3 days later) between 1:00 p.m. and 1: 30 p.m. when R1's family voiced concerns to LPN-D. DON was not aware of R1's progress notes written on 5/17/26 (1 day after incident) until now, when family voiced concerns about digital removal of stool, painful, and dissatisfaction with nurse who performed procedure. That progress note identified the same concern as discussed by family with nurse on 5/18/26, and she would have wanted to follow up right away and collected more details. DON stated LPN-D was not interviewed. DON stated it was hard to tell if R1 displayed any behavioral changes after the incident due to recent medical issues and a tremendous about of change in a short amount of time (stroke, sleep apnea, history of depression, anxiety, uprooted from Arizona). R1 was negatively impacted and affected by this incident identified during her interview she stated it caused her worry, fear and she was afraid LPN-A would come back.During an interview on 5/27/26 at 9:46 a.m., NA-B stated she worked the evening shift on 5/16/26. R1 had constipation issues for approximately three or four days. This was her first day working with R1. NA-B stated earlier in shift R1 was uncomfortable and stressed out, she had assisted with R1's transfer to and from bathroom, but unable to go. She returned to R1's room that evening, she passed LPN-A in R1's doorway. LPN-A had just completed digital removal and scooped the BM out. NA-B assisted R1 off the toilet with the stand lift. R1 was crying, very emotional, and asked her are you ok, she stated no. R1 did not complain of pain prior to this incident. LPN-A was the only nurse NA-B had worked with, he was kind of on the quiet end, did not really have conversations with others, seemed like he did a good job but would tell us what to do and expected it to be done right away. NA-B stated in the past she had to beg him to help when she required assistance with a lift transfer and other staff were not available, and he would state oh am I a NA now? NA-B stated if a resident told a nurse to stop, they should have stopped, the resident had the right to choose what was done to them. NA-B since 5/19/26, we have been required to have two staff in room to care for R1, to have a witness if something should happen to protect her.During an interview on 5/27/26 at 11:00 a.m., a family member (FM) stated she informed LPN-A R1 needed to poop and needed his help, she was told he was busy. LPN-A appeared frustrated, upset, and stated loudly, placed R1 on the bed and administered a suppository at approximately 7:30 p.m. At 8:00 p.m. R1 stated I think I have to poop. NA-A answered the call light and indicated she would take her to the bathroom. FM informed NA she needed to leave and went home to rest. At 8:39 p.m. R1 called her crying and sounded scared stating help me, he hurt me, he hurt me, he hurt me; he had his fingers in my vagina and anus hanging from the lift machine, tears coming down my checks and said you're hurting me, and he wouldn't stop, turned around, and saw him grinning at me. FM asked R1 if she wanted her to come back to facility and she stated just want to know if I'm safe from him, reassurance was given. The following morning (5/17/26) FM arrived at facility and talked to RN-D, explained what happened with my mother the previous evening and RN-D replied she would have to ask her supervisor about the incident, checked documentation, verified R1 had stool removed, and stated the nurse should have not manually removed stool without order. R1 talked about this incident all day over and over again and had not realized the day before the extent and how awful this incident had been for her. FM stated on Monday (5/17/26), she brought the incident up again to LPN-D. This nurse went into R1's room and talked to her about what happened on 5/16/26, and indicated she planned on going directly to the DON and report this. At approximately 2:00 p.m., the DON was in R1's room, spent over one hour taking notes while she visited with her. R1 had the same story every time. DON stated this would be reported to the state of Minnesota, was very serious, and the nurse would be placed on administrative leave for at least one week while an investigation would be completed. DON opened the door and R1 saw LPN-A outside her door and stated, he's here! The DON stated yes, he had picked up a shift and we are handling it. A [NAME] count investigator entered the room and R1 stated are you here to arrest me? The investigator asked if we wanted to press charges and R1 stated I don't think so. R1's behavior had changed since the incident, she's afraid he will come back. R1 continued to be affected by this incident, refused cares, toileting, getting out of bed, and not wanting to eat much. FM stated she had asked DON if R1 had a rectal tear and she stated we would have known by know if she had one, no. The incident on 5/16/26 with the male nurse LPN-A had been psychologically traumatizing to her and the family both. R1 talked about the incident all the time, at least three times a day, and yesterday was the first day she had not mentioned it. R1 was afraid LPN-A would come back and go to her window, smother /suffocate her, the psychological and emotional piece is very real and huge with her. This was a wrench that had been thrown into an already difficult situation since she had her stroke. We are worried that after the investigation is over, he will be coming back to work. LPN-A can never be around her mother again. R1 was perfectly fine 6 weeks ago. FM stated she was gone only 40 minutes on 5/16/26, and R1 called her screaming, crying, and sounded scared stating help me, he hurt me, he hurt me with his fingers in her vagina and anus and wouldn't stop. R1 stated

Based on interviews and document review the facility failed to thoroughly investigate an allegation of staff to resident abuse and protect residents during the investigation for 1 of 1 residents (R1) who reported abuse. Findings include: R1's Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility on [DATE], from the hospital. R1 had moderately impaired cognition and no behaviors. R1 had functional limitations in range of motion (ROM) in upper and lower extremities on one side. R1 required substantial/maximal assistance with personal hygiene and lying to sit on bed, was dependent on staff for all transfers, repositioning in bed, toileting hygiene, and lower body dressing. R1 used a manual wheelchair for mobility. R1 was frequently incontinent of bladder and occasionally incontinent of bowel with constipation. R1's diagnoses included stroke, atrial fibrillation, hemiplegia or hemiparesis (weakness or paralysis on one side of the body), adjustment disorder with mixed anxiety and depressed mood.R1's care plan dated 5/14/26, identified: R1 was at risk for abuse and/or neglect. Staff were directed to follow the facility Vulnerable Adult (VA) policy. Keep her safe and refer to resident services as needed (PRN).R1's physician orders identified:Behavioral Expression: every shift for clinical monitoring for seven days. Start dated 5/19/26. End dated 5/26/26.Buddy Cares at all times. Nurses and aides, every shift. Start date: 5/19/26.R1's NA Target Behavior documentation reviewed 5/14/26 through 5/27/26, target behaviors 1. Crying/sad and 2. Anxiety/Agitation occurred. Intervention attempted. Intervention effective/ineffective. Documentation identified: Target behaviors were documented as did not occur or not applicable from 5/14/26 through 5/18/26, 5/20/26, and 5/27/26 (7 days).5/19/26 at 1:38 p.m., anxiety/agitation, other, intervention ineffective. 5/21/26 at 10:59 p.m., anxiety/agitation, crying/sad, reassure, intervention effective. 5/22/26 at 2:50 p.m., anxiety/agitation, crying/sad, conversation, intervention ineffective. 5/23/26 at 5:36 a.m., anxiety/agitation, other, intervention effective. 5/24/26 at 11:08 p.m., anxiety/agitation, reassure, intervention effective. 5/25/26 at 8:55 p.m., anxiety/agitation, reassure, intervention effective. 5/26/26 at 9:55 p.m., anxiety/agitation, reassure, intervention effective. R1's progress notes from 5/16/26 through 5/22/26, identified: 5/16/26 at 11:22 p.m., R1's daughter complained her mother had no bowel movements for the last three days. Senna was given per orders, rectal check was done and hard stool noted, suppository administered without results. Manual evacuation of stool was performed with removal of large amounts of stool. R1 expressed discomfort during the removal but relieved at the end.5/17/26 at 12:16 p.m., Alert and orientated to self with some confusion, increased anxiety observed upon rising this morning. Assist of two with stand lift transfer.5/17/26 at 12:41 p.m., Family expressed concerns to staff regarding bowel habits, digital removal, policies regarding procedure. Family concerned that digital removal was painful, and she called family distressed after procedure was performed. Family expressed dissatisfaction with nurse who performed procedure. 5/18/26 at 1:00 p.m. Writer entered R1's room and daughter was present and brought up some concerns that she had been having. Writer reassured R1 and daughter that she would bring concerns to superiors. Writer immediately brought concerns to supervisor and director of nursing (DON) upon leaving room.5/19/26 at 7:16 a.m., R1's daughter called writer and reported her mother called crying and needed help immediately. Writer went into R1's room and she observed her sitting on bedside on the verge of tears. R1 stated I haven't slept since 5:00 a.m., because do not know why people have to come in here and change people at 5:00 am when they supposed to be sleeping. Writer apologized, reassured her care plan will be updated. R1 stated I am sorry to bother you with my complaints, but I am in pain. Writer offered medication, accepted, and administered.5/19/26 at 2:36 p.m. R1 alert oriented to self, family, place with forgetfulness and confusion within her baseline. R1 refused therapy this morning due to fatigue per resident, slept in per request and cares were done as allowed by R1.5/19/26 at 4:07 p.m., Email message sent to Pastor, daughter requested a visit for R1, thought it benefit her mom.5/21/26 at 10:58 a.m. Pastor visit made.5/21/26 at 4:30 p.m. DON checked in on R1. Daughter and ex-husband were both in R1's room. Daughter inquired about the possibility of rectal bleeding following recent stool removal procedure, expressed concern related to potential rectal tearing. DON informed daughter if any tissue injury had occurred symptoms would likely have presented by this time and no observed or reported signs/symptoms identified.5/22/26 at 2:21 p.m., R1 refused toileting, bed bath, and scheduled weekly shower, requested to be able to go back to sleep, stated not now, later, and reapproached with no success.R1's Body Audit completed on 5/22/26 at 6:25 p.m., by registered nurse (RN)-C identified current alterations in skin integrity: other type of alternations. Scattered bruising on belly and near both elbows/antecubital spaces. R1 had an old/healing scratch mark on her left shin, daughter said she thought it was from the lift machine in the hospital. All other areas of skin are clean, dry and intact. The Body Audit did not include an assessment of R1's peri-rectal area.R1's Body Audit completed on 5/27/26 at 9:11 p.m., by DON identified overall skin is clean, dry and intact. All bruises are in the healing stage, and the scratch continues to heal without issues. The peri-anal area was assessed and unremarkable. The anus is clean, intact, without visible cutes, tears, or lumps and is normal in size and shape.Facility Vulnerable Adult (VA) Maltreatment Report filed with State Agency (SA) dated 5/18/26 at 5:36 p.m., identified estimated date and time of most recent occurrence was 5/16/26 at 8:00 p.m., in resident bathroom. Description of incident: Allegation of sexual contact by daughter today on 5/18/26. VA complained of rectal pain before, during, and after administration of bowel evacuation regime. Daughter stated VA called her crying around 8:30 p.m. on 5/16/26 stated he hurt me! He hurt me! He put his fingers in my rectum and vagina. VA interviewed in room today 5/18/26, she wept, I looked back at him while he was behind me and was smiling at me while he hurt me, digging around in my anus. Allegation: sexual abuse.Facility internal investigation documents identified on 5/18/26, R1's daughter reported an allegation of inappropriate sexual contact involving facility staff. R1's constipation was identified as a current problem on 5/15/26. R1 complained of rectal pain prior to and during administration of a bowel evacuation regimen (rectal suppository and manual stool removal). This information was documented by the nurse on 5/16/26. On 5/18/26, alleged perpetrator nurse was interviewed and again for clarification on 5/22/26. Additionally, (undated) two NA's (one witnessed incident) were interviewed. On 5/22/26, interviews were completed with six residents out of 60. Questions asked: do you feel safe here, have you ever witnessed any abuse here, has anybody intentionally hurt you, and if you had a problem with someone here who would you report it to? No concerns noted.LPN-A's time card identified work history from 5/16/26 through 5/23/26: -On 5/16/26 started work at 6:30 a.m., break taken from 10:30 a.m. to 11:00 a.m., worked 11:00 a.m. to 3:00 p.m. -On 5/16/26 started work at 3:00 p.m., break taken from 7:00 p.m. to 7:30 p.m., worked 7:30 p.m. to 12:00 a.m.-On 5/18/26 started work at 2:30 p.m., worked until 5:15 p.m. Unpaid administrative leave taken from 5:15 p.m. through 11:00p.m. During an interview on 5/22/26 at 11:38 a.m. NA-F stated on 5/18/26, R1's daughter informed her the incident happened on 5/16/26 at approximately 8:30 p.m., LPN-A placed his finger in to pull out the BM and hurt R1. R1 stated she just wanted him to stop, it was so painful. NA-F reported this incident right away to the DON on 5/18/26. NA-F stated when R1 requested the nurse to stop he should have stopped. NA-F stated LPN-A arrived at work on 5/18/26 at 7:00 a.m. and at 10:00 a.m. the DON talked to him, and he left the building. NA-F stated she had not received any education regarding abuse since incident on 5/16/26.During an interview on 5/22/26 at 12:37 p.m., R1 stated she had no concerns about staff until 5/16/26, when she was constipated and unable to have a BM. R1 felt the nurse was in a hurry, and one or two other female staff were in the room with him. The nurse inserted his finger into her anus, started to circle it around and informed her he had to do that to make the stool come out. R1 stated the male nurse kept circling his finger, Over and over, and she started to cry and begged him to stop. LPN-A told R1, We need to get it out of here, just relax. R1 told LPN-A, Oh please stop you are hurting me. When R1 looked at LPN-A, He smiled at me and I felt he was laughing at me. R1 stated she begged him to stop, it made her vulnerable, embarrassed, and felt he was making a mockery for her. You can ask the other staff when I begged him to stop, they were standing right there. During a follow-up interview on 5/22/26 at 4:55 p.m., R1 stated the nurse kept digging with his finger, It felt like it was in the vaginal area but hard to say for sure, he was doing it so fast. It was very painful. I told him he was hurting me. He grinned at me. It was awful. It made me feel like a piece of dirt. R1 stated she tried to let it go but it continued to bother her and felt it was horribly demeaning. R1 stated she cried when it came to mind. R1 was sad that someone could treat her that way. R1 stated she wondered what the repercussions were for the nurse, Will he be upset and come back and hurt me? Does he expect me to be submissive and let him hurt me? It was very unprofessional. I do not want to believe he treated other people like that but if he came back to work, would he retaliate? R1 stated it was perplexing for her. During an interview on 5/22/26 at 2:04 p.m. NA-E stated today had been a hard day for R1, she refused breakfast, offered toast, accepted and ate only 4 bits, refused shower, accepted a bed bath instead but was unable to complete a bed bath before end of day, and passed it onto the next shift. Yesterday, 5/21/26, R1 informed her at the end of the day something about a nurse assisting her with constipation and how she had not liked his approach. NA-E stated she planned on reporting it to the DON but forgot and told her today instead. NA-E received abuse education one month ago. Staff were expected to approach R1 with two staff now and she was unaware of why.During an interview on 5/22/26 at 2:42 p.m., LPN-D stated on 5/18/26 at approximately 1:00 p.m., she entered R1's room and R1's daughter reported she had concerns about the care her mother received. Daughter indicated specifically the name of the nurse [LPN-A] administered a rectal suppository, dug out stool from R1's rectum with possible vaginal penetration, and R1 experienced quite a bit of pain. LPN-D informed R1 and daughter she would bring this information immediately to her supervisor. LPN-D left R1's room, went directly to DON and reported the incident. LPN-D stated she was unaware of who was responsible for completing the assessment on R1 after an allegation of abuse. LPN-D did not complete an assessment. LPN-D stated the nurse would be expected to listen to the resident if they indicated they were in pain, stop what they were doing, and contact provider if needed. LPN-D had not received education on abuse since orientation in 1/2026.During an interview on 5/22/26 at 3:15 p.m., the LPN-C any allegation of abuse should have been reported immediately to the supervisor, removal of staff involved to protect the residents, and a physical assessment including the area of concern, should have been completed right away to provide a clear picture of what may of happened, and to make sure it did not happen again. The assessment should have included a behavioral assessment and any changes noted and documented from baseline. If a resident was scared, they would be more anxious and possibly crying. The LPN-C verified documentation of a physical or behavioral assessment was not identified in R1's medical record. On 5/22/26, a change in R1's care plan was noted, two staff were expected to go into R1's together for everything to make sure R1 was safe. The LPN-C stated she had not received any additional education on abuse or impaction of stool since the incident.During an interview on 5/27/26 at 8:15 a.m., the DON stated NA-A was a witness to the R1's incident and would have been expected to share concerns with her and/or another nurse as soon as possible after it happened on 5/16/26. The DON was unsure if that happened and would have been important for the safety and well-being of the residents, to start an investigation to determine what the complaint was, to determine if it had occurred and prevent it from occurring again. The bottom line was to make sure residents were safe and felt safe with the care they were receiving. The DON stated she was not made aware of the incident until 5/18/26 between 1:00 p.m. and 1: 30 p.m., when R1's family voiced concerns to the LPN-D. The DON was not aware of R1's progress notes written on 5/17/26, when family voiced concerns about digital removal of stool, painful, and dissatisfaction with nurse who performed procedure. The DON was notified of the progress note written on 5/17/26, today. The progress note identified the same concern as discussed by family with the LPN-D on 5/18/26, and she would have wanted to follow up right away and collected more details. DON stated LPN-D was not interviewed. DON stated it was hard to tell if R1 displayed any behavioral changes after the incident due to recent medical issues and a tremendous amount change in a short amount of time (stroke, sleep apnea, history of depression, anxiety, uprooted from Arizona). The DON stated she initiated an investigation as soon as she was aware of the situation on 5/18/26 on 1:20 p.m. No physical exam was completed at that time, there was an emotional component as mentioned in report and interviews. R1 was negatively impacted and affected by this incident which was identified during R1's interview. R1 told the DON stated it caused her [R1] worry, fear and she was afraid LPN-A would come back. LPN-A was placed on administrative leave on 5/18/26. The DON stated, We are still investigating and waiting for the outcome of your [State Agency] investigation. To have her [R1] that scared, see him [LPN-A] working here again and have no outcome of what was determined would not have been appropriate. The DON stated LPN-A worked at the facility as a trained medication assistant (TMA) and NA since 2018, he worked as a LPN since 3/1/25. LPN-A worked on both units, had potential contact with all residents in the facility, and worked all three shifts (a.m., p.m., nights), but mostly a.m. and p.m. shifts. On 5/22/26, six residents (determined by administrator) out of 60 were interviewed. The DON stated all residents who were able to be interviewed should have been. For those residents who we were not able to interview, we should have contacted family and asked if they had any concerns. We needed to assure all the residents were safe, nothing had happened to them to mitigate any harm.During an interview on 5/27/26 at 4:30 p.m., the RN-C confirmed he completed R1's body audit on 5/22/26 at 6:25 p.m. The body audit included a full skin check of abdomen/arms/shin, how often R1 was wet, her bowel and bladder function, and if at risk for skin breakdown. The RN-C stated he did not assess R1's rectal area.Follow-up information provided on 5/28/26 at 12:17 p.m., the DON verified via email she had completed R1's Body Audit on 5/27/26 at 9:11 p.m., and assessed the peri-anal area, no concerns.During an interview on 5/28/26 at 1:24 p.m., the administrator stated staff education would have been expected to be started sooner, usually before submission of the five day report to the State Agency (SA) and may take a day or two to be completed after investigating. Staff education was important to make sure the facility was in compliance right away and staff knew what was expected of them, also to ensure the safety of all residents. Resident interviews usually started before the five day was submitted to the SA to identify any concerns and should included in the report. The resident interviews were started on 5/22/26. These interviews should have been done sooner to ensure no concerns or patterns were identified and to protect all residents from abuse. The administrator stated she had determined a certain percentage of residents, 10 to 20%, were interviewed. If a pattern was identified, all residents would have been interviewed. We did not interview those residents who were unable to be interviewed and we did not looked for signs of distress. If noted, the nurse would have charted those findings and concerns would have been brought to our attention. It would have been a good idea to audit those residents unable to speak for themselves to identify if there were any concerns. Other staff were not made aware of the incident.Facility policy Vulnerable Adult Abuse Prevention Plan dated 10/2025, identified all cases of maltreatment or potential maltreatment must be reported immediately to an employee's supervisor who will then report immediately to the administrator. Care should be taken immediately to remove the resident from immediate danger and intervene in any situation to protect residents. Remove any individual from the facility if necessary for the protection of residents or staff, including but not limited to employees, visitors, contractors, and family members. Call local law enforcement for assistance for the protection of residents or staff. The following action must be taken in cases of suspected sexual assault/rape: immediately put suspected perpetrator on administrative leave pending investigation. Assess the resident for possible injuries immediately. The administrator or designee will complete a full review of the investigation documentation before investigation is signed off on and filed to identify trends or patterns in individuals involved, or system issues. Review of each occurrence will be made to determine if policies, procedures or facility systems need to be modified to prevent further occurrences. Take necessary corrective action with employee (after consulting with Human Resources) and document results. Implement follow-up education/training with appropriate personnel. Complete investigation form and staff interviews for your investigation. Notify medical director of allegation and investigation proceedings. Notify appropriate board for substantiated cases of abuse/neglect (nurse aide registry, board of nursing). Follow-up action plan: complete an action plan for follow-up after the investigation: update care plan, staff assignment sheets, update physician and discuss whether any new MD orders needed, and follow-up with resident and resident's designated representative for resolution.

Based on interview and document review, the facility failed to hold, at a minimum, quarterly care conference meetings with the resident and their representative to allow the resident and/or representative the opportunity to review and participate in the revision of the care plan for 1 of 2 residents (R13) reviewed for care conferences. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], indicated R13 was admitted to the care facility on 8/28/24 and was cognitively intact. R13's electronic medical record (EMR) indicated the most current care conference was documented on 1/23/24. The care conference note, dated 1/23/24, indicated the care conference was held on 1/5/24 with R13's family, clinical staff, life enrichment, social services and R13 present. During an interview on 9/26/24 at 8:04 a.m., nurse manager and registered nurse (RN)-A confirmed R13 had not had a care conference since the documented care conference on 1/5/24. RN-A stated there had been a care conference set up but R13's representative was unavailable and it fell through the cracks. RN-A further stated regular care conferences were important to keep families up to date on how the resident was doing. During an interview on 9/23/24 at 2:00 p.m., R13 was unable to state when he last attended a care conference and appeared to have confusion on why he was still living at the care facility, stating multiple times he unsure why he lived at the care facility. During an interview on 9/25/24 at 12:30 p.m., social worker (SW)-A stated it was her role to schedule care conferences, and it was expected to hold a care conference for each resident at admission, quarterly and if a resident had a change in condition. SW-A stated she would reach out to the resident's family (representative), typically via email, set a date and time for the care conference and ensure staff and family were aware. During a follow up interview on 9/25/24 at 2:30 p.m., SW-A confirmed there had not been a documented care conference for R13 since 1/5/24. SW-A stated she and the nurse manager helped arrange a video call between R13 and family on Fridays, stating the nurse manager sat in on one but it was not documented. A facility policy titled Care Plan Policy and Procedure, modified 11/22, indicated a resident's care plan would be reviewed at least quarterly and with any significant change and would not be complete until a care conference was held to review with the resident and/or resident representative.

Based on interview, and document review, the facility failed to implement interventions to prevent further development of decreased range of motion for 3 of 4 residents (R2, R4, and R28) reviewed for positioning and mobility. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted to the facility on [DATE] and had a moderate cognitive impairment and the following diagnoses: Hypertension (HTN) (high blood pressure), diabetes, hyperlipidemia (HLD) (elevated levels of fat in the blood), Parkinson's disease, epilepsy (seizure disorder), anxiety and depression. R2's Care plan dated 9/26/24, included an ambulation program to walk 400 feet with assistance twice a day. An active range of motion (ROM) program for bilateral (both sides) upper extremities five repetitions twice daily. Finally, an active ROM program to bilateral upper and lower extremities daily. The facility document R2's Tasks dated 9/26/24, where staff document the completion of tasks, included an ambulation program to walk 400 feet with assistance twice a day. An active ROM program for bilateral upper extremities five repetitions twice daily. Finally, a ROM program to bilateral upper and lower extremities 10 times daily. R2's Follow-up question report dated 7/26/24 through 9/24/24, included the documentation for the ROM program for bilateral upper extremities to be completed with five repetitions twice daily. For the 60 days reviewed and 120 documentation opportunities the following information was documented: Task completed: 45/120 Not applicable: 40/120 Resident Refused: 30/120 Missed/No documentation: 5/120 R2's follow up question report dated 7/26/24 through 9/24/24, included the documentation for the ambulation program to be completed twice daily. For the 60 days reviewed and 120 documentation opportunities the following information was documented: Task completed: 56/120 Not applicable: 33/120 Resident Refused: 25/120 Missed/No documentation: 6/120 R2's Follow up question report dated 8/26/24 through 9/24/26, included the documentation for the ROM program to bilateral extremities 10 repetitions daily. For the 30 days reviewed and 30 documentation opportunities the following information was documented: Task completed: 20/30 Not applicable: 7/30 Resident Refused: 2/30 Missed/No documentation: 1/30 R2's medical record lacked any documentation as to why the program was not completed or the rational for not applicable being documented. R4's quarterly MDS dated [DATE], indicated R4 was admitted to the facility on [DATE] and had a severe cognitive impairment and the following diagnoses: Alzheimer's, depression, and psychotic disorder. R4's care plan dated 9/26/24, indicated a ROM program to be completed daily to bilateral lower extremities. The facility document, R4's Tasks dated 9/26/24, included a ROM program for 10 repetitions to bilateral upper extremities to be completed daily and a passive ROM program to lower extremity 10 repetitions daily. R4's occupational therapy (OT) discharge summary dated 7/3/24, indicated discharge recommendations to complete daily ROM to bilateral upper extremities. R4's Follow up question report dated 7/26/24 through 9/24/26, included the documentation for the ROM to bilateral upper extremities 10 repetitions daily. For the 60 days reviewed and 60 documentation opportunities the following information was documented: Task completed: 43/60 Not applicable: 12/60 Resident Refused: 4/60 Missed/No documentation: 1/60 R4's Follow up question report dated 7/26/24 through 9/24/26, included the documentation for the ROM to bilateral lower extremities 10 repetitions daily. For the 60 days reviewed and 60 documentation opportunities the following information was documented: Task completed: 43/60 Not applicable: 14/60 Resident Refused: 2/60 Missed/No documentation: 1/60 R4's medical record lacked any documentation as to why the program was not completed or the rational for not applicable being documented. R28's quarterly MDS dated [DATE], indicated R28 was admitted to the facility on [DATE] and had a moderate cognitive impairment and the following diagnoses: cerebral vascular accident (CVA) (stroke), HTN, gastroesophageal reflux disease (GERD), HLD, thyroid disorder, hemiplegia or hemiparesis (unable to use or more one side of the body), and depression. R28's Care plan dated 9/26/24, included a passive range of motion program for the left upper extremity with 10 repetitions daily. A passive ROM program to the left lower extremity with 20 repetitions daily. The facility document R28's Tasks dated 9/26/24, included a ROM program for 10 repetitions to left upper extremity to be completed daily and a ROM program to lower left extremity 20 repetitions daily, and a passive ROM program to the left hand to be completed three times daily. R28's OT discharge summary dated 1/30/24, indicated discharge recommendations to complete daily gentle ROM before and after removing R28's left hand splint. R28's Follow up question report dated 7/26/24 through 9/24/26, included the documentation for the ROM to the left upper extremity 10 repetitions daily. For the 60 days reviewed and 60 documentation opportunities the following information was documented: Task completed: 25/60 Not applicable: 19/60 Resident Refused: 14/60 Missed/No documentation: 2/60 R28's Follow up question report dated 7/26/24 through 9/24/26, included the documentation for the ROM to the left lower extremity 20 repetitions daily. For the 60 days reviewed and 60 documentation opportunities the following information was documented: Task completed: 20/60 Not applicable: 24/60 Resident Refused: 14/60 Missed/No documentation: 2/60 R28's Follow up question report dated 7/26/24 through 9/24/26, included the documentation for the ROM to the left hand three times daily. For the 60 days reviewed and 180 documentation opportunities the following information was documented: Task completed: 37/180 Not applicable: 47/180 Resident Refused: 31/180 Missed/No documentation: 65/180 R28's medical record lacked any documentation as to why the program was not completed or the rational for not applicable being documented. On 9/25/24 at 1:12 p.m., the nursing assistant (NA)-A stated the NA's usually completed the ROM programs with the residents based on the directions they have on their care sheets, and would sometimes put not applicable if they did not have time to complete the ROM or if it was not completed. On 9/25/24 at 12:04 p.m., registered nurse (RN)-B stated the NA's were responsible for completing the ROM programs, and would sometimes put not applicable if the resident was not on the unit or if it was not completed. On 9/25/24 at 12:55 p.m., the RN clinical coordinator, RN-C stated the NA's were responsible for completing the ROM program and walking programs. RN-C stated their expectation was if the program was scheduled for daily, twice, or three times daily it should have been completed as often. RN-C confirmed that R2, R4, and R28's ROM programs were not being completed as ordered. RN-C stated further there was really no reason for not applicable to be documented, either there was not enough time to complete the ROM or it was not completed. On 9/26/24 at 8:34 a.m., the director of nursing (DON) confirmed that R2, R4, and R28's ROM programs were not being completed as ordered, and they expected the ROM programs for all residents to be completed every day as ordered. The DON confirmed the importance of completing the ROM programs for residents to maintain their level of functioning and to prevent contractures and maintain their ability levels. The Range of Motion policy was requested and it was not provided.

Based on interview and document review, the facility failed to act upon the consultant pharmacist's recommendation for 1 of 5 residents (R11) reviewed for unnecessary medications. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 with diagnoses of heart failure, diabetes, dementia, and anxiety and documented R11 receiving High-Risk Drug Classes of antipsychotic, antianxiety, antidepressant, opioid, antiplatelet, and hypoglycemic medications. Also, the MDS documented R11 receiving antipsychotic on a routine and as needed (PRN) basis. In addition, the MDS documented R11 on hospice. Insulin R11's physician orders (PO) dated 8/24/24 documented, Humalog Injection Solution (fast acting insulin that lowers blood sugar in adults and children with diabetes) 100 UNIT/ML (milliliter), Inject as per sliding scale (adjusting the insulin dose based on blood glucose level) : if 200-250=2 units; 251-300=3 units; 301-350=4 units, 351-400= 5 units Call Hospice for BG>400, subcutaneously before meals for Sliding Scale to be given in addition to Scheduled 6 units SQ (subcutaneous-injection of medication between skin and muscle) TID (three times per day) before meals. R11's PO dated 9/13/24 documented, Lorazepam Oral Tablet 0.5 mg (milligram), Give 0.5 mg by mouth three times a day for Anxiety AND Give 0.5mg by mouth every 2 hours as needed (PRN) for Anxiety for 30 days. Sliding Scale Insulin R11's electronic medical record (EMR) progress note (PN) titled Pharmacy Monthly Medication Review (MMR)-Recommendation dated 5/13/24 documented, Medication regimen reviewed. See communication with MD and/or Nursing regarding: SSI (sliding scale insulin) . R11's Consultant Pharmacist Communication to Physician (CPCP) form dated 5/13/24 documented: HOSPICE resident has orders for Sliding Scale Insulin (SSI). AGS Beers criteria places SSI under the Strongly 'Avoid' category, due to the: 'Higher the risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting.' CMS considers hypoglycemia an adverse event as it can contribute to falls and has been one of the top reasons for hospital readmissions. CMS guidelines suggest that continued or long-term need for sliding scale insulin for non-emergency coverage may indicate inadequate blood sugar control' and would result in increased scrutiny. Benefits of moving away from SSI: -Reduced hypoglycemic episodes -Reduced falls -Reduced hospital re-admission -Reduced facility cost -Reduced staff time -Reduced potential F-tags during surveys -Improved patient convenience & quality of life Would you please assess if we could increase basal insulin to limit/eliminate SSI use? Document marked by Other and handwritten managed by Allina Endocrinology-Dr Ibid. Document signed by provider with date of 9/24/2024. Ativan R11's EMR PN titled Pharmacy MMR-Recommendation dated 6/11/24 documented, Medication regimen reviewed. See communication with MD and/or Nursing regarding: Ativan. R11's CPCP form dated 5/13/24 documented: Has orders for PRN Ativan Beers list (a medication guideline from the American Geriatrics Society to help providers safely prescribe medications for adults over age 65) states: 'Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium. Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepines withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, and end-of-life care.' ***New CMS guidelines*** state that for non-antipsychotic psychotropic drugs (anxiolytics, hypnotics .), PRN use should be limited to 14 days UNLESS the prescriber documents the rationale for a longer duration of use in the resident's medical record, an indicated the duration for the PRN order. The CPCP was signed by provider on 9/24/24 with clinical indication for use. During interview with director of nursing (DON) on 9/24/24 at 3:50 p.m., DON verified R11's 5/13/24 and 6/11/24 CPCP forms were scanned into the EMR but not signed by physician or provider as having been reviewed. I don't know why there is not one [sic] I cannot find it. During interview with DON on 9/25/25 at 9:12 a.m., DON provided surveyor with 5/13/24 and 6/11/24 CPCP forms that were signed by the nurse practitioner (NP) on 9/24/24. During interview with consultant pharmacist (CP) on 9/25/24 at 10:03 a.m., CP stated he is on-site at least once a month and talks to staff about any medication concerns. CP stated his process for monthly medication reviews (MMR) is to review with staff any concerns about medication management and he then documents in the CPCP form what his recommendations are. The form will then be provided to the DON who will follow up by faxing it or providing it to the provider for a signed response. After a signed response is obtained from the provider then the order is updated in the EMR, and the signed form is downloaded into the residents EMR. CP stated, I do not communicate with the hospice provider, and I do not communicate with Endocrinology. It is up to the facility to make sure they are doing it [forwarding the recommendations to the appropriate provider]. CP stated they were unaware the 5/13/24 and 6/11/24 MRR's were not signed by provider until 9/24/24. During interview with NP on 9/26/24 at 9:31 a.m., NP stated the process for her responding to the monthly pharmacist recommendations is the facility provides her a stack of CPCP forms once a month to review. NP stated the facility will receive the signed CPCP forms from her, and the facility will then update the orders in the EMR and scan the form into the EMR. If a resident is on hospice, then the hospice provider and NP work together to collaborate on a response. NP stated if the facility has difficulty getting a response from outside providers or hospice then she is asked to review the CPCP form. NP stated she was out of town in May of 2024 and the hospice provider was out of town in June of 2024 which, could explain the lack of response for the 5/13/24 and 6/11/24 MRR's. NP verified she was provided the 5/13/24 and 6/11/24 CPCP forms by the facility to review and signed them on 9/24/24. NP also stated the endocrinologist mentioned in the 6/11/24 CPCP form was no longer involved in managing R11's insulin and that the hospice provider and NP are now managing it. During interview with DON on 9/26/24 at 9:51 a.m., DON stated it was the facility's responsibility to forward the monthly CPCP forms to the appropriate provider to review and expect a response. DON stated he did not know why the 5/13/24 and 6/11/24 CPCP forms were not signed or forwarded to NP and the hospice provider to review before 9/24/24 but that it should have been. Facility policy titled Psychotropic and Unnecessary Medication Use modified July 2024 state, All pharmacist recommendations will be reviewed with the primary physician/NP prior to implementation and with a physician's order.

Based on observation, interview and document review the facility failed to post accessible contact information of all pertinent State agencies or Ombudsman information for 4 or 4 residents (R12, R20, R46, and R47), who routinely attend resident council. This had the potential to affect all 52 residents who resided in the facility. Findings include: During the resident council meeting held on 9/25/24 at 10:01 a.m., with a state surveyor, R12, R20, R46, and R47 participated and indicated they were regular attendees of the Resident Council meetings in the facility. Upon asking, R12, R20, R46, R47 stated they were unaware of who the ombudsman was and did not know where the ombudsman information was located or posted in the building. While on survey in the facility from 9/23/24 through 9/26/24, no posting or contact information for the Ombudsman was observed or noted within the facility or on the additional units of the nursing home and were not accessible to the residents to view or read. On 9/25/24 at 2:40 p.m., the director of Nursing (DON) and the administrator confirmed the Ombudsman contact information was not posted. Both the DON and the administrator stated they believed social services had the information; however, it was not posted or visibly readable or accessible by the residents or visitors unless they were to ask for it. On 9/25/24 at 2:58 p.m., during an additional interview, the administrator provided the contact business card/handout for the ombudsman and confirmed again the information was not posted in the facility. On 9/26/24 at 8:34 a.m., the DON confirmed the ombudsman contact information was not posted and was important to post and provide contact information as the Ombudsman was an advocated for the resident and should be available to them as a support system. A policy regarding the Ombudsman information was requested and none was provided.

Based on interview and document review, the facility failed to comprehensively assess and provide the provision of supervision of self transfer to prevent and/or mitigate the risk of falls for 1 of 3 residents (R2) who had a history of falls. This resulted in actual harm for R2 who fell and sustained back and rib fractures. Findings include: R2's Minimum Data Set (MDS) dated [DATE], indicated R2 was a [AGE] year-old admitted on [DATE] with diagnoses including dementia, diabetes, history of transient ischemic attack (temporary disruption of blood flow to the brain), muscle weakness, difficulty in walking, unsteadiness on feet, other abnormalities of gait and mobility, weakness, and repeated falls. R2's Brief Interview for Mental Status score was 11, indicating moderate cognitive impairment. R2 utilized a wheelchair, required substantial assistance with toileting hygiene, and moderate assistance with bed mobility and transfers. Walking was not attempted due to medical condition or safety concerns. R2 was frequently incontinent of bowel and bladder. R2's care plan dated 1/4/24, identified a focus on falls and noted resident is at risk for falls related to impaired cognition secondary to dementia, impaired balance during transitions, impaired gait, and history of repeated falls, activity intolerance secondary to chronic lung disease and hypertension, potential medication side effects. Other contributing factors noted were lower back pain, sleeplessness, frequently waking up to use the bathroom, and frequent independent transfers. Current fall interventions included: -alert/orient resident to changes in environment routine and caregivers, -keep call light within reach and encourage use as needed, -complete fall risk assessment/evaluation quarterly and as needed, -check post-void residual as needed (amount of urine still in bladder after urinating), -encourage participation in activities that promote exercise and physical activity for strengthening and improved mobility such a physical and occupational therapies, ensure proper footwear is worn, -evaluate effectiveness of interventions on an ongoing basis, follow facility fall protocol, -give pain medication as ordered, -put motion sensor light in bathroom, -monitor for acute illness, -no repositioning sheet in bed, -pharmacy consultant review of medications at least monthly, -put night light near bed, -answer call light promptly, -place wheelchair with wheels locked next to bed when resident in bed, -physical therapy evaluation and treatment as needed, -remove clutter from room and keep a clear path to the bathroom, and noted to also see R2's care plan for activities of daily living (ADLs), mobility, and toileting. -Related ADL interventions included assist of one with dressing grooming and hygiene, and encourage/remind resident to use call light. -Related mobility interventions included active range of motion exercises of both lower extremities daily, resident preference to get up and do morning ADLs between 6:00 a.m. and 7:00 a.m., use of regular draw sheets on bed to prevent sliding off bed, and assistance of one with a gait belt for all transfers. -Related toileting interventions included assistance with toileting and repositioning every two to three hours during waking hours and on all overnight rounds, last revised on 11/9/23. R2's electronic health record (EHR) included documentation of repeated falls since admission. R2's EHR included Falls Follow Up Forms from 6/3/23, 6/6/23, 6/22/23, 7/16/23, 7/17/23, 8/3/23, 9/16/23, 9/27/23, 10/1/23, 10/9/23, 10/28/23, 11/9/23, 11/28/23, 12/11/23, 12/14/23, 1/9/24, and 1/13/24. A progress note dated 12/31/23 at 12:04 p.m. indicated an additional fall on that date. In review of R2's fall records at least 7 of the falls involved toileting; 6/3/23, 7/16/23, 8/3/23, 9/27/23, 10/9/23, 11/9/23, and 1/9/24. R2's Resident Occurrence Report completed by registered nurse (RN)-A and licensed practical nurse (LPN)-A dated 12/14/23, indicated R2 was found on the floor in her room at 1:10 p.m. on 12/14/23. R2 was last observed at 1:00 p.m. when transferred from bed to chair by RN-A. The last time R2 was toileted was unknown. The resident statement indicated R2 was trying to reach the remote control. The analysis of the cause of the occurrence was R2 was unable to demonstrate call light use. The action to minimize reoccurrence was checking on R2 every 15 minutes. Suggestions to prevent this from occurring again noted the resident may benefit from having one-to-one assistance. R2's Falls Follow Up Form completed by registered nurse (RN)-A and licensed practical nurse (LPN)-A dated 12/14/23, indicated R2 fell on [DATE]. The analysis and summary of causal factors noted R2 continued to self-transfer. RN-A's short-term intervention was to check on R2 every 15 minutes. The long-term intervention noted by the director of nursing (DON) on 1/8/24 after inter-disciplinary team (IDT) review was rearrangement of R2's room to create a clear path to the bathroom. A progress note by RN-A dated 12/14/23 at 2:11 p.m., indicated the intervention based on root cause analysis of the fall was the resident is unable to follow directions for call light use. Frequent checks (was not defined) continued with resident to be brought to the bathroom. A fall follow up progress note for R2's fall on 12/14/23 dated 12/17/23 at 7:28 a.m., indicated R2 continued to self-transfer and attempted to self-transfer three times during the night. R2 was rounded on frequently (was not defined) to monitor for safety and needs. A progress note dated 12/18/23 at 5:10 a.m., indicated R2 attempted to self-transfer four times during the writer's shift and was rounded on frequently to monitor for safety and needs. A provider note by nurse practitioner (NP)-A dated 12/19/23, indicated R2 has a history of multiple falls, likely multifactorial and usually when R2 is attempting to self-transfer. The plan directed staff to continue to assist with ambulation to and from the dining room and bathroom and transfers, to continue frequent check-ins, and to monitor for falls. R1's care plan was not revised to include frequent check-in's per NP note on 12/19/24. R2's record did not indicate an assessment or evaluation to determine interventions to reduce R2's self-transfers thereby reducing R2's risk for falls. Additionally, the record did not include completed evaluation of the effectiveness of the 15-minute checks and/or the frequent monitoring that was not individualized or determined to identify how often R2 required increased supervision. A progress note dated 12/20/23 at 1:35 p.m., indicated the resident is unable to demonstrate call light use. A progress note dated 12/22/23 at 6:22 a.m., indicated R2 attempted to self-transfer to the bathroom three times during the writer's shift, was assisted to the bathroom, and was rounded on frequently (was not defined) to monitor for needs and safety. A progress note dated 12/26/23 at 12:29 p.m., indicated R2 was unable to demonstrate call light use. A progress note dated 12/26/23 at 10:13 p.m., indicated R2 self-transferred twice during the writer's shift and does not use the call light. A progress note dated 12/27/23 at 11:50 p.m., indicated R2 self-transferred three times during the shift and did not use the call light. A progress note dated 12/28/23 at 11:18 p.m., indicated R2 was found self-transferring four times and does NOT understand the call light. A progress note dated 12/31/23 at 12:04 p.m., indicated R2 attempted to use the restroom independently and fell in the morning. She did not use the call light for help and was found on the floor between her bed and armoire with her pants around her ankles. A Fall Follow Up Form for R2's 12/31/23 fall was not located in R2's EHR and no causal analsysis of the fall was evident. A progress note dated 1/2/24 at 2:05 p.m., noted the resident has a diagnosis of dementia with a poor ability to recall new learning or follow call light use directions. New interventions related to mobility and/or fall risk included frequent checks and offering toileting every two to three hours, checking on R2 on all rounds overnight and offering toileting when awake, putting wheelchair with brakes on next to bed, rearranging bedroom, and placing bed closer to the bathroom. A progress note dated 1/3/24 at 12:17 p.m., indicated R2 remained impulsive and did not demonstrate the ability to identify the need for call light use. An IDT follow up progress note dated 1/3/24 at 3:25 p.m., indicated a root cause analysis of resident fall in the bathroom with intervention of occupational therapy evaluating for bars from a commode base to be placed on R2's toilet to use for balance and to push up on when R2 self-transfers to the toilet. The date of the fall was not indicated and not evident R1's toileting schedule was re-evaluated for appropriateness. A progress note dated 1/8/24 at 3:59 p.m., indicated R2 self-transferred once during the writer's shift and interventions were minimally effective as the resident was not dissuaded from self-transferring. A progress note dated 1/8/24 at 9:50 p.m., indicated R2 self-transferred multiple times during the writer's shift and does not use call light despite continuing education and reminders. A fall progress note dated 1/9/24 at 7:23 a.m., indicated R2 was found on the floor returning from the bathroom without a wheelchair after self-transfer to the bathroom with a wheelchair. The intervention based on root cause analysis was 1:1 STAFFING WOULD BE MOST USEFUL - NOT AVAILABLE AT THIS TIME. An alternative intervention was not identified. R2's Resident Occurrence Report completed by RN-A dated 1/9/24, indicated R2 was found on the floor in her room on 1/9/24 at 6:45 a.m. The last observation of R2 prior to the fall was by nursing assistant (NA)-A at 6:30 a.m. when R2 was sleeping in bed with a wheelchair next to the bed. The last time R2 was toileted was not noted. The resident statement indicated R2 was trying to go to the bathroom and back to bed. The analysis of the cause of the occurrence was self-transfer to the toilet. The action to minimize reoccurrence noted new strategies were unable to be identified outside of one-to-one staff supervision. Suggestions to prevent this from occurring again were one-to-one staffing and noted frequent checks were inadequate and R2 was unable to follow directions. R2's Falls Follow Up Form completed by RN-A dated 1/9/24, indicated R2 fell on [DATE]. The analysis and summary of causal factors noted R2 self-transferred for purpose of toileting without alerting staff, using a wheelchair to get to the bathroom and ambulating out of the bathroom without a wheelchair. RN-A's short-term intervention recommended one-to-one staff supervision. The long-term intervention noted by the director of nursing (DON) on 1/22/24 after IDT review was to continue to offer morning cares between 6:00 a.m. and 7:00 a.m. per resident preference. R1's record did not indicate an assessment or evaluation to determine interventions to reduce R1's self-transfers including re-assessment of R1's toileting time. A fall progress note by LPN-B dated 1/13/24 at 5:21 p.m., indicated R2 was found on the floor in her room between her bed and the bathroom on her left side with her left arm and leg underneath her body. Upon assessment R2 complained of pain, had unequal grip strength, could not move her left leg off the ground, and could not move her toes. R2 was sent to the hospital for further evaluation and treatment. R2's Resident Occurrence Report completed by LPN-B dated 1/13/24, indicated R2 was found on the ground between her bed and the bathroom at 4:40 p.m. on 1/13/24. Prior to the fall, R2 was last observed at 4:00 p.m. sleeping in bed when NA-B checked on R2 after R2 refused toileting offered at 3:30 p.m. The resident statement indicated R2 was going to the bathroom when she fell . The action to minimize reoccurrence and suggestions to prevent this from occurring again sections were not completed. R2's Falls Follow Up Form by LPN-B dated 1/13/24, indicated R2 fell at 4:40 p.m. on 1/13/24. The analysis and summary of causal factors noted R2 self-transferred, had no grippy socks, and did not use the call light. The short-term intervention was sending R2 to the hospital. A note dated 2/5/24 on the form from the DON after IDT review indicated R2 returned from the hospital with orders for physical and occupational therapies. The IDT would continue to evaluate R2's progress with therapy and update the plan of care as appropriate. A provider note dated 1/18/24, indicated R2 was admitted to Hospital on 1/13/24 for evaluation after an unwitnessed fall at the facility. Imaging revealed a lumbar vertebral fracture and two rib fractures. R2 transferred back to the facility on [DATE] and was discharged from the hospital with a thoracic lumbar sacral orthosis (TLSO) (a mid to lower back brace) to wear for three months. R2's NA care sheet for 2/7/24, indicated that R2 was a fall risk and instructed NAs to perform safety checks at the beginning and end of their shifts, take R2 to the bathroom every two to three hours while awake and on all overnight rounds, and to leave wheelchair with wheels locked next to R2's bed when in bed for self-transfers/falls. In an interview on 2/5/24 at 12:40 p.m., trained medication aide (TMA)-A stated R2 self-transfers and is a fall risk, so staff put her call light right next to her in bed and put her wheelchair next to her bed with the brakes locked. TMA-A stated R2's care plan was to offer toileting every two hours and he tried to monitor R2 more frequently because R2 is a fall risk. TMA-A did not articulate how frequent was frequent. In an interview on 2/5/24 at 1:05 p.m., NA-C stated R2 fell a lot and did not say when she needed to be changed or toileted. R2 did not know how to use the call light at all and tried to self-transfer when in her room. NA-C stated R2's wheelchair was placed at bedside with the bed in low position in case R2 tried to get up. In an interview on 2/5/24 at 2:01 p.m., family member (FM)-A stated R2 had fallen in the past while trying to go to the bathroom. Sometimes R2 had to wait to go to the bathroom and tried to go by herself. R2 did not like to wait, she goes when she wanted to go. When R2 was asked if she needed to go to the bathroom she might say yes and might say no, sometimes she said no and then had to go a few minutes later. In an interview on 2/7/24 at 9:21 a.m., RN-A stated R2 has an inability to retain new learning and education and reminders about using the call light have not been effective. RN-A stated she did not believe it was appropriate to have call light use as a fall intervention because it was not effective, and education was not an appropriate intervention if R2 was unable to learn. R2 could not use it and did not use it. R2 did not refuse cares when offered but was impulsive and had toileting every two hours in her care plan. RN-A stated she wrote R2 needs one-to-one staff supervision on a recent fall report. RN-A reported that she had not seen any changes in how R2 was monitored or supervised since completing the report and believed R2's fall with injury on 1/13/24 could have been prevented with more supervision. In an interview on 2/7/24 at 9:40 a.m., NA-D stated R2 ambulated with extensive assistance and transferred with an assist of one with a gait belt. R2 was a fall risk and interventions were on her care plan such as putting R2's wheelchair at bedside and the call light right next to her. NA-D stated toileting was offered to R2 every two to three hours and NA-D tried to check on R2 every hour. NA-D noted frequent checks would be considered checking on R2 hourly. In an interview on 2/7/24 at 9:50 a.m., TMA-A stated the frequency of checks on a resident depends on the resident's care plan. For R2, the toileting care plan said to check every two hours. In an interview on 2/7/24 at 9:57 a.m., NA-C stated frequent checks meant checking on a resident every half hour or so, at least every hour, but more if possible. Checking on a resident was looking at them to be sure they were okay and safe. In an interview on 2/7/24 at 10:28 a.m., NA-A stated R2 was a big fall risk and tends to self-transfer from her bed to the bathroom all the time. Staff tried to toilet her as much as possible so she did not self-transfer, R2 needed to be toileted every three to four hours. Staff kept R2's call light close by, wheelchair at bedside with brakes locked, and placed a motion sensor light in R2's bathroom. NA-A stated she had never seen R2 hold or push her call light, R2 did not refuse cares, R2 would get up and used the bathroom when she needed to. In an interview on 2/7/24 at 11:42 a.m., director of nursing (DON) stated when a resident had a fall with an injury the first question was to see if the plan of care was followed. The IDT met to review falls and made sure the plan of care was followed. If it was followed the IDT looked at what else could prevent the fall. The team considers what the recommendations were from the nurse and as a team we come up with interventions. Then after two weeks we review the fall again at the IDT meeting, go over what interventions were put in place, see if they are effective, and decide how to proceed. The fall risk assessment was the comprehensive assessment completed when the the resident was admitted . We review that as we get to know the resident and develop the care plan. If someone was a fall risk, we add the risks and interventions to the care plan and do the assessment every three months. DON stated R2 had approximately 14 to 15 falls since admission and fell frequently. For R2, nursing recommended one-to-one supervision, but DON did not offer that as an intervention because knew R2's family did not have resources. DON noted that the last revision to R2's toileting care plan was on 11/9/23 with the addition of an intervention to toilet R2 every two to three hours and on overnight rounds. DON stated the falls form from R2's 7/16/23 had a short-term intervention to continue hourly safety checks which staff could do but was not added to R2's care plan. DON explained there was an assessment of safety which included meeting a resident's needs but there was no separate assessment that determined supervision. To determine R2's level of supervision DON thought a sleep log was completed, pain management assessment, and the nurses and aides did safety checks at the beginning of their shifts. DON explained there were repeated recommendations from nursing to increase R2's supervision. DON stated I don't think it is practical to say someone will go in every half hour or every hour to check on [R2], it is not realistic. Checking on a resident frequently is not on care plans because if you say frequently you have to say how often, I can't tell the aides to check on the residents frequently without giving a time frame. DON believed the toileting every two to three hours that was currently in place was appropriate. After R2's fall on 1/9/24, the intervention was continuing the plan of care, DON was not sure why. We can continue the plan of care but continue to also reapproach the resident when offering toileting if they say they do not need to toilet at the time. DON believed R2 has used the call light or but not aware of how frequently she used it. DON stated an awareness R2's cognition was continuing to decline. In an interview on 2/7/24 at 3:45 p.m., NP-A stated numerous interventions have been tried regarding R2's falls but it seems like every intervention tried helps for a short period of time and R2 continues to not use the call light. R2 often says she wants to go back to bed, and it is tough to keep her up. NP-A thought trying to keep R2 in the common area more, having eyes on her more so R2 can't just climb out of bed would help. NP-A stated she could talk to R2's care team about how to have more eyes on her and not have R2 in bed the majority of the day so when R2 feels the need to get up she can be watched more closely by staff. NP-A stated staff do check-ins on R2 every two hours and believed staff should lay eyes on R2 every hour at least and make sure her basic needs are being met, especially during the day when she is more up and active. NP-A was not sure of the facility's availability but thought the facility was able to do that and it would be a good idea to step up those checks on R2. The facility's Fall Prevention and Management Program Policy dated April 2021 included the following: Clinical Coordinator or designee is responsible for implementation and oversight of individualized residents fall prevention care as follows: a.) Assessing fall risk upon admission, quarterly, with significant change in condition. b.) Determining risk for fall and establishing appropriate interventions in the care plan related to fall risk in the plan of care. c.) Implementing the interventions specific to fall risk data collection. d.) Supervising personnel in delivering safe and personalized care. e.) Evaluating the effectiveness of interventions in relation to the resident specific plan of care. f.) Collaborating with the interdisciplinary team in the prevention of falls. g.) Appropriately managing residents who experience a fall by implementing interventions to prevent further falls. h.) Complete and update fall tracking. Prevention Interventions/Strategies: a.) Environmental Safety - Environmental rounds will be completed monthly. b.) Nursing staff will implement interventions according to resident specific risk factors. c.) Medications will be reviewed monthly by the consulting pharmacist and quarterly by nursing staff. d.) Care plans will indicate the resident specific interventions to prevent falls. Post Fall Management: The staff nurse will review the Occurrence Report and will: i.) Assess all factors contributing to the fall event including intrinsic and extrinsic factors and which interventions were in place at the time of the fall using Falls Follow Up Form as a guideline. ii.) Recommend interventions and changes to plan of care to prevent a repeat fall. iii.) Communicate and document results.

Based on observation, interview and document review, the facility failed to follow an intervention to prevent bruising for 1 of 2 residents (R26) reviewed for non-pressure related skin concerns. Findings include: R26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had moderate cognitive impairment and required extensive assist of one staff for activities of daily living. R26's care plan with a revision date of 4/7/22, indicated R26 had venous stasis ulcers (abnormal vein function) on left shin and was at risk for further skin impairment due to diabetes, impaired mobility, [CONDITION(S)] (excessive fluid trapped in the body's tissue), aspirin use, [CONDITION(S)], left sided stroke, and medication side effects. R26's care plan with an initiated date of 4/6/22, further indicated R26 was to wear geri-sleeves (a product that protects the resident's arms) or stockinette to bilateral hands/arms during the day and were to be removed at night. On 5/22/22, at 12:32 p.m. R26 was observed wearing a short sleeve shirt, no protective sleeves or stockinettes in place. R26 was observed having multiple bruises to bilateral arms, the bruises extended from the elbows to the top of her hands. R26 indicated not knowing where the bruises came from. On 5/24/22, at 10:56 a.m. R26 was observed wearing a short sleeve shirt with no protective sleeves or stockinettes in place. A Progress Note dated 5/19/22, indicated R26 had a 5.2 centimeter by 3 centimeter bruise to her right forearm. The Progress Note further directed R26 could wear geri-sleeves to bilateral upper arms. A Body Audit dated 5/17/22, indicated R26 had bruises to left and right forearms and that all bruises were at different stages of healing. During an interview on 5/24/22, at 10:57 a.m. nursing assistant (NA)-G indicated R26 had stockinettes for her legs but not for her arms. During an interview on 5/24/22, at 1:08 p.m. R26 indicated she had never been told to wear anything to her arms, or that she had to wear long sleeve shirts. R26 stated she preferred both short and long sleeve shirts. During an interview on 5/24/22, at 1:53 p.m. NA-G verified on the nursing assistant care sheets that R26 was to have geri-sleeves or stockinettes applied to her bilateral arms. NA-G then stated I have not seen them, but I will go look. NA-G then enters R26's room and asked do you ever wear geri-sleeves or long sleeves on your arm. R26 replied with yeah sometimes. NA-G then proceeded to look around R26's room and indicated she could not find any geri-sleeves or stockinettes for R26's arms. During an interview on 5/24/22, at 1:59 p.m. licensed practical nurse (LPN)-A indicated staff should be following the care plan, and should be attempting to put the geri-sleeves or stockinettes on R26 as the care sheets indicated. During an interview on 5/24/22, at 2:06 p.m. director of nursing (DON) indicated the geri-sleeves or stockinettes should be used or at least attempted to be applied to R26's arms. The facility's Skin Integrity Management Policy dated 6/21, directed a care plan will be developed or modified to reflect alterations in interventions and implementation of new interventions specific to the resident. The policy further directed the care plan interventions will be communicated to the appropriate staff via the nursing assistant assignment sheet or My Best Day and/or through report.

Based on observation, interview and document review the facility failed to reposition or off load a resident timely, who had an unhealed pressure ulcer, without evidence of decline for 1 of 1 resident (R47) reviewed for pressure ulcers. Findings include: R47's annual Minimum Data Set (MDS) dated [DATE], indicated R47 was severely cognitively impaired and required extensive assistance by two staff for bed mobility, transfers and toileting. R47's MDS further indicated R47 was always incontinent of both bowel and bladder. R47's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's Pressure Ulcer Care Area Assessment (CAA) dated 4/19/22, indicated R47 required assistance for bed mobility, pressure ulcer and incontinence and had a stage 3 (full-thickness skin loss) pressure ulcer on coccyx. R47's CAA further indicated Braden score 13 indicating risk for skin breakdown. R47's care plan (CP) last revised 5/12/22, indicated R47 had a pressure injury to coccyx and was at risk for further impaired skin integrity due to a history of impaired skin, decreased mobility, decreased nutritional intake, weight loss, cognitive impairment, palliative cares, med SEs [medication side effects], incontinence/moisture, advanced age and Braden score indicating risk. R47's CP directed staff to check or change brief and reposition every three hours. R47's Skin and Wound Evaluation dated 5/18/22, indicated R47 had a stage 3 pressure ulcer on coccyx with progress noted as stable. Treatments listed include wound cleanser, dressing, cushion, incontinence management, mattress with pump, nutrition/dietary supplementation, and turning/repositioning program. R47's Skin and Wound Evaluation dated 5/25/22, indicated R47 had a stage 3 pressure ulcer on coccyx with progress noted as stable. Treatments listed include wound cleanser, dressing, cushion, incontinence management, moisture barrier, mattress with pump, nutrition/dietary supplementation, and turning/repositioning program. The Maple Ridge unit nurse aide care sheet (CS) last updated 5/16/22, indicated R47 required assistance of two staff using a full lift for transfers. The CS directed staff to toilet and reposition R47 every three hours. The CS's attached Toilet/Reposition Tracking Sheet for 5/23/22, indicated R47 was toileted and repositioned at 8:05 a.m. and 11:00 a.m. On 5/23/22, at 11:17 a.m. R47 was observed sitting up in wheelchair (WC) in room, fully dressed and groomed. During continuous observation on 5/23/22, from 11:56 a.m. to 3:23 p.m., R47 was not repositioned timely. -At 11:56 p.m. R47 was pushed into the dining room in WC for lunch. -At 12:39 p.m. nursing assistant (NA)-D pushed R47 back to room and overheard asking R47 if he wanted to return to bed. R47 stated he did want to lay in bed. NA-D told R47 that since he was an assist of two staff for transfers, she would go get help and return. R47 asked how long it would take and NA-D stated someone would return in five minutes or so. R47's door was left open. -At 1:02 p.m. trained medication aide (TMA)-A walked to refrigerator in small dining room across from R47's room. TMA-A did not enter R47's room. -At 1:13 p.m. NA-F entered and sat in the small dining room across from R47's room and did not approach R47's room. -At 1:30 p.m. no staff had entered R47's room. R47 still sitting in WC. Room was dark and quiet. R47's eyes were closed, and he appeared to be sleeping. -At 1:39 p.m. NA-A entered R47's room and approached the small kitchen area of the room behind and to the right of where R47 sat. NA-A exited the room within 10 seconds and did not approach or speak to R47. When interviewed upon exit, NA-A stated she just had to drop something off in his room. -At 2:00 p.m. no staff had entered R47's room. R47 still sat in WC. -At 2:21 p.m. NA-B and NA-C walked down hallway and sat in common area just outside R47's room. NA-B stated they were reviewing care sheets left by the previous shift's staff. NA-B further stated typically they would talk to previous shift for report off, but if they do not see staff from previous shift will just look at care sheets. Today neither NA-B nor NA-C received verbal report from NA-A. -At 2:30 p.m. NA-B and NA-C leave common area and walk toward main dining area. No one approached or entered R47's room. - At 2:59 p.m. NA-B and NA-C exited a different resident's room and walked past R47's without entering R47's room. -At 3:16 p.m. no staff had entered R47's room. -At 3:19 p.m. NA-B and NA-C entered R47's room with a full mechanical lift, attached sling and prepared R47 for transfer to bed. -At 3:23 p.m. R47 was lifted off the WC and transferred into bed. R47 was incontinent of stool. NA-A completed a brief change and peri care. R47's bottom and back of thighs were reddened and wrinkled. A dressing covered R47's coccyx. When interviewed on 5/23/22, at 3:38 p.m. NA-B stated R47 was last toileted and reposition at 11:00 a.m. according to the CS and that she normally checked on R47 every hour since he did not use the call light. When NA-B was asked how often R47 should be checked and repositioned, she stated, every time. When NA-B was asked to specify frequency, she stated, every three hours. NA-B confirmed R47 had not been repositioned timely according to the CS. When interviewed on 5/23/22, at 4:14 p.m. registered nurse (RN)-A stated staff should follow the CP and CS. RN-A further stated if the CS instructed staff to reposition, check and change a resident every three hours, then it should be done as close as possible to that schedule. When interviewed on 5/23/22, at 4:16 p.m. director of nursing (DON) stated the expectation was that staff would provide care according to the CP. DON further stated that if a resident was on every three-hour repositioning and was last repositioned at 11:00 a.m., he would be due to be repositioned at 2:00 p.m. and should be the first resident cared for at the start of the evening shift. DON stated when staff tell a resident someone would return in five minutes and did not return for almost three hours, it was disappointing. DON further stated R47 should have been repositioned at the beginning of the evening shift and that four plus hours was too long in between re-positioning's. When interviewed via phone on 5/23/22, at 4:37 p.m. NA-A stated she changed and repositioned R47 twice during her shift that day with the last time being at 11:00 a.m. NA-E assisted with R47's 11:00 a.m. transfer to the WC. NA stated R47 did have a pressure ulcer and should be repositioned every three hours. NA-A further stated the 11:00 a.m. check and reposition was documented on the CS and that he was due for another check and reposition at 2:00 p.m. which would be the responsibility of the evening shift staff. NA-A further stated NA-D had assisted R47 with lunch and reported to her (NA-A) that R47 ate approximately 50 percent of his lunch. When interviewed on 5/24/22, at 8:43 a.m. NA-A stated R47 was changed on 5/23/22, at 8:00 a.m. and repositioned but remained in bed. NA-A further stated that on 5/23/22, at 11:00 a.m. R47 was changed, dressed, groomed, and transferred into his WC for lunch. NA-A stated never receiving report that R47 wanted to return to bed after lunch. When interviewed via phone on 5/24/22, at 9:12 a.m. NA-D stated she helped R47 eat lunch on 5/23/22, and that she reported to NA-A that he ate 50 percent of his lunch. NA-D further stated she wheeled R47 back to his room after lunch and that R47 told her he was ready to go back to bed. NA-D stated she told R47 she would tell NA-A since he was a two person assist and that someone would be back in about five minutes. NA-D stated she provided R47 with his call light and thought he could use it pretty well. NA-D stated she reported to NA-A that R47 was ready to go back to bed and that NA-A responded she would go there after she finished cleaning up the lunch trays. When interviewed on 5/24/22, at 10:53 a.m. nurse practitioner (NP)-A stated R47's coccyx pressure ulcer status fluctuated as she will see a little improvement and then a decline but added that it was currently stable. When interviewed on 5/25/22, at 8:30 a.m. administrator stated nursing assistants received turning/repositioning and customer service training in orientation and annually. When interviewed on 5/25/22, at 11:08 a.m. DON stated that per facility policy, the expectation was residents should be repositioned per their CP and therefore, R47 should be repositioned every three hours. DON further stated that the Maple Ridge unit was well staffed on 5/23/22, so there should not have been a delay in transferring R47 back to bed per his wishes. DON stated going over the repositioning schedule by an hour was not acceptable. DON further stated he just completed wound rounds and R47's coccyx pressure ulcer was stable. Review of progress note by MD-A from 5/10/22, at 1:51 pm indicated, [R47] Has known coccyx wound, followed by our wound care nurse. At least stable, not worsening. Facility policy Repositioning of Residents dated 9/2015, indicated, All residents assessed as requiring assisted repositioning due to wounds, mobility concerns, etc., as identified in their Care Plan, will receive the required reposition by the nursing staff and will be monitored via the repositioning schedule. The policy instructed staff to reposition resident per their plan of care and as needed or requested.

Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in a facility medication error rate of 18% (percent). Findings include: R31's Medication Administration Report dated 5/1/22 through 5/31/22, identified R31 had orders for: -[MEDICATION(S)] tablet 10 milligrams (mg) give 1 tablet via G-tube [gastric tube] one time a day for high blood pressure -Aspirin chewable tablet 81 mg give 1 tablet via G-tube one time a day for stroke prevent. -[MEDICATION(S)] tablet 3.125 mg give 3.125 mg via G-tube two times a day for high blood pressure disorder. -[MEDICATION(S)] 10 mg tablet give 10 mg via G-tube one time a day for depression. -Tylenol extra strength 500 mg tablets, give 1000 mg via G-tube two times a day for pain. -Senna-[MEDICATION(S)] Sodium tablet 8.6-50 mg give 1 tablet via G-tube one time a day for constipation. -[MEDICATION(S)] give 17 gram (1 cap full) via G-tube in the morning for constipation. On 5/24/22, at 8:21 a.m. registered nurse (RN)-C was observed preparing R31's medications which included: - Aspirin 1 tablet (81 mg) - [MEDICATION(S)] 1 tablet (3.125 mg) - [MEDICATION(S)] 1 tablet (10 mg) - Tylenol Extra Strength 500 mg (2 tablets- 1000 mg) At 8:36 a.m. RN-C was observed attempting to crush the listed medications for R31's together and administer the medications via G-tube. RN-C was stopped by the surveyor and was requested RN-C review R31's medication orders. RN-C stated after review of the medication orders looks like they want them [medications] done one at a time. RN-C then indicated she was going to crush all the medications together and give the medications all at once. During an interview on 5/24/22, at 10:21 a.m. director of nursing (DON) indicated that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview the DON verified R31 did not have an order to administer the medications all at once. During at interview on 5/24/22, at 11:47 a.m. consultant pharmacist indicated medications should not be mixed together and administered through the G-tube without notifying pharmacy first due potential medication interactions. The facility's Enteral Tube Medication Administration policy dated 1/27/19, directed the individual administering the medication that each medication must be prepared separately and administered one at a time (unless otherwise ordered).

Based on observation, interview and document review, the facility failed to conduct root cause analysis in an attempt to reduce falls for 2 of 4 residents (R37, R96) reviewed for falls. This resulted in actual harm for R37 who sustained multiple falls including two falls resulting in fractures and head injuries. Findings include: R37's significant change minimum data set (MDS) assessment dated [DATE], indicated he was severely cognitively impaired, required extensive assistance with bed mobility, transfers and toileting, was frequently incontinent of bladder and always continent of bowel. The MDS indicated R37 had sustained falls with injury since admission to the facility. R37's care plan dated 1/17/20, identified limited physical mobility related to muscle weakness, lack of coordination and a history of falls resulting in fracture. The care plan further indicated R37 was at risk for falls related to decreased mobility, incontinence and advanced age. Care plan interventions included: staff to perform hourly safety checks, initiated 1/2/20; if up at midnight, offer snacks and fluid, initiated 1/9/20; perimeter mattress to bed, initiated 1/15/20; check at 7:00 a.m. and offer to get up if awake, added 1/29/20. The care plan further identified a problem area of bowel and bladder incontinence, and directed staff to assist with toileting every three hours and during all over night (N[NAME]) rounds, initiated 11/23/20. A review of R37's medical record identified the following: A Progress Note dated 11/26/19, indicated at 3:10 a.m. R37 was found on the floor in his room bleeding from a laceration on his head. R37 was sent to hospital and was to be re-evaluated for fall interventions. A Resident Occurrence Report dated 11/26/19, indicated R37's scheduled toileting had been revised, including during all N[NAME] rounds. A Physician's Progress Note dated 12/3/19, indicated R37 had experienced a fall in the facility which resulted in R37 hitting his head, sustaining a cervical fracture and requiring staples to his head. A Progress Note dated 12/20/19, indicated R37 was heard yelling for help at 3:47 a.m., and was found lying on the floor between his bed and the bathroom sink. The note indicated R37 had stated he was trying to use the bathroom. Further the note indicated R37 had sustained a wound to the left elbow and the left outer shin, indicating both were scraped. The corresponding Resident Occurrence Report dated 12/20/19, indicated R37's wheel chair had gotten caught on the bed, so it was possible he'd stood up to go to the toilet. The intervention again indicated R37 should have toileting during all N[NAME] rounds. A Progress Note dated 12/25/19, indicated R37 was found lying flat on his back in his room at 10:00 a.m., yelling for help. The note further indicated R37 was sent to the hospital for increased confusion and weakness. The corresponding Resident Occurrence Report dated 12/25/19, indicated R37 was found lying on the floor in his room on his back. The report did not identify any root cause analysis or revised interventions. A Progress Note dated 1/1/20, indicated R37 was seen kneeling on the side of his bed saying help, me, help me. The corresponding Resident Occurrence Report dated 1/1/20, indicated the fall occurred at 4:20 a.m. and indicated R37 had redness noted to both knees. Interventions included: every hour safety checks and discussion with family about providing a one to one companion. A physician's Progress Note dated 1/2/20, from the hospital included: Summary of hospital Course, (R37) was hospitalized following a fall on 11/26/19 and was found to have a cervical spine fracture. (R37) had an unwitnessed fall on 12/25/19, and was found to have an acute subdural hematoma and new cervical spine fractures. Family decided to proceed with hospice for end of life cares. (R37) was discharged with hospice cares. A Progress Note dated 1/9/20, indicated R37 fell at 7:00 a.m. and that R37 had been unable to verbalize why he fell . The notes further identified a second fall that same day when R37 was found kneeling on the floor next to his bed. The corresponding Resident Occurrence Reports dated 1/9/20, identified interventions including: frequent checks/monitoring and review of medications. Regarding the second report for 1/9/20, the report indicated the incident had occurred at 1:00 a.m., and indicated if R37 was still up at midnight, staff should offer snacks and fluids. A Progress Note dated 1/14/20, indicated R37 was observed on the floor next to his bed and indicated R37 was crawling out of bed. The corresponding Resident Occurrence Report dated 1/13/19, indicated R37 had fallen at 11:30 p.m., and was unable to state what had happened. The report further indicated R37 had sustained an abrasion to his left elbow. Intervention implemented included: placing a perimeter mattress to define the edges of the bed. A Progress Note dated 1/14/20, indicated R37 was found lying on his right side at 3:50 a.m. outside the entrance of his room door. The note indicated R37's wheelchair was by the side of his bed, and R37 had reported he'd hit his head. Abrasions and redness were noted on both elbows. The corresponding Resident Occurrence Report dated 1/14/20, indicated the hospice nurse would be requested to review medications. Another Progress Note dated 1/14/20, indicated R37 had fallen again that day in the dining room near the sink. R37 was found lying on his back with his arms behind his head. The note indicated R37's wheelchair brakes were not locked at the time of the fall. The corresponding Resident Occurrence Report indicated the fall had happened at 3:30 p.m. and identified an intervention to offer toileting every three hours during the day. A Progress Note dated 1/18/20, indicated R37 was heard yelling help, help and was found on the floor in front of his recliner. The note indicated R37 had reported he was attempting to transfer into his wheelchair and it slipped. The corresponding Resident Occurrence Report dated 1/18/20, indicated the fall occurred at 2:00 p.m. and R37 had redness noted to his left cheek. Interventions included, ask hospice to review [MEDICATION NAME] to possibly discontinue due to adverse reactions, and to add anti-roll brakes to wheel chair. A Progress Note dated 1/24/20, indicated R37 was observed sliding to the floor. The corresponding Resident Occurrence Report dated 1/24/20, indicated the fall occurred at 7:10 a.m. and occurred from the bed. Intervention was to check on R37 at 7:00 a.m. and if awake, get him up for the day. A Progress Note dated 1/26/20, indicated R37 attempted to self transfer from his wheelchair to a dining room chair and lost his balance. The dining chair was tipped over on its side and R37 had one arm draped over the leg of the chair. The note indicated R37 had reproted he'd banged up his knee. The corresponding Resident Occurrence Report dated 1/26/20, indicated the fall had occurred at 4:00 p.m. and indicated R37 had been last seen sitting in his wheelchair in front of the television. Additional interventions identified included [MEDICATION NAME] lotion and regular staff visits. During observation on 1/28/20, at 8:44 a.m. R37 was attempting to leave the dining table. Dietary aide (DA)- A was overheard speaking with R37, and asked him where he needed to go. R37 responded he did not need to go anywhere. At 8:47 a.m. R37 was observed still trying to move away from the dining table. He was placing his arms on the wheelchair arm rests and pushing himself up. At 8:51 a.m. R37 attempted to stand up. An unidentified nursing assistant (NA) was heard to say to R37, Maybe after I am done passing trays I can help you stand up. The NA brought R37 to the other side of the dining room and placed him in front of the television. At 8:56 a.m. R37 was propelling himself around the dining room in his wheel chair. He again attempted to stand up from his chair. At that time a nurse on the unit put him in front of a table and offered him ice cream. A Progress Note dated 1/29/20, indicated R37 was observed on the floor in his room. The note indicated R37 had stated he was trying to get up. During interview on 1/29/20, at 2:44 p.m. registered nurse (RN)-E stated R37 came to the facility following a suspected [MEDICAL CONDITION]. RN-E verified R37 fell in the facility on 11/26/19, and sustained a fracture and a head injury and stated she'd increased his scheduled toileting to include all N[NAME] rounds. RN-E stated, that's usually the first thing I do is add toileting. RN-E stated when R37 fell again on 12/20/19, she thought maybe toileting had been added to just the second and fourth N[NAME] rounds after the first fall so she added toileting to all rounds, even though R37's care plan already indicated he was to be toileted on all N[NAME] rounds beginning on 11/23/19. RN-E stated R37 fell again on 12/25/19, and was sent to the hospital where it was identified he'd sustained additional fractures and a head injury. RN-E stated R37 returned to the facility on hospice. In regard to the intervention to speak with family about providing a one to one companion, RN-E said the family told them they could not provide one so safety checks were initiated every hour however, RN-E stated there was no documentation of the safety checks. RN-E further stated although R37 had changes to his toileting plan, no one had completed a bowel and bladder diary to determine patterns. The director of nursing (DON) was present during the interview and stated when a resident had a lot of falls she would sometimes have the corporate nurse review the falls. The DON stated in R37's case, that had not happened. The DON further stated the assisted living had been providing a staff to sit one to one at night with R37 but as of the previous night that was no longer going to happen. The DON was unable to verbalize a plan for R37's safety at night. RN-E stated she felt like most of R37's falls had occurred during the evening and overnights and said she thought he was bored a lot of the time. RN-E stated, I think we need to maybe really look at why he is falling. During interview on 1/30/20, at 5:31 a.m. nursing assistant (NA)-A stated there were two aides on the N[NAME] shift on the unit where R37 resided. NA-A stated recently the facility had provided a one to one staff for R37 but was not aware it was no longer going to continue. NA-A stated, we can't keep him safe without the one to one. On 1/30/20, at 7:51 a.m. R37 was observed in bed with his eyes closed. At 9:50 a.m., R37 was observed sitting up on the side of his bed calling for help. There were no staff in the vicinity of his room. The Surveyor entered R37's room and pressed the call light for assistance. Registered nurse (RN)-F entered the room and assisted R37 to get up. R96's entry tracking record Minimum Data Set indicated he admitted to the facility on [DATE]. R96's care area assessment (CAA) dated 1/21/20, indicated the care area triggered due to impaired balance, a history of falls and a fall in the facility. The CAA indicated R96 had intact cognition. R96's care plan dated 1/15/20, identified a risk for falls and directed staff to provide education about calling for assistance, place call light in reach and answer promptly and provide safety checks every two hours. During interview on 1/27/20, at 2:09 p.m. R96 stated the facility must be short staffed. R96 stated when he brought it up to staff they said they were not allowed to talk about it. R96 stated when he pushed his call light it took staff usually at least 15-20 minutes to answer it. R96 stated, the latest thing that happened was I had to go to the bathroom, I have this stupid bag on (referring to a catheter bag), I hit the call button, I can get out of bed myself but it takes a while, I have to find the bag. R96 stated after 5-10 minutes a woman came in and by that time his need to go to the bathroom was urgent. R96 stated the woman turned around, said just a minute and left. R96 stated he ultimately was incontinent of bowel so he got himself to the bathroom and finished cleaning himself up. He stated he stood up, took off the brief and started washing himself up and he fell and could not get up. R96 stated he crawled to the call light and pulled the cord. R96 stated, I must have been on the floor for 5-10 minutes. R96 said his friend and an aide showed up and got him up. A facility Progress Note dated 1/26/19, indicated R96 was observed on the floor in his bathroom sitting on his back with arms and legs straight. The note indicated R96 stated he pressed the call light after he had fallen. A Resident Occurrence Report dated 1/26/20, indicated the fall occurred at 10:05 a.m. and indicated R96 stated he was using the bathroom. The report indicated staff had last seen R96 in the bathroom at 9:50 a.m. The follow up indicated interventions to include two hour safety checks and non skid strips in front of toilet. A call light report dated 1/6/20, indicated R96 had pressed his call light at 9:36 a.m. and again at 10:39 a.m. During interview on 1/30/20, at 3:26 p.m. the director of nursing (DON) stated she was told R96 was standing to do his own grooming and fell on the floor in the bathroom. The DON stated she had never asked R96 what happened. At 3:31 p.m. registered nurse (RN)-E stated she had put the interventions in place after R96 fell . RN-E stated she had never asked R96 about the circumstances leading to the fall. A facility policy titled Fall Prevention and Management Program Policy dated (MONTH) (YEAR), indicated upon admission, quarterly, annually and with significant change residents will be assessed for their risk for falls. The clinical coordinator was responsible for implementation and oversight of residents fall prevention to include determining risk for fall and implementing appropriate interventions and collaborating with the interdisciplinary team in the prevention of falls. The policy indicated following a fall an occurrence report would be filled out by the staff nurse and a follow up will be forwarded to the interdisciplinary team. A site root cause analysis was to be completed by the interdisciplinary team and action plans created.

Based on observation, interview and document review the facility failed to ensure appropriate staffing levels to meet the needs and safety for 10 of 10 residents (R9, R96, R15, R25, R97, R12, R17, R39, R246, R37) and had the potential to affect other residents who resided at the facility. Findings include: Resident interview: R9's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R9 required limited to extensive physical assistance of one staff with activities of daily living (ADL's) which included walking, toilet use and personal hygiene. On 1/27/20, at 6:40 p.m. when asked how long it took staff to come when he used the call light, R9 stated during the night time it is hard to get help. R9 also stated It seems like a long time. Sometimes 15 to 20 minutes. R9 further stated Night staff is tough to deal with. I may ask for a urinal and they will say it's time for shift change and we can't have people sitting on the toilet. The biggest issue I have it's hard to get staff to walk with me. Lately only once a week. R96, on 1/27/20, at 2:02 p.m., when asked how long it took staff to come when he used the call light, R96 stated I rang my little red button, after a long time, maybe 20 to 30 minutes, someone will ask if you are all right. It seems like it takes a really long time at night, quite a bit. R96 also stated they must be short staffed, when I bring it up, staff say, we are not allowed to talk about it. When I push my button it takes an unbelievable amount of time, the latest one that happened was that I had to go to the bathroom R96 explained that, I have this stupid bag on (catheter bag) I hit the button, I can get out of the bed by myself but it takes a while. I have to find the bag and after 5 to 10 minutes, this woman came in but by this time it was very urgent. I said I have to go to the bathroom but she turned around and said just a minute and left. R96 explained being incontinent, in my pants, I started to put one of these on and then I got the old one off and I slipped and fell and I could not get up. I crawled to the cord and pulled the cord. I must have been on the floor for 5 to 10 minutes. R15's quarterly MDS dated [DATE], indicated R15 required extensive to total physical assistance of two staff with ADL's which included bed mobility, transfers, toilet use and personal hygiene. In addition, MDS indicated R15 had intact cognition. On 1/27/20, at 1:21 p.m. when asked how long it took staff to come when she used the call light for assistance, R15 stated depends on the day. I have waited what seems like a long time. I feel like sometimes I wait a long time. R25's significant change MDS dated [DATE], indicated R25 required extensive to total physical assistance of one to two staff with ADL's which included bed mobility, transfers, toilet use and personal hygiene. In addition, MDS indicated R25 had intact cognition. On 1/27/20, at 2:10 p.m. when asked how long it took staff to come when he used the call light for assistance, R25 stated Mainly in the afternoon short staffed. I need two people. Staff will tell you they are short. R12's quarterly MDS dated [DATE], indicated R12 required extensive physical assistance of one staff with ADL's which included bed mobility, transfers, toilet use and personal hygiene. In addition, MDS indicated R12 had intact cognition. On 1/27/20, at 1:12 p.m. when asked how long it took staff to come when she used the call light for assistance, R12 stated, last night I waited an hour before I got help and I went to bed, happens just about every day. R17's admission MDS dated [DATE], indicated R17 required extensive to total physical assistance of one to two staff with ADL's which included bed mobility, transfers, toilet use and personal hygiene. On 1/27/20, at 6:04 p.m. when asked how long it took staff to come when she used the call light for assistance, R17 stated To get moved to bathroom or out of bed it took longer over the Holidays. Also weekends and nights may be the worst and over the Holidays. R39's quarterly MDS dated [DATE], indicated R39 required extensive physical assistance of one staff with ADL's which included bed mobility, transfers, toilet use and personal hygiene. In addition, the MDS indicated R39 had intact cognition. On 1/27/20, at 6:29 p.m. when asked how long it took staff to come when he used the call light for assistance, R39 stated Not nearly enough staff to help. Last week, all night I was all alone, no one checked on me. R246 on 1/27/20, at 7:10 p.m. stated staffing was the biggest issue when asked how long it took staff to come when he used the call light for assistance. During a review of the MDS, it was revealed R246 was admitted to the facility on [DATE]. Family interview: On 1/27/20, at 4:40 p.m. family member (FM)-A stated when asked how long it took staff to come when they used the call light for assistance when we have pushed the button you don't know how long it will take. I think they were short staffed on the weekend so I had to take her to the bathroom. During a review of the daily staff schedules from 11/23/19, through 1/30/20, which included weekends, week days and holidays, it revealed 33 days staff had called in which was a total of 65 shifts, however the facility had not found replacements. On 1/30/20, at 2:48 p.m. the staffing coordinator verified the yellowed out blank spots on the schedules indicate that the position was not filled. R37's significant change minimum (MDS) data set [DATE], indicated he was severely cognitively impaired, required extensive assistance with bed mobility, transfers and toileting, was frequently incontinent of bladder and always continent of bowel. The MDS indicated R37 had sustained falls with injury since admission to the facility. R37's care plan dated 1/17/20, identified limited physical mobility related to muscle weakness, lack of coordination and a history of falls resulting in fracture. The care plan identified a risk for falls related to decreased mobility, incontinence and advanced age. The care plan directed staff to perform hourly safety checks, initiated 1/2/20, if up at midnight, offer snacks and fluid initiated 1/9/20, perimeter mattress initiated 1/15/20, check at 7:00 a.m. and offer to get up if awake, added 1/29/20. The care plan further identified bowel and bladder incontinence and directed staff to assist with toileting every three hours and all over night (N[NAME]) rounds, initiated 11/23/20. A review of R37's medical record identified the following: A Progress Note dated 11/26/19, indicated at 3:10 a.m. R37 was found on the floor in his room bleeding from a laceration on his head. Progress Note dated 12/20/19, indicated R37 was heard yelling for help at 3:47 a.m. and was found lying on the floor between his bed and the bathroom sink. Progress Note dated 1/1/20, indicated R37 was seen kneeling on the side of his bed saying help, me, help me. A Resident Occurrence Report dated 1/1/20, indicated the fall occurred at 4:20 a.m. Progress Notes dated 1/9/20, indicated R37 fell at 7:00 a.m. A second report indicated R37 fell again 1/9/20, at 1:00 a.m. A Progress Note dated 1/14/20, indicated R37 was observed on the floor next to his bed and stated he was crawling out of bed. A Resident Occurrence Report dated 1/13/19, indicated R37 fell at 11:30 p.m. A Progress Note dated 1/14/20, indicated R37 was found lying on his right side at 3:50 a.m. outside the entrance of his door. A Progress Note dated 1/24/20, indicated R37 was observed sliding to the floor. A Resident Occurrence Report dated 1/24/20, indicated the fall occurred at 7:10 a.m. On 1/30/20, at 7:51 a.m. R37 was in bed with his eyes closed. At 9:50 a.m. R37 was sitting up on the side of his bed calling for help. There were no staff in the vicinity of his room. Surveyor entered R37's room and pressed the call light for assistance. Registered nurse (RN)-F entered the room and assisted R37 to get up. During interview on 1/30/20, at 5:31 a.m. nursing assistant (NA)-A stated there were two aides on the N[NAME] shift on the unit where R37 resided. NA-A stated recently the facility had provided a one to one staff for R37 but was not aware it was no longer going to continue. NA-A stated, we can't keep him safe without the one to one. NA-A further stated she was unable to take breaks because she could not leave the other NA on the unit alone and there was not enough staff. On 1/30/20, at 5:10 a.m. registered nurse (RN)-A indicated she covered both north and south care centers. RN-A stated usually the facility staffed three nursing assistants (NA) and one trained medication assistant (TMA) for both north and south care centers. RN-A also indicated that falls and resident's that have a change in condition are the major concerns when working the overnight shift. RN-A indicated when a resident fell , the nurse performed an assessment, and the TMA would take over passing medications but stated that left one aide on the unit to assist residents. On 1/30/20, at 5:30 a.m. TMA-A stated we are short staff all the time. TMA-A further indicated instead of having four NAs they would only have three NAs between both care centers. TMA-B stated when it's just one person working the floor it is very stressful, it should be two all the time. TMA-A stated (R17) fell about three or four days ago, and I was by myself that night, and I found that he self transferred out of bed. On 1/30/20, at 10:36 a.m. the staffing coordinator (SC) indicated that overnights had one nurse that floated between both care centers, one NA on the north care center and two NAs on the south care center, and a TMA that floated between the floors to pass medications. On 1/30/20, at 2:48 p.m. the facility administrator, director of nursing (DON) and the SC were interviewed together. During the interview, when asked how staffing levels were determined, the SC and DON stated it was determined by the acuity level and the census. When asked if staffing was tracked and trended with incidents such as falls, the DON and administrator both stated no patterns had been identified. When asked if they had tracked, trended and identified any patterns on the falls from (MONTH) 2019, the DON and administrator acknowledged they had not. Surveyor(s) informed them of the 22 falls in (MONTH) 2019, 11 had happened on the night shift. The SC indicated that staffing could be a potential reason that residents fall at night. When asked if staffing concerns are brought forward by the staff members, the administrator stated staff are very open with us. The DON, administrator and SC acknowledged the past weekend 1/25/20, through 1/26/20, a staff had resigned without the staffing coordinator knowledge and they had been made aware of the staffing issues experienced during the weekend. When asked if staff had come to them with staffing or workload concerns, all stated no staff had approached them. The SC stated she was aware of a few staff who did not take breaks, however did not know if staff were taking breaks on the floor/units because they did not feel safe to leave the other staff alone. The SC stated currently there had been staffing concerns because the facility had lost staff and some were our heavy picker uppers. When asked if they use pool staff, the administrator stated yeah our central agency is used for pool staff, but we don't get to use them on a short notice or for call-ins, we have to give a two month notice. On 1/30/20, at 3:30 p.m. human resources (HR) indicated that the turnover rate for the facility is 78% for NAs and 33% for RNs in the last year. PHS Clinical and Culinary Staffing Policy updated 9/25/19, indicated the decision to increase or reduce staffing hours will always be based on resident needs, care priorities and census.

Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 18 residents (R246) reviewed for advanced directives. Findings included: R246's Admissions Record indicated admitted was [DATE]. R246's care plan dated [DATE], indicated R246's cognition was impaired and wished for staff to follow advanced directives by following the doctor's orders. R246's Providers Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicated R246 desired, do not attempt resuscitation if the patient has no pulse and is not breathing. Allow natural death. R246's Order entry dated [DATE], identified an order status of full code. The order was reflected on the Admission Record. On [DATE], provider order was obtained indicating R246 was do not resuscitate (DNR), see POLST. An interview with the director of nursing (DON) on [DATE], at 3:25 p.m. confirmed there was an order in R246's paper medical record signed as completed on [DATE], for DNR, yet the order in the electronic medical record indicated cardiopulmonary resuscitation (CPR). During an interview on [DATE], at 3:00 p.m. licensed practical nurse (LPN)-A stated in the event of an emergency, she would first look in the electronic medical record. Interview with registered nurse (RN)-B on [DATE], at 2:15 p.m. stated looking for code status depended on what record was closest at the time of the code, the electronic or the paper chart. During an interview with R246 on [DATE], at 2:11 p.m. R246 was asked about her wishes and said let me go. No CPR. On [DATE], at 3:25 p.m. the DON stated the facilities procedure was as follows; When a new admission entered the building the admission nurse placed the orders in the electronic chart. If the resident did not have orders the nurse practitioner or physician were notified and worked with the resident and families to complete wishes on the POLST. A facility policy titled Code status: physician's orders [REDACTED]. if the resident does not have a POLST, the nursing staff would go over the POLST on admission and obtain an order from the physician corresponding with the residents wish for code status.

Based on observation, interview and document review the facility failed to ensure assistance with shaving for 1 of 2 residents (R37) dependant on staff for assistance with personal hygiene. Findings include: R37's significant change Minimum Data Set ((MDS) dated [DATE], indicated he was severely cognitively impaired and required extensive assistance with grooming. R37's care plan dated 11/23/19, identified a self care deficit and directed staff to assist with dressing, grooming and hygiene. Review of Progress Notes dated 11/23/19, and 11/25/19, indicated R37's daughter requested he be shaved daily. During observation on 1/27/20, at 6:02 p.m. R37 was observed with facial hair that appeared to be a few days growth. On 1/28/20, at 8:55 a.m. R37 remained unshaven. On 1/30/20, at 10:21 a.m. R37 was assisted to get up and dressed for the day and brought to a table in the dining room by registered nurse (RN)-F. R37 had facial hair that had not been removed since 1/26/20. On 1/30/20, at 10:56 a.m. the director of nursing stated R37 should be shaved every day, or at least every other day. On 1/30/20, at 11:14 a.m. R37's family member (FM)-A stated she had seen R37 the previous evening and he had not been shaved and stated I was not happy. FM-A stated she would like staff to shave him at least every other day and stated, that's one of the things I can give (R37) is a little dignity.

Based on interview and document review, the facility failed to ensure recommendations made by the consultant pharmacist were acted upon for 2 of 6 residents (R7, R14) reviewed for unnecessary medications. Findings include: R7's [DIAGNOSES REDACTED]. R7's quarterly Minimum Data Set ((MDS) dated [DATE], indicated moderate cognitive impairment and deficits in activities of daily living. R7's Care Area Assessment (CAA) identified R7 was taking antidepressants for [MEDICAL CONDITION] and that mood had been stable. Review of the Consultant Pharmacist Communication to Physician dated 9/27/19, indicated that R7 was taking both [MEDICATION NAME] and [MEDICATION NAME] (medications for depression) and that it was recommended to have [MEDICATION NAME] decreased and indicated taking two different antidepressant medications had the potential to cause confusion and increase the risk for falling. The Consultant Pharmacist Communication to Physician further indicated it was originally created on 7/23/19, and there was no response from the facility as of 9/26/19. Review of R7's medical record indicated that R7 had six falls in the last two months and the facility failed to address the recommendations made by the pharmacist. On 1/29/20, at 12:29 p.m. the administrator stated the nurse practitioner just addressed the recommendations after surveyor inquiry. On 1/30/20, at 8:38 a.m. the director of nursing (DON) indicated a new procedure was started the previous week. The DON further indicated that previously, the pharmacist would send the recommendations to the nurse practitioner or physician and acknowledged the recommendations by the pharmacist were not being followed up on. R14's [DIAGNOSES REDACTED]. R14's [MEDICAL CONDITION] Drug Use care area assessment (CAA), dated 10/1/19, indicated R14 had a [DIAGNOSES REDACTED]. In addition, the CAA indicated R14 received scheduled [MEDICATION NAME] for hallucinations and [MEDICATION NAME] for sleep. The CAA also directed staff to attempt a gradual dose reduction (GDR) as appropriate. R14's care plan dated 10/21/19, indicated R14 had moderately impaired cognition. The care plan indicated R14 used antipsychotic medications related to adjustment [DIAGNOSES REDACTED]. R14's physician orders, dated 5/16/19, included Quetiapine [MEDICATION NAME] ([MEDICATION NAME]- an antipsychotic medication) 12.5 milligram (mg) orally in the evening for agitation/hallucinations/delusions and [MEDICATION NAME] 75 mg by mouth one time a day for difficulty with sleeping. R14's Consultant Pharmacist Communication to Physician, dated 12/11/19, indicated to please consider the following: R14 currently has an order for [REDACTED]. She has not had sleep trouble noted in her sleep and target behaviors monitoring but she does continue to endorse sleep concerns in her personal health questionnaire (PHQ) 9. PHQ9 is an indicator for depression. In an effort to determine a minimum effective dose please assess if a trial reduction of [MEDICATION NAME] would be appropriate at this time-perhaps to 50 mg every hour of sleep. If dose reduction would not be appropriate please document in your next progress note why this would not be in R14's best interest. Physician response was not signed or dated. The communication indicated the recommendation was originally given to physician on 8/29/19; reissued 10/25/19. No response found as of 12/11/19. On 1/30/20, at 8:38 a.m. the director of nursing (DON) indicated a new procedure was started the previous week. The DON further indicated that previously, the pharmacist would send the recommendations to the nurse practitioner or physician and that the recommendations by the pharmacist were not being followed up on. The [MEDICAL CONDITION] and Unnecessary Medication Use policy dated (MONTH) 2010, indicated that all pharmacist recommendations will be reviewed with the primary physician/nurse practitioner prior to implementation and with a physician's orders [REDACTED].>

Based on observation and interview, the facility failed to label medications and store medication to prevent administration of expired medications for 4 of 8 (R13, R17, R29, R39) residents with unlabeled eye medications resulting in the administration of expired medication. In addition, the facility failed to safely store insulin and insulin supplies for 1 of 4 residents (R27). Findings include: During observation of a medication cart on north Gables on 1/28/20, at 1:13 p.m. with trained medication aid (TMA)-C, the cart contained multiple open eye drops that lacked the date opened. R13's Admission Record indicated he admitted to the facility on [DATE]. R13's Order Summary identified an order dated 12/5/14, for Artificial Tears, one application at bedtime for dry eyes. R17's Admission Record indicated he admitted to the facility on [DATE]. R17's Order Summary identified an order dated 11/19/19, for Carboxymethocellulose solution, one drop in both eyes as need for dry eye syndrome. R29's Admission Record identified an admission date of [DATE]. R29's Order Summary identified an order dated 12/19/19, for [MEDICATION NAME] solution, instill one drop in both eyes every two hours as needed for dry eyes and an order dated 12/19/19, for [MEDICATION NAME] solution, instill one drop in both eyes daily for [MEDICAL CONDITION]. R39's Admission Record identified an admission date of [DATE]. R39's Order Summary identified an order dated 5/8/17, for Refresh Tears solution, instill one drop in both eyes four times daily for dry eyes. During an interview with the director of nursing (DON) on 1/29/20, at 3:26 p.m. she stated the expectation was the staff who opened the medication, would place a date on the label and follow their teaching to know the expiration date from the open date. During interview on 1/30/20, at approximately 3:00 p.m. registered nurse (RN)-B stated she had reviewed the delivery dated from the pharmacy and confirmed the eye medications for R13, R17, R29 and R39 were expired. During observation of R27's insulin administration on 1/29/20, at 9:49 a.m. it was observed the insulin and insulin supplies were stored in a cupboard which was unlocked in R27's room, when RN-B went to administer the insulin. During interview on 1/29/20, at 2:55 p.m. licensed practical nurse (LPN)-A stated all insulin and insulin supplies were kept in the residents rooms. During an interview with the DON on 1/29/20, at 3:26 p.m. she explained that each diabetic resident can have their own glucometer in the room, but not the insulin. DON stated, the insulin should not be in the room, it needs to be locked up. A facility policy titled Medication Storage in the Facility dated 12/17/16, indicated outdated medications are to be immediately removed from stock and reordered from the pharmacy.

Based on observation, interview and document review the facility failed to provide timely repositioning for 1 of 4 residents (R37) reviewed for pressure ulcers. Findings include: R37's quarterly minimum data set ((MDS) dated [DATE], indicated she was severely cognitively impaired, required extensive assistance for bed mobility, transfers and toileting and was incontinent of bowel and bladder. The MDS further identified an unstageable pressure ulcer. R37's care plan dated 10/24/18, indicated a self care deficit related to weakness and impaired mobility and limited physical mobility. The care plan directed staff to assist with repositioning in bed, transfers and toileting. The care plan further identified pressure injuries to the heel and coccyx and directed staff to reposition R37 every two hours while awake. Review of a facility Wound assessment dated [DATE], identified a stage II pressure ulcer to R37's coccyx that was acquired in the facility. During continuous observation on 11/ 15/18, R37 was observed dressed and up in her wheel chair at 7:03 a.m. At 7:22 a.m. R37 was seated at a table in the dining room where she remained unit 9:26 a.m. when staff wheeled her to a common area in front of the television. At 9:45 .m. Staff escorted R37 to the auditorium where she remained until 10:26 a.m. During interview on 11/15/18, at 10:59 a.m. nursing assistant (NA)-A stated another NA had taken R37 to the bathroom at 10:10 a.m., three hours after she had risen for the day. During observation on 11/15/18, at 10:59 a.m. NA-A assisted R37 to the bathroom. R37's skin was observed to be red over the coccyx area. During interview on 11/15/18, at 12:35 p.m. registered nurse (RN)-A stated R37 had acquired a pressure ulcer to her heel a little over a month ago. RN-A stated R37 developed a pressure ulcer on her coccyx more recently. She stated the coccyx ulcer showed up, went away and then appeared again. RN-A stated R37 is able to make slight adjustments in her wheel chair but was not able to off-load. She stated staff were directed to reposition her every two hours based on R37's risk factors. At 12:42 p.m. the director of nursing stated she expected staff to follow the plan of care for turning and repositioning. A facility polity titled Skin Integrity Management Policy - Minnesota dated (MONTH) (YEAR), was reviewed and indicated it was the policy of Presbyterian Homes to assess, monitor, implement preventative measures and provide treatment modalities for pressure ulcers. The policy indicated implementation of a turning and repositioning schedule would be developed and communicated to the appropriate staff.

Based on observation, interview and document review, the facility failed to assure that [MEDICAL CONDITION] medications were reviewed timely for 1 of 5 residents (R2) reviewed for unnecessary medications. Findings include: Review of R2's Minimum Data Set, dated dated [DATE], identified R2's cognitive status as intact cognition. On 11/14/18, at 2:45 p.m., R2 was observed in her room resting on the bed. R2 stated today was her birthday and she already had a celebration in the morning and would have another one that night with family. R2 explained not liking to leave the facility because of toileting concerns that made her anxious. She acknowledged being anxious, at this time, due to company coming. She said that she had just asked for another anxiety medication but it was too early. Review of physician orders [REDACTED]. On 10/11/18, the order for [MEDICATION NAME] 0.25 mg was renewed and ordered to be given PRN every 12 hours, end date of 12/10/18, with instructions to update the nurse practitioner that [MEDICATION NAME] order ends today and if she wants to resume order or not. The Medication Administration Record [REDACTED]. Interview with Administrator and Director of Nursing on 11/15/18, at 8:35 a.m., regarding procedure for anti-anxiety medication [MEDICATION NAME], stated that initially the facility will obtain a 14 day order for a PRN [MEDICAL CONDITION] medication and will check with the physician to see if the physician wants to extend the medication further than 14 days, indicating this information would be documented in the physician progress notes [REDACTED]. The [MEDICAL CONDITION] and Unnecessary Medication Use Policy, modified (MONTH) (YEAR), identified under PRN [MEDICAL CONDITION] medications: [REDACTED] 1. PRN orders for [MEDICAL CONDITION] must have a specific condition and indication for use. PRN medications are limited to 14 days. Except as provided below: a. [MEDICAL CONDITION] (excluding anti-psychotic) may be used for 14 days, unless the prescribing practitioner documents the rationale for an extended period of time and indicates a specific duration.

Based on interview and document review, the facility failed to provide care and treatment in accordance with the resident's comprehensive care plan to promote intact skin integrity for 1 of 1 residents (R1). This resulted in actual harm for R1, who developed moisture associated skin damage on the left wrist and hip. Findings include: R1 was admitted to the facility on hospice with a [DIAGNOSES REDACTED]. R1's admission cognitive assessment, dated [DATE], indicated R1 was severly cognitively impaired, unable to answer simple questions, and unable to communicate her needs. R1's Skin Risk and Braden assessment, dated [DATE], indicated R1 was at high risk for skin breakdown. R1's skin was intact and R1 had a pressure reducing mattress in her bed and wheelchair. The assessment directed staff to lay R1 down after meals, reposition R1 on night rounds using pillows to support R1, and to monitor for skin breakdown. The assessment indicated R1's skin was intact. R1's careplan, dated [DATE], indicated R1 was at risk for impaired skin integrity due to being incontinent, [MEDICAL CONDITION] medication use, and limited physical mobility. R1's careplan directed staff that R1 required repositioning according to R1's toileting schedule. R1's careplan further included R1 was incontinent and indicated R1 used an incontinent pad, did not use the toilet, and required assistance of one staff member to check and change the incontinent pad every three hours during the day and on second and fourth rounds overnight. The careplan further indicated staff was to apply barrier cream to R1's perineal area with every incontinent pad change. R1's undated caresheet included R1 required assistance of one staff member to reposition every three hours during the day and on night rounds. The caresheet directed staff to reposition R1 side to side and keep off of her back. The caresheet further included R1 was to be toileted every three hours and as needed and barrier cream to be applied to R1's coccyx with toileting. R1's (MONTH) (YEAR) treatment administration record (TAR) included a nursing order every shift for nurses to ensure resident assistants are changing briefs and applying barrier cream to peri area every three hours per R1's care plan. A progress note dated [DATE] at 1:39 p.m. indicated R1's skin was intact including her buttocks and coccyx area. A progress note dated [DATE] at 11:22 a.m. indicated a nurse was called into R1's room around 7:30 a.m R1 was observed lying on her left arm.(NAME)pads were saturated with urine as well as R1's pajamas from shoulder to thighs. R1 was yelling ow, ow, ow when aides were repositioning R1 to her back from her left side. R1 was wincing and facial grimacing was observed. R1's left arm was red with swelling on the left hand and six blisters scattered on R1's left hand and wrist. A welt was observed on R1's left hip. Blisters measured the following on R1's left wrist and hand 3.5 cm x .5 cm, 2 cm x .5 cm, 6.5 cm, 0.5 cm, 1 cm x 0.5 cm, 6 cm, 3.5 cm, and 1.5 cm x 1 cm. Welt on hip measured 4 cm x 4 cm. Family, management and hospice notified. Review of R1's (MONTH) (YEAR) TAR indicated the nursing order for every shift for nurses to be sure resident assistants are changing briefs and applying barrier cream to peri area every three hours per R1's care plan was signed off on for all shifts from [DATE] through [DATE]. Review of R1's (MONTH) (YEAR) care tracker documentation indicated NA-E signed off on providing cares to R1 at 4:57 a.m. on [DATE] and indicated R1 was continent. A progress note dated [DATE] at 3:17 p.m. indicated R1 had moisture associated skin damage (MASD). The nurse practitioner (NP) and R1's responsible party were notified. A physician order [REDACTED]. Keep blisters clean, dry and wrap with gauze and kerlix. If blisters open use 4x4 and contact hospice. Skin and Wound Assessments dated [DATE] included measurements and locations of the blisters were as follows: -A Left inner wrist MASD intact blister area that was 2.1 cm in length and 1.3 cm in width -A second left inner wrist MASD intact blister area which measured 5.8 cm in length and 4.2 cm in width -A left outer forearm MASD intact blister which measured 6.8 cm in length and .8 cm in width -A left outer wrist MASD blister which measured 2.3 cm in length by 1.9 cm in width -A left trochanter MASD red area which measured 4.6 cm in length by 3.6 cm in width The assessments further indicated at the time of the assessments R1 was tense with observed facial grimacing. A [DATE] Skin Risk and Braden Assessment indicated R1 was at high risk for skin breakdown, was unable to offload independently, and staff was to assist R1 every 3 hours and as needed. R1 was assessed to be repositioned and toileted every 3 hours and barrier cream applied at each toileting. An email from R1's NP dated [DATE] at 10:01 a.m. indicated further insight was provided by the physician. The email included: On further review, I do think the blisters are most likely friction blisters from prolonged contact with urine in those areas, and since they are linear I am worried that she was restlessly rubbing/moving the affected urine-soaked areas of her skin in bed last night. A progress note dated [DATE] at 12:10 p.m. indicated R1 was seen by hospice. R1 has developed a red area, warm to touch, close to blister in the inner part of her left wrist. An antibiotic (Keflex) 500 mg was prescribed to be administered three times per day for one week for [MEDICAL CONDITION]. R1's family was updated with the order. A progress note dated [DATE] at 9:26 p.m. indicated R1 was finished with the antibiotic for [MEDICAL CONDITION]. Dry blister on left hand and redness on left hip healing well and redness on left hand is fading away. A progress note dated [DATE] indicated R1 MASD areas were improving. A progres note dated [DATE] indicated R1 had a progressive decline in condition and passed away on [DATE]. Interview with the Administrator on [DATE] at 11:13 a.m. indicated on [DATE] morning staff discovered blisters on R1's arm and hip. The Administrator stated Nursing Assistant (NA)-C and NA-D reported the blistering immediately to the Registered Nurse (RN)-F, who reported it to the Administrator. The Administrator indicated the Director of Nursing was not in the facility on [DATE]. The Administrator stated the incident was reported and she began interviewing the staff that found the blisters and the previous night shift staff about R1's cares. During interviews with night shift staff, the Administrator stated NA-E stated he did not reposition R1 because she had been restless at the beginning of his shift and when R1 fell asleep, he did not want to wake her up. NA-E stated he did check and change R1's incontinent pad and stated R1 had been continent. NA-E told the Administrator he did not discuss this with the nurse (RN)-J prior to not following R1's plan of care. The Administrator stated that after her conversation with NA-E, NA-E was placed on admnistrative leave. NA-E was later re-educated and monitored while providing cares before returning to work independently. The Administrator stated she also spoke with the night shift nurse (RN)-J who had signed off that R1's cares were completed every 3 hours during the night. RN-J stated she did not actually witness NA-E provide cares to R1 and did not recieve any specific report regarding R1's behavior or cares from NA-E at the end of the shift. The Administrator stated RN-J was also disciplined regarding the incident as she had signed off that R1's cares were completed without ensuring cares were completed. The Administrator stated that following this incident the facility immediately implemented tracking sheets on residents who required turning and repositioning schedules so staff were aware of the last time residents had been repositioned. Interview with Nursing Assistant (NA)-C on [DATE] at 12:47 p.m. confirmed she was assigned to care for R1 on [DATE]. NA-C stated she recieved no report regarding R1 or when R1 was last repositioned or checked on at the beginning of her shift. NA-C stated she entered R1's room between 7:00 a.m. and 7:30 a.m. NA-C stated R1's room smelled of ammonia or a strong urine scent. NA-C stated the smell from R1's room was so strong she could smell it upon entering the unit. NA-C stated she called NA-D in to assist with R1's cares. NA-C stated R1 was found laying on her left side. When NA-C and NA-D turned R1 to begin providing morning cares, they observed dark red swelling and blisters to R1's left arm and wrist area. NA-C stated R1's clothing and bedding was saturated with urine from R1's shoulder to hip area. NA-C stated the bed sheets were urine stained as if the urine had been there for an extended period of time. NA-C stated that during morning cares, R1 was visibly in pain and observed facial grimacing and R1 crying out in pain. NA-C stated during cares there was a reddened area on R1's left hip that was also observed. NA-C stated she informed RN-F immediately of the blisters, wet clothing and wet bedding found upon entering R1's room. Interview with NA-D on [DATE] at 1:10 p.m. indicated she smelled a strong urine odor upon entering R1's room around 7:20 a.m. on [DATE]. NA-D stated R1 was laying on her left hand and arm upon entering the room. NA-D stated when she and NA-C began to reposition R1, she screamed out in pain. NA-D stated R1's arm was red, swollen and had began to blister and there was a red area on R1's hip the size of a 50 cent piece. NA-D stated R1's clothing was wet from shoulder to feet, R1's bedding was wet and the mattress was saturated with urine. NA-D stated she had heard the night staff (Nursing Assistant) NA- E had last changed the R1 at 6:00 a.m. and stated that this was impossible due to the amount of wet bedding and clothing. Interview with Registered Nurse (RN)-F on [DATE] at 2:10 p.m. indicated RN-F was called into R1's room by NA-C and NA-D on [DATE]. RN-F stated the room smelled of urine and R1's clothing and bedding were saturated with urine from shoulder to thigh. RN-F stated R1 had reddened and blsitered areas on her left hand, wrist, and hip area. RN-F stated R1 was visibly in pain during repositiong. RN-F stated she immediately assessed R1's skin integrity and informed the nurse manager (RN-G), R1's hopsice nurse and R1's family regarding the change in R1's skin condition. RN-F went on to say she could not recall if she was updated in morning report on the last time R1 was repositioned. RN-F further stated when this incident was discussed regarding repositioning she thought Wow, there is no way this happened in a short amount of time . she couldn't have been that saturated if she was recently changed. Interview with the Hospice nurse, Registered Nurse (RN)-H, on [DATE] at 4:00 p.m. indicated she was aware of the blisters found on R1, however was not the nurse working when the blisters were found. RN-H indicated when Hospice was updated, LPN-I went to the facility to visit R1. RN-H stated LPN-I had never seen [MEDICAL CONDITION] severe on a resident. RN-H indicated she was updated when she returned to work and had been the primary Hospice nurse for R1. RN-H stated she was told by the facility that the night shift nursing aide (NA)- E did not reposition R1 during the night, due to R1 being restless and when R1 finally fell asleep NA-J did not want to reposition R1. RN-H stated R1 could not have repositioned herself during the night and should have been repositioned every 3 hours. Interview with the hospice nurse, licensed practical nurse (LPN)-I on [DATE] at 12:48 p.m. indicated she was informed by the facility of concerns with blisters found on R1 on [DATE]. LPN-I stated when she arrived to the facility and saw R1's skin she was shocked and had never seen a urine burn that bad in all of her years of nursing. LPN-I stated she was told R1 was found in urine soaked clothing and bedding when the blistered were discovered. LPN-I stated Hospice and the Nurse Practitioner (NP) were updated and orders were provided for treatment of [REDACTED]. Interview with RN-J on [DATE] at 12:02 p.m. indicated she was the nurse working overnight on [DATE]. RN-J stated she did not recall getting any report that R1 was restless on the evening shift. RN-J stated she was busy during the night shift, as she was the only nurse working, and did not recieve any update from NA-E or any concerns regarding R1. RN-J stated she depends on the aides to complete the work assigned and signed off that R1's cares were completed. RN-J stated she did not directly see NA-E go into R1's room or directly witness R1's cares during the night. RN-J assumed R1's cares were completed and signed off that R1's treatments were completed. RN-J stated after blisters were found on R1 the following day, she was interviewed and questioned regarding NA-E's cares provided to R1. RN-J stated she was placed on leave and later disciplined for signing off on a treatment that was not completed. Interview with NA-K on [DATE] at 12:25 p.m. confirmed he worked on the [DATE] evening shift and was the aide who assisted R1 into bed the evening prior to when the blisters were found. NA-K stated R1 was good on his shift and could recall nothing out of the ordinary with R1. NA-K stated he assisted R1 with evening cares and into her pajamas between 7:,[DATE]:30 p.m. NA-K stated he assisted R1 into bed and placed R1 onto her left side as she had recently been on her backside in her wheelchair. NA-K stated the last time he checked on R1 was 9:30 p.m and R1 was talking to herself in bed, but stated this was not out of the ordinary for R1. NA-K stated when the night shift arrived he reported R1's talking out to NA-L who was the first person to report for the night shift. NA-K denied reporting R1 was restless. Interview with NA-L on [DATE] at 3:51 p.m. indicated she did not recall receiving a report regarding R1 on [DATE] night shift. NA-L could not recall if she spoke with NA-K at all during the night shift from ,[DATE]-[DATE]. NA-K stated she did not assist R1 with cares at all during the night and did not asssit NA-K with any cares during the night. NA-L stated at the time this incident occurred there was no consistent report being given from shift to shift, however this was implemented after this incident occurred. Interview with NA-E on [DATE] at 11:14 a.m. indicated when he started his shift on [DATE] he was given report that R1 was restless. NA-E stated the nurse had provided him this report. NA-E stated when he first checked on R1 she was yelling or calling out in her bed. NA-E stated he checked on R1 on rounds as directed by R1's caresheet. NA-E stated he did not reposition R1 but that R1 had repositioned herself. NA-E stated R1 was initially on her left side, then during the second check on her back, and during the final check on R1 she was again on her left side. NA-E stated each time he entered R1's room he checked her pad by feeling if it was wet with his hands and indicated R1 was dry during the night shift. NA-E indicated he last checked on R1 around 4:20 a.m. NA-E stated he did not reposition R1 as R1's careplan did not include to reposition R1; it only included to check and change R1 on rounds. NA-E confirmed he did not discuss any care concerns with RN-J. Interview with R1's family member (FM)-A on [DATE] at 11:00 a.m. indicated she was on vacation when she was updated on R1's change in skin condition. FM-A stated a family friend (FM)-B had been visiting R1 in FM-A's absence and was the first one to inform her of R1's blisters and hip area. FM-A stated FM-B took pictures of the areas and sent them to her. FM-A stated she was later informed of the incident by the facility Administrator who told her that R1 was not repositioned during the night and on her left side during the period of the night. FM-A stated she was later told by the facility that they investigated and found the aide responsible had last checked on R1 at 6:00 a.m. and R1 was continent. FM-A stated the aide was suspended, but later returned to work. FM-A stated she was concerned that only one person was assisting R1 and thought R1 should be a two-person assist for cares. FM-A questioned why only one person was responsible for the night cares of R1. FM-A stated the facility removed the aide from caring for R1 and later put cameras around R1's room for two weeks and also implemented the nurse be the second person assisting R1 with cares. FM-A stated when visiting she often witnessed that the nurse did not help reposition R1. FM-A stated R1's blisters later healed and R1 died at the facility shortly after this incident. Interview with a family member friend (FM)-B on [DATE] at 12:02 p.m. indicated she visited R1 at the facility the day the blisters were found. FM-B stated that as she was walking towards R1 room the hallway smelled very strongly of urine and as she got closer to R1's room it was obvious the smell was coming from R1's room. FM-B stated that upon entering R1's room she was told by facility staff that R1 slept on her side in urine all night and there were blisters on her hand. FM-B could not recall what side the blisters were on. FM-B stated she had never seen anything like this in her life and stated there were six fluid filled blisters on R1s hand and wrist area and R1's buttocks area was red and raw and there was a red area the size of a softball on R1's hip. FM-B stated she took pictures of the areas and sent them to FM-A. FM-B stated a Hospice nurse later came to assess and treat R1's blistered and reddened areas. FM-B stated she frequently visited R1 at the facility and had never known of any skin concerns and she frequently was in the room for cares. Interview with R1's Nurse Practitioner (NP) on [DATE] at 12:01 a.m. indicated she was made aware of R1's blistered and reddened areas on her left side on [DATE]. The NP stated she assessed R1's skin the same day. The NP stated initially, she wanted to rule out any concerns that R1 would have been having a reaction to an antibiotic. The NP stated after an assessment she did not feel the blisters or red areas were cause of the antibiotic, however discontinued the antibiotic as a precaution. The NP prescribed a treatment for [REDACTED]. The NP stated Hospice later prescribed an antibiotic due to concerns with the blistered areas becoming red and swollen. The NP stated the facility was questioning if R1 had been laying in one position during the night, however stated she was not told if this was confirmed. The NP stated pictures were taken and were sent to a physician to review. After review, the physician concluded the blisters and red areas were caused by friction rub from prolonged contact with urine in the areas affected. An interview with the Director of Nursing (DON) on [DATE] at 4:30 p.m. indicated she was not at the facility at the time the blisters and red areas were found on R1. The DON indicated most of the internal investigation was completed by the Administrator. The DON did indicated she sat in with one interview with NA-E, and stated NA-E did not follow the R1's care plan and did not reposition R1 during the night shift on [DATE]. The DON further indicated RN-J signed off that cares were completed for R1 and both NA-E and RN-J were disciplined regarding this incident. The DON indicated NA-E stated he had checked R1's incontinent pad during the night by feeling the pad and checking if the pad was wet. The DON confirmed this is not the expectation of nursing staff. The DON stated she expected staff to provide pericare, toileting, and reposition in accordance with the care plan and if not the nurse needs to be informed immediately as to why the careplan was not followed. The DON stated all staff were re-educated on the importance of following resident care plans and audits were completed following this incident and new tracking and monitoring sheets were implemented. A facility policy dated (MONTH) (YEAR) entitled Care Plan Policy and Procedure indicated a comprehensive care plan will initiate a complete and comprehensive prior to the intial care conferance and the care plan will ensure the resident has the appropriate care required to maintain or attain the resident's highest practicable physical, mental, and psychosocial well-being.