Every finding on record at Anoka Rehabilitation and Living Center

Based on observation, interview, and record review the facility failed to identify, treat, monitor, and manage 1 of 3 residents (R1) reviewed for pain to the extent possible in accordance with R1's care plan, goals, and preferences. R1 stated pain and was observed having pain. R1 had available morphine sulfate every two hours as needed (PRN), which was not administered to him for his breakthrough pain. Findings include: Upon observation and interview on 11/12/25 at 9:54 a.m. R1 laying in his bed wearing a hospital gown. On his wall was a sign indicating for staff to be gentle and go slow with R1. R1 stated the care was bumpy, R1 referred to himself as an old, skinny man with soft skin. He stated it hurt every time he was moved. R1 stated he took Tylenol, a narcotic, and a steroid. R1 was not aware that he could ask for pain medication when he was having pain. Why didn't they tell me that? Upon observation on 11/12/25 at 10:58 a.m. nursing assistant (NA)-A entered R1's room to start his morning cares. NA-A emptied R1's catheter bag, brought in the mechanical lift and waited for another NA to assist with cares. NA-B entered the room, and the aides proceeded to dress R1's upper body. The staff worked slowly, gently and explained what they were doing with R1. Upon lifting R1's left arm to put on his shirt R1 winced in pain, flailing his right arm out as if he were going to strike the staff. The staff proceeded to change R1's incontinent brief, NA-A cleansed his catheter insertion area with a wet wipe. R1 had a thick layer of barrier cream on his penis and testicles. R1 was screaming out to NA-A to be gentle because his private areas were sensitive, and stated NA-A should understand as he was a man as well. R1 was then turned to his right side so staff could clean his backside. R1 screamed ouch and to hurry while being turned. Registered nurse (RN-A) entered the room as staff was wiping the thick barrier cream between R1's buttock folds and scrotum. R1 screamed to stop as he was in pain. The staff stopped momentarily and explained to R1 that they needed to get the old cream off before applying the fresh barrier cream. NA-B got a wet washcloth and NA-A continued to clean R1. A fresh incontinent pad and pants were placed on R1. R1 was transferred to his wheelchair using the mechanical lift. R1 made facial grimaces and winched in pain during the lift. R1 stated that was the process every single day. Upon observation and interview on 11/13/25 at 9:10 a.m. NA-A and NA-C brought R1's breakfast tray into his room. The aides boosted R1 up in his bed using the lift sheet. R1 winced in pain shouting my back, my back. R1 was placed with the head of his back up so he could eat his breakfast. R1 stated his pain was in his back and his buttock. He rated the pain a 5 on a scale from 1 to 10, 10 being the worst pain. Upon observation on 11/13/25 at 10:21 a.m. NA-A and NA-C entered R1's room to start his morning cares. The staff explained to R1 what they would be doing and R1 agreed. Upon putting R1's shirt over his head R1 screamed damn that hurt. Staff slowly and gently cleaned R1's penis and scrotum R1 was silent but made facial grimaces and jolted his body in a tight position when they touched him. R1 was rolled on his right side for staff to clean his back side. R1 screamed you are beating up my legs. R1's pants were put on and R1 was lifted in the mechanical lift sling. R1 was flailing his arms out to hit NA-C. NA-C handed R1 a bed pillow to hug during the lift and telling R1 to relax. The staff got R1 seated in his wheelchair. NA-C removed the sling from under R1 and R1 stated my pain is a 10 now. R1's care plan dated 3/12/22 indicated R1 had pain related to rheumatoid arthritis (chronic inflammatory disorder), polymyalgia rhematica (muscle pain and inflammation around the shoulder and hips), and chronic pain. R1's goal was to remain comfortable. His interventions were:-Administer pain medication per physician order for breakthrough pain-Medications as ordered-Monitor for probable cause of pain. Notify nursing-Monitor opioid side effects: sedation, hypoxia (the body not receiving enough oxygen), urinary retention, pruritis (itching)-Monitor pain characteristics: quality, severity, location, onset, duration, precipitating or relieving factors. R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 12 indicating R1 was cognitively impaired. R1's did not have any behavior symptoms. R1 required maximum assistance with toileting, upper body dressing, and rolling side-to-side in bed. He was dependent upon staff for lower body dressing and transferring from chair-to-bed and bed-to-chair. R1's pertinent diagnoses were cerebrovascular disease (stroke), monoplegia of the upper limb affecting nondominant side (paralysis), age-related physical debility, chronic pain, lower back pain and weakness. R1's physician orders dated 10/30/25 indicated to give morphine sulfate, 2.5 milligrams (mg) sublingually (under the tongue) every two hours as needed (PRN) for pain solutab (dissolvable tablet). R1's medication administration sheet (MAR) dated October 2025 indicated R1 was administered scheduled morphine sulfate oral solution 0.125 milliliters (ml) twice a day at 8:00 a.m. and 8:00 p.m. Morphine sulfate 2.5 mg solutab every two hours PRN for pain was not administered. R1's MAR dated 11/1/25 - 11/13/25 (the date of the survey) indicated R1 was administered scheduled morphine sulfate oral solution 0.125 milliliters (ml) twice a day at 8:00 a.m. and 8:00 p.m. R1 was not administered morphine sulfate 2.5 mg solutab PRN for pain. R1's Nursing - Resident/Staff Interview Pain Data Collection dated 11/7/25 indicated R1 had received scheduled pain medication in the past five days. He had received PRN pain medication or was offered and declined in the past five days and in past five days he had received non-medication interventions for pain. R1 stated he had occasional pain during the past five days. The pain occasionally made it difficult to sleep, participate in therapy and day-to-day activities. R1 rated his pain a level 3 on a scale of 0-10 with 0 being no pain and ten the worst pain you can imagine. The assessment did not include any documentation in the comments or pain summary section. Upon interview on 11/12/25 at 12:30 p.m. R1's family member (FM)-A stated the family was very involved with R1's care as they visited him often. He stated pain was a significant concern for R1. He was aware R1 was on multiple pain medications, and he could not figure out why R1's pain was not controlled. FM-A believed R1 was receiving morphine sulfate every two hours along with other scheduled pain medications. Upon interview on 11/12/25 at 1:12 p.m. NA-A stated R1's cares that morning was a typical morning with R1. He punched out at staff and complained of pain with almost every movement. NA-A stated he had reported the pain to nursing and the response he received was to be gentle and go slow. NA-A was not aware of what R1's medication regimen was. Upon interview on 11/12/25 at 1:30 NA-B stated R1 always flailed his arms around in pain and [NAME] in pain with his cares. NA-B stated she had reported R1's pain and behaviors to nursing and was also told to be gentle and slow. Upon interview on 11/12/25 at 3:21 p.m. RN-A stated R1 will have skin breakdown if staff does not clean him well during his cares, they must get the old, thick barrier cream off and put on the new cream. Today was the first time RN-A had visualized the aids caring for R1. She stated she was not aware of the intensity of his pain and was not certain why staff had not been giving him his PRN doses of morphine sulfate. RN-A stated it would be a good idea to use the PRN medication. Upon interview on 11/12/25 at 4:45 p.m. R1's Primary Care Physician (PCP) stated the pain regimen R1 was on should cover his pain. The PCP was not aware that R1 was not receiving his PRN morphine sulfate. He stated he was not certain why the staff was not utilizing the PRN medication and was going to emphasize with the staff that they should be using the medication and that was why he ordered it. Upon interview on 11/13/25 at 1:10 p.m. RN-B the nurse manager stated she was aware R1 had pain during cares as he had complained of staff being rough with him and the staff was educated and told to be gentle and go slowly with R1. She stated R1 was extremely sensitive due his fragile skin. The moment staff touched R1 he cried, but cares needed to be conducted, or his skin would breakdown. RN-B stated she was not certain why R1 was not pre-medicated prior to cares with his PRN morphine sulfate. She did not have a system in place for checking the usage of PRN medications on the unit. Upon interview on 11/13/25 at 1:55 p.m. the assistant director of nursing (ADON) stated prior to the beginning of the survey he was not aware of R1's pain. He spoke with the nurse manager and staff on the unit during the survey on 11/12/25 and found out R1 had pain and anxiety about his pain. The ADON had not visualized R1's cares. He was not certain why the staff was not utilizing R1's PRN morphine sulfate. He was not aware of a system on the unit for tracking PRN medication or narcotic medication usage. A facility policy titled Pain Management dated 4/14/25 indicated the facility used a systematic approach for recognition, assessment, treatment, and monitoring of pain, ensuring that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive per the person-centered care plan, and the resident's goals and preferences.

Based on interview and document review the facility failed to ensure services were provided in a dignified manner to promote quality of life during incontinence care for 1 of 1 resident (R10) reviewed for dignity, Findings include:R10's face sheet printed 8/21/25, indicated R10 was admitted to the facility 3/12/25 and had the following diagnoses: hypertensive heart disease, chronic obstructive pulmonary disease, monoplegia of upper limb following cerebral vascular infarct (loss of voluntary muscle movement related to a stroke), adjustment disorder with depressed mood, pain and need for assistance with personal cares.R10's care plan with last completion date of 8/6/25, indicated a need for activities of daily living (ADL's) assistance with interventions to include assistance with placement of bedpan and extensive staff assistance with personal hygiene and grooming. The care plan identified R10 triggered for altered elimination with interventions to include assistance with placement of urinal, assist with perineal hygiene after toileting, and change incontinent briefs as needed.During interview on 8/18/25 at 2:08 p.m., R10 stated earlier that morning he had requested staff assistance. Staff brought in his breakfast tray when they answered his call light. R10 stated he requested his bedding changed and to be 'cleaned up'. R10 stated staff touched his bedding and told him it was dry. R10 stated he was left in wet bedding and brief to eat his breakfast. R10 stated it made him feel like an invalid and embarrassed because he couldn't do things for himself. R10 went on to say staff frequently told him to 'just go in the brief'. He was embarrassed because he was a grown man and shouldn't be wetting the bed. During interview on 8/20/25 at 7:19 a.m., R10 stated when he asks for assistance with placing his urinal staff frequently instructed him to go in his brief. R10 stated it made him feel like a child for wetting his bed. R10 stated 'it's embarrassing, and certified nursing assistant (CNA)-A does it every day'.During interview on 8/20/25 at 8:47 a.m., CNA-A stated R10 was care planned to use a urinal but 'he just goes in his brief'. CNA-A stated R10 wasn't able to use the urinal by himself. CNA-A stated her supervisor had said R10 wasn't able to use the urinal. CNA-A stated R10 was a 'difficult resident' to work with. She had not offered the urinal or assist with placement of the urinal.During interview on 8/20/25 at 10:06 a.m., licensed practical nurse case manager (LPN-CM) stated residents were assessed for their toileting abilities and reassessed at least annually or with a change of condition. LPN-CM stated if a resident was assessed to need assistance with urinal placement staff were to physically place the urinal in the correct place for the resident and then provide peri-care after the resident was finished and empty the urinal. LPN-CMA confirmed R10 required staff assistance to place a urinal and it was on his care plan. LPN-CM stated if a resident required assistance, she expected staff to place the urinal. It was a dignity issue and staff were required to follow the care plan. During interview on 8/20/25 at 10:32 a.m., Director of Nursing (DON) stated residents were assessed by nursing for their toileting abilities and based on the assessment would determine what, if any, assistance they needed. DON stated the results of the assessments helped to create the resident care plans and care sheets. DON reviewed R10's care plan and confirmed R10 required assistance with a urinal and stated he expected staff to assist with that placement. DON stated there could be potential negative effects of leaving a resident in a wet brief or not assisting them with a urinal which included skin breakdown, urinary tract infection or loss of dignity. DON went on to state he expected staff to assist residents in whatever manner the care plan dictated them to have assistance. DON stated it was important follow the care plan and treat all residents with dignity and respect and stated it was the resident's rights.Facility policy titled Resident's [NAME] of Rights and Dignity policy indicated the facility must treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality.

Based on interview and record review the facility failed to ensure a psychotropic medication ordered as needed (PRN) was limited to 14-days or extended to a specific date with supporting rationale provided by the medical provider for 1 of 2 residents (R2) reviewed for psychotropic medication use.Findings include:R2's quarterly review minimum data set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, required assistance with activities of daily living (ADL's), and had the following diagnoses: Hypertension, Renal Insufficiency, Diabetes Mellitus, Hyperlipidemia, and Dementia. Review of R2's physician signed medication review dated 7/26/25, indicated the following order: Lorazepam Oral Tablet 0.5MG. Give 0.5MG by mouth every 4 hours as needed for anxiety, give PO/SL. The order had a start date of 7/9/25, but no end date noted. Review of monthly pharmacist recommendation and review dated 8/5/25 indicated the following: ' R2 has a PRN order for an anxiolytic, which has been in place greater than 14 days without a stop date: Lorazepam 0.5MG 1 tab by mouth sublingually every 4 hours as needed for anxiety.During interview on 8/20/25 at 1:06 p.m., Director of Nursing (DON) stated each month the consulting pharmacist would review all resident medication for irregularities. The pharmacist would make recommendations for things such as monitoring, dose changes, contraindications or discontinuation of medications. DON confirmed the consulting pharmacist had noted on 8/5/25 R2's lorazepam 0.5mg order started on 7/9/25 did not have an end date. DON stated all PRN psychotropic medications can only be given 14 days, and must have appropriate diagnosis and, if extended must be evaluated by the provider and have appropriate rationale for extending beyond 14 days. DON stated he expected staff to follow all regulatory practices regarding all medications and put in the 14-day end date for all PRN psychotropic medications when they were entered into the resident's electronic medical record. DON went on to say it was important to ensure residents were not receiving medications unnecessarily. Facility policy title Unnecessary medications, Psychotropic Medications, and Gradual Dose Reduction with a last review date of 4/22/25, indicated the purpose of the policy was to ensure that all medications prescribed and administered within the facility are clinically appropriate, evidence-based, and aligned with each residents individualized needs, preferences and goals of care. The policy outlined expectations for preventing unnecessary medication use, ensuring the safe and appropriate use of psychotropic medications. The policy went on to indicate PRN orders for psychotropic drugs are limited to 14 days, unless the attending physician or prescribing physician believes that it is appropriate for the PRN order to be extended beyond 14 days. in such cases the attending physician or prescribing physician will evaluate the resident for appropriateness, document their rationale in the resident's medical record, and indicate the duration of the PRN order.

Based on interview and record review the facility failed to maintain a complete, accurately documented and, readily accessible medical record in accordance with accepted professional standards of practice for 3 of 5 residents (R25, R9, R2) reviewed for advanced directives documentation. This deficient practice gave staff access to inaccurate information. Findings include: R25's quarterly minimum data set (MDS) dated [DATE] indicated R25 was admitted to the facility 9/29/21, had a BIMS of 15 indicating cognitively intact and had the following diagnoses, Diabetes, Hemiplegia (paralysis of one side of the body), and Multiple Sclerosis (an autoimmune disease that affects the spinal cord).Review of R25's electronic medical record (EMR) on 8/18/25, indicated the code status as DNR, and current orders indicated DNR. However, the Advance Directive link in R25's EMR revealed an outdated POLST which indicated FULL CODE. R9's re-admission MDS dated [DATE], indicated R9 was admitted to the facility on [DATE], had a BIMS of 15 indicating cognitively intact and had the following diagnoses: hypertension, peripheral vascular disease, diabetes and anxiety.Review of R9's EMR on 8/18/25, indicated R9's code status as Full Code, and current orders indicated Full Code. However, the Advance Directive link in R9's EMR revealed an outdated POLST which indicated DNR/DNI.R2's quarterly MDS dated [DATE] indicated R2 was admitted to the facility 1/28/25, had a BIMS of 8 indicating moderate cognitive impairment and had the following diagnoses: hypertension, renal insufficiency, diabetes and dementia.Review of R2's EMR on 8/18/25, indicated the code status as DNR, and current orders indicated DNR. However, the Advance Directive link in R2's EMR revealed an outdated POLST which indicated FULL CODE. During interview on 8/18/25 at 7:22 p.m., registered nurse case manager (RN-CM) stated in an emergent situation staff was instructed to check the EMR banner for the code status and follow that directive. RN-CM went on to say that the code statuses were cross checked every Monday and as needed if a resident went to the hospital. RN-CM stated staff does not use the link in the EMR for code status. During interview on 8/18/25 at 7/23 p.m., registered nurse (RN)A stated the banner in the EMR was the easiest and quickest way to know a resident's code status and this code be verified by checking it against the POLST form in the paper chart. During interview on 8/18/25 at 7:24 p.m., licensed practical nurse (LPN)-A stated staff will look at the EMR on the computer to find a resident's current code status stating it is 'right here' and pointed at the banner under the resident's name. LPN-A went on to state code status could be found in the resident's paper chart, but she had been instructed to use the banner for most current status. LPN-A stated, 'we don't use that button' and pointed to the Advanced Directives link on the EMR.During interview on 8/18/25 at 7:31p.m., RN-B stated she would look at the EMR and look to the banner under the resident's name for code status. During interview on 8/20/25 at 1:06 p.m., Director of Nursing (DON) stated staff should look to the banner below a resident's name to identify individual resident code status. DON went on to state staff could also look in the EMR orders tab or the paper chart but stated the EMR banner was the fastest way to find it. DON stated staff does not use the Advance Directives link located in the EMR banner, however agreed the link was active and staff could use it at any time. DON stated he expected staff to look for a resident's code status on the banner in the EMR, and staff should not have immediate access to outdated, inaccurate information in the resident's chart. DON stated it was important that all aspects of the resident's chart had the most current information available to staff and stated that using the wrong information had the potential for staff to give or withhold care that could hurt the resident.A policy regarding documentation and record accuracy was requested by not given.

Based on observation, interview and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for for 2 of 2 residents (R8, R9) observed for COVID-19 transmission based precautions (TBP) and for 1 of 2 residents (R10) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This deficient practice had the potential to affect all 112 residents who resided in the facility. Findings Include: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. Review of CDC guidance dated 6/24/24, Infection Control Guidance SARS-COV-2 indicated health care professionals (HCP) who entered the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of CDC guidance dated 5/16/23, How to Use Your N95 Respirator indicated N95 respirators must form a seal to the face to work properly. This was especially important for people at increased risk for severe disease. R8's admission Minimum Data Set (MDS) dated [DATE], identified R8 had moderately impaired cognition with diagnoses of hypertension (high blood pressure), heart failure, diabetes, and dementia. Identified R8 required extensive assistance of two staff with bed mobility, transfers, toileting and was independent with setup help for eating. R9's admission MDS dated [DATE], identified R9 had intact cognition with diagnoses of heart failure, hypertension, and end stage renal disease (ESRD). Identified R9 required limited assistance of two staff with bed mobility, transfers, toileting and was independent with setup help for eating. R10's admission MDS still in progress dated 1/26/25, identified R10 had intact cognition with diagnoses of hypertension, diabetes, chronic kidney disease, obesity, chronic obstructive pulmonary disease (COPD). The MDS lacked completion of R10's requirements of staff assistance for activities of daily living (ADL's). R8's covid test dated 1/20/25, identified positive COVID-19. R9's covid test dated 1/20/25, identified positive COVID-19. R10's EBP dated 1/20/25, identified EBP through 1/28/25. During an observation on 1/21/25 at 1:34 p.m., nursing assistant (NA)-A put on a gown, N95 mask and gloves outside of R8's room and entered R8's room. NA-A was not wearing eye protection while providing cares for R8. NA-B was in R8's room observed to have on a surgical mask, gown and gloves. NA-B was not wearing eye protection or a N95 mask while providing cares for R8. NA-A and NA-B completed cares for R8, removed PPE in R8's room and exited R8's room. NA-B did not remove the surgical mask and continued to wear the surgical mask. During an interview on 1/22/25 at 9:43 a.m., NA-A verified R8 had COVID-19. NA-A stated she did not recall putting on eye protection prior to entering R8's room the previous day. NA-A stated it was important to wear all the recommended PPE including eye protection to prevent the possible spread of the disease to others. During an interview on 1/22/25 at 9:51 a.m., NA-B verified R8 had COVID-19. NA-B stated the recommendation of PPE for COVID-19 residents was a surgical mask, gown and gloves. NA-B was asked to read the precaution sign on R8's door, NA-B verified the COVID-19 precaution PPE recommendations on R8's door stated to wear a N95 mask, eye protection, gown and gloves. NA-B stated she was unaware of the PPE recommendations for COVID-19 and that it was important to follow the guidelines to prevent the spread of infection to others. During an observation on 1/21/25 at 3:51 p.m., NA-C was wearing a surgical mask in the hallway exiting resident room [ROOM NUMBER]. NA-C put on a gown and gloves outside of R9's room and entered R9's room. NA-C did not have eye protection on. NA-C removed the gown and gloves prior to exit of R9's room six minutes later, continued to wear the same surgical mask, put on gloves and a gown and entered R10's room. During an interview on 1/21/25 at 4:03 p.m., NA-C verified R9 was in COVID-19 precautions and R10 was in EBP. NA-C stated staff were expected to wear a N95 mask and eye protection while caring for COVID-19 positive residents to prevent the spread of infection and staff were expected to remove PPE prior to leaving an EBP or TBP resident room. NA-C stated she was aware of the recommended PPE to wear however, lacked follow through. During an interview on 1/22/25 at 10:00 a.m., LPN-A stated staff were aware of which residents were in EBP or TBP based on the sign on the resident's door and all staff received training on proper PPE use. LPN-A stated the nurse working was expected to monitor the nursing assistants to ensure proper PPE was being used. During an interview on 1/22/25 at 11:16 a.m., director of nursing (DON) stated staff were educated on proper PPE use and received daily updates on which residents were in TBP or EBP. DON verified the expectation of staff was to wear a N95 mask, eye protection, gown and gloves when working with a COVID-19 positive resident. In addition, DON indicated staff were expected to remove PPE prior to exiting a EBP resident room and prior to entering another resident room. DON confirmed these practices were important for transmission reasons and to protect the staff and residents from becoming ill. A facility policy titled Infection Control and Manual for Transmission Based Precautions dated 2023, identified PPE use to Prevent Spread of Multidrug-resistant Organisms (MDROs) identified examples of high-contact resident care activities requiring gown and glove use for EBP included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. A facility policy titled Red, Yellow, [NAME] Personal Protective Equipment, Resident Placement and Signage Supplemental Guidelines for Use related to COVID-19 revised 6/26/23, identified a positive COVID-19 (Red) guidelines included; N95 mask would be worn prior to entry of a COVID-19 resident room and removed and discarded when leaving the specific isolation unit/area or if soiled or damaged. If unable to obtain a new N95 every shift due to supply shortage, rotate at least every 72 hours and replace after 5 uses or if soiled or damaged. A face shield or goggles would be worn prior to entry of a COVID-19 resident room and would be cleaned and disinfected (or changed) if visibly soiled, including splashes and sprays or difficult to see through. A gown would be worn prior to entry of a COVID-19 resident room and changed when soiled. Gloves would be worn prior to entry of a COVID-19 resident room and would be changed per standard precautions guidelines

Based on observation, interview and document review, the facility failed to maintain proper holding food temperatures for 18 of 19 residents observed to receive the noon meal on the Reflections unit. Further, the facility failed to maintain the ice machine in a sanitary manner to prevent potential food-borne illness for 39 residents who currently received ice from the ice machine in the Transitional care unit and Cardiac care unit area, and 36 residents who currently received ice from the ice machine in the Riverbend and cornerstone unit area. Findings include: FOOD TEMPERATURE During an interview on 1/21/25 at 1:20 p.m., family member (FM)-A stated several times when she was at the facility visiting R1, the food was cold and R1 refused to eat the food. FM-A further stated she began bringing food in for R1 to ensure R1 had food to eat. During a continuous observation on 1/21/25 at 11:49 a.m., dietary aide( DA)-A entered the Reflections unit with a covered cart of food trays in a heated cart from the second floor kitchen. DA-A plugged in the cart and left the unit. Nursing staff began removing the trays with food from the cart and placed a cover on each tray as they passed them out to each resident in the dining room. At 12:42 p.m., staff removed two of the remaining trays from the food cart and delivered them to the residents rooms. At 12:46 p.m., as the last tray was being delivered in the dining room DA-A checked the temperature of a test tray that had been stored in the food cart since the beginning of food service and the temperatures were as follows: Spaghetti noodles were 102 degrees F. Hamburger meat sauce was 114 degrees F. Peas and carrots were 115 degrees F. During an interview on 1/21/25 at 12:55 p.m., DA-A stated it was his first day of work and he was unsure of what the holding temperatures for hot food were expected to be. DA-A stated he would need to find out what the proper holding temperatures for hot food were to ensure in the future the hot food remained within the proper temperatures so residents do not become ill. During an interview on 1/21/25 at 1:05 p.m., dietary manager (DM) stated her expectation was that holding temps for hot food would have been between 135 and 165 degrees F. DM stated it was important to maintain holding temperatures, to prevent foodborne illness and to ensure quality of food for the residents. 49620 ICE MACHINE R7's annual Minimum Data Set (MDS), dated [DATE], identified R7 had intact cognition with diagnoses of hypertension (high blood pressure) and arthritis. R7 was independent with eating after setup help from staff. During an observation on 1/21/25 at 11:42 a.m., the ice machine located in the dining area of the Riverbend and Cornerstone unit had a white flaky substance approximately one-half an inch to three-quarters of an inch in height on both the inside and outside rim of the ice spout and water spout. The tray of the ice machine had a white flaky substance covering the entire removable tray with noticeable dripping of water from the ice spout about every one to two seconds into the tray. During an observation on 1/21/25 at 2:10 p.m., the ice machine located in the dining area of the Transitional care unit and Cardiac care unit had a white flaky substance approximately one-half an inch to three-quarters of an inch in height on both the inside and outside rim of the ice spout and water spout. The tray of the ice machine had a white flaky substance covering the entire removable tray with noticeable dripping of water from the ice spout about every one to two seconds into the tray. During an interview on 1/21/25 at 3:42 p.m., R7 stated the ice and water tasted terrible. R7 further stated he had to discard seven glasses of water before being able to get water that tasted alright from the ice machine. R7 stated he reported the terrible ice and water taste to licensed practical nurse (LPN)-A on many occasions and the ice machine continued to be dirty with water and ice that tasted terrible. During an interview on 1/22/25 at 10:04 a.m., LPN-A verified a resident had asked for the ice and water machine to be cleaned. LPN-A stated maintenance was notified and LPN-A did not follow up with maintenance about the ice machine after that. During an interview on 1/22/25 at 9:14 a.m., dietary manager (DM) verified a white substance on the outside and inside of the ice and water machine spouts and identified it was calcium buildup. DM verified the white substance on the ice machine in the dining area of the Riverbend and cornerstone unit and the ice machine in the dining area of the transitional care unit and cardiac care unit. DM stated the calcium buildup could break off of the spouts and get in the ice and or water and residents could become ill. DM further stated, maintenance staff cleaned the machine and was unsure when the ice machines had been cleaned last. DM stated maintenance staff was out ill and unavailable. DM confirmed cleaning logs for the ice machines were not available. A facility policy titled Food Temperatures dated 2021, identified all hot food must be cooked to appropriate internal temperatures, held, and served a temperature of at least 135 degrees F. Identified hot foods may not fall below 135 degrees F. after cooking unless it is an item which was to be rapidly cooled to 41 degrees F. Further identified temperatures should have been taken periodically to assure hot foods stayed above 135 degrees F.

Based on interview and record review the facility failed to include a resident discharge summary that included a reconciliation of all pre-discharge medications with resident's post-discharge medication (both prescribed and over-the-counter) at discharge for seven of ten residents (R1, R2, R5, R6, R7, R9, and R12). R1 received R2's Mirtazapine (a medication to treat depression) at discharge. Findings include: According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised and issued 8/8/24: -Reconciliation of Medications: A process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. R1's Facesheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of multiple fractures of ribs on right side. R1's additional diagnoses included anxiety disorder and need for assistance with personal care. R1 discharged from the facility on 12/6/24. R1's brief interview for mental status (BIMS) dated 11/14/2024 indicated R1 scored thirteen which indicated R1 was cognitively intact. R1's discharge summary and recapitulation assessment dated [DATE] indicated R1 was discharged home on 12/6/24. The form question #5 titled Medication Reconciliation indicated: -At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? Yes - Current reconciled medication list provided to the patient, family and/or caregiver? Yes, sent by paper. Physical medication(s) are to be compared to current medication orders, counted and instructions explained prior to giving medication to resident and or resident representative Ensure that individual receiving medications signs and acknowledges amount. of medications received. -Were medications sent home with resident and/or representative? Yes -Medication and amount of medication sent with resident and/or responsible party. This area of the summary and recapitulation was left blank and was not identified in the resident medical record. R1's medication administration record (MAR) dated 12/6/24 indicated R1 was not administrated mirtazapine during her admission. R2's Facesheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of nontraumatic intracerebral hemorrhage. R2's additional diagnoses included anxiety disorder and need for assistance with personal care. R2 was discharged from the facility on 11/5/24. R2's MAR dated 11/5/24 indicated R2 had an order for mirtazapine three point seven five milligrams (mg) by mouth at bedtime for anxiety. R2's discharge summary and recapitulation assessment dated [DATE] indicated R1 was discharged home on 11/5/24. The form question #5 titled Medication Reconciliation indicated: -At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? Yes - Current reconciled medication list provided to the patient, family and/or caregiver? Yes, sent by paper. Physical medication(s) are to be compared to current medication orders, counted and instructions explained prior to giving medication to resident and or resident representative Ensure that individual receiving medications signs and acknowledges amount. of medications received. -Were medications sent home with resident and/or representative? Yes -Medication and amount of medication sent with resident and/or responsible party. This area of the summary and recapitulation was left blank and was not identified in the resident medical record. R5's Facesheet indicated R5 was admitted to the facility on [DATE] with a primary diagnosis of spinal stenosis of lumbar region without neurogenic claudication. R5 was discharged from the facility on 12/17/24. R5's BIMS assessment dated [DATE] indicated R5 had a score of fifteen, which indicated R5 was cognitively intact. R5's discharge summary and recapitulation assessment dated [DATE] indicated R5 was discharged home on 12/17/24. The form question #5 titled Medication Reconciliation indicated: -At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? Yes - Current reconciled medication list provided to the patient, family and/or caregiver? Yes, sent by paper. Physical medication(s) are to be compared to current medication orders, counted and instructions explained prior to giving medication to resident and or resident representative Ensure that individual receiving medications signs and acknowledges amount. of medications received. -Were medications sent home with resident and/or representative? Yes -Medication and amount of medication sent with resident and/or responsible party. This area of the summary and recapitulation was left blank and was not identified in the resident medical record. R6's Facesheet indicated R6 was admitted to the facility on [DATE] with a primary diagnosis of polymyalgia rheumatica. R6 was discharged from the facility on 12/17/24. R6's BIMS assessment dated [DATE] indicated R6 scored fifteen, which indicated R6 was cognitively intact. R6's discharge summary and recapitulation assessment dated [DATE] indicated R6 was discharged home on 12/17/24. The form question #5 titled Medication Reconciliation indicated: -At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? Yes - Current reconciled medication list provided to the patient, family and/or caregiver? Yes, sent by paper. Physical medication(s) are to be compared to current medication orders, counted and instructions explained prior to giving medication to resident and or resident representative Ensure that individual receiving medications signs and acknowledges amount. of medications received. -Were medications sent home with resident and/or representative? Yes -Medication and amount of medication sent with resident and/or responsible party. This area of the summary and recapitulation was left blank and was not identified in the resident medical record. R7's Facesheet indicated R7 was admitted to the facility on [DATE] with a primary diagnosis of neoplasm of unspecified behavior or the brain. R7 was discharged from the facility on 12/12/24. R7's BIMS assessment dated [DATE] indicated R7 scored fifteen, which indicated R7 was cognitively intact. R7's discharge summary and recapitulation assessment dated [DATE] indicated R7 was discharged home on 12/12/24. The form question #5 titled Medication Reconciliation indicated: -At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? Yes - Current reconciled medication list provided to the patient, family and/or caregiver? Yes, sent by paper. Physical medication(s) are to be compared to current medication orders, counted and instructions explained prior to giving medication to resident and or resident representative Ensure that individual receiving medications signs and acknowledges amount. of medications received. -Were medications sent home with resident and/or representative? Yes -Medication and amount of medication sent with resident and/or responsible party. This area of the summary and recapitulation was left blank and was not identified in the resident medical record. R9's Facesheet indicated R9 was admitted to the facility on [DATE] with a primary diagnosis of displaced intertrochanteric fracture of right femur. R9 was discharged from the facility on 12/16/24. R9's BIMS assessment dated [DATE] indicated R9 had a score of fifteen, which indicated R9 was cognitively intact. R9's discharge summary and recapitulation assessment dated [DATE] indicated R9 was discharged home on 12/16/24. The form question #5 titled Medication Reconciliation indicated: -At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? Yes - Current reconciled medication list provided to the patient, family and/or caregiver? Yes, sent by paper. Physical medication(s) are to be compared to current medication orders, counted and instructions explained prior to giving medication to resident and or resident representative Ensure that individual receiving medications signs and acknowledges amount. of medications received. -Were medications sent home with resident and/or representative? Yes -Medication and amount of medication sent with resident and/or responsible party. This area of the summary and recapitulation was left blank and was not identified in the resident medical record. R12's Facesheet indicated R12 was admitted to the facility on [DATE] with a primary diagnosis of heart failure. R12 was discharged from the facility on 12/3/24. R12's BIMS assessment dated [DATE] indicated R12 had a score of fifteen, which indicated R12 was cognitively intact. R12's discharge summary and recapitulation assessment dated [DATE] indicated R12 was discharged home on 12/3/24. The form question #5 titled Medication Reconciliation indicated: -At the time of discharge, did your facility provide the resident's current reconciled medication list to the resident, family and/or caregiver? Yes - Current reconciled medication list provided to the patient, family and/or caregiver? Yes, sent by paper. Physical medication(s) are to be compared to current medication orders, counted and instructions explained prior to giving medication to resident and or resident representative Ensure that individual receiving medications signs and acknowledges amount. of medications received. -Were medications sent home with resident and/or representative? Yes -Medication and amount of medication sent with resident and/or responsible party. This area of the summary and recapitulation was left blank and was not identified in the resident medical record. During an interview on 12/17/24 at 8:33 a.m., family member (FM)-A stated R1 was in the facility for approximately three weeks. At the time of discharge, R1 was sent home with R2's Mirtazapine medication. FM-A stated she did not give R1 any of R2's Mirtazapine medication. During an interview on 12/17/24 at 9:47 a.m., registered nurse (RN)-A stated when a resident is discharged from the facility, they will determine what medications the resident can go home with any medications that need to be sent back to the pharmacy. RN-A will go through the locked medication cabinet in the resident's room when she is explaining the medications and the instructions at discharge. During an interview on 12/17/14 at 10:34 a.m., licensed practical nurse (LPN)-A stated during a discharge she will fill out a discharge form that includes a medication list, upcoming appointments, and medication's the resident is taking home in the computer system. LPN-A will put the resident's medications in a bag and then have the resident sign the form. LPN-A stated there was a spot in the discharge form that talks about what medications the resident is going home with but will not fill out that part in the form due to lack of time. At the time of discharge, the discharging nurse will go through the resident's medications to determine which medications can be sent home with the resident or medications that need to be returned to the pharmacy. Medication bubble packs that are opened, any bottled medication, refrigerated medications, or pre-scored tablets in bubble packs need to send home with the resident. Any medication bubble packs that are not used should be returned to the pharmacy. A discharging nurse would check the resident's locked medication cabinet in their room for medications that the resident may have left or medications that need to be sent back to the pharmacy at discharge and again when another resident is being admitted to the room. LPN-A discharged R1 from the facility. LPN-A stated she did not think she sent any medications home with R1 that did not belong to her. During an interview on 12/17/24 at 10:57 a.m., nurse manager (NM)-A stated when a resident is discharging, they will determine what medications the resident can take home with them and what medications need to be sent back to the pharmacy. NM-A will go through medication instructions with the resident. NM-A stated it depends on the nurse who discharges a resident, but the nurse may just grab everything in the resident's locked medication cabinet and put it in a bag without looking at the medications but stated that was not the protocol. The protocol was to go over each medication with the resident. An interview was attempted with R2 on 12/17/24 at 1:11 p.m. but was unsuccessful. An interview was attempted with R1 on 12/17/24 at 1:51 p.m. but was unsuccessful. During an interview on 12/17/24 at 3:04 p.m., the director of nursing (DON) stated when a resident is discharged , the resident would get discharge instructions including therapy recommendations, the most recent set of vitals, the most recent nursing assessments, pain management, pain levels, pain assessment, and activities of daily living (ADL). The resident would also get a signed medication list from the facility provider. During an interview on 12/17/24 at 3:18 p.m., R5 stated she was discharged on [DATE] and the discharging nurse had educated her on her medications and other instructions before putting the medications directly in the bag. R5 was not sure if she was given any other resident's medication but saw the nurse grab the medication cards directly from her locked medication cabinet and put them in her bag. An interview was attempted with R7 on 12/17/24 at 3:20 p.m. but was unsuccessful. An interview was attempted with R6 on 12/17/24 at 3:24 p.m. but was unsuccessful. During an interview on 12/17/24 at 3:31 p.m., DON stated a resident's medication disposition should be in the resident's discharge summary assessment. DON stated that is the only place in a resident's chart where the medication dispassion is. DON planned to provide education to the discharge nurses regarding the medication disposition portion of the discharge summary and recapitulation assessment. An interview was attempted with R8 on 12/17/24 at 3:37 p.m. but was unsuccessful. An interview was attempted with R9 on 12/17/24 at 3:38 p.m. but was unsuccessful. An interview was attempted with R10 on 12/17/24 at 3:39 p.m. but was unsuccessful. An interview was attempted with R11 on 12/17/24 at 3:53 p.m. but was unsuccessful. An interview was attempted with R12 on 12/17/24 at 3:57 p.m. but was unsuccessful. During an interview on 12/17/24 at 4:38 p.m., the administrator stated his expectation is when a resident is discharging, the discharging nurse would give the resident their list of medications they are going home with and document the name of the medication along with the quantity in the discharge summary and recapitulation assessment. The facility's Discharge Planning, Summary and Recapitulation of Residents Stay policy and procedure revised on 9/12/23 indicated the resident should be discharged with a list of medications with instructions in simple terms. The discharging staff member would complete the discharge summary data collection and recapitulation, print it off, and give it to the resident. The discharge summary served as the final notation and recapitulation of the resident's stay.

Based on observation, interview and document review, the facility failed to ensure 1 of 2 unit ice and water dispensers for resident use were maintained in a clean and sanitary manner on the Cornerstone unit kitchenette. In addition, the facility failed to ensure 1 of 2 unit refrigerators were maintained in a clean and sanitary manner. This had the potential to effect 60 residents served by the Cornerstone unit kitchenette. Findings include: On 10/2/24 at 12:43 p.m., family member (FM)-A stated in August of 2024, the family council had shared concerns with management regarding the condition of the Cornerstone unit ice and water dispenser. There was excessive build up of hard water residue on the dispenser, leaving the family members concerned that the residents were ingesting bacteria. On 10/2/24 at 4:10 p.m., FM-B stated she had concerns about debris in the ice and water dispenser on the Cornerstone unit that served her family member. She had approached management about this concern in August 2024. On 10/2/24 at 4:37 p.m., the Cornerstone unit ice and water dispenser was observed with dietary aide (DA)-A. The drip tray was covered in a whitish gray colored matter. There was whitish-gray colored residue covering the stainless steel of the machine, the chute where the ice was dispensed, and the chute where the water was dispensed. In addition, there was whitish-gray residue on the left side of the refrigerator which was positioned to the left of the ice and water dispenser. At 4:47 p.m., the Cornerstone unit ice and water dispenser unit was observed with the director of maintenance (DM)-A. DM-A stated, We have tried everything to get the hard water off. DM-A stated the ice and water dispenser is cleaned for hard water build up weekly by the maintenance department and daily by housekeeping. On 10/2/24 at 4:44 p.m., nursing assistant (NA)-A was observed preparing several cups of ice water from the ice water dispenser on the Cornerstone unit kitchenette. She placed them on a cart. NA-A stated she was transporting the cups to the unit for the supper meal. NA-A stated the dietary staff was responsible to clean the ice and water dispenser. On 10/3/24 at 10:10 a.m., DA-B stated R1 recently complained about the taste of the water. They have tried to clean the ice and water dispenser, but have not found anything to successfully remove the residue buildup. The Cornerstone freezer was also observed with DA-B. An unidentified light brown colored substance was observed in the grooves of the length of the rubber door seal. There was also an unidentified white substance observed at the front of the base of the freezer. DA-B stated the refrigerator/freezer was cleaned daily by the dietary department. On 10/3/24 at 10:27 a.m., the freezer rubber seal was observed with the assistant culinary director (ACD)-A. She stated the DA's were supposed to clean these items daily. On 10/3/24 at 11:22 a.m., R1 was asked if he drinks the water from the ice and water dispenser on the Cornerstone unit. R1 responded, he does drink the water, but, It's terrible! It tastes so bad! 10/3/24 at 1:45 p.m., registered nurse (RN)-A stated a resident complained about the taste of the water from the Cornerstone unit about one month ago. RN-A stated, Sometimes it (the dispenser) is not clean and stated sometimes she tried to wipe it down. RN-A stated the kitchen staff were responsible to clean it. A facility policy regarding cleaning the kitchenette equipment was requested, but was not provided.

Based on observation, interview, and document review the facility failed to ensure food was properly stored, labeled, dated, and failed to maintain a clean and sanitary kitchen to reduce and/or prevent the risk of food borne illness this practice had the potential to affect all 112 residents, staff and guests who consumed foods from the facility kitchen. Findings include: During initial kitchen tour on 7/15/24 at 11:26 a.m., with certified dietary manager (CDM) the following concerns were observed: - Three dietary staff were observed without hairnets as they placed plastic wrap over plates of cooked food. - A reach in refrigerator to the immediate left of the stove top contained the following items of concern: 1) An unsealed bag of shredded cabbage dated 7/8/24. 2) Two open unsealed undated bags of bagels of bagels. 3) A small metal dish containing an undated, unidentified liquid, partially covered with plastic wrap. 4) An undated plate containing 2 baked biscuits loosely covered with plastic wrap. - The metal shelving units across from the stove had unidentified dried food particles next to clean dishes. - A floor drain under the ovens was covered with a grate like barrier which contained bread ties, tinfoil, dirt, hair, discarded food items, and other debris. The floor of the drain was also damp with unknown liquid. - The walk-in cooler had the following concerns: 1) An undated opened quart of heavy cream. 2) An undated pumpkin pie with one piece removed and a fork in the tin. 3) An undated, uncovered container of sliced tomatoes. (approximately 6 cups of tomatoes) 4) A loosely wrapped package of pulled pork was observed on top of a box of roasted turkey breast. Liquid from the pork was observed to drip onto the turkey, the refrigerator shelf and the floor. 5) A box of gluten free meatballs dated 6/14/24 (one month prior to survey). 6) One half of a fruit pie dated 6/10/24. (This pie was located directly below the dripping pork.) 7) An open bag of precooked baby red mashed potatoes was observed with potatoes oozing out of the top of the bag next to the fruit pie. 8) A red/brown liquid was pooled on the refrigerator floor next to the meatal shelving wheels. The CDM stated she did not know what the liquid and the walk in cooler had not been cleaned in weeks. - The walk-in freezer had the following concerns: 1) A sign on next the top shelf indicated Top shelf do no stack anything on these shelves. The top shelf contained: An uncovered, undated paper tray of cooked corn bread with the edges covered in frost, two plate of uncovered, undated chocolate pie, an undated, unsealed plastic bag of barbeque ribs along with 25 assorted boxes and loose food items. 2) An undated open bag containing four unidentified meat patties. 3) An open bag of ham dated 1/11/24. 4) A loosely covered undated 4 inch x 4 inch x six inch deep metal pan contained an unknown pureed substance which was covered with white crystals. The CDM was unable to identify the pureed substance. 5) An undated open bag of raw chicken was on top of an open bag of breaded cooked chicken. 6) An open undated bag of strudel bread was located below the chicken. 7) A loosely covered blueberry pie dated 3/1/24, was noted to have thick white frost around the edges of the crusts. 8) A open undated bag of diced green peppers were found on the floor under the metal shelves. During interview on 7/15/24 at 1:10 p.m., the CDM confirmed the kitchen was in poor condition. The CMS stated they worked as the cook, manager and dietary aide. CDM stated with multiple roles, routine items were missed. The facility had recently changed policies regarding the food storage and preparation, therefore she was unsure of the current policies. They did not have a set cleaning scheduled to ensure all areas of the kitchen were maintained in an orderly fashion. The CDM confirmed they were responsible to direct the kitchen staff, ensure all aspects of food sanitation and preparation were completed in a manner to minimize food bore pathogens. A copy of the kitchen cleaning schedule was requested but not provided. During follow up visit to the kitchen on 7/16/24 at 12:36 p.m., the following concerns were identified: - Cook-A was observed browning meat without a hairnet. - The aforementioned dried food on the metal shelving across from the stove remained next to the clean dishes. - The aforementioned floor drain below the ovens was unchanged. - The walk in cooler additional area of concern: 1) An undated, open container of Mrs. Jerry's chicken salad. 2) An undated, open bag of fresh mixed vegetables. 3) Undated, open take-out food containers with unidentified food were noted on the top shelf. 4) The aforementioned brown liquid remained on the floor of the cooler. 5) A three inch by six inch by six in deep steam table pan was observed with three open undated packages of pureed beef. 6) A loosely covered six inch by six inch by six inch steam table pan dated 6/15/24, indicated the contents were chili. There was a layer of green/black/white fuzzy like substance on top of the chili. -Walk in freezer additional areas of concern: 1)An open, undated bag of frozen tater triangles. 2) An open, undated bag of frozen seasoned French fries. 3) An open undated bag of sliced zucchini. During observation and interview on 7/16/24 at 3:35 p.m., the administrator, CDM and other facility staff were observed to remove items from the walk-in cooler and walk-in freezer and placing items in garbage cans. The administrator stated he could not find any record or cleaning log for the kitchen but indicated the staff were in the process of a full deep cleaning of the kitchen and removing any undated open food items. During interview on 7/17/24 at 2:26 p.m., administrator stated the CDM duties included overseeing all areas of the dietary department. This would include ensuring food was stored and prepared appropriately, all areas and equipment were to be maintained in a clean/sanitary condition. The facility currently utilized a private companies' policies and procedures for the kitchen which had been tailored to the facilities unique needs and expected the facility dietary staff to be compliant with all State and federal regulations. The CDM was to be knowledgeable with all food related health codes and was to delegate task to the appropriate dietary staff. In addition, the CDM was also to the dietary department quality officer. The administrator confirmed the kitchen had many areas of concern which they were unaware of. The administrator's expectation was the CDM would maintain regular cleaning schedules for all areas in the kitchen, follow sanitary regulations as they pertained to the dietary department. This practice was to ensure the residents of the facility were only served properly stored and prepared food that would minimize any potential food borne illnesses. The Food Storage policy dated 3/22, indicated sufficient food storage would be provided to keep food safe, wholesome, appetizing and stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The policy further stated: - All refrigerator units were to be kept clean and in good working condition. - Cooked foods were to be stored above raw foods to prevent contamination. - Raw animal food was to be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. -All foods were to be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) were to be consumed by their safe use by dates, or frozen (where applicable), or discarded. -Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. -All freezer units were to be kept clean and in good working condition. -Frozen foods were to be maintained at a temperatures to keep the food frozen solid. -Meat, fish, and poultry were to be stored on lower shelves, while fruits, vegetables, juices, and breads should be stored on upper shelves. The Cleaning and Sanitation of Dining and Food Service Areas policy dated 5/11, directed the food and nutrition services staff to maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. A copy of the written cleaning schedule was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 5 of 5 residents (R3, R14, R74, R36, and R95), reviewed and observed for self-administration of medications. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact, and required assistance/supervision with activities of daily living (ADL's). The self-administration of medications assessment completed on [DATE], indicated R3 did not wish to self-administer medications or to keep them bedside. During observation and interview on [DATE] at 4:13 p.m., a bottle of prescription fluticasone propionate (nasal spray) was sitting on over-bed table. A tube of prescription arthritis pain relieving cream was sitting on stand in front of television. R3 stated he used the nasal spray whenever he needed due to his nose being dry all the time. R3 also stated he applied the pain-relieving cream to his knees, hands, feet and ribs all the time to help with his pain. R14's quarterly MDS dated [DATE], identified R14 had intact cognition and was independent with all ADL's. The self-administration of medications assessment completed [DATE], indicated R14 did not wish to self-administer medications or to keep them bedside. During observation and interview on [DATE] at 5:19 p.m., three different bottles of eye drops were sitting on stand in front of R14's television. R14 stated he used the eye drops several times a day or as much as he needed them for his dry and burning eyes. R74's admission MDS dated [DATE], identified R74 had moderate cognitive impairment and required partial to moderate assistance with all ADL's. The self-administration of medications assessment completed on [DATE], indicated R74 did not wish to self-administer nebulizer's even after setup. During observation and interview on [DATE] at 12:33 p.m., R74 was sitting on the side of his bed, was holding nebulizer pipe in his mouth, nebulizer treatment running with clear solution noted in the nebulizer cup, no staff present in room. R74 stated staff set up nebulizer, handed it to him, turned the machine on and left the room while it is running. R74 stated that staff will come back later to shut the nebulizer machine off. During interview on [DATE] at 12:16 p.m., licensed nursing staff (LPN)-B stated there were no residents on this unit that were able to self-administer medications. LPN-B stated if a resident wished to self-administer medications, an assessment needed to be completed and an order needed to be obtained from the physician before resident would be allowed to self-administer medications. LPN-B confirmed that R3 did not have an order to self-administer medications and confirmed that R3 had pain relieving cream and nasal spray present in room. LPN-B confirmed that R14 did not have an order to self-administer medications and confirmed that R14 had three bottles of eye drops present in R14's room. LPN-B confirmed that R74 did not have an order to self-administer medications and confirmed staff set up solution in R74's nebulizer machine, turned the machine on, left the room and came back later to shut the machine off. During interview on [DATE] at 12:27 p.m., registered nurse case manager (RN)-A stated there were no residents that had a self-administration of medications order currently. RN-A stated that if a resident stated they wanted to self-administer medications, an assessment would need to be completed to ensure that resident was capable of safely self-administering medications. If assessment determined resident was capable, then an order would be obtained from the provider for the resident to be able to self-administer medications. RN-A confirmed that staff set up solution in R74's nebulizer machine, turned the machine on, left the room and came back later to shut the machine off. RN-A confirmed that R3, R14 and R74 did not have an order for self-administration of medications. RN-A stated it was important to complete the assessment to ensure that the resident was competent and able to self-administer medications safely and correctly. R36's significant change Minimum Data Sheet (MDS) dated [DATE], identified her cognition was intact. R36's did not have upper extremity impairment. R36's self-administration of medications data collection assessment dated [DATE], indicated resident did not wish to self-administer medications or keep them at the bedside. During observation on [DATE] at 1:45 p.m., R36 had Voltaren arthritis topical gel (a topical cream for pain relief) and simethicone anti-gas chewable tabs on her bedside tray table. During interview on [DATE] at 5:00 p.m., R36 stated she kept her Voltaren arthritis topical gel (a topical cream for pain relief) and simethicone anti-gas chewable tabs in her room. R36 stated she took simethicone 125 mg tabs three times a day and would have staff assist with application of Voltaren gel twice a day. R36 stated staff have talked with her about the simethicone anti-gas chewable tabs prior and were aware she had the in her room. During interview with [DATE] at 1:03 p.m., registered nurse (RN)-A confirmed R36 did not have an order for self-administration of medications. RN-A stated the facility was aware R36's family brings in simethicone tabs from home and staff would look for medications every time they came in the room. RN-A confirmed resident had simethicone anti-gas chewable tabs and Voltaren cream in her room. R95's admission Minimum Data Set (MDS) dated [DATE], identified R95 was cognitively intact and had diagnoses which included a fracture around the internal prosthetic right hip joint, and right hip pain. The MDS also indicated R95 received scheduled and as needed medication for pain and non-medication interventions for occasional mild pain. R95's order summary report dated [DATE], included the following current orders: Oxycodone HCL oral tab 5 milligrams (MG). Take 0.5 tabs by mouth every four hours as needed for pain. The order start date was [DATE]. Acetaminophen 500 mg. Take two tablets three times daily. The order start date was [DATE]. R95's care plan dated [DATE], identified R95 was a readmission at risk for falls, pain, and safety. The care plan included interventions including administer medication per MD order for pain management. The care plan lacked direction regarding R95 self-administration of medication or storage of medications at bedside. R95's Self Administration of Medication form dated [DATE], indicated R95 did not want to administer medications per self or keep at his bedside. During observation and interview on [DATE], at 10:53 a.m., an unidentified nursing assistant was seated in R95's room directly behind a bedside table as R95 exited the bathroom. A bottle of Tylenol 8 Hour Arthritis Pain sat on R95's bedside table. R95 reported he took the medication himself and received scheduled doses from facility staff. During observation on [DATE], at 5:03 p.m., the bottle of Tylenol remained on R95's bedside table. A pharmacy dispensing label was not affixed to the bottle. During interview on [DATE], at 5:05 p.m., licensed practical nurse (LPN)-B stated it was rare residents in the facility self-administered their medications and he was not aware of any resident who did so. For a resident to self-administer their medications and keep it at their bedside there would need to be an order and the nursing staff would have to ask the resident when the medication was taken so it could be documented in their medical record. Further, LPN-B stated if staff observed a resident to have medication at their bedside, nursing staff would have to have a discussion with the resident about it and review the facility policy on self-administration with the resident. At this time, LPN-B was brought to R95's room where the bottle of Tylenol remained on the bedside table. LPN-B asked R95 how often he took the medication, to which R95 replied he did not take it often. LPN-B then removed the bottle of Tylenol from R95's bedside table and placed it in the locked medication cabinet above the sink in R95's room. LPN-B confirmed R95 did not have an order to keep the medication at the bedside, nor an order for self-administration. During interview on [DATE], at 10:01 a.m., registered nurse (RN)-G stated a resident would have to be assessed for appropriateness of self-administration of medications and a provider order would need to be obtained. The assessment would be required to identify the medication, indication and dosage and if the resident was cognitively able to be safe to self-administer. The provider and nursing would need to ensure the resident was safe to keep the medication at the bedside and self-administer. RN-G stated she expected staff to immediately notify nursing staff if it was identified a resident had medications at the bedside, ask the resident where it came from, and identify if there was an active order for the medication. Nursing staff would need to check for residents' allergies, if the medication was expired, if the medication belonged to the resident, and how it got there. This would be important information so the resident labs could be monitored. The medication could potentially interact with the residents' other medications, so it was a safety issue. RN-G stated although R95's record included a self-administration assessment from a previous admission, he did not have a current assessment completed for this admission and there was no order for R95 to self -administer his Tylenol. During interview on [DATE], at 10:39 a.m., assistant director of nursing (ADON) stated the facility required an assessment from a nurse and the resident would need to be able to demonstrate they were safe to administer medication by themselves. They would also need to have a written provider order. The order should specify what medication the resident wanted to administer and if they wanted to keep the medication at the bedside to self-administer. ADON confirmed R95 did not have a current assessment or order for self-administration of medications. He expected that if staff observed, medications at a resident's bedside, they would clarify if there was an order for the medication and a completed assessment. This was important for resident safety to prevent medication errors and to prevent overdose of a medication. It was also important for accurate documentation. The facility Self-Administration of Medications policy, dated [DATE], indicated the facility will act in accordance with the right of the resident to self-administer their medications if the interdisciplinary team has assessed and evaluated that the resident is able to physically and cognitively, safely administer the prescribed medication. 1. The resident will be informed of their right to self-administer medications upon admission. 2. If the resident wished to self-administer their medications, at the time of admission or anytime during their stay at the facility, the Interdisciplinary Team will initiate a Self-Administration of medication assessment to determine if the resident is capable and clinically appropriate, base on the resident's cognition, physical ability, functionality, and status of health conditions(s). 3. A physician order will be obtained by the nurse prior to proceeding with self-administration. 49035 49654

Based on interview and document review, the facility failed to complete care conferences for 5 of 7 residents (R14, R16, R24, R29 and R69) reviewed for care planning. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition. During interview on 7/15/24 at 5:37 p.m., R14 stated he could not remember having quarterly care conferences with the facility. R14 had MDS submissions completed on 12/3/23, 2/2/24 and 5/20/24. The medical record failed to include documentation of care conferences. R16's quarterly MDS dated [DATE], identified R16 had severe cognitive impairment. During interview on 7/15/24 at 2:14 p.m., family member (FM)-A stated care conferences are held every 6 months or so and does not recall the last care conference with the facility. R16 had MDS submissions completed on 11/17/23, 1/23/24, 4/16/24 and 7/9/24. The medical record failed to include documentation of care conferences. R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact. During interview on 7/15/24 at 12:04 p.m., resident stated he could not remember having quarterly care conferences with the facility. R24 had MDS submissions completed on 2/29/24 and 5/23/24. The medial record failed to include documentation of care conferences. R29's quarterly MDS dated [DATE], identified R29 had intact cognition. During interview on 7/15/24 at 4:57 p.m., R29 stated he could not remember having quarterly care conferences with the facility. R29 had MDS submissions completed on 12/27/23, 3/20/24, 4/19/24 and 7/12/24. The medical record failed to include documentation of care conferences. R69's quarterly MDS dated [DATE], identified R69 had intact cognition. During interview on 7/16/24 at 9:01 a.m., R69 stated he could not remember having quarterly care conferences with the facility. R69 had MDS submissions completed on 10/14/23, 12/31/23, 3/25/24 and 6/18/24. The medial record failed to include documentation of care conferences. During interview on 7/17/24 at 3:03 p.m., licensed social worker (LSW)-A stated care conferences should be held quarterly or with any changes and be held within two weeks of completion of the MDS. LSW-A stated documentation of the care conference should have been placed in a progress note. LSW-A confirmed the last care conference for: -R14 was on 9/14/23 and he should have had three additional care conferences. -R16 was on 10/18/23 and she should have had four additional care conferences. -R24 was completed 9/21/23 and he should have had 2 additional quarterly care conferences. -R29 was on 10/11/23 and that he should have had three additional care conferences. Further, LSW-A confirmed that R69 has not had a care conference and he should have had 4 additional care conferences. LSW-A stated regular care conferences are important because it is a resident right and for collaboration of care. LSW-A stated even if the family and resident did not want to attend, the care conference should still be completed. The facility Care Conference policy, dated 10/23, indicated it is the facility policy to hold Care conferences for each resident at least quarterly or more often as needed. Residents/resident representatives will be involved with the development of their plan of care to promote autonomy and dignity. The care conference will take place no more than 7 days after the MDS is completed. 49035

Based on interview and document review the facility failed to ensure 4 of 5 residents (R24, R56, R80, and R102) were offered, educated and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R24' s annual Minimum Data Set (MDS) dated [DATE], indicated R24 was 79, moderately cognitively impaired and had the following diagnoses: atrial fibrillation (top two chambers of the heartbeat erratically), congested heart failure (CHF), high blood pressure (HTN), diabetes (DM), and peripheral vascular disease (PVD) (inability of the body to return blood effectively from the extremities). R24's immunization record dated 7/18/24, indicated they received a PPSV23 on 7/23/2010 and a PCV13 on 5/23/16. The record lacked evidence of shared clinical decision making with the physician for a PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence R24 or representative was offered, educated on or received a PCV20. R56's quarterly MDS dated [DATE], indicated R56 was [AGE] years old, cognitively intact and had the following diagnoses: coronary heart disease (CAD) (hardening of the arteries of the heart), CHF, HTN, and chronic renal insufficiency (CRI) (poor kidney function. R56's immunization record dated 7/18/24, indicated they received a PPSV23 on 11/24/2012 and a PCV13 on 7/12/18. The record lacked evidence of shared clinical decision making with the physician for a PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R56 or representative was offered, educated on or received a PCV20. R80's quarterly MDS dated [DATE], indicated R80 was [AGE] years old, severely cognitively impaired and had the following diagnoses: HTN, Alzheimer's disease, and dementia. R80's immunization record dated 7/18/24, indicated they received a PPSV23 on 12/1/1998 and a PCV13 on 10/06/15. The record lacked evidence of shared clinical decision making with the physician for a PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence R80 or representative was offered, educated on or received a PCV20. R102's admission MDS dated [DATE], indicated R102 was [AGE] years old, cognitively intact and had the following diagnoses: HTN, orthostatic hypotension (blood pressure drops when they stand), and DM. R102's immunization record, dated 7/18/24, indicated they received a PPSV23 on 10/31/2008 and a PCV13 on 9/1/16. The record lacked evidence of shared clinical decision making with the physician for a PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence R102 or representative was offered, educated on or received a PCV20. On 7/18/24 at 9:57 a.m., the infection preventionist and registered nurse (RN)-E, stated they thought the residents were up to date and did not need PCV20. They also stated when they call and offer the corona virus vaccinations they would ask if the resident would like PCV20. However, the medical records for R24, R56, R80, and R102 all lacked any evidence of what was discussed, when the calls took place, education provided and whether consent was obtained or declined for PCV20 per the CDC recommendations for pneumococcal vaccinations. On 7/18/24 at 5:08 p.m., the assistant director of nursing (O)-B stated their expectation was upon admission the resident vaccination record was to be reviewed, when appropriate the vaccinations should be offered and educated on and the nurses will administer them to prevent the spread of communicable diseases. The facility policy Pneumococcal Vaccine Program dated 5/17/23, indicated for adults [AGE] years or older who have received PCV13 at any age and PPSC23 at or after age [AGE] years, CDC recommends shared clinical decision-making on whether to administer PCV20. If the vaccine provider and patient decide PCV20 is appropriate, the dose of PCV20 should be administered at least 5 years after the last pneumococcal vaccine.

Based on document review and interviews, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) was provided to 1 of 3 residents (R86) reviewed for beneficiary notification. Findings include: R86's part A discharge minimum data set (MDS) dated [DATE], indicated R86 was admitted to the facility on [DATE] and their Medicare part A coverage ended on 5/23/24. R86's progress notes dated 5/21/24, indicated R86 received a Medicare-A Non-Coverage (CMS-10123) form. The form indicated R86's current covered services would end on 5/23/24. Although R86 remained in the facility, R86's medical record lacked evidence R86 received the SNFABN-CMS-10055 form as required. On 7/18/24 at 1:20 p.m., registered nurse (RN)-C and RN-D confirmed no SNFABN-CMS-10055 form was provided, and it should have been. On 7/18/24 at 3:37 p.m., the administrator stated their expectation was the SNFABN-CMS-10055 form should have been provided to R86, and it was important to provide the SNFABN-CMS-10055 form to ensure the residents were aware of the date on which their services ended, and their right to appeal the process. The SNF ABN (Advanced Beneficiary) Notice Policy and Procedure revised on 9/2022, indicated the SNF ABD (Advanced Beneficiary Notice (CMS 10055) is issued before providing care or services that do not meet Medicare coverage criteria.

Based on interview, and document review the facility failed to ensure a written notification of transfer was sent to the office of the Ombudsman for long term care for 2 of 2 residents (R106, R107) with the potential to affect all residents transferred to the hospital. Findings include: R106's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition with medical diagnoses of displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, anemia, hypertension, gastroesophageal reflux (GERD), chronic kidney disease stage 3, diabetes mellitus, hyperlipidemia, depression, insomnia, chronic pain, muscle weakness, and history of falls. R106's progress note dated 5/26/24, indicated resident went to the emergency room (ER) for evaluation of new concerns. It was also noted that a bed hold was signed and sent with R106 to the hospital, and her family was notified of the transfer. Resident returned to the facility and discharged to home from the facility 5/29/24. R106's medical record lacked evidence a written notification of transfer was sent to the ombudsman for long term care. R107's admission MDS dated [DATE], identified moderately impaired cognition with medical diagnoses of unilateral primary osteoarthritis, left knee, hypertension, hyperlipidemia, arthritis, anemia, atrial fibrillation (Afib), insomnia, personal history of peptic ulcer disease, presence of prosthetic heart valve, presence of right artificial knee joint, muscle weakness, difficulty walking. R107's progress note dated 4/6/24, indicated resident went to the ER due to new concerns. It was also noted that a bed hold policy was sent with the resident and was declined by family. R107 returned to the facility 4/9/24 and discharged home 4/16/24. R107's medical record lacked evidence a written notification of transfer was sent to the ombudsman for long term care. Facility provide document, referred to as, Monthly Notice to MN Office of Ombudsman for Long-Term Care for Emergency Acute Care Transfers and Discharges. The fax cover sheet lists May as the time frame. R106 was not listed on the report provided. During interview on 7/17/24 at 4:59 p.m., Licensed Social Worker (LSW)-A stated the previous employee responsible for this data transmission kept the faxes in a folder and she was not able to locate the fax or report for the month of April that was requested to confirm R107's notification to the ombudsman was sent. LSW was able to provide the transmitted data for the remaining months of 2024. LSW confirmed no fax confirmation pages were retained. LSW verified that R106 was not listed on the report for May, which was the time that she was sent to the hospital. LSW stated she was aware that if the report is not generated correctly the information is not accurate, and she has been training staff on the correct way to pull the information. LSW also stated she had trained former employee to save the information to a shared drive and update there as well to ensure accuracy and information availability. Email received on 7/18/24 at 12:09 p.m. from the Ombudsman confirming no notification was received for either resident for either hospital transfer. The facility policy, titled Facility Initiated Notice of Intent to Discharge, section 5 Notice of Voluntary Resident/Patient Transfer or Discharge indicated in an emergent situation notice to the LTC Ombudsman must be sent as soon as practicable, including in the form of a list of residents on a monthly basis.

Based on interview, and document review the facility failed to complete neurological assessments following falls for 1 of 1 resident (R85) who had unwitnessed falls. Findings include: R85's significant change Minimum Data Set (MDS) dated [DATE], identified R85 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R85's diagnoses included progressive neurological condition, hypertension, BPH, renal failure, diabetes mellitus, non-Alzheimer's dementia, Parkinson's disease, depression, and repeated falls. R85's post incident review, dated 6/2/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 6/6/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 6/8/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 6/11/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 6/19/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 6/22/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 7/5/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 7/8/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 7/10/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. R85's post incident review, dated 7/11/24, identified an unwitnessed fall. R85 was found lying on floor in his room. Record indicated that neurological assessment was initiated but was not completed. During interview on 7/18/24 at 9:45 a.m., licensed practical nurse manager (LPN)-A stated when a resident fell staff notified the nurse. The nurse obtained vitals and assessed the resident for injury. LPN-A stated if fall was unwitnessed staff would initiate neurological assessments as follows: -every fifteen minutes times two, -every one-hour times two, -every two hours times two, -every four hours times two, -every shift on days two and three. LPN-A stated the neurological assessments should be completed at all times, even if a resident was sleeping, as it would be important to monitor throughout the day and night in case the resident had a head injury. LPN-A stated the nurses completed the neurological assessments and notified the provider of any abnormal readings. LPN-A stated if a time got missed, staff continued with the current flow sheet. LPN-A confirmed that the neurological assessments on 6/2/24, 6/6/23, 6/8/23, 6/11/24, 6/19/24, 6/22/23, 7/5/24, 7/8/24, 7/10/24 and 7/11/24 were not thoroughly completed with assessment times on flow sheet missing documentation. During an interview on 7/18/24 at 10:51 a.m., assistant director of nursing (ADON) stated when a resident fell the nurse completed a risk management assessment that consisted of the details of the fall and implement any immediate interventions to prevent future falls. ADON stated if fall was unwitnessed or if there was suspected head injury, neurological assessment would be initiated and completed as follows: -every fifteen minutes times two, -every one-hour times two, -every two hours times two, -every four hours times two, -every shift on days two and three. ADON stated if a neurological assessment time was missed, staff continued on the current flow sheet and the nurse manager followed up with staff to see why assessment was missed. ADON stated staff monitored the resident throughout the day and night. ADON confirmed the neurological assessments on 6/2/24, 6/6/23, 6/8/23, 6/11/24, 6/19/24, 6/22/23, 7/5/24, 7/8/24, 7/10/24 and 7/11/24 were not thoroughly completed with assessment times on flow sheet missing documentation which was very concerning. ADON stated neurological assessment were important to rule out any neurological damage. A facility Neurological Assessment policy was requested but was not received.

Based on interview and document review the facility failed to ensure coordination of dialysis care for 1 of 1 resident (R14) who required dialysis (treatment to filter blood when kidneys are no longer able). Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition and independent with all activities of daily living (ADL)'s. R14's diagnoses included end stage renal disease, heart failure, hypertension, depression, dependent on renal dialysis, tremors, and personal history of traumatic brain injury. R25's provider order printed 7/18/24, indicated R14 left for dialysis treatments every Monday, Wednesday, and Friday. On 07/15/24 at 5:19 p.m., R14 stated the facility had never sent any paperwork with him when he went to dialysis appointments. On 07/18/24 at 9:41 a.m., licensed practical nurse (LPN)-A stated when a resident went to dialysis, a communication sheet was usually sent with them which included a weight and vital signs. LPN-A further stated the paperwork was kept in a book located at the desk. LPN-A verified there were no dialysis communication sheets for R14, and LPN-A had never sent any paperwork with R14 to dialysis appointments. On 7/18/24 at 1:35 a.m., health unit coordinator (HUC)-A stated residents who received dialysis were sent with communication sheets. After their appointment, the communication sheet and dialysis run sheet were returned and placed in the resident's binder. HUC-A further stated R14 refused to take or bring back any communication sheets as dialysis was his baby and R14 does everything regarding dialysis. HUC-A confirmed there has been no communication between facility and dialysis center in the past 5 years. HUC-A stated if there was a new order the dialysis center called the facility. A long-term care facility and outpatient dialysis services coordination agreement directed both parties shall ensure there was documented evidence of collaboration of care and communication between the long-term care facility and dialysis facility. Furthermore, the contract directed the care facility to keep a copy of the resident's short term and long-term dialysis care plan. A facility Hemo Dialysis policy, dated 8/2021, indicated the facility is to assure that each resident receives care and services for provisions of hemodialysis consistent with professional standards of practice - including ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility, and includes the comprehensive person-centered care plan, and the residents' goals and preferences, and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Dialysis binder specific to resident to be kept at assigned Nurses Station and sent with resident to each hemodialysis appointment. Dialysis Binder to include but is not limited to the following: a. Face Sheet b. Facility contact information c. Current Medication List including supplements d. Recent lab work e. Dialysis Communication Form The following items should be sent with resident to hemodialysis appointment: c. Dialysis Binder with information (see above) g. Other Communication to include, but not limited to: i. Medication administration (new medications initiated, administered, held or discontinued) by the nursing home or dialysis facility. ii. Physician treatment orders, labs and vital signs iii. Advance Directives and code status iv. Nutrition/fluid management including weights, resident compliance with food and fluid restrictions. v. Dialysis treatment completed and resident response, including declines in functional status, falls, anxiety, depression, confusion and or behavioral symptoms that interfere with treatments. vi. Dialysis adverse reactions/complications and or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site catheter. vii. Changes or decline in condition unrelated to dialysis. viii. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility.

Based on interview and document review, the facility failed to assure the use of PRN (as needed) psychotropic medications (a drug which affects mood/behavior) were limited to 14 days, or had a physician specified, time limited order for 2 of 2 residents (R74 and R85) reviewed for Hospice. Findings include: R74's admission Minimum Data Set (MDS) dated [DATE], identified R74 had moderate cognitive impairment and required partial to moderate assistance with all activities of daily living (ADL)'s. R74's diagnoses heart failure, hypertension, GERD, anxiety disorder, depression, asthma/COPD, and encounter for palliative care. R74's electronic health record (EHR) identified R74 had an order for Lorazepam 0.5 mg PRN every four hours as needed for anxiety. The care plan indicated the facility worked with resident, hospice, and staff to meet resident needs. R74's medication administration record (MAR) indicated lorazepam 0.5 mg every four hours as needed. This order was initiated on 6/14/24 and was open-ended. The documentation reflected use of this medication four times in the month of July. R85's significant change MDS dated [DATE], identified R85 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R85's diagnoses included progressive neurological condition, hypertension, BPH, renal failure, diabetes mellitus, non-Alzheimer's dementia, Parkinson's disease, depression, and repeated falls. R85's electronic health record (EHR) identified R85 had an order for Lorazepam 0.5 mg PRN every four hours as needed for unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The care plan indicated the facility worked with resident, hospice, and staff to meet resident needs. R85's medication administration record (MAR) indicated lorazepam 0.5 mg every four hours as needed. This order was initiated on 6/21/24 and was open-ended. The documentation reflected use of this medication two times in the month of July. During interview on 7/18/24 at 9:23 a.m., registered nurse case manager (RN)-A stated for psychotropic medications, monitoring needed to be completed for behaviors. RN-A stated she was not aware any reassessment was required for PRN Lorazepam. RN-A confirmed R74's lorazepam was ordered on 6/14/24 and had no end date. RN-A confirmed R85's lorazepam was ordered on 6/21/24 and had no end date. During interview on 7/18/24 at 9:38 a.m., licensed practical nurse case manager (LPN)-A stated PRN Lorazepam required reassessment every 14 days. LPN-A stated it was important to reassess to see if medication was still needed and if it was effective and that the resident was not having any adverse side effects from medications. During interview on 7/18/24 at 10:48 a.m., assistant director of nursing (ADON) confirmed the lack of stop date for the PRN Lorazepam for R74 and R85. The ADON stated PRN psychotropic medications required a stop date of 14 days. ADON stated the provider needed to re-evaluate medication after 14 days and write a new order with rationale and end date if the medication was to be continued. ADON stated it was important to re-evaluated to see if the medication was effective and the resident did not receive any unnecessary medications. During interview on 7/18/24 at 1:38 p.m., consultant pharmacist (CP) stated Lorazepam required re-evaluation every 14 days. Provider was expected to document rationale and specify duration of medication. CP stated it was important to re-evaluate medication to make sure the resident was benefiting from it and to ensure the resident was not having any adverse effects from the medication. The facility Psychoactive Medication Use policy, reviewed 8/14/2023, indicated a resident will not receive unnecessary medications including psychoactive medications, unless non-pharmacological interventions have failed to sufficiently modify a resident's target behavioral, mood, or sleep disturbance. Residents prescribed psychoactive medications will receive adequate monitoring and will have gradual dose reductions attempted, unless clinically contraindicated. For PRN psychotropic medication orders, they must be reevaluated after 14 days, Add to TAR order for MD to re-evaluate after 14 days.

Based on interview and record review, the facility failed to assist in obtaining routine dental services for 1 of 1 resident (R56) reviewed for dental services. Findings include: R56's quarterly Minimum Data Set (MDS) dated [DATE], identified R56 was cognitively intact and could make her needs known. The admission MDS dated [DATE], indicated R56 required supervisor and verbal cues to complete oral care. R56 did not display any type of dental concerns. During interview on 7/15/24 at approximately 12:00 p.m., R56 stated they would be interested in seeing a dentist and could not recall facility staff offering a dental appointment since admission. R56 could not recall their last dental appointment. During follow up interview on 7/17/24 at 1:35 p.m., R56 stated their teeth did not hurt but would like to see a dentist. R56's care plan dated, 11/15/23, directed the staff to assist R56 with oral cares. The plan directed R56 to brush teeth, gums, end of tongue; observe for mouth pain, ulcers, sensitivity, loose teeth, tooth decay, or improper fitting dentures; schedule dental exams as ordered, per facility policy, and/or as needed. R56's medical record lacked an oral assessment, or a referral for a dental evaluation. During interview on 7/18/24 at 7:33 a.m., licensed practical nurse (LPN)-A stated the facility had an in-house dental provider and LPN-A was usually the person who coordinated dental referrals for the long-term care residents. In order for a resident to be seen by the dental provider, the resident or family would sign a consent to share information with the dental provider. They would then be added to the list of residents to be seen on their next visit. LPN-A confirmed R56's record lacked a dental consent and had not expressed their wishes to be seen by the dentist. LPN-A stated they would contact R56's family for a dental visit consent. During follow up interview on 7/18/24, at 8:09 a.m. LPN-A stated R56 had signed the dental consent and R56's family had been contacted. During interview on 7/17/24 at 10:01 a.m., the assistant director of nursing (ADON) stated if the resident wanted to see the dentist they had two options; they could use the in-house dentist who visited the facility every couple of months, or they could choose to find their own dentist and the facility would arrange transportation and assist with setting up any appointments. ADON confirmed R56 had not received a dental referral or examination since admission. The Dental Care policy dated 10/2019, directed the facility to meet the dental needs of the residents, to ensure quality of life, proper nutrition, dignity, and psychosocial well-being. Resident's dentition was be assessed upon admission and appropriate referrals were to be completed. Upon admission, the resident was to be provided information on dentist of choice or was to be given information on dentists available. Referrals were be made to the dentist as needed, per physician order and approval of resident/responsible party. Health unit coordinator or designee were make the residents appointment with the provider of choice.

49657 Based on observation, interview and document review the facility failed to ensure enhanced barrier precautions were used for 1 of 3 residents (36) reviewed for infection control. Findings include: R36's significant change Minimum Data Sheet (MDS) dated [DATE], identified her cognition was intact. R36's required partial assistance with dressing her upper body, substantial assistance with dressing her lower body and was dependent with transfers. R36's diagnosis list dated 7/18/24 listed the following diagnoses: surgical amputation, diabetes, osteomyelitis (infection of the bone), methicillin resistant staphylococcus aureus infection (MRSA-type of bacteria that is highly resistant to antibiotics), a colostomy (opening in the abdomen to expel feces) and chronic ulcers (skin breakdown). R36's care plan dated 5/14/24, indicated R36 has a diagnosis of mulit-drug resistant organism (MDRO) and met the criteria for enhanced barrier precautions. Care plan interventions included to don gown and gloves during high contact resident care activities including dressing, transfers, and providing hygiene. On 7/16/24 at 10:02 a.m., nursing assistant (NA)-B was observed entering R36's room without donning a gown. Signage on the door of R36's room indicated enhanced barrier precautions. A clear rubber three drawer cart was placed outside of R36's door and held yellow gowns. NA-B was observed providing morning hygiene cares to the resident without [NAME] precautions. On 7/16/24 at 10:02 a.m., NA-B confirmed she assisted R36 with emptying her colostomy bag, providing personal hygiene cares, getting dressed, putting on compression socks, making her bed and transferring. NA-B confirmed she wore gloves but not a gown. NA-B stated the sign for enhanced barrier precautions means the resident was contagious, but she would only have to wear a gown if the resident had an active infection such as COVID. On 7/17/24 at 1:07 p.m., registered nurse (RN)-F was in F36's room completing a medication pass, they realized they had forgotten something and removed their gloves completed hand hygiene, however, did not remove the gown and proceeded to leave the room and go out in the hall and enter the medication storage room. Writer interjected, and RN-F stated they had forgotten to remove the gown, and stated they should have removed both gloves and gown prior to exiting the room and put on new ones upon entering the room again to prevent the spread of infection. On 7/17/24 at 5:08 p.m., the assistant director of nursing (O)-B stated they expected staff, in a resident room with enhanced barrier precautions, to remove both gloves and gowns prior to exiting the room to prevent the spread of contagious infections. On 7/18/34 at 09:57 a.m., the infection preventionist RN-E stated the expected staff, in a resident room with enhanced barrier, precautions to remove both gloves and gown prior to exiting the room to prevent the spread of infection. The facility policy Infection Prevention and Control Manual Personal Protective Equipment (PPE) dated 2020, indicated personal protective equipment will be removed before leaving the work area and placed in an appropriately designated area or container.

Based on document review and interviews the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 112 residents residing in the facility and their visitors who may wish to view the information. Findings include: During the review of the staff posting documentation from 6/3/24 through 7/18/24 the facility failed to provide evidence of staff postings for the following dates: 6/8/24, 6/9/24, 6/15/24, 6/16/24, 6/22/24, 6/23/24, 6/29/24, 6/30/24, 7/4/24 through 7/7/24, 7/13/24 and 7/14/24. On 7/18/24 at 1:11 p.m., the staffing manager (O)-D confirmed they had not been doing the staff posting on the weekends. On 7/18/24 at 3:37 p.m., the administrator stated they were unaware it had not been completed, and their expectation was it would be completed daily to ensure the information was available for residents or visitors who may like to see it. The Staffing Hours Posting Policy last revised 01/2015, indicated the facility will post daily at the beginning of each shift the facility-specific shift schedule for the 24-hour period.

Based on observation, interview, and record review the facility failed to ensure comprehensive assessments were consistently completed, provide and implement interventions to prevent recurrent pressure ulcers (PU) for 1 of 1 residents (R13) who had a history of facility acquired stage 3 pressure ulcers. The facility's failures resulted in actual harm when R13 developed a recurrent pressure ulcer to the right heel. Findings include: R13's significant change Minimum Data Set (MDS) dated [DATE], indicated R13 was admitted to the facility on [DATE] with diagnoses including aphasia following intracranial hemorrhage (difficulty understanding or expressing speech following a brain bleed), morbid obesity, muscle weakness, heart failure, diabetes mellitus, non-Alzheimer's dementia, and arthritis. R13 required maximal assistance with mobility in bed and was dependent on staff for sitting up, lying down, and transfers. The MDS identified R13 as at risk of developing pressure ulcers/injuries with three current stage 3 pressure ulcers which were not present upon admission/entry or reentry. Treatments included pressure reducing device for chair, pressure reducing device for bed, application of ointments/medications other than to feet, and pressure ulcer/injury care. MDS did not identify R13 required a turning/repositioning program. R13's MDS dated [DATE], included the last Brief Interview for Mental Status (BIMS) completed, with a score of 3 indicating severe cognitive impairment. R13's orders included a physician order dated 1/16/24, ensure resident is being turned and repositioned frequently due to wounds every evening and night shift. R13's wound physician note dated 1/17/24, noted R13 was referred for a wound care assessment and evaluation and had wounds on her right heel, left coccyx, and right buttock. The wounds were identified as a stage 3 pressure wound of the right heel full thickness, stage 3 pressure wound of the left coccyx full thickness, and stage 3 pressure wound of the right buttock full thickness. Treatment recommendations included floating heels in bed (positioning to keep heel up and not in contact with bed to avoid putting pressure on the area), off-loading the wound (minimizing weight bearing on the affected foot), repositioning per facility protocol, and using a low air loss mattress. Review of R13's record between 1/17/24 and 3/25/24 identified the the left coccyx wound and the right buttock wound were resolved or healed on 2/21/24. The record identified the right heel wound was resolved on 2/24/24, however two days later on 2/26/24 a stage 2 PU had developed on right heel. On 3/11/24 and on 3/25/24 the record indicated the wound had resolved, however by 3/26/24, another pressure ulcer on R13's right heel had developed. Record of R13's right heel wound included the following: R13's physician order dated 1/18/24 (with no stop date), instructed staff to cleanse right heel with normal saline and pat dry. Apply skin prep to surrounding skin, Xeroform [a gauze wound dressing impregnated with petroleum] to wound bed and cover with gauze island every day shift. R13's physician order dated 1/26/24 instructed, at these times, you need to ensure that her heels are floating on a pillow, and she is also turned. She prefers to have pillow on her (R) [right] buttock side due to her wound. Family is reviewing her video camera daily and reporting back to the facility three times daily at 12:00 a.m., 5:00 a.m., and 7:00 p.m. R13's care plan with review date of 2/2/24, included skin as a focus area related to a history of right heel pressure injury. Current interventions included a pressure-reducing mattress on R13's bed and wheelchair (1/18/24), assisting as needed with repositioning while sitting and lying as R13 was unable to reposition self initiated (4/20/23), inspecting skin daily with cares and nursing assistants (NAs) reporting concerns to the nurse (10/4/21), floating the right heel and applying skin prep [protective skin barrier applied with wipes that helps to reduce friction on skin] per orders (initiated 10/4/21), and weekly skin assessments by licensed nurses (initiated 7/25/23). R13's electronic health record (EHR) included additional wound care notes from wound physician visits on 1/23/24, 1/31/24, and 2/7/24 that included comprehensive assessments of R13's heel wound. The note dated 2/21/24 did not include assessments of R13's wounds and documented Signing off on patient who remains in the facility. Per facility wound care is being transferred to [name of agency]. Sign off without visit. R13's wound physician note dated 2/7/24, noted R13 had a stage 3 pressure wound of the right heel full thickness measuring 0.25 square centimeters (cm) in area/0.5 cm long/0.5 cm wide/0.1 cm deep with light serous exudate (clear thin discharge), 30% thick adherent devitalized necrotic tissue, 70% other viable tissues, and was improved R13's Skin and Wound Evaluation dated 2/21/24, R13's right heel wound was not addressed on 2/21/24 along with the other wounds. R13's Nursing Weekly Skin Check dated 2/24/24, indicated she had pressure wounds that were not new. Comments noted R13's heel was healed but a dressing was still applied to protect the newly fragile area. No further description of the heel wound was included. R13's Skin and Wound Evaluation dated 2/26/24, noted a stage 2 pressure wound on R13's right heel that was acquired at the facility, present for between one and three months, measured less than 0.1 square cm in area/0.4 cm in length/0.2 cm wide, had a wound bed 100% filled with granulation tissue, was staged by a healthcare provider, did not have evidence of an infection, had a scab present, no drainage, no odor, attached edges between the wound and surrounding skin, scarring of tissue surrounding the wound without hardening or swelling that was a normal temperature, no wound pain, and the dressing was intact. Additional cares were none, a heel suspension/protection device or turning/repositioning program were not identified. The progress of the wound was marked as improving. This was the first comprehensive assessment of R13's heel wound noted in records since the wound physician visit on 2/7/24. R13's Nursing Weekly Skin Check dated 3/3/24, indicated she had an other skin issue that was not new. Comments noted R13's right heel wound was improving with treatment in place. The documentation did not include further description of R13's right heel wound. R13's Skin and Wound Evaluation dated 3/4/24, noted a stage 2 pressure wound on R13's right heel that was acquired at the facility, present for between one and three months, measured 0.2 square cm in area/0.5 cm long/0.4 cm wide, had a wound bed 60% covered with epithelial tissue and 40% covered with granulation tissue, was staged by a healthcare provider, did not have evidence of infection, had a scab present, no drainage, no odor, attached edges between the wound and surrounding skin, unbroken/intact skin surrounding the wound without hardening or swelling that was a normal temperature, and no wound pain. The assessment indicated the tissue surrounding the wound was not reddened. The dressing was intact and treatment included additional cares of a heel suspension/protection device. The progress of the wound was marked as improving. R13's Nursing Weekly Skin Check dated 3/6/24, indicated she had an other skin issue that was not new. Comments noted no new skin concern currently. No further description of the heel wound was included. R13's Nursing Weekly Skin Check dated 3/9/24, indicated she had both an other skin issue and none identified/no skin issues found that were not new. Comments indicated no new skin concerns were noted, R13's right heel wound was improving with treatment in place. No further description of the heel wound was included. R13's Skin and Wound Evaluation dated 3/11/24, noted a stage 3 pressure wound on R13's right heel that was acquired at the facility, present for between one and three months, had an intact surface (was not an open wound), was staged by a healthcare provider, did not have evidence of infection, had a scab present, no drainage, no odor, attached edges between the wound and surrounding skin, unbroken/intact skin surrounding the wound without hardening or swelling that was a normal temperature, and no wound pain. The assessment indicated the tissue surrounding the wound was not reddened. The treatment included additional cares of repositioning devices and a turning/repositioning program. The progress of the wound was marked as resolved. The wound measurement section was blank. R13's Nursing Weekly Skin Check dated 3/13/24, noted no skin issues were identified or found. Email communication dated 03/20/24 at 7:01 a.m., was from family member (FM)-B to DON, ADON, Administrator, nurse manager (NM)-(A) and NM-B and expressed concerns within the last week and noted the following had occurred: - Monday [3/18/24] got up at 7:55 am not to receive a diaper check or change until 3:45 pm - 8 hours. - Left in bed for 3 hours calling to get out with no one checking her from Tuesday [3/19/24] 1:45 pm - 5:05 pm - never checked on by any staff. - Placed to bed Tuesday evening [3/19/24] at 7:15 pm, no diaper check or reposition until 4:55 am this morning - almost 12 hours. I willl be coming in after work this morning to check on her and expect to have answers as to why her care plan has not been followed and to decide what action needs to be taken. I was told Monday that the care plan was going to be executed which didn't even last one day. We are truly concerned with the level of care being provided in River Bend as a whole with not only mom but other residents as well. We are hoping this sudden change in care for our mom was not reflective of claim filed justifiably with state as we were not the only resident family who filed claims. R13's Nursing Weekly Skin Check dated 3/24/24, noted the presence of a scar that was not a new skin injury. It lacked further details about the scar and did not include information related to R13's heel wound. R13's progress note dated 3/25/24, indicated that, regarding completion of the 1/18/24 order for right heel wound care, it was healed per nurse manager. R13's Point of Care task for turning and reposition instructed direct care staff at these times you need to ensure that her heels are floating on a pillow, and she is also turned. She prefers to have pilow on her (R) buttock side due to her wound. Family is reviewing her video camera daily and reporting back to the facility.With a look back of 14 days identifed no data found'. During continuous observation on 3/26/24 from 5:27 a.m. to 7:52 a.m., R13 was noted to be lying directly on her back in bed with blanket over her body. R13's legs at the same height on top of the bed with toes pointed upward, one leg was not higher than the other. Staff did not enter the room to offer to turn or reposition R13 during this time. At 7:52 a.m., nursing assistant (NA)-A and NA-B entered R13's room. R13 had a turn me frequently sign above her bed. When NA-A pulled back the blanket both of R13's heels were positioned directly on the mattress. NA-A reported R13's heels were not supposed to be lying directly on the bed and were supposed to have a pillow underneath them. NA-A identified a pillow to the side of R13's leg in bed and reported the pillow should be under R13's right leg. NA-A reported R13 did not have heel protectors or anything else to prevent contact between R13's heels and the bed. At 8:07 a.m., R13 stated owweee when NA-B put on her right sock. NA-A and NA-B did not respond to R13's report of discomfort. During an interview on 3/26/24 at 8:47 a.m., NA-A reported R13 was last turned and repositioned around 5:00 a.m. and staff were to document this in the electronic charting system, including if a resident refuses care. NA-A stated staff should not go longer than three to four hours between turning and repositioning residents but for R13 anything longer than two hours was too long. NA-A stated overnight staff were responsible for ensuring R13's heels were floated while she was in bed. During an interview on 3/27/24 at 11:13 a.m., NA-E reported to be R13's overnight NA from 3/25/24 to 3/26/24. NA-E stated she/he checked/changed and repositioned R13 at 12:00 a.m. and then again at around 4:40 a.m. NA-E indicated a pillow had been placed under R13's right heel. During observation on 3/26/24 at 1:21 p.m., R13's feet were examined with clinical manager (CM)-B. R13's socks were removed and feet were bare with no dressings or coverings in accordance with active physician orders. R13's right heel was noted to have a small intact scab approximately 1/4 x 1/4 in the middle of the backside of the heel with an area of generalized redness extending around the scab approximately 1 above and to the sides and 1 1/2 below extending to the bottom side of the foot that blanched (turned white) when pressed. To the left and right of the scab were areas of darker redness, both approximately 1/4 x 1/4 that did not blanch when touched. The left heel had generalized blanchable redness extending across the back of the heel and onto the bottom surface and sides of the foot approximately 3 x 3. CM-B gently pressed on R13's heels and indicated the tissue on both heels was boggy (tissue that has a spongy or mushy quality when pressed) to touch. During an interview on 3/26/24 at 1:36 p.m., clinical manager (CM)-B stated there was redness on both of R13's heels and they were boggy to the touch. CM-B noted the areas of darker redness next to the scab on R13's right heel and noted the generalized redness to be blanchable. CM-B did not remark on the non-blanchable areas that had been identified. CM-B stated the redness was concerning because it will get worse. CM-B stated the redness on the left heel was a new issue. CM-B stated there was concern for stage 1 pressure injuries on both heels. During a subsequent interview on 3/26/24 at 2:01 p.m., CM-B stated R13's care plan identifies she has a history of a pressure injury on the right heel with related interventions that included floating the right heel and applying skin prep. CM-B noted R13's heel should be floated to relieve pressure so the skin doesn't break down further. CM-B confirmed that someone with a history of a pressure injury on their heel would be at increased risk of developing another pressure injury in that area. In an interview on 3/26/24 at 3:30 p.m., director of nursing (DON) reviewed a photograph of R13's right heel taken at 1:37 p.m. during examination with CM-B. The DON stated it was something he would note and document when completing a skin check. He described R13's heel as a scab with an unstageable wound base because the wound base was not visible so he could not determine if it was eschar [dead tissue] or just not clean. The DON described the skin surrounding the scab as darker in pigment and intact. In review of a photograph of R13's left heel taken at 1:37 p.m., the DON described the left heel as intact without further comment. The DON stated R13 had a history of pressure wounds on her bottom and right heel, previously up to stage 3 wounds. The DON confirmed R13's care plan directed staff to float her right heel and use skin prep and perform weekly nursing skin assessments with the expectation that the heel be floated when R13 was in bed. The DON confirmed that the Nursing Weekly Skin Check completed two days prior on 3/24/24 did not include any documentation of skin issues or concerns related to R13's heels. The DON stated he would 100% expect to see documentation of R13's right heel on the skin assessments and the lack of documentation on the assessment was unacceptable. The DON stated staff did weekly skin checks and reported issues. The facility's provider doctor of medicine (MD)-A was monitoring R13's heels weekly and I am looking to see if he has anything in his notes right now, I don't see anything in his note. The DON stated the facility needed to work on their communication among staff, ensure R13's heels were floated, DON also stated R13's assessments needed to be accurate, the care plan needed to be accurate, and all staff should be following the care plan for R13. Facility Policy titled Prevention and Treatment of Pressure Ulcers/Pressure Injury dated 11/22/22 included: B.) Nursing: Monitoring of Skin Integrity: Skin will be observed daily with cares by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse; Weekly skin audits will be performed by the Licensed Nurse (Refer to Body Audit Policy and Procedure). An alert will trigger from question B of the assessment to the clinical dashboard that will notify the IDT that a new skin issue has occurred and follow up is needed; If a dressing is ordered, it will be monitored for appropriate placement on resident; If a skin concern is noted, refer to section II. Treatment of Pressure Ulcers and Lower Extremity Ulcers (arterial, venous, neuropathy/diabetic, or mixed) procedure and Wound Care Protocols. C.) Turning and Repositioning Observation (tissue tolerance): Pressure is the primary cause of pressure ulcers. An effective turning and repositioning schedule can help reduce the risk of developing a pressure ulcer. Everyone's ability of their skin and its supporting structures to endure the effects of pressure without breakdown, is different. Therefore, it is important to individualize each resident's turning and repositioning schedule based on abilities and needs. II.) Treatment of Pressure Ulcers and Lower Extremity Ulcers (arterial, venous, neuropathy/diabetic, or mixed)If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: (8) Update the residents individualized Care Plan for Skin Integrity and nursing assistant Kardex with any skin concerns and interventions. Include appropriate risk factors, turning intervals and interventions as appropriate. (9) Initiate Weekly Wound Documentation to be completed every seven days and PRN in electronic health record which will include: type of wound, location, date, stage (pressure ulcers only) or indicate partial or full-thickness (arterial, venous, neuropathy/diabetic ulcers), length, width and depth; wound base description, wound edge description and if present: drainage, odor, undermining, tunneling, and/or pain. The Weekly Wound Documentation Progress Form should only have ONE WOUND per form. See Weekly Wound Documentation Progress Sheet & Wound Documentation Guidelines for instructions. (10)When a wound is present, daily wound monitoring should include: An evaluation of the wound, if no dressing is present; An evaluation of the status of the dressing, if present; The status of the area surrounding the ulcer/wound (that can be observed without removing the dressing); The presence of possible complications, such as signs of infections; Whether pain, if present, is being adequately controlled; Document on any changes or concerns in the nurses notes and re-evaluate prior steps 1-9 as appropriate. 49338

Based on interview and document review the facility failed to perform root cause analysis to determine patterns for falls and failed to develop and implement person centered interventions to reduce the risk for falls for 1 of 3 residents (R5) reviewed for falls. This resulted in actual harm for R5 who fell and sustained a fractured finger and a laceration to her eye that required sutures and hospitalization to monitor for a concussion. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated she required extensive assistance for transfers and toileting, was always incontinent of bladder and always continent of bowel. The MDS indicated R5 had one fall since the prior assessment with no injury. R5's Care Area Assessment (CAA) dated 9/21/22, indicated a risk for falls due to a history of fall in the past and self transfers in and out of bed at times. R5 had one fall during the quarter with no injury and was able to make needs known and utilize call light appropriately. Staff to ensure call light and items of use within reach at all times and answer call light promptly. R5 had a fall risk assessment score of 60 indicating a high risk for falls. The CAA indicated staff would continue to meet needs. R5's care plan updated 11/16/22, identified a self care deficit due to preferences and items of need listed and indicated a risk for falls. The care plan indicated R5 required assist of one staff for transfer. The care plan identified bladder incontinence and directed staff to provide toileting assistance upon rising, after meals, before bedtime and upon her request or as needed, last updated 4/1/21. The care plan further identified a risk for falls and directed staff to ensure call light was in reach, anticipate needs, safety bar over toilet (already standard in room),and a pancake call light in bed. R5's Fall assessment dated [DATE], indicated a high risk for falls. The assessment identified a history of falls and indicated she overestimated or forgot limitations. A facility incident report dated 9/10/22, indicated staff found R5 sitting on the floor at the foot of her bed with her wheel chair next to her. R5 stated she slid out of bed transferring to her wheel chair. An IDT (interdisciplinary team)/Fall Team Post Investigation Review dated 10/13/22, identified date and time of incident as 9/30/22, however notification to risk manager indicated 9/10/22. The root cause was identified as R5 refusal to call for help during transfer, attempted unsafe transfers daily and indicated staff remind and intervene when found transferring self. Interventions included: ensure call light is near patient, ensure needed items are in reach, auto lock brake on wheel chair and remind patient to call for assistance. (all interventions had been previously care planned). A facility incident report dated 9/28/22, indicated R5 was on her back on the floor and her wheelchair was next to her. R5 was screaming for help getting up. Her pants were wet and some urine was on the floor. R5 said she was trying to get to her wheelchair and heading out for lunch. An IDT Fall Team Post Investigation Review dated 10/4/22, identified the incident being reviewed at 9/30/22, at 2:26 p.m. however, notification to risk manager was dated 9/28/22. The review indicated R5 fell due to her pants being wet from urine causing her to slide down from her bed during self transfer to wheel chair. An IDT (interdisciplinary team)/Fall Team Post Investigation Review dated 10/4/22, indicated date and time of incident under review was 9/30/22, at 12:15 p.m. The review indicated R5 refused to call for help with transfer and attempted unsafe transfers daily. No additional information was noted in the fall report to identify if current care planned interventions were implemented prior to fall or new interventions were identified. Staff reminded and intervened when found transferring herself. A facility incident report dated 11/15/22, indicated staff at the desk heard a loud banging as writer had noted resident was in the bathroom [ROOM NUMBER] minutes prior. Staff went to R5's room and found her on the floor. An IDT /Fall Team Post Investigation Review dated 11/17/22, indicated review of fall that occurred on 11/15/22, at 1:15 p.m. The report indicated R5 was found with the wheelchair in front of her, had urinated and had bowel movement in toilet. R5 was laying on her back with her feet against the wall and head near the shower area with her pants down around her knees. Interventions included a safety bar over the toilet (all rooms were equipped with a safety bar over the toilet when constructed.) and a pancake light. A correlating Progress Note dated 1/15/22, indicated the IDT reviewed the fall and determined the root cause to be R5 lost her balance and fell during transfer. The record lacked evidence the facility identified a pattern of falls related to toileting even though R5 had fallen on three occasions due to need for toileting. Additionally, no information was noted in the fall report to identify if current care planned interventions were implemented prior to fall or new interventions were identified. A facility incident report dated 1/11/23, indicated at 10:30 a.m. staff noted R5 on the floor on her right side, wheel chair close to her head. R5 was last seen around 8:00 a.m. for medications and told staff to come back around noon to give medications. R5 sustained lacerations to the right side of her face and left hand and complained of left hip pain. Facility Progress Note dated 1/11/23, indicated R5 was admitted to the hospital related to fall with a left pinky fracture as well as laceration to her eye and observation for concussion. Progress Note dated 1/12/23, indicated R5 returned to the facility. Right face bruising, left and right hand bruising, sutures to below and above her right eye. During interview on 1/12/23, at 1:13 p.m. nursing assistant (NA)-A stated R5 had a couple of falls. NA-A stated fall interventions included checking on R5. NA-A stated R5 did not walk by herself but would self transfer and use the bathroom by herself and said R5 did not tell staff when she needed to use the bathroom. NA-A said R5 had a history of refusing cares and was able to use her call light but only used it once in a while. On 1/12/23, at 11:20 a.m. registered nurse (RN)-A stated she only worked at the facility once in a while and on different units. RN-A stated fall interventions could be found on the Kardex, the medication administration record and on assignment sheets. RN-A stated she was present on 1/11/23, when R5 fell . RN-A said she went to give R5 medications around 8:00 a.m. and R5 told her to come back around 10:00 a.m. RN-A stated she found R5 on the floor around 10:00 a.m. - 10:30 a.m RN-A said R5 was between her bathroom and the bed with her head closer to the bathroom doorway and was bleeding. During interview on 1/12/23, at 3:21 p.m. the director of nursing (DON) stated determining the root cause of the fall was completed by the nurse on the floor. The DON stated staff filled out a risk management form and was supposed to put new interventions in place. The DON said when the IDT met they looked to make sure staff had reviewed and implemented interventions. The DON stated the unit managers met Monday - Friday to discuss interventions. The DON said R5 should have been looked at multiple times due to multiple falls. The DON said when reviewing R5's care plan he did not see anything specific for her falls and said the IDT is not getting to the meat of the matter. The DON stated a new process was needed. A facility policy Fall Data and Collection Protocol dated reviewed 2/26/19, indicated all residents are assessed to identify risk for falls and individualized fall precautions will be developed on their care plan. Preventative measures shall be taken to decrease the number of falls whenever possible. Use the huddle information to perform root cause analysis. Staff will work together to determine the underlying cause(s) and contributing factors of a resident's fall. Once the cause and contributing factors are identified, identify a new intervention that will eliminate or minimize the cause and contributing factors. The Interdisciplinary Team will meet daily and as needed to review accident/incidents and determine if investigation of incident is needed and will assist with assessing for further interventions(s). The Interdisciplinary Team will evaluate the resident's fall risk in conjunction with the care plan to develop, review and revise.

Based on interview and document review, the facility failed to provide services to prevent the worsening of pressure ulcers by failing to consistently assess wounds and monitor effectiveness of treatment for 1 of 3 residents (R63) reviewed for pressure ulcers. This resulted in actual harm to R63, who developed a pressure ulcer that worsened. Findings include: National Pressure Injury Advisory Panel staging definitions for pressure injuries: Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). R63's Admission Record printed [DATE], indicated R63's [DIAGNOSES REDACTED]. R63's admission Minimum Data Set ((MDS) dated [DATE], indicated R63 had intact cognition, required assistance with bed mobility and transfers, and did not ambulate. The MDS further indicated R63 was at risk for pressure ulcers, had an unstageable suspected deep tissue pressure ulcer present upon admission, and had a history of [REDACTED]. The MDS also indicated R63 received pressure ulcer care, had application of nonsurgical dressings other than to feet, received applications of ointments/medications other than to feet, and received application of dressings to feet. R63's physician orders [REDACTED]. R63's care plan initiated [DATE], indicated R63 had a skin impairment related to amputation to toes/post-surgical wounds of left foot, diabetic wound of left foot, unstageable deep tissue injury of left heel, wound of right second finger, and sheer wound right lateral heel. Interventions included licensed staff to monitor wound progress weekly, wound consultation as ordered, pressure relieving device for bed, and pressure relieving device for wheelchair. R63's hospital readmission record dated [DATE], indicated R63 had an unstaged pressure ulcer on his sacrum, and was to have a silicone dressing in place to be changed as needed. R63's record lacked assessment or measurements by the facility of his coccyx (sacrum) pressure ulcer at the time of readmission. On [DATE], a New Skin Concern form indicated R63 had pressure ulcers on his buttocks. The pressure ulcer on the right buttock measured 2 centimeters (cm) x 3 cm. The pressure ulcer was not staged. R63's left buttock area had a pressure ulcer staged as a deep tissue injury measuring 3 cm x 4 cm. R63's Physician order [REDACTED]. R63's orders lacked instructions and treatment orders for area on the right buttock. R63's Physician order [REDACTED]. R63's Weekly Skin Inspections on the coccyx pressure ulcer were not completed from [DATE], through [DATE]. R63 was seen by the nurse practitioner on [DATE], and [DATE], and documentation lacked indication R63's pressure ulcers were evaluated at those visits. R63 was seen by his primary physician on [DATE], and documentation lacked indication R63's pressure ulcers were evaluated at that visit. On [DATE], R63's weekly wound measurements indicated the coccyx pressure ulcer had worsened and was measured at 8 cm x 6.5 cm. The pressure ulcer was assessed as partial thickness, green scant watery drainage, intact surrounding skin, suspected deep tissue injury. The pressure ulcer was not staged. On [DATE], a progress note indicated R63 was seen by a wound care provider. The note indicated R63's coccyx pressure ulcer measured 8 cm x 6.5 cm. and was a Stage 3. The pressure ulcer was cleansed with normal saline and 36.40 cm of devitalized tissue including slough, biofilm, and non-viable subcutaneous fat, and surrounding connective tissues were removed at a depth of 0.1 cm. Healthy bleeding tissue was observed. On [DATE], a progress note indicated R63 was admitted to hospice for end of life care, and was being transferred to a hospice facility. On [DATE], at 10:10 a.m. R63's family member (FM)-A was interviewed and stated she was notified on [DATE], of the coccyx pressure ulcer. FM-A stated it was not until [DATE], that she was notified again when the facility told her the pressure ulcer had worsened. FM-A stated she felt the facility did not properly manage and monitor the pressure ulcer. FM-A stated R63 was transferred to hospice care on [DATE], and an unidentified hospice nurse relayed the extent of the pressure ulcer. FM-A stated R63 died on [DATE], and it was then she visually observed the pressure ulcer, and she was horrified at its condition. On [DATE], at 10:10 a.m. R63's wound care physician (MD)-A was interviewed and stated she had not been made aware of R63's coccyx pressure ulcer until [DATE]. MD-A stated the facility should have followed their protocol as far as assessing and monitoring the pressure ulcer, and updating the physician. On [DATE], at 11:50 a.m. nursing assistant (NA)-A stated she had provided direct cares for R63. NA-A stated R63 had a large pressure ulcer on his buttocks. NA-A further stated R63 had an air mattress in place, and a wheelchair cushion because of the pressure ulcer on his buttocks. NA-A stated licensed nurses were responsible for measuring and completing dressing changes on pressure ulcers. On [DATE], at 11:28 a.m. registered nurse (RN)-A stated he was the RN manager responsible for overseeing R63's care while he resided at the facility. RN-A stated R63's pressure ulcer should have had weekly monitoring and assessments. RN-A stated on [DATE], R63 was identified to have an open area on his coccyx. RN-A stated R63's coccyx pressure ulcer assessments and measurements were not done weekly until [DATE]. On that date, R63's pressure ulcer was measured by nursing, and had become significantly larger in size. RN-A stated the nurse practitioner (NP) and the MD did not evaluate R63's pressure ulcer when they did rounds. RN-A stated more could have been done for R63, and R63's pressure ulcer was not adequately taken care of. On [DATE], at 11:52 a.m. RN-B stated she was not made aware of R63's pressure ulcer on [DATE]. RN-B said she was made aware of the pressure ulcer on [DATE], when wound care would be following him. On [DATE], at 2:24 p.m. the director of nursing (DON) stated R63's pressure ulcer assessment and monitoring was not done weekly. The DON stated R63's NP and MD were not made aware of R63's pressure ulcer on his coccyx during rounding visits. The DON stated R63's coccyx pressure ulcer should have been seen by a provider, and weekly wound assessment and monitoring should have been completed. The DON said this would be important to prevent other systemic issues from developing, and making sure infections and wound progression did not occur. The facility policy Prevention and treatment of [REDACTED]. The policy further directed when a wound is present, daily monitoring should include evaluation of the wound, evaluation of the ordered dressing, status of the surrounding area, evaluation for infection and pain monitoring.

Based on interview and document review, the facility failed to ensure documentation of resident's resuscitation status was consistent throughout the clinical record to ensure resuscitation code status accurately reflected each resident's current resuscitation preference. This resulted in an immediate jeopardy for 2 of 3 residents (R318, R10) reviewed for advanced care directives on the transitional care unit (TCU) when their resuscitation status was inconsistently recorded in their clinical record. This had the potential to affect 16 residents who resided on the TCU. The immediate jeopardy (IJ) began on [DATE], when it was determined R318 and R10's electronic medical records (EMR) indicated their code status as Do Not Resuscitate (DNR) however, their Provider Orders for Life Sustaining Treatment (POLST) indicated Cardiopulmonary Resuscitation (CPR) should be provided. When interviewed, staff gave inconsistent information about which code status they would implement. The Assistant Executive Director (AED), Director of Nursing (DON), and Vice President of clinical operations were notified of the IJ on [DATE], at 5:45 p.m. The IJ was removed on [DATE], however non compliance remained at a lower scope and severity of E, no actual harm with potential for more than minimal harm at a pattern. Findings Include: R318's admission Minimum Data Set (MDS) assessment identified R318 was admitted to the facility on [DATE]. The MDS also indicated R318 was cognitively intact, required extensive assistance with activities of daily living (ADL's) and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R318's hospital discharge records from Mercy Hospital indicated R318's code status as DNR. R318's facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] R318's POLST, signed but not dated by R318's family member (FM)-B, indicated R318 should receive CPR in the event R318 stopped breathing or had no pulse. During interview on [DATE], at 3:15 p.m. R318 stated his wishes were to be DNR. Further R318 stated FM-B had originally signed the POLST due to his [R318's] limited capacity when admitted . R10's admission MDS identified R10 was admitted to the facility on [DATE]. The MDS also indicated R10 was cognitively intact, required limited assistance with ADL's, and had several medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10 was admitted to the facility from Mercy hospital on [DATE]. R10 was admitted with a copy of the hospital history and physical indicating DNR status. R10's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A POLST initiated by a nurse on [DATE], identified CPR should be provided. A POLST was signed by R10 undated, and was signed by the nurse practitioner on [DATE], indicating R10's desire for CPR to be initiated if required. However, review of the EMR indicated R10's status as of [DATE], continued to identify R10's code status as DNR. This surveyor attempted to interview R10 on [DATE] at approximately 3:25 p.m. to determine what R10's wishes were due to the discrepancy in code status, however R10 was unavailable due to being out of the building at a medical appointment. Based on interview with During interview on [DATE], at 2:55 p.m. registered nurse (RN)-B and licensed practical nurse (LPN)-B, both stated if a resident became unresponsive, they would start CPR and the resident's medical record would be obtained to review the signed POLST. In addition, RN-B stated she also reviewed the patient header on the top of the resident's electronic medical record to determine the resident's code status. RN-B stated when the resident came to the facility from the hospital, the admitting nurse reviewed the resident's code status orders and discussed code status on admission with the resident and/or the power of attorney (POA). RN-B stated if the hospital orders were different from the expressed wishes for code status, the chart was to be flagged for the nurse manager and the resident's medical provider for follow up. During the interview, RN-B and LPN-B both stated they were unaware whether the facility had a policy regarding code status. RN-B and LPN-B further stated the ultimate responsibility is with the admitting nurse and the resident's provider. Further RN-B and LPN-B stated there are chart checks done on the night shift to review for any discrepancies to makes sure code status is entered into the EMR correctly, and to ensure the POLST is on the chart. Additionally RN-B and LPN-B stated, If the nursing staff have questions regarding either the orders in the EMR and the POLST, they were to clarify with the nurse manager. The nurse manager is involved if anything is noted as a discrepancy during the chart checks on the night shift. During interview on [DATE], at 3:35 p.m. registered nurse (RN)-C stated if she was in a resident's room, and a code was identified, a call would be placed to 911, and the medical chart would be obtained to review the POLST for direction of resuscitation status. RN-C stated the facility crash cart would be brought to the room for use. RN-C further stated, she would look at the resident's header in the EMR but stated, You cannot always trust the information in the EMR is accurate. Further, RN-C stated when a resident went to an office visit, the facility sent the resident's face sheet, medication record and the treatment administration record, which would include the resident's code status based on physician orders. (The face sheet and MAR for R10 who was sent to a medical appointment earlier that day indicated R10's code status was DNR. R10's POLST indicated CPR) During interview on [DATE], at 4:50 p.m. RN-D (nurse manager) stated all residents admitted to the facility should have a code status order however, if this was not provided on admission, the resident was considered to be CPR. RN-D stated the code status orders were entered into the resident's EMR and the hard copy POLST was scanned into the EMR. The paper copy POLST was then added to the paper chart as the first page of the chart. RN-D stated if there were discrepancies with the code status orders and the resident and/or POA wishes, follow up was to be completed. However, RN-D was unable to specify who would do the follow up or what the process included. During record review, it was identified the director of nursing (DON) had documented on [DATE], at 6:46 p.m. that she (the DON) had contacted FM-B to review code status for R318 and affirmed it was the wish of both family and R318 for R318 to be CPR status upon admission. The progress note indicated, during visit today between 4 p.m. to 5 p.m. R318 told FM-B he wanted to be DNR. R318's provider was contacted and telephone orders were obtained to reflect this. R318's code status was changed to follow R318's wishes for DNR. A POLST signed by R318 was on R318's hard chart, and DNR was reflected on R318's EMR. During interview on [DATE], at 7:09 a.m. RN-E stated when residents are admitted , the POLST is reviewed with the resident by nursing staff, resident choices are identified, and the document is signed. The preference was then to be compared to the code status from the hospital. If the POLST completed was different from the code status from the hospital, the facility required two nurses to witness the change in code status. Following verification, the provider was updated and a verbal order was obtained from the provider. The documentation was then signed with subsequent visit to the facility. RN-E stated the process for entering the change in code status in the EMR included: the order is entered into the EMR and placed in a work queue in the EMR for a second nurse to verify that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on [DATE], at 9:14 a.m. RN-B stated she received training on [DATE], which was her first day back since the facility had been notified of the IJ deficiency. RN-B stated when a new resident was admitted to the facility, the code status was reviewed from the hospital, and the staff reviewed and completed the POLST document with the resident and/or POA. The resident or POA then signed the POLST, followed by the nurse signature, and a copy was placed in the resident's paper medical record. The order was also then entered into the resident's EMR, and a second check was done by another nurse before the code status order was active in the EMR. RN-B stated both nurses must have verified the POLST and the hospital order matched the resident's wishes, before they sign off on the POLST. If the POLST was different from the hospital orders, the physician would be called and updated. The POLST document was then signed by the physician when in the facility. If, at a later time the resident changed their mind, the process would be reviewed, an update of documents completed, and any orders which would no longer be correct would be discontinued. The updated POLST would then be scanned into the EMR and the hard copy would be placed in the front of the resident's chart. During an interview on [DATE] at 9:30 a.m., the assistant director of nursing (ADON) stated they added an addendum to their code status policy on [DATE], to further clarify the process for facility staff. The ADON further stated training on the addendum policy/process started on [DATE]. The ADON stated every nurse in the facility had been trained, or would be trained prior to working their next shift, and stated she had a tracking system with a list of the nursing staff and a signature line which identified when they received the training. The facility's [DATE] policy F,d+[DATE].24 Cardiopulmonary Resuscitation, was revised to include additional steps: 1. Nurse completes POLST with Patient 2. Nurse checks and verifies completed POLST against hospital orders 3. If Hospital orders and POLST DO NOT match: Nurse obtains Telephone order from the Physician to support resident current POLST Entering Orders in Point Click Care (PCC) 4. Nurse enters the code status into PCC Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 5. Place order in the queue 6. The 2nd nurse verifies the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 7. If the order verification matches (by checking the POLST and Hospital orders) then SAVE what is in the queue 8. The active code status will then be auto-populated under the patient's name in PCC - the upper left screen 9. If the physicians orders from the Hospital and resident POLST DO NOT match: Follow steps ,d+[DATE] Discontinue all Previous Code status from PCC orders and then 10. At any time resident/representative may change their preferences for code status. If this occurs follow steps ,d+[DATE]. The immediate jeopardy which began on [DATE], was removed on [DATE], when the facility had implemented an acceptable removal plan including review of all residents' code status' to ensure accuracy; review and revision of policies with staff education provided. Implementation was verified by nursing staff interview, review of educational documents, and review of the facility's revised policies. In addition, resident records were reviewed to verify consistency with code status documentation had been achieved.

Based on observation, interview and document review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 3 of 15 residents reviewed, Residents (R)-1, (who experienced head entrapment between the mattress and a grab bar), R-2, and R-3 who had large spaces (5 or more inches) between the mattress and grab bars, with the potential for entrapment. Findings include: Medical record review revealed R-1 was admitted to the facility 5/10/2013 with [DIAGNOSES REDACTED]. R-1's Quarterly review for the use of devices dated 8/12/2013 was reviewed and revealed R-1 utilized left and right grab bars on his/her bed. R-1's careplan dated 5/20/2013 was reviewed and revealed that R-1 required the extensive assist of 2 for transfers, and was at risk for falls related to cognitive impairment and agitation. R-1's nursing note dated 10/12/2013 and signed by Licensed Practical Nurse (LPN)-D was reviewed and revealed LPN-D entered R-1's room at 4:20 a.m. and saw R-1 holding the left grab bar with both hands with his/her face below his/her hands. R-1's face was facing down with his/her head wedged between the grab bar and the mattress, with his/her right temple pressed against the grab bar. When the resident was moved s/he was noted to have a reddened and swollen right eye with a superficial open area measuring 0.3 cm by 1 cm on the outer corner of the right eye. R-1's on-call physician was notified and ice was applied to reduce the swelling. The resident was non verbal but appeared to be in pain and was treated with pain medication. LPN-D was interviewed on 10/24/2013 at 8:30 a.m. and stated s/he entered R-1's room at about 4:20 a.m. S/he saw R-1 with his/her hand on the left grab bar face down. There was a gap between the mattress and the grab bar and R-1's head was in the gap. R-1's temple was resting against the grab bar. When staff turned R-1 the resident's right eye was red, swollen and R-1 had a superficial open area to the outer corner of his/her right eye. R-1 had last been seen about 1 hour before and at that time was resting comfortably in bed. LPN-D stated the mattress on the bed was a new mattress, placed on the bed that night for the purpose of skin protection/healing. Registered Nurse (RN)-C, Administrative Nurse, was interviewed on 10/22/2013 at 12:00 p.m. and stated s/he was informed of the incident immediately. RN-C stated that s/he investigated the incident and found an 8 cm gap between the mattress and the grab bar on R-1's bed. RN-C stated the new mattress, called an APM-2 mattress was narrower that the original mattress. RN-C stated that the original mattress was wide and utilized extenders on the beds to accommodate the width. When the extenders were removed from R-1's bed on 10/12/2013 after the incident, the APM-2 mattress fit snugly between the grab bars. Medical record review revealed R-2 was admitted to the facility in 1993 with [DIAGNOSES REDACTED]. R-2's device assessment dated [DATE] was reviewed and revealed R-2 used left and right grab bars on his/her bed. R-2's careplan dated 6/27/2013 was reviewed and revealed R-2 was at risk for falls related to seizures and required the maintenance of a safe environment. Medical record review revealed R-3 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. R-3's device assessment dated [DATE] was reviewed and revealed R-3 utilized left and right grab bars on his/her bed. R-3's careplan dated 6/28/2013 was reviewed and revealed R-1 required the extensive assistance of 1 staff member for transfers and ambulation. A facility tour was conducted on 10/22/2013 at 12:50 p.m. A gap was observed on R-2's bed between the mattress and the inside surface of the grab bar. The gap was measured at 5 inches. Extenders were observed to be on R-2's bed. A gap was observed on R-3's bed between the mattress and the inside surface of the grab bar. The gap was measured to be 5 1/2 inches. Extenders were observed to be on R-3's bed. Facility staff immediately removed the extenders on the beds of R-2 and R-3. R-2 and R-3's beds were observed again on 10/22/2013 at 1:22 p.m. and the mattresses were observed to have no gap between the mattress and the inside surface of the grab bar. The policy titled Physical Device Data Collection and Evaluation dated revised January 2010 was reviewed and revealed the following under Procedure: 2. Our devices will follow the FDA guidelines and will be assessed prior to use and at a minimum quarterly for appropriate dimensions. The document titled Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued March 10, 2006 was reviewed and revealed the "FDA is recommending a dimensional limit of less than 120 mm (4 3/4 inches) for the area between the inside surface of the rail and the compressed mattress."

Based on interview and record review the facility failed to ensure that 1 of 8 residents reviewed (resident #1) was free from a significant medication error when the resident did not receive 17 doses of the medication [MEDICATION NAME] (anticoagulant medication), resulting in three surgeries for a blood clot in the left leg. Findings include:Resident #1's medical record revealed that resident #1 has [DIAGNOSES REDACTED]. The facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The orders directed staff to hold the dose of [MEDICATION NAME] on 3/14/2013, give 2.5 mg of [MEDICATION NAME] daily until 3/16/2013, and recheck the INR (International Normalized Ratio--a blood draw to monitor the effectiveness of the medication [MEDICATION NAME]) on 3/17/2013. Employee (B) was interviewed on 4/29/2013 at 11:31 a.m. and stated that resident #1 was admitted to the facility on [DATE] with orders for [MEDICATION NAME], and a recheck of the INR on 3/17/2013. She stated that resident #1 did receive the [MEDICATION NAME], as ordered on [DATE] and 3/16/2013, but did not receive additional dosages of the [MEDICATION NAME] until 4/1/2013. Employee (B) stated that on 4/1/2013, a family member inquired why resident #1 was not receiving [MEDICATION NAME]. The physician was notified and the [MEDICATION NAME] was reordered at the previous dose, with a recheck of the INR to be drawn on 4/3/2013. She verified that resident #1 did not receive 17 doses of [MEDICATION NAME]. Resident #1 was hosptalized on [DATE] for confusion and a blood clot in her left leg. She stated that upon investigation, the lab slip that was to be completed for the lab draw on 3/17/2013 was not found. In addition, a system was not in place for staff to verify that a lab was drawn, the results were confirmed by the nurse, and the physician was updated for additional dosages of the medication. Individual (G) was interviewed on 5/28/2013 at 10:20 a.m. and stated that while at the facility resident #1 began to develop confusion and [MEDICAL CONDITION] (approximately 11 days prior to hospitalization ), and on 4/1/2013, she asked facility staff for resident #1's medication record. She inquired why resident #1 had not been given [MEDICATION NAME] at the facility for 17 days. She stated that the facility admitted it was due to a medication error, and resident #1 was restarted on [MEDICATION NAME] at her previous dose that day. On 4/5/2013, resident #1's left leg was noted to be discolored and cool to the touch. She was taken by family to the hospital, and was hospitalized for [REDACTED]. Resident #1 has had three surgeries on the left leg as a result of the clot. Hospital records, dated 4/5/2013, revealed that resident #1 presented to the emergency room with confusion, left lower extremity discoloration and absent pulses in the left leg. An ultrasound of the left lower extremity showed an acute occlusion as a result of a clot, and an emergent angiogram and thrombectomy was performed to increase blood flow to the left leg. Resident #1 required additional surgeries on 4/6/2013 and 4/8/2013 to increase the circulation to the left leg. Interview with facility staff, record review, and review of the facility's corrective action regarding the incident revealed that the facility had implemented and completed corrective action by 4/25/2013, which was prior to the onsite visit of 4/29/2013. The facility implemented a system to ensure that lab draws are completed and documented in the electronic medical record (emar), and verified by staff. The procedure includes: 1) the nurse will initial in the emar that an INR lab was drawn. 2) The nurse that receives the INR fax results from the lab will initial in the emar that the results were received from the lab, document the results in the emar, and document when the physician was updated. The nurses will also document any additional orders that were received. 3) Beginning 4/2/2013, the PM shift supervisor initiated daily monitoring and audits of all INR lab draws, to ensure that they were complete and the physician was updated. The daily audits are then reviewed by the DON. 4) Beginning 4/2/2013, the PM supervisors began daily monitoring of the 24 hour reports to ensure the list included all of the residents on [MEDICATION NAME] therapy. 5) On 4/2/2013, a lab book was placed on each unit, so for staff to verify the labs are drawn for the day and ensure the results of the labs are received. A review of the mandatory re-education was completed and verified that all nurses were re-educated on the new system by 4/25/2013. The implementation of the system was verified on 4/29/13. The records of eight residents on [MEDICATION NAME] therapy were reviewed, and verified the procedure was implemented to ensure the labs were drawn, and verified as completed, and that the results were obtained and called to the physician for additional orders. Several staff interviews, during the course of the investigation, verified knowledge of the new system, and verified the procedure to ensure the labs are drawn, documented in the emar, and the physician is updated.

Based on observation, interview, record review and policy review, the facility failed to ensure that a resident admitted without limited range of motion received appropriate treatment and services to prevent an avoidable loss of range of motion resulting in actual harm for 1 of 2 residents (R99) reviewed in the sample. Findings included: Resident 99 (R99), who was admitted status [REDACTED]. R99 did not receive appropriate services for prevention and effective treatment through restorative nursing to address potentially avoidable progressive contracture formation that developed following admission to the facility and experienced actual harm as a result. R99 was admitted [DATE] with [DIAGNOSES REDACTED]. Following admission, R99 developed transient complications of a finger infection (6/25/10), [MEDICAL CONDITION] (7/7/10), an episode of pneumonia (7/20/10) and [MEDICAL CONDITIONS] (8/7/10). These complications all eventually resolved without residual deficits. The most recent annual minimum data set ((MDS) dated [DATE] identified R99 with cognitive independence (Brief Interview Mental Status BIMS=15), extensive assistance of two staff required for bed mobility and transfers, non-ambulatory, functional limitations in range of motion in both lower extremities and did not receive a restorative nursing program or physical therapy during the seven days of the assessment period. The care area assessment (CAA) dated 4/26/11 noted weakness and limited range of motion, unable to ambulate or meet goals in physical therapy (PT) and "exercise program for leg strengthening." Restorative nursing involvement and a method to ensure clinical effectiveness of self-directed attempts at range of motion or strengthening exercises was not identified in the CAA. A previous quarterly MDS dated [DATE] identified R99 with severely impaired cognitive skills (BIMS=7), with no functional limitations of range of motion of either lower extremity and did not receive a restorative nursing program or physical therapy during the seven days of the assessment period. Lower extremity range of motion was identified with no functional limitations on the quarterly MDS dated [DATE], and on MDS's from previous admissions dated 11/12/09 and 12/17/09. The admission MDS dated [DATE] following the impacted, not surgically repaired right [MEDICAL CONDITION], identified functional limitation of the right hip only. There were actual medical contraindications in effect for only certain hip motions at that time per physician order. R99's impacted [MEDICAL CONDITION] was not displaced and therefore not treated by internal fixation. Initial precautions were for non-weight bearing and prevention of untoward motions of the hip. There were no precautions related to knee motions. PT for transfer training and exercise was started during hospitalization with on-going rehabilitation recommended at the nursing home. Lower extremity weakness was noted during initial hospital PT; however, screening for range of motion on 4/15/10 was "within functional limits- mild hamstring tightness both legs." R99's current care plan dated 5/24/10 with numerous (undated) manual update entries identified the focus areas of mobility, transferring and risk for falls; however, the care plan did not identify any risk for contractures or muscle weakness, nor were there any updates added for restorative/rehabilitative nursing programs and/or exercises performed independently or supervised by nursing staff as recommended by PT from admission up to the present date. A facility PT evaluation dated 4/20/10 noted range of motion was within normal limits (WNL) for R99 ' s left lower extremity, the right lower extremity was not tested . PT treatment proceeded from 4/20/10 to 5/20/10 when therapy was discontinued awaiting medical approval to increase weight bearing at the next orthopedic appointment which was scheduled for three weeks later. A PT note dated 5/19/10 indicated, "communicated with staff for transfers bed/commode with partial weight assist of two; 25 pound toe touch weight bearing." PT recommended exercises be performed by R99 twice daily, 20 repetitions each and an instruction sheet was located in the inactive PT records. However, these instructions were not carried-over to R99's medical chart or the restorative nursing book. No record existed to indicate whether R99 actually performed the recommended exercises or whether restorative nursing oversight was provided. Weight bearing as tolerated on the right hip was recommended by the orthopedist on 6/10/10 and PT resumed. The orthopedic referral noted, "X-ray-healing impacted fracture, good ROM/limited by arthritis, not pain. Progress to weight bearing as tolerated, walker and strengthening, follow-up four weeks." A PT progress note summary dated 6/23/10 noted, "Ambulates 3-15 feet contact guard assistance...Poor posture unable to extend knees, bow legged, low endurance." A soft tissue contracture of -20 degrees of right knee flexion was noted on a subsequent PT evaluation dated 6/30/10. PT continued until 7/20/10; the discharge note dated 7/20/10 identified, "Unable to meet goals, medically compromised...EZ (mechanical stander) stand program with staff for weight bearing as tolerated...EZ stand or slide board transfers...plans are LTC (Long Term Care)." An interdisciplinary note dated 1/19/11 read, "Resident is Hoyer for transfers, not ambulatory at this time and has expressed desire to walk and go home. Staff also state they believe he is capable of walking as well. Writer spoke to therapies and has requested PT/OT (Occupational Therapy) evaluate for strength training, transfers and ambulation. Using electric wheelchair." By 3/23/11, PT records noted soft tissue flexion contractures of -35 degrees on the right knee and -20 degrees on the left knee. R99 was provided Theraband exercise straps to perform independent, unsupervised exercises for upper extremities. The Resident Care Card for nursing assistants did not identify any exercises performed by R99, nor did it note any supervision, restorative nursing activity or oversight to the exercises. The care plan did not identify any exercise, range of motion or restorative nursing program was performed or completed. R99 was observed on 5/16/11 at 3:54 p.m. in a wheelchair in his room while he attempted to push the flexed right leg out into extension against the Theraband with only partial success. A printed exercise sheet and other Therabands were on the bed. R99 reported, "I broke my hip 13 months ago and haven't walked since. They said I couldn't stand then and couldn't do nothing for you, go home and die. Therapy gave me this for exercise; I can't afford $30/hour for therapy. I am supposed to go to therapy tomorrow to see if I can stand up without the lift and I should have three sessions left. Nursing doesn't walk me, or help me any with exercises, I use the lift, I haven't stood for 13 months." R99 was not performing his exercises correctly. There was no restorative rehab nursing program such as a bilateral knee stretching program to increase R99 strength or any supervision of the exercises the resident was attempting to do to help him regain some strength and maintain his range of motion in order to prevent any contractures from occurring. On 5/17/11 at 9:15 a.m. R99 was observed in the wheelchair in the hallway outside PT. Physical therapy assistant (PTA)-G reported she was not aware of any standing trial to be done that day. PTA-G stated R99 was doing independent exercises. PTA-G added, "We tell nursing if they see any improvement to let us know...he was in the parallel bars some time back but did not do well and was non-weight bearing a long time ago." PTA-G suggested this surveyor talk to the PT when she arrived that afternoon. Physical Therapist(PT)-C reported during interview on 5/18/11 at 1:05 p.m., that the therapist who treated R99 from April to September 2010 was no longer employed by the facility. PT-C reviewed the PT records and reported R99 had received several courses of therapy following admission. PT-C verified R99 did do standing activity and pivot transfers during May 2010 and a functional maintenance plan for exercises was recommended, "and should have been supervised by nursing" on 5/20/10 to continue until weight bearing was again permitted. PT was resumed June 10, 2010 and PT-C stated their records noted increased knee tightness during the sessions that week; however, some ambulation with the rolling walker and assistance was achieved but was difficult due to the right knees "soft tissue contracture" that was measured at -20 degrees on 6/29/10. PT-C reported R99 had been hospitalized and was weak; instructions for restorative nursing in July 2010 (7/20/10) were to continue a prolonged standing program with the EZ stand. PT-C reported R99 stated he was doing better and wanted to work on standing and ambulation and was seen twice for sliding board transfers on 12/22/10 and at time of discharge from PT, nursing was again to use the EZ stander. PT was requested to work with R99 on sliding board/car transfers from 1/24/11 to 2/5/11 and R99 was again discharged from PT. PT-C reported R99 again requested to work on standing and walking and was treated from 3/23/11 to 3/31/11 for four visits. PT-C said R99 was not able to ambulate and the "soft tissue knee contractures" were measured at -35 degrees on the right and -20 degrees on the left. PT gave R-99 Theraband exercises to do on his own and instructed, "If you feel you are making progress I will watch you push up in the chair." PT-C reported nursing was directed to supervise the exercise program. Clinical Manager (CM)-A reported during interview on 5/18/11 at 10:10 a.m. that he was not aware R99 had actual knee contractures and also stated R99's decline was "expected," according to therapy; "The decline was because he couldn't have surgery and couldn't bear weight." CM-A also stated, "The standing program had to be discontinued and therapy was not going to do aggressive treatment due to the [MEDICAL CONDITION]" that had developed in August and R99 now went to therapy, "from time to time for validation of the limitations." CM-A verified R99 had not been and was not currently on a restorative nursing program and nursing did not provide supervision or oversight for R99's independent exercise programs. CM-A also verified there was no assigned restorative nursing staff and supervision of any restorative program recommendations was up to each clinical manager. CM-A verified no exercises, range of motion or restorative nursing updates had been added to R99's care plan, but R99, "did get some range of motion during daily cares (ADLs)." Nursing assistant(NA)-A reported on 5/18/11 at 2:45 p.m. that R99 was able to use a walker and take some steps initially, "then (R99) got tight in the knees." NA-A verified nursing never did any range of motion exercises or prolonged standing in the EZ stand since R99 moved to long term care from transitional care. NA-A also verified that there were no specific staff assigned to complete any restorative nursing activities and R99's independent exercise activity had not been supervised or assisted by the nursing assistants. NA-H, also verified on 5/18/11 at 3:00 p.m. that R99 did his own exercises with the Theraband and did not receive any restorative nursing activity but could bear weight with the EZ stander without any pain. On 5/19/11 at 9:00 a.m. PT-C reported R99 had soft tissue contractures because, "some things were not done that should have been and restorative nursing is a weakness in this building...I talked to my boss and did mention it but it's always been this way in the building....splinting could have been done or other treatments at the time when the contracture was less than 20 degrees but now it's almost too late for walking...it was my understanding they (nursing) were doing the standing program." The acting director of nursing, Clinical Manager(CM)-C requested P T-C perform a current range of motion measurement of the knees on 5/19/11. During interview at 2:15 p.m., CM-C verified the measurements taken recorded -30 degree flexion contracture on the right knee, and a -20 degree flexion contracture on the left knee. CM-C also reported R99 was a resident in the facility during a previous admission before the fall and fracture in April 2010 and was "walking with his knees bent" at the time of discharge; however, could not locate records to verify if it was from muscle weakness or actual knee tightness present at that time. PT records for 2009 were later faxed to the district office on 5/23/11; however, there was no documentation of a lower extremity contracture or range of motion measurements noted during that admission. There was notation of, "flexed posture, short steps, sliding of feet and knees buckling during stance," recorded during therapy sessions. Additionally, there was significant hip and knee muscle weakness noted. R99 was able to improve and ambulate over 100 feet with his walker and supervision to stand-by assistance was noted prior to discharge in January 2010. During this same interview, CM-C could not locate any restorative nursing records that indicated any involvement in R99's exercise programs as recommended by therapy since May 2010 but restated the unit nursing supervisor was responsible for any restorative nursing performed on that unit and therapy had advised against "aggressive" treatment. No physician orders were located that contraindicated or precluded restorative nursing or maintenance range of motion activity to the knees. CM-C additionally reported the IDT note of 1/19/11 that read, "staff believe (R99) is capable of walking," was written in error. The current facility policy was requested and provided at 3:30 p.m., "Guidelines and Procedures for Specific Restorative Programs," (not dated or signed) identified: "All residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. A program will be developed and involving formalized therapy and/or restorative nursing. This program will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. When a resident has been identified as at risk for contracture and there is no indication to involve formalized therapy, the resident's name and ROM interventions will be added to the nursing tracking tool, goals and approaches determined and care planned and a restorative nursing flow sheet implemented. Nursing's primary responsibility is to preserve the resident's present range of motion (ROM). The Physical Therapist's role concerns building muscle strength and restoring function as much as possible." After the survey, a Fax was sent to the Department of Health which indicated that R99 was evaluated by Phyical Therapy on 5/25/11 and was placed on Bilateral Knee stretching Program.