Every finding on record at Appleton Area Health

Based on observation, interview, and document review, the facility failed to ensure professional standards of practice were followed during administration of eye drops for 1 of 1 resident (R29) observed for medication administration.Findings include: According to the American Academy of Allergy, Asthma, and Immunology, Tips For Administering Eye Drops dated 8/2010, if more than one drop has been ordered, wait three to four minutes before putting another drop into the same eye. When administering multiple eye medications, wait five to fifteen minutes before delivering send medication to the same eye in order to prevent dilution. R29's Annual Minimum Data Set (MDS) dated [DATE], identified R29 as cognitively intact and required assistance with activities of daily living (ADLs). R29 had a diagnosis of diabetes and hypertension (high blood pressure). R29's admission record printed 4/15/26, identified R29 had a diagnosis of dry eye syndrome, and degeneration (eye disease that affects vision). R29's care plan revised 1/27/25, indicated staff were to administer medications as ordered. Observe for side effects and effectiveness. R29's physician's order signed 2/20/26, identified cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice a day for dry eyes, and Refresh Tears ophthalmic solution one drop in both eyes four times a day for dry eyes. R29's administration summary for the week of April 8 2026 to April 15 2026, revealed cyclosporine ophthalmic emulsion 0.05%, and refresh tears ophthalmic solution were both order for 5:00 p.m. admission order summary revealed both medications were signed off as being given at the same time on 4/14/26 at 4:46 p.m., 4/13/26 at 4:56 p.m., 4/12/26 at 7:59 p.m., 4/11/26 at 5:57 p.m., 4/10/26 at 4:53 p.m.,7:59 p.m., 4/9/26 at 4:27 p.m., and 4/8/26 at 4:55 p.m. During an observation/interview on 4/13/26 at 4:53 p.m., trained medication aid (TMA) brought oral medications, cyclosporine ophthalmic emulsion 0.05%, and Refresh Tears ophthalmic solution into R29's room. TMA gave R29's oral medications and then applied gloves. TMA asked R29 to relax her eyes and administered one drop of cyclosporine ophthalmic emulsion 0.05% to both eyes. TMA then took the Refresh Tears ophthalmic solution and gave one drop in each eye. TMA removed gloves and washed hands. TMA verified the cyclosporine ophthalmic emulsion 0.05% were given, and then the refresh eye drops. TMA went to the computer and signed off on the medications were given. During an interview on 4/15/26 at 11:01 a.m., director of nursing (DON) indicated it was best practice to wait between eye drops to allow the first eye drop to disperse. DON verified her expectation would be to follow the medical provider order. During an interview on 4/15/26 at 12:58 p.m., pharmacy consult indicated it was best practice to wait five minutes between eye drops and was unsure if there would be a clinical impact of cyclosporine ophthalmic emulsion 0.05% and Refresh Tears ophthalmic solution given without waiting five minutes between eye drops. During an interview on 4/15/26 at 2:49 p.m., medical provider recommended staff to wait fifteen minutes between cyclosporine ophthalmic emulsion 0.05%, one drop in both eyes twice a day for dry eyes, and Refresh Tears ophthalmic solution. Policy requested, no policy was received regarding ophthalmic medications.

Based on interview and record review the facility failed to ensure care plan interventions were revised and implemented as needed for 1 of 3 residents (R1) who was at risk of elopement and was demonstrating consistent behavior for elopement.Findings include:R1's admission Record indicated R1 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, unspecified dementia with other behavioral disturbances.R1's annual Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and a wander/elopement alarm was used daily.R1's care plan dated 11/13/25 indicated R1 had impaired thought processes related to vascular dementia and history of cerebral infarction, potential wandering and exit seeking to go home. Interventions included cue, reorient and supervise as needed, keep R1's routine consistent and try to provide consistent care givers as much as possible, wander guard on wheelchair related to comments about leaving and wanting to go home. The care plan section related to elopement and safety, lacked evidence of the interventions directed here.R1's care plan dated 1/11/26 indicated R1 was an elopement risk related to history of attempts to leave facility unattended, impaired safety awareness, disease process (dementia), memory impairment. Interventions included distracting R1 with pleasant diversions, structured activities, food, conversation, television, and books. Despite significant history of wandering behavior, not additional interventions were added to R1's care plan, even when she had packed a suitcase with the intention to go home. Revisions were started on 1/22/26 but not completed to keep R1 safe from elopement. R1's Wandering Risk Scale dated 10/23/25, indicated R1 had recent history of packing items in a suitcase intending to go home, difficult to redirect. R1 had history of wanting to go to granddaughters. Wander guard in place on wheelchair.R1's facility Progress notes indicated on 1/11/26, R1 was agitated and reported to staff wanting to go home and packed her belongings. R1 managed to open the door and stepped outside onto the snow. Staff were able to redirect R1 back inside the facility. Wander guard was changed the day before, functioning normally with alarms going off when near a door. (wander guard did not activate)R1's medical record lacked evidence care planned interventions were implemented to redirect, reorient, or increase supervision prior to the elopement event despite clear signs of elopement behavior. During interview on 1/22/26 at 2:07 p.m., MDS Registered Nurse (RN)-A stated her role was complete MDS, care plans and nursing assessments. RN-A stated after R1's elopement the inter-disciplinary team (IDT) team met and another wander assessment was completed and it had changed a little bit, and R1 was now a high risk wanderer; the care plan was reviewed and no changes were needed however during interview RN-A reviewed R1's care plan and identified the care plan was not complete and specific interventions should have been added.During interview on 1/23/26 at 11:49 a.m., social worker (SW) stated the IDT team met after R1 had eloped; R1's care plan was reviewed and was not found to need revisions. SW stated staff are to distract R1 when agitated with food, activities and provided one to one by staff when available. SW stated R1 was an avid reader, however only had a couple of books in her room, R1 also was a hoarder and the facility wanted to keep her room as minimal to avoid safety concerns. SW stated she had not worked with the family recently to develop a more personalized care plan and agree this could be beneficial for R1 and her agitation.Facility policy titled Care Plans- Comprehensive Person-Centered Policy revision date 12/29/23 indicated the IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview and record review the facility failed to supervise 1 of 3 residents (R1) at risk for elopement when R1 was able to leave the facility without staff knowledge despite while wearing a wander guard pendent, which was not placed according to Manufacturers Guidelines and did not alert staff. Findings include:R1's admission Record indicated R1 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, unspecified dementia with other behavioral disturbances.R1's annual Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and a wander/elopement alarm was used daily.R1's care plan dated 1/11/26 indicated R1 was an elopement risk related to history of attempts to leave facility unattended, impaired safety awareness, disease process (dementia), memory impairment. Interventions included distracting R1 with pleasant diversions, structured activities, food, conversation, television, and books. Document wandering behaviors and attempted diversional interventions in behavior log.R1's care plan dated 11/13/25 indicated R1 had impaired thought processes related to vascular dementia and history of cerebral infarction, potential wandering and exit seeking to go home. Interventions included cue, reorient and supervise as needed, keep R1's routine consistent and try to provide consistent care givers as much as possible, wander guard on wheelchair related to comments about leaving and wanting to go home.R1's Wandering Risk Scale dated 10/23/25, indicated R1 had recent history of packing items in a suitcase intending to go home, difficult to redirect. R1 had history of wanting to go to granddaughters. Wander guard in place on wheelchair.R1's facility progress notes indicated on 1/11/26, R1 was agitated and reported to staff wanting to go home and packed her belongings. R1 managed to open the door and step outside to the snow. Staff were able to redirect and bring the resident back inside. Wander guard was changed the day before, functioning normally with alarms going off when near a door.Observation on 1/22/26 at 10:32 a.m., R1's wander guard was under the seat of the wheelchair hanging from a metal piece and secured by the wrist band closure.Camera footage reviewed on 1/22/26 indicated on 1/11/26 at 9:17 a.m., R1 was in her wheelchair self-propelling toward dining room door which led outside. Two other residents were present in dining room, and one staff came into the dining room and escorted another resident out of the dining room. R1 pushed the door open with her hands and continued to go outside but remained on campus at 9:17 a.m. Staff was observed outside at 9:19 a.m. with R1 and she returned to the facility with staff at 9:29 a.m.Facility Incident Report dated 1/11/26, indicated R1 had gone to the dining room and staff reported R1 had made it out of the building through the south exit door by the dining room. Wander guard alarm did not go off and R1 was found to be about 15 feet out the door. R1 had two sweaters on, shoes and bag. Staff spent time attempting to calm and redirect R1 when outside. R1 later agreed to come back into the facility on the condition she will be allowed to talk to the doctor. R1 was assisted back to the facility safely, R1 refused vitals and nursing assessment. R1 talked with a doctor and was upset with the doctor as they would not give discharge orders. Doctor did give an order for haloperidol 5 milligrams for behavior management, and it was effective. No further behaviors noted. Maintenance was notified of south door exit alarm and was fixed by replacing the battery to the transmitter. R1 wander guard was checked and was functioning as expected. Call placed to wander guard manufacturer, Securitas, and requested to have a technician assess at the facility. On 1/12/26 director of nursing (DON) confirmed all wander guards in working conditions. On 1/15/26 DON updated Unsafe Resident Policy and Elopement Policies and updated to have the day nurse check all wander guard doors and use a pendent to ensure alarm doors sound and are operational. Daily check log sheets updated and placed in binder at nurses' station with manual for the wander guard.Securitas assessment, wander guard manufacturer, was completed on 1/20/26 and assessment indicated the wander guard system was operational.[NAME] Healthcare wander guard blue manual published 7/16/17 indicated the strap of the wander guard was to be worn on the individual's wrist or ankle. During interview on 1/22/26 at 10:55 a.m. R1 stated she tried to leave the facility, but they would not let her go and left the facility through the dining room. R1 stated she was not aware of an alarm sounding when leaving the facility. R1 recalled she had a wander guard on her wheelchair.During phone call interview on 1/22/26 at 1:30 p.m., [NAME] Healthcare Wander Guard representative stated the pendent was to be worn on the wrist or ankle and if pendent was placed on metal it would not be as effective and could malfunction.During interview on 1/22/26 at 2:07 p.m., RN-A stated she completed all the MDS, care and nursing assessments. RN-A nurse stated after R1's elopement the care plan was reviewed, and no changes were needed however there was no mention of the pendent location on R1's wheelchair and if that was a factor in the pendant not alarming. R1 did not wear the pendant on her wrist or ankle. RN-A stated she had not reviewed the wander guard manual or called the company to verify placement of the pendant would continue to operate safely if placed in other locations.During interview on 1/22/26 at 3:15 p.m., maintenance staff (MS) stated when R1 eloped he came to the facility and assessed the system, transmitter battery was changed, and system was working again. MS stated the wander guard company came a few days later and found no issues with the system.During phone call interview on 1/22/26 at 3:41 p.m., director of nursing (DON) stated she was notified of R1's elopement via phone call from staff and we put a plan together to protect the residents especially with those that had wander guards which included maintenance to assess function of the system, which found a new battery was needed. DON stated the Wandering policy and wander guard manual was reviewed and found wander guards were to be tested daily and that was changed in our practice and policy. DON stated she had called the wander guard company to inform them of the elopement and asked for an updated manual. DON stated the root cause finding was the transmitter battery was dead or low. DON stated she was not aware why R1's wander guard pendant was under the wheelchair seat and was not aware the pendant was to be on an individual's wrist or ankle as she had to not reviewed that section of the manufacturers guide. Facility policy titled Wandering-Unsafe Resident, revised date 1/15/26, indicated if it is determined by IDT that a resident is in need of a wandering signaling device, and an order is obtained from practitioner, a wander guard bracelet will be placed on either the resident's wrist or ankle. If resident is confined to a wheelchair, wander guard pendant may be placed on resident's wheelchair. Facility will follow manufacturer's guidelines for wander guard activation and use.

Based on observation, interview and record review facility failed to develop mental health strategies for 1of 3 resident (R1) who experience agitation related to a desire to go home. Findings include:R1's admission Record indicated R1 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, unspecified dementia with other behavioral disturbances.R1's annual Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and a wander/elopement alarm was used daily.R1's care plan dated 1/11/26 indicated R1 was an elopement risk related to history of attempts to leave facility unattended, impaired safety awareness, disease process (dementia), memory impairment. Interventions included distracting R1 with pleasant diversions, structured activities, food, conversation, television, and books. Document wandering behaviors and attempted diversional interventions in behavior log.R1's care plan dated 11/13/25 indicated R1 had impaired thought processes related to vascular dementia and history of cerebral infarction, potential wandering and exit seeking to go home. Interventions included cue, reorient and supervise as needed, keep R1's routine consistent and try to provide consistent care givers as much as possible, wander guard on wheelchair related to comments about leaving and wanting to go home. R1's care plan dated 1/27/25, indicated R1 had a behavior problem of hoarding items and food, yell/scream, verbally abusive, twisting staff wording and situations, fabricating stories, and rejection of care. Interventions included administer medications as ordered, anticipate and meet R1's needs, assist R1 to develop more appropriate methods of coping and interacting. Encourage R1 to express feelings appropriately. R1 gets defensive when discussing abundance of items and clutter in room; family reports a historic issue her whole life. If reasonable, discuss her behavior, Explain/reinforce why behavior is inappropriate for R1's health and safety. Care plan lacked evidence on how the staff were to engage R1 when she was anxious, what methods of coping were successful for R1, activities to engage R1 with and what level of supervision would be necessary to keep her safe.Observations of R1's private room on 1/22/26, spacious with bed, closet, television, private bathroom, and dresser. R1 had limited personal belongings in room such as books, pictures, or other forms of activities.During interview on 1/22/26 at 10:55 a.m., R1 stated she wanted to return home and be with her belongings and did not need the care from the facility. R1 stated she had love to read and enjoyed doing activities, however her room had nothing to do in it.During interview on 1/22/26 at 2:07 p.m., MDS registered nurse (RN-A) stated R1's care plan revisions had not been completed since the elopement incident, and she was not aware of staff using different interventions when R1 was agitated then what was in the care plan. RN-A stated R1 does attend activities which can be helpful when she is agitated, and staff try their best to keep R1 safe.During interview on 1/23/26 at 10:38 a.m., licensed practical nurse (LPN)-A stated when R1 was agitated she would show pictures of babies and ask her about when she was a mom, this distraction was not always effective and R1 was very unpredictable. RN-A stated this specific intervention was not on R1's care plan and recalled R1 did not have a lot of personal items in her room which could help her feel more at home.During interview on 1/23/26 at 11:49 a.m., social worker (SW) stated she developed the behavioral part of the care plan and did not find it needed to be revised. SW stated staff are to distract R1 when agitated with food, activities and one to one by staff, there was nothing more we could personalize her care plan with. SW stated R1 was an avid reader, however there were only had a couple of books in her room, she was also a hoarder and the facility wanted to keep her room as minimal as possible to avoid safety concerns. SW stated she had not worked with the family to develop updated personalized care plan to explore providing R1 with more items from her home and things R1 enjoyed doing. SW agreed these additional things could help with R1 agitation to have things around her she knows, enjoys and care about.Facility policy titled Care Plan Comprehensive Person Centered Policy revised date 12/29/23, indicated care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making: when possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.

Based on interview and document review the facility failed to have a current, ongoing system of surveillance to identify potential outbreaks of infectious disease, ensure transmission-based precautions (TBP) were implemented timely, perform root cause analysis with contact tracking to identify patterns of illness in staff or residents, and prohibit staff from returning to work prematurely following identified symptoms. This had the potential to affect all 33 residents in the facility. In addition, the facility failed to ensure 1 of 1 whirlpool tub was appropriately disinfected between resident use according to the manufacturer's directions. This had the potential to affect 10 of 32 residents who used the whirlpool tub. Findings include: SURVEILLANCE RESIDENTS Review of the December 2024, resident infection control log identified the facility experienced a COVID-19 outbreak between (December 15, 2024, through January 20, 2025). 17 of 32 residents were identified as testing positive for COVID-19 between December 15, through 31, 2024, (R1, R2, R7, R10, R13, R14, R15, R18, R19, R23, R24, R25, R32, R33, R86, R87, and R88). Review of the January 2025, infection control surveillance log identified one resident tested positive (R27). The resident surveillance logs above identified the resident name, room number, date tested positive, and off isolation date. The log failed to identify the date and type of TBP and when the precautions were implemented. STAFF Review of the staff infection control log for November 2024 identified call-ins for illness as follows: 1)Registered nurse (RN)-A reported vomiting on 11/11/24 with no additional follow up or notation of when she returned to work. She then also reported headache, fever, cough, sore throat and body aches on 11/24/24 and tested positive for COVID. 2) Nursing assistant (NA)-A reported vomiting, nausea, cough on 11/11/24. 3) Unidentified staff person-reported illness on 11/12/24 with no S/S identified. 4) Licensed practical nurse (LPN)-C -reported a sore throat on 11/18/24 with no additional S/S identified. 5) NA-B- reported illness with vomiting on 11/20/24. 6) NA-C- reported illness with vomiting, diarrhea, nausea, and cough on 11/21/24. 7) NA-D reported illness with vomiting on 11/21/24. 8) LPN-D- reported illness with vomiting and diarrhea on 11/25/24. 9) NA-E-reported illness with diarrhea on 11/25/24. 11) NA-F-reported illness with diarrhea on 11/26/24 There was no mention of any additional follow up, potential testing or identification of when staff were cleared to be able to return to work. Review of the staff infection control log for December 2024 identified 1 staff illness. NA-F-reported ill with no S/S identified and was tested positive for COVID-19. There was no mention of any additional follow up, potential testing or identification of when staff were cleared to be able to return to work. Review of the staff infection control log for January 2025 identified 3 staff illness: 1) An unidentified staff reported illness of vomiting, nausea, and headache on 1/4/25. 2) NA-E reported illness of flu symptoms on 1/9/25. 3) RN-A reported illness of vomiting and fever on 1/13/25. There was no mention of any additional follow up, potential testing or identification of when staff were cleared to be able to return to work. Interview on 1/27/25 at 5:00 p.m., with the director of nursing (DON) identified there was no documentation of the type or when TBP had been initiated on the surveillance logs. She also observed the staff illness tracking and confirmed the documentation was incomplete and should have listed staff S/S, time off work, date of return, and if they had been seen by a medical provider or had any testing for illness completed. When a staff call in was reported either she or the scheduling coordinator were to attempt to contact the employee to discover the reason for call in if it was not documented. Interview on 1/27/25 at 6:27 p.m., with LPN-E identified LPN-E worked as the charge nurse and if a staff person called in for themselves of a child, she would use the provided illness form, document the name of the staff person, S/S if they were provided and if they reported plan to see a medical provider. If they were calling in for a child, she might ask for the S/S, but reported she was not certain if she had done so. She stated the ill slip was then given to the scheduler, but she was not certain what happened after that. Interview on 1/27/25 at 6:34 p.m., with RN-B identified when a staff member called as ill, she recorded the information in the binder located at the nursing station and had spaces to record S/S, time of the call, and if the staff member was seeing a provider. She reported she recorded the information that was given, but the person calling in, did not always give the information. She stated the form was routed to infection control, but she was not aware of any follow up process. Interview on 1/29/25 at 9:08 a.m. with the infection preventionist (IP) identified she agreed employee tracking was incomplete and noted she failed to include determination of S/S, if the employee was seeing a medical provider and when it was appropriate for them to return to duty. She did receive calls from staff at times about a family member's illness, but did not perform tracking or trending or follow up about potential precautions due to contact. Interview on 1/29/25 at 11:13 a.m., with the scheduling coordinator confirmed she was only aware of one call in for a staff member in December who tested positive for COVID and three call ins for January 2025 one with flu symptoms and two with no S/S identified. She confirmed when a staff called in ill, they were supposed to give the reason for their absence, if they were seeking medical attention, and S/S of either their or family member's illness but confirmed this did not consistently occur. Following receipt of the paper slip, her job was to enter the information into the electronic employee illness log but was not aware of who/what/when reviewed further. WHIRLPOOL Interview on 1/28/25 at 10:15 a.m. with the environmental services (EVS) manager identified the whirlpool tub as a jetted [NAME] tub with water jets.The disinfectant used as CenKleen IV-Quaternary Ammonium compound disinfectant mixed at ratio of 1 ounce/gallon and filled by EVS staff for nursing staff to be used for cleaning and disinfecting the tub. Observation and interview on 1/29/25 at 3:30 p.m. with NA-G as she cleaned and disinfected the [NAME] Spa tub identified NA-G returned the bath chair to the tub and secured the door. She retrieved the quart spray bottle of Cev-Kleen IV cleaner, applied gloves placed the plug in the bottom of the tub, and using the spray bottle sprayed all surfaces of tub and chair by with the spray bottle. She then ran water into tub to above the level of the jets. While the tub was filling with water, she used a long-handled brush to bush the surfaces of the tub and chair by dipping the brush into the water and then onto the sprayed surface of the tub and chair. NA-G pushed the button labeled jet rinse and stated she held it for a few seconds. NA-G reported she allowed the solution to sit for 1-3 minutes to allow it to disinfect the surfaces and used the hand sprayer to spray off all surfaces. No clock or timer was observed in the tub room. As she waiting the solution on the sides of the tub and chair were observed to be drying. When asked how long she needed to wait, since there was no clock in the room, NA-G replied she had looked at her watch and timed it for 2 minutes. She then took the hand sprayer and rinsed off the tub sides and chair, and allowed the solution to drain from the tub and rinsed all surfaces again. NA-G released the latch on the back of the tub and reported she left the seal open, so it was able to dry. She was not aware of an instruction sheet being posted in the tub room and identified that was how she had been trained to clean and disinfect the whirlpool tub and was unaware of manufacturer's instructions requiring a specif amunt of disinfectant to be infused into the water in the base of the well and run for 10 min, keeping surfaces wet was required for appropriate disifection. Review of the [NAME] Spa Tub manufacture's guide for cleaning and disinfection of the tub following resident bath listed: 1) The tub was to be rinsed initially rinsing all surfaces with the shower sprayer, 2) Drain any water, and then refill by pressing the disinfect button which allows the properly mixed cleaning solution to run through the system. 3) Release the button after you see solution coming out of the jets and have 1 1/2 gallons of disinfectant solution in the foot well of the tub. 4) Scrub all surfaces of the tub and chair with the solution that remains in the well of the tub 5) Let disinfectant remain on the surface for 10 minutes or as recommended on the disinfectant container. 6) Remove the plug from the drain. 7) Rinse the soapy water away. 9) Press and hold the rinse button until water runs clear. Interview on 1/27/25 at 5:00 p.m., with the director of nursing (DON) identified she was not aware there was no longer a sign with cleansing/disinfecting instructions posted in the tub room. She stated her expectation for the tub to be cleansed and disinfected according to the manufacturer's instructions. Both the ADON and DON reported they would take immediate action to correct the procedure. Later interview on 1/29/25 at 11:20 a.m., with the DON identified she had reviewed the manufacture's guidelines for the whirlpool tub and confirmed staff were not following the manufacture's guidelines. Review of the 3/15/24, infection control plan identified the IP and committee were to develop evidence-based national guidelines in the development of the infection prevention and control program. The employee illness log was identified as available on the facility's shared drive with each department head responsible to log sick time utilized by their employees. The nursing home was identified as responsible for sending their data to the IP monthly with the information to be reviewed at the infection control meetings. The Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) surveillance methodology was to be utilized by the facility. The IP was to coordinate and review infection control issues and summarize and report to the Infection Control committee. Review of the 1/29/25 Bath- Shower/Tub - Level II policy failed to identify the procedure for cleaning and disinfecting the whirlpool tub according to manufacturer's guidelines following resident bathing.

Based on interview and document review, the facility failed to implement a comprehensive antibiotic stewardship program with antibiotic Time Outs (ATO) (formal review of a patient's antibiotic therapy that occurs 48-72 hours after the initial dose), or evaluation of continued need for antibiotic treatment for 3 of 3 residents (R6, R15 and R28). This has the potential to affect any resident receiving antibiotic treatment. Findings include: Interview and document review identified: R6's medical record (MR) identified a 1/18/24, physician (MD) order for Macrobid (an antibiotic used to treat urinary tract infections (UTIs)), 50 milligrams (mg) by mouth (PO) every (Q) evening (PM), for UTI prevention. The medical record failed to identify any urine cultures or sensitivity (UC/US) completed following the MD order, and no ATO for continued need of the medication. The record also failed to identify any non-pharmacological interventions attempted. R15's medical record identified a 1/21/25 MD orders for Macrobid 100 mg PO x 5 days for UTI. The record failed to include any criteria implemented nor was there documentation of an ATO completed. R28's medical record identified a 12/18/24 MD orders for Macrobid 100 mg PO twice daily (BID) x 10 days. The record failed to identify any criteria identified prior to initiation of the antibiotic. R28 developed a rash, and the antibiotic was changed on 12/29/24 to Ertapenem 1 gram (GM) intramuscularly (IM) x 5 days. A UA/UC was completed, and Ertapenem 1 gm IM X 10 days was reordered. A UA/UC was again completed on 1/27/25 with negative results. R28 received antibiotics from 12/29/24 through 1/23/25 with no criteria documented prior to requesting a UA and antibiotics and ATOs were not completed during this time. Interview on 1/27/25 at 5:00 p.m. with the director of nursing (DON), reported the infection preventionist (IP) had emailed her the information to provide, reported there was not consistent documentation of criteria used for updating the provider prior to requesting an antibiotic for a UTI, nor were ATO being completed. The DON identified there had been a meeting on 1/24/25 with the DON, ADON, IP, medical director, in-house pharmacist, and a nurse practioner(NP) to discuss antibiotic stewardship, criteria to be utilized for updating the provider of a resident with a potential UTI, ATOs, and the development of individualized care plans for those residents who demonstrated S/S outside the parameters and the inclusion of that information on the Standing Order Set. There was nothing implemented prior to the survey after it was identified. Interview on 1/27/25 at 5:43 p.m., with the medical director identified he had attended the meeting on 1/24/25 with discussion of guidelines for antibiotic stewardship and what criteria was to be use in the facility. He reported they had discussed current trends, with antibiotic use, and criteria such as Loeb's, or McGeer's to include in determining the use of antibiotics. He identified his agreement for review and documentation of a resident that had orders for a prophylactic antibiotic for a UTI and it should not just be assumed that an ongoing order was sufficient. ATO should be completed. Interview on 1/29/25 at 8:45 a.m., with the IP reported she attended morning meetings which included discussion of infections, wounds, changes in resident status, laboratory tests completed. She reported she would then follow up by checking EPIC (medical record application) for any new infections, labs, then follow up for orders for UTIs and C/S. She was aware two residents were currently receiving prophylactic antibiotics. The IP stated the nursing staff was going to use Loeb's as the criteria for requesting UA/UC, and her understanding was they had the criteria posted at the nursing station. She was not aware it was not being utilized, and ATO were not currently being completed and documented according to facility policy. Review of the September 15, 2022, Antibiotic Stewardship Policy for Long Term Care Identified the need for treatment of infections with the promotion of appropriate use of antibiotics. A monthly tracking report was to include summary of data collected with review by the consulting pharmacist, and IP with reports to the Quality Assurance Committee. Areas to be identified with antibiotic orders included: Resident name, antibiotic name, indication for the medication, route, dose, length of treatment, who prescribed the order, Antibiotic time out-yes/no, the record was to be reviewed, and information recorded in the e Excel database with review by the consulting pharmacist. ATO were to be collected and reported monthly for all antibiotics ordered whether from an outside or inside facility source.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R32) was reassessed for as needed (PRN) anti-anxiety medication (diazepam) every 14 days to ensure the appropriateness of continued use. Findings include: R32's 10/8/24, Significant Change Minimum Data Set (MDS) identified R32 had a diagnoses of Alzheimer's and dementia with agitation. R32 was cognitively impaired and was administered antipsychotic, antianxiety and antidepressant medication daily. R32's diazepam was ordered on 11/8/24 and started the same day, however, there was no indication the physician (MD) had limited the order for 14 days to ensure it was reviewed for continuation. R32's December 2024, Medication Administration Record (MAR) identified diazepam 5 milligram (mg) was to be given by mouth every 8 hours as needed for agitation, physical aggression, and restlessness beginning 11/08/24. The MAR lacked documentation of an end date. R32's Progress note identified on: 1) 11/26/24, the physician ordered PRN diazepam and was to be reviewed in 14 days. 2) 11/26/24, the pharmacist's (RPh) recommendation identified staff were to monitor R32's behaviors. The pharmacist identified the physician (MD) reviewed the diazepam and the order was extended to 14 days. 3) 12/10/24, the nurse practitioner (NP) reviewed R32's diazepam. R32's behaviors had improved with medication management and the NP extended the diazepam 14 days. 4) 12/28/24, the RPh recommendation identified R32's diazepam was reviewed. They had no recommendations. There was no mention the RPh had identified the MD reviewed the diazepam within 14 days by 12/24/24. R32's December 2024, Treatment Administration Record (TAR) identified a reminder for staff to notify the MD to review the diazepam prior to the end of the 14 days to justify the continuation of the need for the medication. Review of the printed December 2024, TAR given to the MD on 1/15/25 identified staff wrote FYI: Nursing orders require notification of use of R32's diazepam in the last 14 days. There was no indication staff had notified the MD prior to 1/15/25 to review the diazepam and justify the continued use and place a new order. R32's current, undated care plan identified R32 had taken diazepam for anxiety. Staff were to administer anti-anxiety medications and monitor for the effectiveness of the medication and report adverse reactions and side effects such as memory loss, slurred speech, confusion, or nausea. Staff were to monitor and record target behaviors and inappropriate responses to verbal communication and violence and/or aggression towards staff or others. There was no mention staff were to notify the MD to review the diazepam at 14 days to continue the medication. During interview and TAR review on 1/29/25 at 10:09 a.m., with licensed nurse (LPN)-A identified R32's TAR provided reminders for the nursing staff to notify the MD to review the diazepam every 14 days. LPN-A agreed there was documentation to support the provider was contacted on 12/24/24. Interview on 1/29/25 at 10:10 a.m., with LPN-B identified she agreed R32's PRN order should have been reviewed by the provider every 14 days. Interview on 1/29/25 at 11:41 a.m., with medical director identified staff should have notified the MD for R32 by day 14 to have the MD review the diazepam and document the rational to continue the order. Interview on 1/29/25 1:29 p.m., with director of nursing (DON) identified her expectation was for to staff notify the MD of the absence of a stop date on limited 14-day psychotropic medications and notify the MD if re-evaluation of the medication needed to occur for continuation. Review of October 2019, Psychotropic Medication Usage policy indicated the facility was to monitor residents receiving psychotropic medications to evaluate their effectiveness. In addition, the facility was to ensure a process for reviewing the continued need for psychotropic medications. There was no mention how the facility ensure duration of psychotropic medication use was enforced.

Based on interview and document review, the facility failed to act on a positive tuberculosis (TB) test result for 1 of 5 staff (housekeeping (HSK)-A) tested for active TB upon hire. Furthermore, the facility failed to ensure any person or persons with a positive history of TB was added to surveillance to mitigate potential risks for spread of possible active TB. This had the potential to affect all 43 residents, other staff, and visitors. Findings include: Review of housekeep (H)-A's employee file identified on 3/15/23, H-A's baseline TB Screening and questionnaire identified H-A had no symptoms of active TB however, it was identified that H-A had lived in Micronesia, and it was unknown if Micronesia had a high TB rate. Review of the National Library of Medicine (NIH) website, located at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000724, identified the Federated States of Micronesia is a US-affiliated jurisdiction that comprises more than 600 islands dotted across 1 million square miles in the western Pacific Ocean. Micronesia is a low-income country where 27% of the people live below the US poverty line. While TB incidence in the United States continues to drop (4.4 reported cases per 100 000 population in 2007), Micronesia has sustained some of the highest rates of TB among the US-affiliated Pacific Islands (169 reported cases per 100 000 in 2008). Further review of H-A's Baseline TB Screening Tool for Healthcare Workers, identified H-A's hire date was 3/27/23. The form identified questions related to symptoms of active TB which were to be circled if present. The answer was listed as none. The screening form noted if TB symptoms were present staff would promptly be referred for a chest X-ray and medical evaluation prior to working. The screening form further had questions about staff's personal history such as if the employee had ever had a positive test result, which was answered no on H-A's form. There was also a question asking if the staff had been a temporary or permanent residence in a country with a high TB rate for a month or longer (any country other than the United States, Canada, Australia, New Zealand, and those in Northern Europe or Western Europe). The answer was yes, with a note next to the answer if Micronesia counts. All other questions on the screening form to determine if active TB or symptoms of TB were present were answered as no. Review of H-A's QuantiFERON-TB Gold Result identified as abnormal. The QuantiFERON-TB Gold test was completed on 3/17/23, with the results verified on 3/19/23 as positive. Interferon-gamma response to M. tuberculosis antigens detected, suggesting infection with M. tuberculosis. Positive results in staff at low risk for tuberculosis should be interpreted with caution and repeat testing should be considered as recommended. There was no indication test results were repeated for accuracy. Review of March through November 2023, resident infection and illness surveillance log had no evidence of residents with signs or symptoms of active TB and the staff infection and illness surveillance log had no evidence that H-A had ever called in to report any illness. The surveillance lacked identification of increased surveillance for H-A who had a known positive TB test result for signs or symptoms of active TB, that would have put all 43 residents at risk. Interview on 11/7/23 at 3:48 p.m., with infection preventionist (IP) identified that he was not aware of H-A's positive TB test result until H-A's information was requested as part of the sample of staff to be reviewed for TB screening and testing. He reported the minute he reviewed the test results and saw H-A's positive result, he immediately sent H-A for a medical exam and chest X-ray. He was unsure why the previous IP had not acted upon the positive results. He confirmed he reviewed all the resident surveillance and found no residents to have had signs or symptoms of active TB since H-A started working. He further confirmed staff were not to start employment until a TB negative result was obtained per the facility policy and was the facility policy to not hire any staff with an active TB test. Review of H-A's 11/7/23, Chest X-ray result were negative. There was no physician progress note to review related to the medical examination portion. Interview on 11/8/23 at 1:17 p.m., with director on nursing (DON) identified she was unaware H-A had a positive TB test result on 3/19/23. The DON reported the IP was responsible for ensuring new hires were screened and had laboratory testing for active TB and found positive, they were to be sent for a medical exam and/or chest X-ray with a physician. The IP was responsible to act on any positive TB results and file the results in the staff personnel file. The previous IP ended her employment on 8/1/23. H-A was employed full time and had never called in for work since starting her employment. Staff were not allowed to work at the facility if a staff was shown positive until they had a repeat test showing it was truly negative. Review of January 2023, the facilities Tuberculosis (TB) risk assessment identified the facility had no resident suspected or confirmed with TB disease. The assessment identified the facility to be at a low risk for TB. The assessment identified the facility had no staff with a test conversion rate for TB infections that exceeded the health-care setting's annual average. There was no indication in the assessment that the facility identified they employed a staff with a positive TB test result. Review of 11/6/23, Tuberculosis-Employee Screening policy identified all staff will be screened for Tuberculosis (TB) infection and disease through a blood assay for Mycobacterium tuberculosis (BAMT) or two-step tuberculin skin test (TST) prior to working. If the results return as negative the staff will not be given another test prior to working. If the test results are positive or unavailable, the staff must have additional verification of absence of active TB. The policy furthermore identified staff who had a positive reaction to the TB test would be referred for a chest X-ray and symptom screening, which must be completed prior to working. If the staff chest X-ray results are negative and the staff has no symptoms of active TB, the staff will be considered free of active tuberculosis.

Based on observation, interview and document review the facility failed to revise the comprehensive care plan with individualized communication intervention for 1 of 1 (R19) resident reviewed. Findings include: R19's 11/7/23, admission record identified diagnoses of hemiplegia (paralysis of one side of body) following a stroke, dysphasia (difficulty speaking) and dysphagia (difficulty swallowing). R19's 10/3/23, revised care plan identified a communication deficit as R19 was from Micronesia and only understanding simple words of English. Staff were to get R19's attention by making eye contact, and show or point in direction R19 was going to roll in bed. R19 was able to indicate yes or no by shaking her head in that gesture. R19 preferred to communicate in Micronesian. The facility was to provide a translator as necessary to communicate with resident. The translator was identified as a family member (FM)-A. Staff may call the FM-A or face time FM-A to translate. There was no mention of how the staff would communicate if they were unable to contact FM-A. There was no mention of alternate translation options if needed. R19's 1/11/23, Care Area Assessment related to communication identified R19's primary language was Micronesian. R19 understood simple English phrases and could answer yes or no. The interdisciplinary team had determined R19 had a communication problem as evidenced by hesitation and need to repeat or rephrase a statement. R19's primary language was Micronesian with FM-A providing interpretation. R19's communication difficulties could result in social isolation, depression, and/or safety concerns. Observation on 11/6/23 at 12:30 p.m., of R19 in her bed awake with television on identified when addressing R19 after saying hello, how are you?, R19 looked but had not responded. Interview on 11/6/23 at 12:51 p.m., with nursing assistant (NA)-A identified R19 knew very little English but could communicate yes or no. R19 did not have a communication board that she was aware of to assist with her communication. Interview on 11/6/23 at 12:58 p.m., with trained medication aide (TMA)-A reported R19 communicated her pain by a number system or R19 would blink if she had pain when asked. TMA-A reported that R19 had been at the facility for a long time and staff just knew her routine. She identified R19 had family members who worked at the facility, and they would translate. Interview on 11/6/23 at 2:45 p.m., with FM-A and FM-B who reported that the facility will call a family member if they could not figure out what R19 needed, and the family was okay with that. FM-B revealed it would be a good idea to have another translator as a backup though. FM-A confirmed that R19 did not have a communication board. R19's 11/2/23, progress note at 2:40 p.m. identified the facility had been unable to contact FM-A and FM-B to update about R19's new orders, the note indicated the facility would continue to attempt to contact. Additional progress notes on 11/2/23 at 4:14 p.m., facility unable to contact FM-A or FM-B facility will continue to attempt to reach. Interview on 11/7/23 at 9:25 a.m., with social service designee (SSD) identified R19 spoke minimal English but could communicate cares. The facility used family when they needed to communicate in more detail. SSD revealed there was a translation service number located in the emergency room that connected to a television for translation that she thought the facility could use if needed. The SSD then reported during the daytime hours the facility had translation covered as there were family members who worked at the facility. The SSD was unsure if R19 had ever had an assessment for a need for a translator. She reported that she had tried Google translate before, however, that does not translate from English to Chuukese or visa versa when talking as the language is very specific to certain regions in Micronesia. The SSD confirmed all translation was done by family and if the facility was unable to reach family, they could potentially use the number located in the attached hospital ER room. Interview on 11/7/23 at 9:39 a.m., with the director of nursing (DON) identified R19 spoke in Chuukese her primary language. The DON reported the facility had a staff member that had created signs of COVID and admission questions in Chuukese however, the facility still needed an interpreter to translate that information once asked. The DON revealed the clinic had a receptionist that was a paid translator for the hospital and the nursing home that the facility could use if needed. She confirmed R19's care plan lacked identification of any back up translation services the facility could use if family was unavailable, which she confirmed did occur at times. The DON confirmed that there was a real struggle to communicate with R19. She further confirmed the facility should have an alternate translator option available and identified on the care plan. There should be direction noted for staff if the facility was unable to reach the family to translate. Additional interview on 11/8/23 at 1:17 p.m., with the DON identified that the care plans were not updated like they should be. Her expectation was all residents care plans should reflect their current level of care and were individualized. Review of 11/6/23, Translation and/or Interpretation policy identified when an individual with limited English proficiency would have an initial language assessment completed. All residents with limited English would receive a written notice in their primary language of their rights to obtain an oral translation service free of charge. The interpreters and translators must be appropriately trained in medical terminology, confidentiality, and ethical issues that may arise. Family members and friends shall not be relied upon to provide translation services unless explicitly requested by the resident. If friends or family are used to interpret the resident must provide written consent for disclosure of protected health information. Review of 11/7/23, Care Plans-Comprehensive Person-Centered policy identified a resident would have a comprehensive individualized care plan developed and implemented to meet the residents needs. The care plan was to include the residents cultural and personal preference and describe specialized services needed to enhance optimal functioning of the resident. The comprehensive person-centered care plans were to be reviewed and updated to reflect the residents needs or condition changes.

Based on document review and interview, the facility failed to ensure 1 of 1 required member (infection preventionist) and/or their designee attended and documented the attendance at the quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the January 2023, through July 2023, quarterly Quality Assurance and Performance Improvement (QAPI) meeting minutes attendance record did not identify the facility infection preventionist was present at the second quarter meeting held in April 2023. Interview on 11/7/23 at 3:48 p.m., with the infection preventionist (IP) identified he was an interim IP who was to be responsible for covering the IP role until the new infection preventionist started. He confirmed he had not attended any of the QAPI meeting but he should be while covering the position. Interview on 11/8/23 at 8:25 a.m., with the director of nursing (DON) identified the IP could not make it to the April meeting. Normally, if the IP could not make it, they would delegate someone to cover the information and that was to be documented in the meeting minutes. The DON confirmed her expectation was the required QAPI members including the IP attended the quarterly meetings unless arrangements were made for someone else to cover for her. Review of the undated, QAPI plan identified all department managers, and infection control staff will be involved in the quarterly meetings. The departments will share findings with the medical staff and the board of directors. The policy had no mention of the required committee members such as the administrator or medical director that would be required to be identified and participate in the committee's quarterly meeting.

Based on observation, interview and document review, the facility failed to comprehensively assess and obtain informed consent, prior to resident use of bed rails for 1 of 1 resident (R23) reviewed for bed rail use. Findings include: R23's 8/31/23, annual Minimum Data Set (MDS) assessment identified R23's cognition was intact, R23 required moderate to substantial assistance with personal hygiene. R23 required supervision to get from a lying to sitting position on the bed and R23 was able to stand independently from a sitting position. R23 was identified in section P of the MDS as having no bed rails used. R23's undated, care plan identified R23 used a lift chair recliner to maximize independence with repositioning. Occupational therapy has assessed R23's use of the lift chair for safety. Staff were to respect R23's right to sleep in his recliner if choosing not to sleep in the bed. There was no mention of the bilateral 1/2 side rails on R23's bed. R23's 6/1/23, Safety Risk Assessment identified history of low back pain currently controlled with spinal stimulator. R23 had urge incontinence, and a recent room change that R23 reported he liked and was adjusting well to with no issues noted. R23 had bed, side table, recliner, walker, and wheelchair. R23 had a lift chair and was able to show appropriate ability to move from a lying to sitting position. R23 was able to get from a sitting to standing position. R23 was able to ambulate the length of the hallway without difficulty. R23's walker and call light kept within reach. There were no mention of 1/2 side rails on the bed. R23's 8/31/23, Safety risk assessment identified 2 falls in past year however none in last quarter. Physical therapy orders were obtained however, R23 refused to work with therapy. R23 had a riser over the toilet with handles to help with getting on and off toilet. R23's cognition was intact and R23 kept his walker within reach. There was no mention of R23 having or using 1/2 side rails on his bed for mobility. Interview on 11/8/23 at 11:19 a.m., with R23 who reported he sleeps in his bed, and he uses the side rails to pull himself up to a sitting position and maybe he used them when he turns around in bed, but he could not remember. Interview on 11/8/23 at 12:31 p.m., with maintenance supervisor (MS) identified the nurse's let maintenance know if there was a loose side rail or something and then they would go assess and fix that. He confirmed that maintenance did not complete any type of routine checks on the bed rails for safety in the facility. The direct care staff work with the residents in their rooms daily and they would be the ones to notice if something needed to be repaired and then notify maintenance. Interview on 11/8/23 at 11:25 a.m., with director of nursing (DON) identified R23 had moved to his current room on 5/24/23, and the bed was already in the room so the 1/2 side rails must have been already on the bed when R23 moved in. The DON confirmed that the 1/2 side rails were not identified on his safety risk assessment, not on his care plan, and there was no side rail assessment completed as they were not aware R23 even had the bed rails on his bed. She reported prior to R23's move to his current room he did not have side rails on his bed and when the nurse completed his assessment, they must have missed that. Additional interview at 1:17 p.m., with the DON who identified her expectation was that any resident with a bed rail or grab bar would have an assessment completed and the care plan would reflect the assessment. Review of 1/6/21, Bed Rail policy identified goal to reduce safety risks and hazards commonly associated with bed rail use and prevent entrapment. The facility will complete regular bed maintenance to inspect all bed systems are operational and ensure they are safe. Residents using bed rails will have bed rail evaluation to determine alternatives to bed rail use. Education to resident pertaining to the risk and benefits of bed rail use will be provided. The bed rail policy was used to determine if the resident was safe and able to use the bed rail. The interdisciplinary team would use data collected from regular bed inspections and individual bed rail assessments to care plan for positive outcomes. Ther was no indication the policy had been reviewed and updated annually per the regulation.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R23) were appropriately vaccinated against pneumonia. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at any age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 1 of 5 sampled residents for vaccinations identified: 1) R23 was over 65 and admitted to the facility September of 2019. R23 had the PCV-13 on 10/20/15 and PPSV-23 on 11/14/12. R23 should have been offered and /or administered the PCV-20 at least 5 years after prior PCV-13 in October of 2015. Interview on 11/7/23 at 2:44 p.m., with registered nurse (RN)-B identified the case manager was responsible to complete the TB screening and testing for new admissions. The case manager was responsible to review the new admission records and offer immunizations that were due or document on the immunization spreadsheet when an immunization would be next due. RN-B confirmed the facility followed CDC guidelines for recommended vaccinations. Interview on 11/7/23 at 3:48 p.m., with infection preventionist (IP) identified this was the first time he had heard about the PCV-15 and the PCV-20 vaccination. Interview on 11/8/23 at 1:17 p.m., with director of nursing (DON) identified R23 was not offered the new PCV-15 or PCV-20. The DON revealed that she was honestly unaware of the PCV-20 however when she reviewed the vaccine information statements (VIS) sheet there it was right next to the information on the PCV-15. She further reported that the nurse manager was responsible to track and offer immunizations that were due. Review of the 11/6/23, Pneumococcal policy identified residents will be offered pneumococcal vaccines to prevent pneumococcal infections. Upon admission residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated will be offered the vaccine unless medically contraindicated. The pneumococcal vaccine or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations.

Based on interview and document review the facility failed to report an allegation of abuse timely to the State Agency for 1 of 1 resident (R1) reviewed for allegations of abuse. Findings include: An anonymous Vulnerable Adult Maltreatment Report submitted to the State Agency on 10/25/23, alleged staff to resident sexual abuse when it was reported a caregiver touched R1's genitals. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of dementia and Parkinson's disease. R1 had severe cognitive impairment, no hallucinations, and did not reject cares. The MDS also noted R1was dependent on staff for toileting hygiene, dressing, and transfers. During an interview on 11/1/23 at 10:10 a.m., R1 indicated he had an issue with one staff but the staff person did not work with him anymore. R1 stated had already answered alot of questions and didn't want to answer anymore. During an interview on 11/1/23 at 11:10 a.m., family member (FM)-A indicated on 10//21/23, R1 reported he was having an issue with a NA that was touching him inappropriately at night, further explaining the staff person reached between his legs touched his privates [gentitals]. FM-A described R1 as being more alert and more clear than he had been on previous visits. FM-A further stated that although R1 has some confusion, R1 repeated the same allegation three (3) different times throughout the day. On 10/21/23, FM-A could not find a nurse to report the allegation to but, did report the allegation to a charge nurse (could not recall name of charge nurse) on 10/22/23. At that time FM-A was told they were already aware of the allegation. FM-A indicated the social worker (SW) called on 10/25/23 and told her that she was just made aware of the allegation of abuse and had moved R1 to a different room and team [of caregivers]. During an interview on 11/1/23 at 12:35 p.m., FM-B indicated she was aware of R1's allegation of inappropriate touching of the genitals and reported it to registered nurse (RN)-A on 10/21/23 and again on 10/22/23. During an interview on 11/1/23 at 11:45 a.m., the SW indicated R1's daughter reported the allegation of abuse on 10/25/23 at 11:50 a.m The SW further indicated R1 was interviewed by the facility but he declined to dicuss the allegation and only provided concerns related to another staff he did not care to work with. As a result of the ongoing concerns with that staff and the allegation they immediately moved R1 to a different room which meant a different team of caregivers and implemented two staff for all personal cares. The SW stated she did not report the allegation to the SA because everything she was hearing was second hand and R1 did not tell her anything firsthand. Further stated she did not feel the allegation was reportable [to the SA]. During an interview on 11/1/23 at 12:00 p.m., the director of nursing (DON) indicated she had been on medical leave and returned on 10/31/23. She was made aware of the allegation on 10/31/23 but did not think it was reportable [to the SA]. During an interview on 11/1/23 at 12:25 p.m., the administrator indicated the SW reported the allegation of abuse to her on 10/25/23. Further indicated she wasn't aware that it was reportable but planned to report it immediately now that she was aware of the regulatory requirements. The Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy last revised 1/7/21, indicates it is the policy of the facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 (two) hours after the allegations is made.

Based on interview and document review the facility failed to ensure comprehensive fall assessments, identification of casual factors and probable root cause, and development and implementation of interventions that would prevent/or mitigate the risk or re-current falls and injury for 2 out of 3 (R2 and R3) residents evaluated for falls. Finding include: EZ lift = (Hoyer) full body mechanical lift. EZ stand=mechanical lift that residents are able to bear weight and assist to stand with R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2's diagnoses included heart failure, diabetes, and seizure disorder. R2 had moderate cognitive impairment. R2 required extensive assist of 2 staff for bed mobility, transfers, and toileting. R2 required human assistance with balancing while moving from a seated to standing position, walking, moving on and off the toilet and surface-to-surface transfers. R2 used a wheelchair and a walker for mobility. R2 had two falls without injury since the last MDS. R2's fall care plan dated 12/21/22, identified R2 was at risk for falls related to multiple health problems including weakness evidence by low tolerance to activity. Interventions included: -gripper strips on floor in front of bed to prevent slipping, start date 5/4/23, -Assist of two staff, walker, and gait belt, to walk a few steps in room, revised date 6/22/23, -R2 Required wheelchair and assist of one staff with locomotion outside of room, revised date 6/22/23, -R2 required assist of two staff with transfer to and from commode next to the bed for bowel movements, one staff to wipe after bowel movements and adjust and change brief. R2 used call light to request assist, start date 6/22/23, -the resident is able to come to standing potion from bed by raising bed height before standing and with staff assist, gait belt and walker, revised date 6/22/23 R2's safety risk assessment dated [DATE], indicated a risk for falls secondary to multiple comorbidities and generalized weakness. R2 was non-compliant with most treatments and orders. R2 had been educated on risk for falls with independent transfers and ambulation but desired to be left alone despite the risk for injury or death. R2's care sheet (abbreviated care plan used by direct care staff), dated 6/22/23, did not identify R2 as a fall risk and did not list any fall interventions. R2's fall records were reviewed between 2/21/23 thru 6/22/23, the record identified R2 had six unwitnessed falls and one witnessed fall. Although R2's record identified predisposing risk factors, the record consistently lacked a comprehensive fall assessment to determine root cause for appropriate interventions or failed to include appropriate interventions when the root cause was identified. Fall 1 R2's progress note dated 2/21/23, indicated R2 had a witnessed fall, R2 lost his balance while stepping off the portable scale and nursing assistant (NA) lowered R2 to the floor. R2 was sitting on his bottom with legs/feet folded to the left side of his body. No injuries denied pain. R2 was not wearing any footwear or stocking per his preference. Assisted off the floor after assessment and vital signs (VS) obtained. Oxygen saturations were low at 84%, (normal is above 90%) on room air, oxygen reapplied as R2 removed the oxygen for his transfer. Corresponding incident report identified the fall occurred at 9:20 a.m. with predisposing factors included gait imbalance during transfer. R2's post fall interdisciplinary team (IDT) notes dated 2/23/23, identified R2 refused to allow staff to place gait belt or provide contact guarded assist (CGA) or allow assistance for all transfers. R2 removed his oxygen prior to being weighed and saturations dropped to 84%. R2 refused physician required rounding visit on 2/22/23. Encouraged staff to be more aware during collection of weight, R2 refuses multiple staff in room at once. R2's follow up IDT note for 3/2/23, indicated no injury from fall. NA stated that R2 had already stepped off the scale and was standing with walker when he lost his balance. Portable scale used as R2 refused to leave room. Will initiate standby by assist (SBA) of one staff when resident weighed to minimize risk of falls. R2's care plan did not reflect revisions. Fall 2 R2's progress note dated 4/15/23, indicated R2 had an unwitnessed fall with no injuries. Corresponding incident report identified the fall occurred at 3:00 p.m. R2 stated that his bathroom was too small and slipped. Denied injuries and denied hitting his head but neuros were started due to unwitnessed fall. Immediate action was noted to be VS obtained and neuros started, transferred from floor to bed via Hoyer lift assisted by three staff. Predisposing factors listed wet floor, R2 was incontinent, ambulating without proper footwear, ambulating without assist and using walker. R2 was offered gripper socks but refused. R2 post fall IDT notes dated 4/20/23 Reviewed. Offered gripper socks, resident refused. R2's follow up IDT was not completed until 4/27/23; that note indicated R2 had a status change and was no longer using bathroom without help and was using his call light for assistance now. Although, R2's fall record identified potential causal factors, the record lacked full comprehensive analysis to determine probable root cause and was not evident immediate interventions were developed and implemented to mitigate modifiable risk factors to prevent recurrent falls or the risk. Fall 3 R2's progress notes dated 4/19/23, indicated R2 had an unwitnessed fall. R2 was noted to by lying on his right side. R2 was not able to say what he was doing prior to fall. Denies injuries. [NAME] noted near foot of bed, R2 was barefoot. Assisted off floor with two staff and EZ-Lift into bed. Seizure like activity noted for about 20 seconds during assessment and occurred two more times at 7:30 a.m. and 7:45 a.m. After episode R2 was able to answer questions and was alert, pupils no longer fixed. Corresponding incident report identified the fall happened at 7:15 a.m. Immediate interventions were to start neurological checks and vital signs (VS) as R2 allowed, and housekeeping to mop floor. Predisposing factors included decrease in ornamentation over the past week, confusion, incontinent, wet floor-floor sticky with jello particles, gait imbalance, recent change in medications/new- increase Ativan (anti-anxiety medication) over weekend, recent change in condition and weakness/fainted. R2's post fall IDT notes dated 4/27/23, referred to IDT note second fall for 4/19/23. Which was R2 had a status change and was no longer using bathroom without help and was using his call light for assistance now. Although R2's record identified a new medication was started, the record did not address interventions to prevent and/or mitigate R2's risk for falls related to seizure activity. Fall 4 R2's progress note dated 4/19/23, indicated R2 has an unwitnessed fall. R2 was found with right leg bent under him and left leg out in front of him. R2's back was against the bed. R2 was able to move right leg and denied pain. Assisted off of floor with EZ-Lift and assist of four staff. Video monitoring initiated with family consent. Corresponding incident report identified the fall occurred at 3:22 p.m., predisposing factors included second fall of the day, weakness, confusion, recent illness. Resident able to say that he slipped off the bed. Recent history seizure like activity of freezing and holding unusual body positions. Immediate actions were to assist off of floor. IDT determined best action would be for video monitoring as a alarm would irritate R2. Hospice requested increasing pain medication. R2's post fall IDT note dated 4/20/23, indicated seizure activity, start Keppra and video monitoring. R2 was medicated as needed. R2's care plan did not include video monitoring as an intervention. Fall 5 R2's progress notes dated 4/21/23, indicated R2 had an unwitnessed fall. R2 was heard calling out for help and was found on floor next to bed, feet tucked under bottom and head and left shoulder resting on walker near foot of bed. Bedding and gown noted to be on floor saturated with urine, water, or soup from meal. Resident denied pain. R2 refused to allow staff to do proper assessment but did allow them to assist him with the EZ-Lift . Once in bed noted to be having visual hallucinations. Staff provided one on one and R2 seemed to have seizure like activity, lasting approximately 30 seconds. R2 was alert after episode but continued to refuse neuro's and VS. Corresponding incident report indicated the fall happened at 12:15 p.m. and R2 received a bruise to his right hip measuring 3-centimeters (cm) x 3 cm. Predisposing factors included wet floor, furniture, confusion, R2 was incontinent, recent change in condition, and recent medication change/new- started Keppra, increase Morphine. R2's post fall IDT note dated 4/27/23 stated to see risk notes. (Asked for and not received). Although, R2's fall record identified potential causal factors, the record lacked full comprehensive analysis to determine probable root cause and was not evident immediate interventions were developed and implemented to mitigate modifiable risk factors to prevent recurrent falls or the risk. Fall 6 R2's progress note dated 4/23/23, indicated R2 was found on floor calling for help by hospital staff. R2 was lying on floor mat with food noted on floor, bowel movement was on floor, underwear and on bedding. R2 refused VS and assessment but did allow staff to assist off the floor with Hoyer lift and two staff. Hematoma noted on R2's right bottom, skin tear on back of right hand, R2 refused measurements of but did allow staff to apply dressing. Corresponding incident report dated 4/22/23, indicted an unwitnessed fall at 6:40 p.m. Predisposing factors include confusion, gait imbalance, impaired memory, ambulating without assist. R2's post fall IDT note dated R2 could have been having seizures and refusing Keppra. R2 was restless and having hallucination, was medicated with Morphine (narcotic pain medication) and Haldol (antipsychotic medication). Mat attempted on floor beside bed but bed table not able to be by beside which upset R2. Gripper strips were applied to floor on 4/27/23. R2 now taking Keppra with no seizure activity, improved mood, and less confusion. R2 using call light for assist. R2's follow up IDT note dated 5/11/23, started on Keppra, more alert, no recent seizure activity and more cooperative. R2's record identified R2's grip strips were not implemented until 5 days after fall on 4/22/23. Fall 7 R2's progress note dated 4/23/23, noted that on 4/22/23 at 7:30 p.m. R2 was found lying on floor mat with bowel movement noted on floor, food on floor. R2 stated he was looking for his remote. R2 was transferred from floor to bed and refused VS and neuro checks. R2 was medicated with lorazepam (anti-anxiety medication) by mouth. There was no corresponding incident report. R2's fall record lacked a comprehensive analysis that identified root cause and was not evident immediate interventions were developed and implemented to prevent and/or mitigate risk of recurrent falls. R3 R3's quarterly MDS dated [DATE], identified R2's diagnoses included Alzheimer's disease, dementia, anxiety, psychotic disorder other than schizophrenia, visual and auditory hallucinations. R3 had severe cognitive impairment. R3 was totally dependent on two staff for transfers, locomotion on and off unit. R3 had range of motion impairment to one side upper and lower extremities. R3 had no fall since previous significant change MDS dated [DATE], which R3 had one fall. R3's revised care plan, dated 5/2/23, indicated R3 had limited physical mobility related to history of cardiovascular accident (CVA), with right sided weakness, syncopal episodes. Physically unable to bear weight, walk or stand without assist of EZ-Stand. R3 was at high risk for falls related to history of and falls since admit to facility. R3 did not remember her limitations. Interventions included -Ensure R3 is wearing proper footwear; gripper socks or her slip-on tennis shoes when transferring with mechanical stand (revised date 9/5/19.) -Anticipate and meet R3 needs. If restless or agitated, assess for sign and symptoms of pain, or need to use bathroom. Staff assist R3 as soon as possible if she is awake, be aware R3 attempts self-transfers, does not wait for assist (revised date 10/04/19.) -Place books of interest with large print in resident's room to enable staff to offer to resident (revised date 11/7/19.) -IDT to review R3's falls, discuss causal factors, relationship to agitation and/or pain (revised date 12/16/19.) -R3 uses TABS chair/bed alarms. Ensure device is in place and functioning with every care contact and nurse to follow up with nursing assistants, document in treatment record (revised date 12/18/20.) -Be sure call light within reach and encourage use during periods of alertness. R3 needs prompt response to all requests for assistance and to TABs alarm sounding. Use mat on floor during night and day especially when agitated to decrease risk of injury with falls (revised date 4/4/20.) -When R3 is attempting to go into her room, she wants to lay down. Assist R3 into bed at these times. Start date 10/29/21. -When restless or agitated, attempting to self-transfer, may try warm blankets or weighted blanket. Sleeps/rests better with lights off and door only slightly open allowing visual checks (revised date 12/21/21.) -Needs a safe environment with even floors free from spills and/or clutter; adequate glare-free lighting; a working and reachable call light, the bed in lowest position at night; grab bar as ordered, personal items within reach. Revised date 12/22/22. -Has grab rails on bed to allow resident to assist if able if/when her status allows. Bed in low position with mat on floor, noodle under outside mattress edge (revised date 12/22/22.) -Allow resident to rest in recliner if desires, use EZ-Lift and assist of 3 staff for transfers. Staff to run the lift chair and lift chair control to be kept out of resident's reach (revised date 5/2/23) R3's current care sheet indicated fall risk with the fall interventions of low bed, floor mat, alarms in bed and while in broda chair. Keep recliner unplugged and to monitor frequently (monitoring frequency was not identified). R3's safety risk assessment dated [DATE], indicated at risk for falls, continue current care plan with high low bed in lowest position when in bed, mat on floor by bed when in bed, TABs alarms on bed and wheelchair, and staff assist resident to lay in bed when tired. Fall 1 R3's progress note dated 4/20/23, indicated R3 had an unwitnessed fall. R3 was noted to be hollering out and was found on floor mat next to bed and attempting to get back into bed. R3 was assisted with two staff to get back into bed. VS obtained. R3 was anxious and restless most of the shift and required one-on-one. Did receive as needed Ativan, had multiple snacks, fluids, repositioning, wheeled in wheelchair up and down the halls. Air mattress overlay was placed earlier; staff thought the mattress caused the fall and encouraged night shift to remove if R3 seemed uncomfortable during the night. Corresponding incident report indicated fall happened at 6:25 p.m. Immediate interventions taken was to assist R3 off the floor via two staff as R3 was partially on the bed. No injuries noted. Predisposing factors included fall alarm, impaired memory, recent change in condition, recent medication change/new. Resident noted to be more anxious and received PRN Ativan and nonpharmacological interventions used with minimal effect noted. R3's post fall IDT note dated 4/27/23, new air mattress overlay thought to be the reason along with increased confusion that day. Evaluated the use of toilet as resident gets restless when needs to have a BM. Attempt to toilet the resident when stating need. R3's fall record did not mention if the TAB alarm had been functioning at the time of the fall. R3's record did not identify when/if mattress was removed and/or revision to the care plan. Fall 2 R3's progress note dated 6/19/23, indicated an unwitnessed fall at 4:15 p.m. R3 stated pain when asked but not able to tell where pain was located. R3 also stated that she did not feel well. VS taken and R3 had an elevated diastolic blood pressure (blood pressure not identified). Recheck of blood pressure 15 minutes later was 127/86. Corresponding incident report indicated the R3 slid out of bed and was found on her mat with TABS alarm going off. R3 had no injuries. Immediate interventions were R3 was assessed for injuries; no injuries were identified, however, R3 reported pain, and stated I don't feel well. Predisposing factors included confusion, memory impairment. Although R3's fall record identified potential causal factors, it was not evident a comprehensive analysis was completed that identified root cause and not evident interventions were developed and implemented to prevent and/or mitigate risk for recurrent falls. During an interview on 6/22/23 at 3:33 p.m., nursing assistant (NA)-L indicated that R2 had been waxing and waning with his level of care and his cognition since his admission. R2 went through a period where R2 he was falling a lot but NA-L could not remember if the falls resulted in injury. NA-L stated staff had to anticipate R3's needs, NA-L was not aware if R3 had any falls. NA-L would refer to the current care sheet to look for residents at fall risk for falls and what their fall interventions were. During an interview on 6/22/23 at 3:47 p.m., NA-A indicated R2 was assist of two staff with transfers and could not remember any recent falls for R2 . R2 wore a TABs alarm at all times and had a fall mat beside her bed. NA-A stated R3 was a hoyer lift with assist of two staff. NA-A indicated R3 liked to crawl out of bed at times. NA-A was able to articulate the steps involved when there was a fall per facility protocol. make sure resident is safe, call for nurse and stay with resident until nurse comes to assess resident, and then help get resident off the floor. During an interview on 6/23/23 at 8:27 a.m., NA-N indicated R2 was a two person pivot transfer from bed to commode and back again, and was able to turn self in bed. R2 had a history of falls, could not remember how long ago R2 last fell , and was not sure of his fall interventions however would check the care sheet. NA-N stated R3 was a EZ-Lift with assist of 2 for most transfers, EZ-Stand for transfers to and from commode only after breakfast. NA-A could not remember R3' s last fall. NA-N was able to articulate the steps involved with falls per facility protocol. During an interview on 6/22/23 at 2:10 p.m., director of nursing (DON) indicated when there was a fall the NAs would contact the nurse to come and do assessment and then staff would assist resident off the floor with the EZ-Lift The nurse would document the incident, note any injuries, and who they contacted. Every Thursday the IDT risk management meeting was held. IDT reviews the incidents from the previous week; notes were made on the incident report during the meetings. On 6/23/23 at 12:00 p.m., DON explained nurses were supposed to complete the Post Fall RCA (root cause analysis) questionnaire with each fall. DON reviewed R2 and R3's fall records; stated she was unable to completed RCA's for R2 and R3's falls. DON stated nurses were supposed to follow and complete the Fall Checklist. DON stated expectation nursing staff followed the facility's fall program policies. Review of revised facility's policies Fall-Clinical Protocol and Assessing Falls and Their Causes, both dated 6/22/23, indicated identifying causes of a fall within 24 hours. Currently IDT meets weekly to discuss falls. Performing post fall evaluation 4) .complete of falls risk assessment and put in appropriate interventions taken to prevent future falls.

Based on observation, interview and document review, the facility failed to ensure infection control practices were followed during handling of soiled laundry. This had the potential to affect all residents whose laundry was completed at the facility. Findings include: During observation on 1/26/23, at 8:27 a.m. laundry aide (LA)-A did not have on proper PPE when sorting soiled laundry. During interview on 1/26/23, at 8:27 a.m. LA-A stated gowns were not worn over clothing to sort soiled laundry items, unless the bag was a different color. However, gloves were worn at all times when sorting laundry. LA-A stated she was not aware of the need to wear a gown while sorting soiled laundry. An interview on 1/26/23, at 10:14 a.m. infection preventionist (IP) stated staff were expected to wear gowns and gloves when sorting laundry. However, I cannot confirm the laundry staff are wearing gowns downstairs when sorting laundry. Further, nurse aides likely did not wear a gown when they sorted laundry items either. The facility policy Departmental (Environmental Services)-Laundry and Linen approve date 1/26/23, indicated employees sorting or washing line must wear a gown and gloves. A mask may be worn if aerosolization is expected. Use heavy duty rubber gloves for sorting laundry. Always wash hands after completing the task and removing gloves.

Based on interview and record review, the facility failed to immediately report an allegation of abuse within the required 2 hours to the State Agency for one of one residents (R11) when R11 reported staff to resident verbal abuse. Findings Include: R11's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition based on Brief Interview for Mental Status (BIMS) score of 13/15. R11 was frequently incontinent of bowel and bladder and required assist of two staff for bed mobility, transfers, dressing, bathroom needs, and personal hygiene. R11's care plan indicated resident's vulnerability potential due to her physical status, complex medical condition, and dependence on two staff for activities of daily living (ADLs). It stated resident will receive needed care in manner that provides her safety and dignity for her over all well-being. During an interview on 1/23/23, at 5:15 p.m. R11 stated nursing assistant (NA-A) refused to help her that morning because she didn't say please. R11 stated she'd to take it higher. NA-A provided cares, however, stated I can walk out of here any time I want to. R11 did not report this to the facility, however, stated it made her feel very inferior. On 1/23/23, at 7:45 p.m. allegation of verbal threat to deny cares was reported by surveyor to the director of nursing (DON) and administrator. During an interview on 1/24/23, at 10:48 a.m. DON stated suspected abuse, was reported to OHFC (office for health facility complaints) and suspected abuser was removed until investigation was complete. However, there was no evidence this incident had been reported to the SA. During an interview on 1/25/23, at 2:03 p.m. DON and administrator stated after an internal investigation, the facility removed the NA-A from the schedule and planned to make a report to the state agency. Further, they acknowledged the report was late and should have been reported within two hours of initial report from R11. NA-A's employee file indicated EduCare training modules titled Abuse Prevention, and Abuse Prevention and Resident Rights were completed on 7/1/20. NA-As Minnesota Nursing Assistant Registry verified. Expires12/9/23. Background clearance completed for NA-A on 1/29/22. Review of Abuse, Neglect, Mistreatment and Misappropriation of Property policy, last revised 1/7/2021, indicated allegations of abuse were to be reported to the SA within 2 hours.

Based on observation, interview, and document review, the facility failed to establish adequate protective measures and supervision to ensure residents who were dependent on oxygen did not smoke while using portable oxygen for 1 of 4 residents (R23) who were listed as smokers in the facility. The deficiency was issued at Immediate Jeopardy (IJ) level as R23 remained at risk for significant injury or death related to smoking while oxygen was in use. The IJ began on 6/29/21, at 10:49 a.m. when R23 was observed smoking a cigarette in the designated smoking area while using a portable oxygen concentrator via nasal cannula and the oxygen was observed to be turned on. Smoking cigarettes in conjunction with using oxygen can rapidly accelerate combustion. This could result in significant injury or death to the residents, staff, and visitors in the area. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy at 1:36 p.m. on 6/29/21. The immediate jeopardy was removed on 6/30/21, at 1:38 p.m. but non-compliance remained at an isolated scope and severity which indicated no actual harm with potential for more than minimal harm (Level D). Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], included R23 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R23 was cognitively intact. R23 required extensive assistance with activities of daily living, locomotion via wheelchair, and was dependent on oxygen. The quarterly MDS lacked documentation of R23's tobacco status. R23's face sheet identified diagnoses included [CONDITION(S)], heart failure, and [CONDITION(S)]. R23's care plan revised 2/15/21, reported R23 had limited physical mobility, used a wheelchair, and was dependent on staff for mobility/wheeling to and from all destinations. R23 required use of continuous oxygen (O2) and became short of breath with exertion, even when talking. The care plan indicated R23 was able to make needs known. The smoking focus area of the care plan indicated R23 smoked three to four times per day and was O2 dependent. A goal revised 2/12/20, listed R23 would smoke without supervision or injury, follow guidelines, and smoke in designated areas. Interventions revised 2/11/21, included staff were to assist R23 to smoking location, ensure O2 was turned off, and remove the nasal cannula prior to R23 lighting a cigarette. Upon returning to resident, staff were to immediately apply nasal cannula and turn the O2 concentrator on. The care plan identified R23 could light and extinguish her own cigarettes, and keep lighter and cigarettes on self. R23's Smoking Safety Screen assessment dated [DATE], at 3:20 p.m. indicated R23 had no cognitive loss, visual deficits, or dexterity problems. The assessment indicated R23 was capable of lighting her own cigarette, required assistance getting to and from the smoking area, and did not need the facility to store her lighter and cigarettes. A note on the assessment read, IDT [interdisciplinary team] feel the resident is A/O [alert and oriented], cognitively intact. Able to light cigarette on own. Can control ashes from cigarette. Understands location where smoking is allowed. Needs assistance to get to/from designated smoking area. Understands O2 must be off when smoking. Conditions also included in the assessment read, Will request to smoke. Staff will escort the resident to the smoking area. Turn off oxygen. Will use Walkie Talkie or phone to alert staff when would like to come in. Staff will turn O2 back on. Staff escort back into building. Has compact O2 able to apply per self, aware of not to use when smoking. R23's electronic health record contained a provider orders dated 8/27/20, for O2 up to 5 liters per minute, per nasal cannula via concentration, and to keep O2 saturation between 88 and 94%. During observation on 6/28/21, at 5:57 p.m. R23 was in her room, sitting in wheelchair. No burn holes or heat damage were noted on her clothing. When interviewed on 6/28/21, at 5:58 p.m. R23 stated she smoked at least once per day, but occasionally went out to the smoking area just to sit while using oxygen. R23 stated she took her portable O2 concentrator with her, turned it off when she smoked, and turned it back on after she put out her cigarette. She stated she kept her cigarettes and lighter with her, but relied on staff to transport her to the smoking area as she was unable to move her wheelchair independently. During interview on 6/29/21, at 9:44 a.m. certified nursing assistant (NA)-F stated anyone who smoked was assessed to make sure they were safe. She stated R23 needed help to get to the designated smoking area but could smoke independently. NA-F stated the O2 concentrator was powered on until R23 arrived at the smoking area. Once there, staff turned off the O2, removed the nasal cannula, and hung the tubing on the back of the resident's wheel chair. She stated residents were given a 'walkie' and called for staff assistance when they wanted to leave the smoking area. During observation 6/29/21, at 10:28 a.m. R23 was smoking in the designated smoking area with a nasal cannula in her nose. R23's oxygen concentrator was off and placed on a chair to the resident's left side. R23 had a lit cigarette in her right hand. R23 placed her cigarette in the cigarette receptacle with her right hand and immediately turned on the oxygen concentrator with her left hand. R23 remained in the designated smoking area with another resident who was smoking within six feet of R23 and the oxygen concentrator. There was one other resident and a visitor also present, neither were smoking. During a subsequent observation on 6/29/21, at 10:49 a.m. director of nursing (DON) and registered nurse (RN)-B were brought to the smoking area. R23 had a lit cigarette in her right hand. Her oxygen concentrator was turned on as indicated by the digital display on the unit. The oxygen tubing was connected to the unit and the cannula was in R23's nose. Another resident sat approximately 5 feet from R23 with a lit cigarette. The two residents were facing each other. DON confirmed the concentrator was turned on and immediately turned it off. DON provided immediate education to R23 regarding smoking when wearing O2 was a safety hazard. DON requested R23 remove the nasal cannula, however R23 refused. DON requested all smoking materials from R23 but R23 refused. R23 stated she was not previously told to remove her nasal cannula when smoking. R23 then placed her cigarette in the receptacle, refused DON's offer to transport her into the facility, and called for alternate assistance to go back into to the building. R23 remained supervised by DON and RN-B until 10:53 a.m. when NA-G arrived. NA-G returned R23 to her room at 10:57 a.m. When interviewed on 6/29/21, at 10:53 a.m. DON stated wearing O2 while smoking was unacceptable. Her expectation was residents removed the nasal cannula prior to smoking. She stated her preference was oxygen was not brought to the smoking area at all. DON confirmed R23 was re-educated immediately regarding the dangers of smoking with O2. R23 agreed to remove the O2 cannula when going out to smoke, but still requested the oxygen concentrator remain with her when she went to smoke. DON stated R23 needed to be reassessed with new interventions placed for safety. R23's progress note dated 6/29/21, at 11:18 a.m. identified, Reported by staff that resident was outside in the designated smoking area visiting with surveyor and she lit a cigarette while she had oxygen on. Resident interviewed in her room and she was tearful stating she had finished her cigarette and turned her oxygen on while still outside visiting. She states she forgot the oxygen was on and lit a cigarette and didn't realize until she had taken two puffs. Reviewed smoking policy with resident and another nurse present. Explained to resident that plan would now change and she would have supervision with smoking and that smoking supplies would be kept at the nurse's desk. Oxygen concentrator and tubing would not be taken outside to smoking area. Resident became upset, raising voice at nurse stating,'What kind of prison is this!' 'You can't take my cigarettes from me!' Risk for injury, [CONDITION(S)], explosion, and possible death explained to her as it has been done in the past. Resident crying and telling staff that they are abusing her. Resident did calm down with 1:1 and gave nurse her lighter and four cigarettes. Stated she did not have anymore in her room. Staff updated on new smoking plan, resident will be supervised with smoking, concentrator and tubing will be left in her room. The facility Smoking Policy last revised 7/18 with expiration of 7/19 outlined expectations for patients, tenants, visitors, and employees. The policy identified the designated smoking areas for visitors and long term care (LTC) center residents were in the LTC center parking lot on the west side near the kitchen entrance, and on the South end of the west parking lot near the street or dumpster, and on the west end of the parking lot under the shade tree. The policy lacked direction for safe smoking assessment, and further lacked any requirement to remove oxygen prior to smoking. No additional policies or procedures related to smoking safety or unsupervised smoking were provided. The Smoking Safety Screen dated 6/29/21, at 11:47 a.m. identified R23 was reassessed safe to smoke with supervision and one-to-one assistance. The facility would store R23's lighter and cigarettes. During continuous observation on 6/30/21, at 12:52 p.m. R23 put on her call light. NA-K entered R23's room, removed R23's nasal cannula and concentrator from her wheelchair then pushed R23 to the nursing station. NA-K checked R23's oxygen saturation level, retrieved a bag containing R23's smoking supplies from the medication room, and gave it to R23. NA-K transported R23 to the designated smoking area where R23 smoked a cigarette accompanied by NA-K. -At 1:03 p.m. NA-K was replaced by NA-F. -At 1:12 p.m. R23 placed her cigarette in the receptacle and requested to return to her room. NA-F transported R23 to the nursing station, checked R23's O2 saturation level, placed the bag with R23's lighter and cigarettes in the medication room, and returned R23 to her room where NA-F placed the nasal cannula on R23 and turned on the oxygen. R23 was never left without staff supervision. The immediate jeopardy that began on 6/29/21, was removed on 6/30/21, at 1:38 p.m. when it was verified, based on observation and interview that the facility successfully implemented a removal plan which included the following: Staff were educated regarding: -The change in R23's smoking supervision requirement -Removal of R23's nasal cannula and oxygen concentrator prior to transportation to the designated smoking area -Facility storage of R23's cigarettes and lighter -Monitoring R23's O2 saturation levels both before and after smoking -All cigarettes and lighters were removed from R23's possession. R23 was re-educated regarding the risk of smoking with oxygen, and care plan was updated to reflect oxygen and nasal cannula will remain in R23's room while smoking. -All residents who smoked, including R23, were re-assessed for safe smoking. The facility smoking policy was reviewed for adequacy and updated to include LTC residents will have a smoking assessment on admission, initiation of smoking after admission, quarterly, and any changes of condition which include functionality. Education on smoking cessation should be addressed with each assessment and documented. Smoking materials and any other source of ignition should be kept at least 15 feet (4.3 meters) away from an oxygen-[MEDICATION(S)] atmosphere such as a resident receiving oxygen via nasal cannula, oxygen mask or other delivery device. All smoking materials will be stored in the medication room for residents who require oxygen. Oxygen, nasal cannula and mask will remain in the resident's room while smoking in the designated smoking area. Residents who require supervision will be accompanied by staff to the smoking area and remain with the resident for the duration of the smoke break. Residents without the dexterity to hold a cigarette will be prohibited from smoking. The need for supervision or independent will be reflected in the smoking assessment, addressed in the care plan, and updated when indicated. The care center reserves the right to prohibit smoking when there is imminent threat to patient safety.

Based on observation, interview, and document review the facility failed to make sure the fans in the kitchen were properly cleaned and free of dust which had the potential to affect all 43 residents in the facility. Findings include: During observation on 6/28/21, at 10:29 a.m. thick dust/debris was observed on black oscillating fan that was blowing towards the steam table and prep counters. During interview on 6/28/21, at 10:29 a.m. cook-A stated it was not sanitary to have dust on fan, she is not sure who cleans it. During interview on 6/28/21, at 10:52 a.m. staffing rep (assisting with dietary) observed the fan and stated that she sees a lot of lint/debris on the fan and further stated it was not ok for that fan to be blowing in the kitchen as it is a fire hazard and not sanitary to be blowing the dust onto the serving areas. Staffing rep stated she was unsure who cleans the fan as she is not sure the facility provided the fan or if it was a staff members. During interview on 6/29/21, at 4:08 a.m. the dietician stated it is not acceptable to have a fan that was caked with dust in the kitchen, as it could contaminate the food sources. Infection prevention and control (Dietary) policy revised 9/2016, indicated the purpose To prevent and control contamination and the spread of infection within the dietary department All equipment shall be thoroughly cleaned after each use

Based on observation and interview, the facility failed to ensure appropriate personal protective equipment including surgical masks and eye protection was worn by staff having direct contact with residents. This had the potential to affect all residents residing in the facility. The facility also failed to ensure proper hand hygiene when handling oral medications for 1 of 5 residents (R5) observed during medication administration. Findings include: R5's Minimum Data Set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment and was usually able to understand others. R5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/29/21, at 5:23 p.m. during medication pass observation, TMA-A was observed returning to the medication cart after administering oral medications to another resident, she did not wash her hands or use hand sanitizer upon returning to the medication cart. TMA-A used the computer mouse to document administration of those medications and to look up R5's scheduled medications. She then removed keys from her pocket. She used the keys to open the medication cart, then returned the keys to her pocket. TMA-A opened the medication drawer then removed three cards containing oral medications from the medication cart and placed them on the top of the cart. She then opened the top drawer of the medication cart and removed an oral inhaler and placed it on the top of the cart. She grabbed a plastic medication cup and placed it on the top of the medication cart. TMA-A grabbed the top medication card in her right hand, placing her left hand under the card. She then pushed the oral medication through the card and into the palm of her ungloved left hand. She then placed the medication in the medication cup on the cart. TMA-A repeated this action with the two other oral medications. TMA-A then returned the three medication cards to the drawer and locked the medication cart. She used the mouse to lock the computer screen. TMA-A then used a spoon to put applesauce into another plastic medication cup. The two cups, with the oral medications and the applesauce, and the oral inhaler were brought into R5's room. On 6/29/21, at 5:28 p.m. TMA stated it is automatic that she punched the oral medications out of the medication card and into her ungloved hand, that she had never been told to not punch pills out into her hand. TMA-A confirmed she did not wash her hands or use hand sanitizer when returning to the medication cart. On 6/30/21, at 2:00 p.m. director of nursing (DON) stated it is expected hand hygiene is performed, whether with soap and water or using hand sanitizer, between each resident. It is expected medications are punched into the medication cup, not into the staff's hand. Facility policy for hand hygiene during medication pass was requested but was not received. PPE On 6/28/21, at 5:15 p.m. nursing assistant (NA)-D was observed wearing a cloth face mask. NA-D was observed going in and out of residents' rooms and interacting face-to-face with residents. During interview NA-D stated the cloth mask he currently had on is the one he has been using since he started approximately two months prior. NA-D indicated no one had told him he was not able to wear a cloth masks and he had seen several other staff also wearing cloth masks. NA-D provided assurance that he is washing the cloth mask after each shift he works. NA-D confirmed he worked with a variety or residents and provided personal cares several times throughout each shift worked. He has worked each unit of the facility, while wearing the cloth mask. On 6/29/21, at 10:25 a.m. housekeeping (HSKP)-A stated cloth masks are allowed now because the risk are low enough in the county. HSKP-A was not sure what the actual number was, I think they are just allowing it. HSKP-A stated there was no communication or training put out regarding the face masks, but it was assumed that cloth face masks were allowed. On 6/29/21, at 1:56 p.m. NA-E was observed wearing a cloth face mask. NA-E stated he washes the face mask, every now and then. NA-E was not sure what the cloth face mask was able to filter out and confirmed there was not a removable/changeable filter inside the mask. NA-E indicated no one had told him he needed to wear a surgical mask, as far as I know they are fine with us having these masks on. NA-E confirmed he had surgical masks available to him, but he preferred the cloth mask because it was thicker. NA-E confirmed he has worked all units within the facility and has provided care to residents which included assisting with a variety of personal cares. On 6/29/21, at 2:01 p.m. registered nurse (RN)-C was interviewed about staff who assist residents with person cares wearing cloth face masks. RN-C responded, they are wearing a facial covering. They do wash it. He was not aware of staff were required to wear surgical masks versus cloth masks. RN-C confirmed, they are not currently experiencing a shortage of personal protective equipment, which included surgical masks. RN-C confirmed information found on facility document, COVID-19 AAH Mask wearing update, dated 6/15/21, indicated all employees must wear a well-fitting cloth or surgical mask when working in common areas. RN-C was not sure what source this guidance was from, but also confirmed a link was referenced on the document to a Minnesota Department of Health website. COVID-19 Recommendations for Health Care Workers, dated 5/10/21, indicated unvaccinated and fully vaccinated health care workers (HCW) should continue to wear a medical-grade facemask and eye protection while at work for source control. On 6/28/21, at 4:12 p.m. nursing assistant (NA)-G was observed at nursing station wearing a mask covering only his mouth. ADON was also present wearing a cloth mask. Neither wore eye protection nor had it on their person. On 6/29/21, at 9:05 a.m. NA-B was observed wearing a surgical mask. No eye protection was observed During interview on 6/29/21, at 9:06 a.m. NA -B stated the need for personal protective equipment was based on the county positivity rate, and the facility communicated the information to staff via mass text. She stated if a resident was in quarantine she would wear an N95 mask, otherwise a surgical mask was required. She stated eye protection was not required. On 6/29/21, at 09:26 a.m. activities staff member (AS)-A was observed wearing a floral disposable mask. Eye protection was neither worn nor on her person. During interview on 6/29/21, 09:26 a.m. AS-A stated she ordered her masks online and preferred them as they were not as 'fibery'. She stated there was no way to know which staff or residents were vaccinated therefore all were treated with the same standard precautions. On 6/29/21, 09:44 a.m. NA-F was observed wearing a surgical mask. Eye protection was neither worn nor on her person. During interview on 6/29/21, at 09:44 a.m. NA-F stated the facility provided masks for staff, but staff were not required to wear eye protection. On 6/29/21, at 12:50 p.m. NA-G was observed wearing a mask covering only his mouth. Eye protection was neither worn nor on his person. During interview on 6/29/21, at 12:50 p.m. NA-G stated he used to wear eye protection when there was COVID-19, but stated it was now optional. He also stated he was allowed to wear his mask under his nose when not with a resident because he was vaccinated against COVID-19, as evidenced by a red tag on his name badge. He stated if staff are vaccinated they can remove masks when around other vaccinated staff. During observation on 6/30/21, at 7:32 a.m. NA-J was at the nursing station wearing a cloth mask. Eye protection was neither worn nor on her person. Two boxes of masks and one box of eye protection were available on the counter at the nursing station. During observation on 6/30/21, at 7:33 a.m. DON was wearing a cloth mask. Eye protection was neither worn nor on her person. During observation on 6/30/21, at 7:35 a.m. TMA-B was not wearing eye protection, nor was it on her person. During interview on 6/29/21, at 2:34 p.m. infection preventionist RN-C stated staff with a red tag on their name badge were vaccinated, and unvaccinated staff should have been wearing eye protection. He stated he could not require them to wear the tag, but most vaccinated staff wore it. He stated he would change the policy to indicate staff must wear surgical masks and cannot wear home made or cloth masks. He stated he did not know if the floral disposable masks were surgical, but the facility had plenty of masks for staff. During interview on 6/30/21, 11:35 a.m. infection preventionist RN-C stated CMS determined the county had a moderate COVID-19 transmission level which warranted the use of eye protection by staff for patient care encounters. The facility did not meet the criteria to remove eye protection as outlined in the Minnesota Department of Health guidance COVID-19 Universal Eye Protection Risk Assessment for Long-term Care and Assisted Living-type Settings dated 6/25/21.

Based on observation, interview, and document review the facility failed to follow orders for monitoring weights for 4 of 4 residents (R3, R24, and R25), the facility failed to assess bruising for 1 of 1 residents (R13). In addition, the facility failed to notify provider for 1 of 1 residents (R41) for a blood sugar readings above a specified range. Findings include: R25's face sheet undated, indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's quarterly minimum data set (MDS) dated [DATE], indicated moderate cognitive impairment. R25's MDS further indicated need for assistance of one assist for dressing and personal hygiene. R25's care plan revised on 6/15/21, indicated the resident has an activity of daily living (ADL) self-care performance deficit r/t chronic diastolic CHF, hx of bilateral pleural effusion, and moderate cognitive deficit. R25's care plan further indicated the resident has congestive heart failure and vital signs should be monitored weekly. R25's weight calculations percentage loss on 05/19/2021, the resident weighed 204.6 lbs. On 06/16/2021, the resident weighed 193.3 pounds which is a -5.52 % Loss. R25's cardiology note dated 6/4/21, clinical impression included: marked [CONDITION(S)] with evidence of pulmonary vascular congestion (extra fluid in the lungs), I believe this patient would benefit from increased diuretics, chronic heart failure. Recommendation included changing [MEDICATION(S)] to 10 mg as [MEDICATION(S)] is likely to make his peripheral [CONDITION(S)] worse. Start [MEDICATION(S)] 2.5 mg by mouth every other day in the morning with his [MEDICATION(S)] to see if we can reduce his pulmonary congestion and peripheral [CONDITION(S)]. R25's provider orders dated 6/19/21 [MEDICATION(S)] (diuretic) 80 mg by mouth every morning for CHF and 40 mg by mouth every evening for CHF. Progress note dated 6/23/21, at 11:20 am indicated new order to obtain weights three times per week, one time a day every Monday, Wednesday, and Friday for weight loss and resident is on isolation precautions for C-diff. Staff care guide sheets updated 6/29/21, indicated R25 should be weighed on Wednesdays. R25's weight list dated 7/1/21, indicated last weight done on 6/16/21 was 193.2. The only other documentation of weight was 5/19/21 which was 209.4 (was in a wheelchair), and 5/17/21 weight was 204.6. During interview on 6/29/21, at 12:59 p.m. trained medication aide (TMA)-A indicated resident is to be monitored for weights due to weight loss and his current infection of c-diff. TMA stated the nursing assistants (NA) weigh the residents and mark them on the clipboard the nurses will review and enter into the computer. TMA further stated it was important to weigh residents to make sure they are stable and not losing or gaining to much weight. During interview on 6/29/21, at 1:15 p.m. licensed practical nurse (LPN)-A stated R25 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-A stated right now they have no way of weighing him outside of his room due to being on precautions, however he thinks they could use the hoyer lift and just clean the machine, but has not brought this to the attention of the registered nurses. LPN-A confirmed R25 should be being weighed three times a week Monday, Wednesday and Friday, and stated It was a nursing order not a provider order. LPN-A stated he was not aware of any weight loss with R25 until he looked into the computer while talking and stated he would classify his weight loss as a significant loss. LPN-A further stated the provider and dietician should be notified as well to further monitor. During interview on 6/29/21, at 2:15 p.m. NA-B stated R25 should be weighed on his bath days which was Wednesday and then reported to the nurse if he refused. NA-B stated it was important to weigh residents to make sure their weights are stable. During interview on 6/29/21, at 4:14 p.m. Dietician stated R25 was put on strong diuretics and now has c-diff and it was important to monitor his weights to make sure he has not lost any more weight. The dietician stated she sees his weight was up to 204, but he is now back to baseline at 193 and stated they should be monitoring his weight to make sure he is not losing anymore weight. The Dietician stated she sees an order that was put in by nursing on 6/18/21 for three times a week weights and would expect staff to be weighting him. During interview on 6/29/21, at 4:51 p.m. registered nurse (RN)-A stated in general all residents should be weighed at least weekly, however with R25 there was an order that was just put in for three times a week weights. RN-A stated she would be expecting staff to weigh residents and if they were unable to weigh him that it should be reported to the RN's. RN-A stated it was important to monitor R25's weight as he was on diuretics and due to his nutritional status and c-diff. During interview on 6/29/21, at 5:05 p.m. RN-B stated R25 should be monitored for weight three times a week and if no specific order all residents should be done once a week. RN-B further stated it is not ok to go a month without being weighed and it is important to monitor his weights due to being on diuretics and c-diff and should monitor for a decline in status. During interview on 6/30/21, at 10:35 a.m. the director of nursing (DON) stated if a resident has a weight that states three times a week weights, she would expect this resident to be weighed three times a week. DON stated she was not aware that he was not being weighed or had no way of weighing R25 due to precautions. DON stated there are ways to weigh someone on precautions if that meant getting a new mobile scale or bringing resident out when no other residents were in the hallway to keep isolation precautions. DON stated it was important to weigh R25 to monitor his status and make sure he is not losing to much weight or regaining weight with the diuretics. Weight assessment and intervention policy expires 6/21, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified nursing will immediately notify the dietitian in writing. Verbal notification be confirmed in writing. R41's Facesheet undated, indicated Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's quarterly MDS dated [DATE], identified no cognitive impairment. R41's provider orders dated 6/29/21, indicated Novolog [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Aspart) (medication to bring down blood sugar) Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 999 = 10 to Notify MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9). R41's weights and vital summary dated 6/29/21, indicated blood sugar on 6/28/21 at 12:01 was 442 and then on 6/15/21 at 10:51 pm blood sugar was 411. During interview on 6/29/21, at 1:05 p.m. LPN-A stated he was aware of R41's blood sugar was 442 on 6/28/21, but stated I knew it was from R41 eating ice cream and sometimes you have to use your common sense and I did not notify the provider. LPN-A stated you should follow the provider orders however with him it is due to R41's bad habits. LPN-A further stated the providers have access to his point click care and can see his results. LPN-A stated he went down and assessed R41 and he wasn't having symptoms so he gave him his insulin but did not follow the order and notify the provider. LPN-A stated he could not find documentation on 6/28/21 nor 6/15/21 when blood sugars where elevated. During interview on 6/29/21, at 4:22 p.m. the Dietician reviewed Novolog orders and stated if residents blood sugar was 442 according to providers orders the provider should of been notified and is unacceptable for staff not to notify the provider. The dietician further stated it is important to notify provider of high blood sugars as it could mean their medications need to be adjusted or there is something else going on with the resident. During interview on 6/29/21, at 5:12 registered nurse (RN)-B stated if a residents blood sugar was 442 she would expect staff to notify the provider and it was unacceptable for the nurse not to notify the provider even if the resident ate ice cream. RN-B stated it was important to follow providers orders. During interview on 6/30/21, at 10:35 a.m. the director of nursing (DON) stated according to R41's Novolog orders any blood sugar over 351 the nurse should be giving him 10 units of insulin and calling the provider. DON stated it is nursing standards to follow provider orders and notify the provider if the order states to or the blood sugar is out of the normal despite R41 having ice cream. DON further stated it was important to notify the provider in case the provider needed to adjust his medication. DON further stated she will be changing the settings for his orders/parameter in point click care as it has the capability to make sure an outcome was completed. Diabetes-Clinical protocol expires 6/21, indicated The physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing care of resident with diabetes mellitus expires 6/21, indicated The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. R13's quarterly MDS dated [DATE], indicated R13 was severely cognitively impaired, she was sometimes able to make herself understood and sometimes able to understand others. R13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13 was able to move her upper extremities without limitations. During observation on 6/28/21, at 12:05 p.m. R13 was noted to have a large bruise on her left arm that started at her wrist and extended to approximately halfway between her wrist and her elbow. The bruise also wrapped around her arm. The bruise was at various stages of healing. Also noted was a large, deep purple bruise starting at the base of her left thumb and extended to the back of her hand. R13 had several smaller, scattered, deep purple bruises on her right arm. R13 was not able to explain how she got the bruises. Progress notes failed to identify the bruising. There were no skin assessments completed during 6/2021. On 6/29/21, at 12:48 p.m. nursing assistant (NA)-A confirmed the bruising on both R13's arms and stated she had previously noted the bruising but was not sure how long they had been there. NA-A explained what she reports to the nurse, when doing daily skin checks, depends on what it is. If it is something that is common for that resident, such as the bruising is for R13, she would first talk with her co-worker, another nursing assistant, to decide if it needs to be reported. NA-A did not recognize the bruising on R13's arms. NA-A was not sure if she would have reported this, indicating she would talk with another nursing assistant first. NA-A stated R13 does not become physically aggressive or resistive with cares but does swing her arms around when she gets excited and is happy. On 6/29/21, at 1:45 p.m. licensed practical nurse (LPN)-A confirmed he was aware of the bruising on R13' arms but was not aware of how they happened. LPN-A confirmed they were not monitoring the bruising or documenting in the progress notes. On 6/29/21, at 2:09 p.m. LPN-B confirmed the bruises located on R13's arms. She stated, R13 is given her call light, but does not consistently use it. She would often slap her arms to get the staff attention. LPN-B indicated she had made previously made notes regarding R13's bruising and discussions with R13's daughter about the bruising. LPN-B's notes were requested but were not received. On 6/29/21, at 2:17 p.m. registered nurse (RN)-B stated she expected all skin concerns or changes, including bruising, were reported to the nurse and documented. This included previously reported skin concerns. Reported bruises should be documented in the progress notes with size and appearance. Bruising should then be monitored either daily or weekly, depending on the severity of it. Bruises are investigated to decide the cause and how to avoid recurrence. RN-B indicated she was not aware of R13's bruises on her arms, but confirmed size, location and varied stages of healing. On 6/30/21, at 1:50 p.m. director of nursing (DON) stated anything that was seen, new or existing, needed to be documented, even if it is a bruise that is fading. DON expected bruising with a known cause is still investigated and documented. If a resident bruises easily, then need to determine the cause so changes can be made to prevent bruising. A facility policy regarding skin checks was requested but was not received. R3's face sheet undated, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarterly minimum data set (MDS) dated [DATE], indicated cognition intact. R3's MDS further indicated need for extensive assist of one for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. R3's care plan revised on 3/27/19, indicated resident on diuretic therapy and hypertension ([CONDITION(S)]) medications r/t [CONDITION(S)], [CONDITION(S)], chronic kidney disease (CKD) and poor circulation. R3's care plan further indicated resident monitored for side effects and effectiveness, wt. (weight) and vital signs (VS) at least weekly or per order and prn (as needed), and MD updated of excessive wt. gain or abnormal VS from resident's baseline. R3's signed provider order summary dated 5/13/21, indicated weight one time a day every Monday, Wednesday, Friday related to localized [CONDITION(S)]. R3's signed provider order summary dated 5/13/21, indicated [MEDICATION(S)] (diuretic) 2.5 mg by mouth one time a day every Mon, Wed, Fri related to localized [CONDITION(S)] was initiated 11/13/17. Additionally, provider order dated 1/24/20, [MEDICATION(S)] (diuretic) 1 mg by mouth two times a day related to unspecified diastolic (congestive) heart failure. R3's weight summary dated 7/1/21, indicated documented weights from the last six months were obtained 1/8/21, 1/19/21, 1/22/21, 1/29/21, 2/2/21, 2/5/21, 2/9/21, 2/16/21, 2/23/21, 3/2/21, 3/5/21, 3/9/21, 3/12/21, 3/16/21, 3/23/21, 3/26/21, 3/31/21, 4/8/21, 4/9/21, 4/13/21, 4/20/21, 4/27/21, 5/4/21, 5/5/21, 5/7/21, 5/11/21, 5/18,21, 5/25/21, 6/1/21, 6/8/21, 6/15/21, and 6/29/21. During interview on 6/30/21, at 9:29 a.m. licensed practical nurse (LPN)-B stated that R3 had her weight taken on Tuesdays. As LPN-B reviewed R3's electronic health record (EHR), LPN-B stated I see the order now for Monday, Wednesday, Friday. It needs to be adjusted. LPN-B further stated R3 wanted to be weighed only one time a week and the management of weights was overall a team effort. During interview on 6/30/21, at 11:13 a.m. registered nurse care manager (RN)-A stated the charge nurse monitored weights. RN-A further stated the charge nurse reviewed resident orders prior to provider visits to ensure order changes were requested, and weights were reviewed at standup meetings. RN-A further stated if provider orders were not followed, it would be written up, During interview on 6/30/21, at 2:51 p.m. interim director of nursing (DON) stated staff were expected to follow provider orders for weights and nurses were expected to monitor weights. The DON further stated if a resident refused to be weighed, she would expect the nurse to completed an assessment and notified the provider after the resident's third refusal. Additionally, the DON stated she expected orders to be followed as written until they were discontinued or changed. R24's quarterly MDS dated [DATE], indicated R24 was cognitively intact, used a walker or wheelchair for locomotion, and required limited assistance/supervision with walking and toileting. The MDS identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's care plan dated 2/14/21, included an intervention to weigh R24 as ordered by provider which was to be completed at the same time under the same conditions with same amount of clothing. R24's order summary report contained a provider order for daily weights relating to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's treatment administration record (TAR) lacked documentation of daily weights on 30 of 104 days between 2/15/21, and 6/28/21. No explanation of missing values were recorded on R24's progress notes. During interview on 6/30/21, at 2:51 p.m. DON stated she expected provider orders to have been followed. She stated if the TAR noted a task was complete she expected it to have been completed otherwise it would be considered falsification. DON reviewed R24's daily weight documentation and stated she observed gaps. She reviewed the TAR and acknowledged there were more weights documented as having been completed than were recorded in R24's vital sign documentation. She stated they [staff] signed off something that was not completed, and her expectation was weights would be recorded and signed off only when completed.

Based on observation, interview, and document review, the facility failed to implement adequate supervision and safety measures to ensure residents were free from accident hazards, for 1 of 3 residents (R1) reviewed. This resulted in actual harm when R1 sustained a fall resulting in two fractures, while receiving therapy. Findings include: R1's admission record, dated 5/2/18, indicated R1 had [DIAGNOSES REDACTED]. R1's Morse Fall Scale, completed 5/7/20, indicated R1 had history of falling, had impaired gait, overestimates or forgets limits, and was categorized as, High Risk for Falling. R1's Safety Risk Assessment, completed 2/6/20, indicated R1 had a history of [REDACTED]. Also included, R1 was at risk for falls due to history of falls and declining cognition and mobility, and was no longer safe to transfer or ambulate on own. R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 had moderate cognitive impairment and required extensive assistance of two staff for bed mobility, transfers, walking in the room and corridor, dressing, and toilet use. The MDS also identified R1 was not steady, was only able to stabilize with human assistance during transitions and walking, and had functional limitation in range of motion in upper extremities on both sides. Also, included, R1 had no falls since the previous MDS assessment, completed 2/20/20 due to a significant change, which indicated one fall with no injury, two or more falls with injury, and one fall with major injury. R1's care plan, last revised 2/25/20, indicated R1 had a performance deficit with activities of daily living (ADL) due to declining cognition, [DIAGNOSES REDACTED]s, decreased mobility, generalized weakness, and chronic back pain, and required extensive assistance of two staff, with gait belt and four wheeled walker for transfers, and extensive assistance of two to three staff, four wheeled walker and gait belt, followed by wheelchair, when ambulating. The care plan also indicated R1 was at risk for falls due to history of falls with injury, declining cognition, and mobility, and needed assistance to stabilize. Review of R1's physician orders [REDACTED]. R1's Physical Therapy PT Evaluation & Plan of Treatment, dated 5/8/20, indicated [DIAGNOSES REDACTED]. Long-Term goals identified R1 would demonstrate ability to perform sit to stand from recliner with minimal assist of one, improvement in bilateral lower extremity strength in order to improve stability in stance, be able to stand without upper extremity support for at least 30 seconds without loss of balance, and would be able to ambulate at least 200 feet with CGA (contact guard assist-physical therapist needs to have one or two hands on patients body to help steady body or help with balance) to minimal assist with rolling walker and cues for anterior weight shift less than 25% of time. Review of the Physical Therapy Treatment Encounter Note(s), dated 5/14/20, indicated, Once standing (R1) is able to maintain balance with only CGA for several minutes. Also indicated, all activities with CGA to minimal assist at all times to avoid loss of balance, and R1 had most difficulty with retrobalance (loss of balance in backwards direction) requiring minimal assist to avoid loss of balance. Physical Therapy Treatment Encounter Note(s), dated 5/15/19, included R1 reported his legs were really sore today, and staff reported R1's knees buckled during a transfer after PT on 5/14/20, and it took three staff to keep R1 from falling. Physical Therapy Treatment Encounter Note(s), dated 5/18/20, included, R1 completed standing glute sets, on parallel bars, CGA on gait belt. PTA (physical therapy assistant) positioned in front of pt (patient); pt sustains falls when PTA steps back to switch position to side of patient. Also included, During standing glute sets pt sustains fall backward when PTA lets go momentarily to switch positions with pt having BIL (bilateral) HHA (hand hold assist) on bars. Patient was wearing a gait belt and until the fall PTA had been in CGA with pt. During an observation on 5/21/20, at 2:00 p.m. R1 was lying in the bed, resting. A sling was noted on R1's right arm/shoulder, and R1 indicated he had to wear a boot on his right foot. R1 stated, (PTA-A) was walking me and went to switch sides. I fell back. R1 stated he just wanted to get stronger so he can walk and indicated he wasn't sure what happened, he just felt himself go backwards and he hit the floor. R1 indicated he had a gait belt on and stated with tears in eyes, (PTA-A) felt bad, but she didn't do it. It was me. I should be able to stand. Review of the Patient Incident/Injury Report Form, dated 5/18/20, at 1:10 p.m. included R1 was working with PTA-A in the parallel bars in the facility rehabilitation room, positioned in front of him holding the gait belt, and R1 was holding onto each side of the parallel bars. PTA-A let go and stepped back as she was going to change position to stand at R1's side. R1 had loss of balance backwards and fell to the floor when PTA-A let go of the gait belt. Review of the Appleton Area Health documentation, dated 5/18/20, included X-ray results indicated R1 sustained a nondisplaced fracture of right fibula (long, thin and lateral bone of the lower leg) and nondisplaced fracture of right humeral neck (long bone of the upper arm that extends from shoulder to elbow) when he fell , and CT (computerized tomography) scan of the brain indicated no [MEDICAL CONDITION] (bleeding in head) or cranial fractures. During an interview on 5/21/20, at 9:55 a.m. PTA-A stated she was working with R1 due to him having poor balance and history of falls. PTA-A stated, on 5/18/20, she ambulated with R1 from his room, into the hallway. R1 wore a gait belt, used a four wheeled walker, and nursing assistant (NA)-A and restorative aide (RA)-A assisted. PTA-A stated, after approximately 75 feet, R1 wanted to sit in the wheelchair. R1 was pushed into the rehabilitation room and PTA-A allowed him to rest. RA-A and NA-A left the room to help another resident. After resting, PTA-A stated she assisted R1 to stand and positioned him inside the parallel bars. PTA-A stated she was standing in front of R1, holding the gait belt, having R1 perform different exercises. PTA-A stated R1 was in the middle of the parallel bars, and she let go of the gait belt momentarily to step around to R1's side, outside of the parallel bars. R1 fell backwards to the floor. PTA-A stated she should have had R1 sit prior to letting go of the gait belt, however, she had let R1's gait belt go in prior sessions and he had never let go of the parallel bars. PTA-A stated the first time she walked with R1 on 5/14/20, he was super staggering and unsteady. On 5/18/20, PTA-A stated, when she and NA-A and RA-A walked R1, he was not nearly as unsteady. PTA-A stated, I thought he was improving. I felt he was stable enough for me to walk around him. PTA-A stated, after R1's fall, her manager talked to her and, Going forward, if someone is unsteady or a balance patient, I would have a second person to steady, or I could have him sit first and then switch positions. During an interview on 5/21/20, at 10:14 a.m. physical therapist (PT) indicated he and PTA-A worked for a therapy agency, and they were contracted to provide therapy services to residents at the facility. PT stated he oversees PTA-A and had talked with her about R1's fall. PT stated he assumed, by PTA-A's description, that she had R1 in the parallel bars, working on balance, and probably had him standing in the middle, and then went out of the parallel bars to change positions when R1 fell . While in the rehabilitation room, PT demonstrated how he would work with a resident in the parallel bars, indicating he would typically have the wheelchair close, and would have the resident sit while he switched positions. PT stated he had not provided any re-education for PTA-A, because she had a manager that was responsible for doing that. When interviewed on 5/21/20, at 10:27 a.m. registered nurse (RN)-A stated she was out in the hallway when RA-A came to say that R1 was on the floor. When RN-A got to the rehabilitation room, R1 was lying within the parallel bars, parallel to the bars. R1 had a skin tear on the left elbow and was complaining of pain in his back and right shoulder. R1 was lifted off the floor with a full body lift, assessed, and R1's health care provider was notified. R1 was sent to the emergency room that was attached to the nursing home, via wheelchair, for further assessment. RN-A stated R1's balance waxes and wanes, and he required assistance of two when transferring due to his unsteadiness. RN-A stated she had only worked at the facility a short time, but stated, I know they used to transfer him with one assist but recently he seemed more unsteady so we were using two. He was more shaky and tired, depending on the time of day. During an interview on 5/21/20, at 10:39 a.m. RA-A stated he had been working with R1 for upper and lower extremity strengthening, and in the past five months, R1 had gained strength in his lower extremities, however, RA-A stated his balance and strength still depended on the day, and time of day, and stated R1 always required assist of two staff in the morning with cares due to being more weak and groggy. RA-A stated R1 was always more alert and oriented in the afternoon, so that was the best time to work with him. On the day that R1 fell , RA-A stated it was around 1:00 in the afternoon, and R1 agreed to work with PTA-A. R1's gait belt was put on, and PTA-A and NA-A assisted R1 to ambulate into the hallway, with RA-A following with a wheelchair. R1 walked part way and became tired, so he was pushed by wheelchair into the rehabilitation room. RA-A stated staff from therapy normally worked with R1 alone, and RA-A stated he left the room to assist with another resident. When RA-A walked back by the rehabilitation room, R1 was lying on the floor, and was complaining of pain in his right shoulder and was crying. RA-A indicated he assisted to lift R1 off the floor with the full body lift and transported R1 to the emergency department in his wheelchair. RA-A stated, We always have two staff with transfers. He is that unsteady. If we were to let go, he tends to go back. I assumed that everyone knew that. The main thing is don't let him go backwards .I have worked with him many times in those parallel bars and never had an incident, but I never let go. When interviewed on 5/21/20, at 1:30 p.m. director of nursing (DON) stated R1 had gone back and forth with therapy, would get stronger and do well, and then would become ill and would require physical therapy again. DON stated R1 had made so much progress and was getting stronger, however, We continued to use two assists because his strength is so variable. DON indicated he had no concerns with PTA-A and stated, She's so good. She's so concerned with safety. She just got too comfortable maybe, feeling that he could hold the bars briefly so she could switch positions. During an interview on 5/21/20, at 1:37 p.m. RN-B stated, after a fall with fracture to his left humerus in December, R1 had really gained some strength back, and as of late, was doing well, however, R1's strength had been variable, and required two assist for ambulation and transfers. RN-B indicated R1 had several falls in the past due to self transferring. RN-B stated PTA-A was working with R1, by herself, when the fall occurred. When completing the investigation after the fall, RN-B indicated PTA-A reported R1 had been gaining strength and PTA-A was so confident in his progress that she felt she could let go of him briefly to switch positions. RN-B stated she told PTA-A that the nursing assistants always used two assists for ambulation and transfers. RN-B stated there were never safety concerns when PTA-A worked with residents, and there had never been any prior incidents with PTA-A or therapy in general. When interviewed on 5/21/20, at 6:01 p.m. PTA-B stated she was the clinic manager for Big Stone Therapies, and was PTA-A's manager/supervisor. PTA-B stated a PT is at the facility three days a week and oversees PTA-A. PTA-B stated she received a phone call from PTA-A immediately after R1 fell . PTA-A reported R1 was in the parallel bars, working on some things, and PTA-A was in front of R1. PTA-A was going to move out of R1's way, and the next thing she knew, R1 was on the floor. PTA-B stated she had worked with R1 a few months ago, and stated, He does have a tendency to lose this balance. PTA-B stated, We talked about the situation and what she should have done or could have done differently .having him sit, move wheelchair closer, having someone assist. PTA-B stated, We don't typically have two staff to assist with therapy, and with COVID, we're trying to keep the exposure down. Therapists are treating all patients by themselves. PTA-B stated, My expectation would be, that in the future, to look at the patient that we're treating. During a follow up interview on 5/22/20, at 10:40 a.m. PT stated, When in parallel bars, with (R1's) fall risk and posterior loss of balance, (R1) should have contact guard assist, and stated, Contact guard assist means having your hand on the patient while walking. PT stated, There comes a period of time where less support is needed, based on judgement .I make that judgement by testing it and being right there to catch the patient .We are trying to progress the patient and when we have our hands on them all the time, it gives them a false sense of security. PT stated he and PTA-A discuss patients' status all the time. PT-A stated, I do believe she should have had her hand on (R1). I don't know what lead up to that decision. It's unfortunate, she's very good at what she does. Review of the facility's policy, Using the Care Plan, dated 7/19, included, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of the facility's policy, Falls and Fall Risk-Managing, dated 7/19, included, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.