Every finding on record at Avera Morningside Heights Care Center

Based on observation, interview, and document review, the facility failed to ensure adequate supervision was provided to prevent falls for 1 of 3 residents (R2) reviewed for falls. R2 needed increased monitoring for safety due to her fall risk with one-to-one (1:1) supervision which was not provided when the nursing assistant (NA) left R2 alone to go wash their hands. R2 then fell causing harm when R2 obtained a left olecranon (elbow) fracture which needed surgery. Findings include: R2's progress note, dated 1/2/26, identified R2 admitted to the nursing home from the hospital. R2 was an assistance of two staff with an EZ Stand for transfers and was non-weight bearing (NWB) to her right upper extremity with a sling on at all times. R2 was recorded as not verbally responding and having poor memory due to dementia. R2's Fall Risk Assessment, dated 1/2/26, identified R2 had sustained a fall within the last three months, had altered mental status, impaired mobility, and consumed at-risk medications. The assessment scored R2 as, 5: Higher fall risk precautions, and directed interventions which included non-skid footwear and PT/OT. R2's 5-Day Minimum Data Set (MDS), dated [DATE], identified R2 had severe cognitive impairment and had sustained falls prior to admission with a fracture. R2's corresponding Falls Care Area Assessment (CAA), dated 1/10/26, identified R2 had advanced dementia with severe aphasia (communication disorder) and was rarely understood. The CAA recorded R2 had sustained a fall prior to her admission with fracture obtained (right elbow) and listed her being not behavioral but just busy which placed her at continued high risk for falls. The CAA identified R2's assessed risks as falls, pain, injury, and decline. R2's progress note, dated 1/11/26, identified R2 had a fall on 1/10/26 at 9:12 a.m. with dictation, . [R2] had been one on one with staff in the evening due to restlessness for her safety. Staff were with [R2] in the open area dining room giving her a snack and getting her settled after her HS [bedtime] medications had been given. Staff were needed to help a two-assist resident, so were called away. It is estimated that about two minutes lapsed from the time they had to leave her to the time this writer came around the corner in the dining room area where she was found in the middle of the room on the floor with her wheelchair behind her. The fall resulted in two lacerations above her left eye, a small bleed on her left elbow, a skin tear, and a hematoma. The provider was updated and ordered R2 to be seen in the emergency department (ED). Registered nurse (RN)-D authored the note. R2's FSI - Fall Scene Investigation Report, dated 1/10/26, identified a section to record the fall details. This identified a hand-drawn photo of how R2 was found on the floor with injuries listed as head laceration and left elbow skin tear. Just prior to the fall, R2 was recorded as sitting by kitchen self-propelling in the wheelchair facing the staff. The staff was called away for a two person assist, then staff came back and gave her a snack, then left again to help another resident when R2 was then found on the floor. R2 hit her head due to the unwitnessed fall. The report included a section to be completed by the primary NA working with R2 who recorded, The patient has been one on one with the writer, offered snacks and drinks and has been moving with the wheelchair all around the unit all under watch. The NA then pushed R2 next to a patient room where the other NA needed help. The NA then left R2 to assist the other NA, returned and spoke with R2, and then left again to dispose of the trash. NA-C authored this section of the note. The report continued and listed a section labeled, Root Cause of This Fall, which identified a checkmark placed next to R2's medical status and mental status with handwritten, Severe Dementia. The section asked, What appears to be the root cause of the fall[?], which was answered in writing by RN-D as, She was not one on one - self-propelled [sic] herself and attempted to get up and fell. A new intervention was written that if staff have to leave R2 unattended, they should let the nurse know so options can be assessed. R2's Fall Follow Up, dated 1/10/26, identified an initial evaluation of the fall and repeated several items from RN-D's progress note along with R2 being sent to the hospital ED and diagnosed with a displaced olecranon fracture. The report identified registered nurse manager (RN)-B was notified of the fall. A section labeled, Fall Severity, identified R2 as having sustained, Major Injury. A section labeled, Post Fall Investigation, identified R2 had sustained falls in the last week or more than three times within the past 30-day period with notes, [R2] admitted to our facility post status right hip fx [fracture] and right arm fx. The intervention placed for this fall on 1/10/26 was if staff were called away to assist others and R2 could not be placed next to a table to prevent her leaning forward, to let a nurse know so options can be explored. A subsequent Follow Up, dated 1/11/26, identified the fall from 1/10/26 but this time included a section labeled, Post Fall Education Additional Information, which directed an intervention was communicated with staff that if they need to leave R2 unattended when she is not settled that they need to tell the nurse so something can be done to get someone by her. A corresponding Threshold Investigation Worksheet, undated, identified R2's fall on 1/10/26 was reviewed by the nursing team. R2's progress note (dated 1/11/26 by RN-D) was reposted to it as background information with a section below which posed arrows going down for staff to ask, WHY? after each item identified. This recorded only two items which were, Why did [R2] fall? > She was trying to get up to find someone. The report identified two strengths from the situation, in which staff identified R2 needed to be a 1:1 due to anxiousness and attempted to see if she had unmet needs. The one opportunity they determined was, Better communication surrounding when staff need to leave a resident due to caring for another resident. R2's Emergency Department (ED) Discharge Plan, dated 1/10/26, identified R2 was seen in an ED for a fall at the nursing home which left an abrasion of her elbow, forehead laceration, and a closed olecranon fracture. R2 presented with advanced dementia and was found on the floor in front of her chair with exact details of the fall being unknown. R2 was recorded as non-verbal at baseline but said, Ow, with movement in the ED so an x-ray was ordered which identified a left elbow olecranon fracture. R2 was placed in a sling, and an orthopedic follow-up was recommended. R2 was discharged back to the nursing home. R2's care plan, dated 1/30/26, identified R2 was at risk for falls or injury due to a history of prior falls and poor balance. The plan listed interventions recorded as Safety Measures, being last revised on 1/11/26. These included notifying the nurse if the NA has to leave her alone, offering food or toileting if restless, and using busy boards or wildlife shows to occupy her time. The care plan lacked any current or historical recorded intervention for 1:1 supervision despite the progress notes saying one was needed. R2's progress note, dated 2/12/26, identified R2 went to an orthopedic appointment with her family member present. The x-rays showed stable alignment of the left elbow and family agreed to proceed with surgery. R2 was ordered to continue with the Exos brace (splint used for fractures in hand or elbow) and orthopedics would schedule an open-reduction internal fixation (ORIF) left olecranon fracture. R2's progress note, dated 2/25/26, identified R2 was sent to same-day surgery for the procedure and returned NWB on her left elbow and with new pain medication prescriptions. During observation on 3/23/26 at 1:22 p.m., R2 was seated in a high-back wheelchair in the commons area of the unit watching television. R2 appeared comfortable and had a black-colored sling on her left arm. R2 smiled when conversed with, however, did not respond to many questions or mumbled a response which was undiscernible. R2 was asked if she had fallen at all in the past months which she did answer, No, and smiled. When interviewed on 3/23/26 at 1:24 p.m., NA-A stated they were working with R2 and described her as needing help with most cares including eating. NA-A stated R2 used the sling on her left arm since she came to the unit from the TCU several weeks prior. NA-A stated they knew R2 had fallen in the TCU but was not sure whether she had gotten injured or not with it. NA-A stated R2 had not sustained anymore falls since she moved to the new unit and R2 was not as active on this unit as she had been on the TCU. NA-A stated staff tried to keep a close eye on her and kept her in the commons area, often including at nighttime but was not on a formal 1:1 anymore. NA-A stated if a resident were on 1:1 and they had to leave them, they would wait to find a nurse or someone else to sit with them first. When interviewed on 3/24/26 at 7:24 a.m., NA-B recalled working on 1/10/26 when R2 fell. NA-C was sitting with R2 in the commons area when NA-B needed help in another room, so NA-C placed R2 while seated in the wheelchair outside the door and told R2 to be patient while they helped. They finished the care and NA-C then left the room while NA-B stayed in the room to clean up. NA-B stated NA-C had then left R2 unattended in the dining room area while leaving to wash their hands and throw trash away. RN-D came into the dining room and found R2 on the floor. NA-B stated R2 did not have any injuries or issues with her left arm or elbow prior to the fall on 1/10/26. NA-B recalled R2 as being 1:1 with staff before she fell that evening due to her cognition. NA-B stated if someone was a 1:1, then staff needed to remain with them and have constant supervision on them and if R2 was in the dining room and someone left to go to soiled utility it would have been out of sight. NA-B stated they were unsure why NA-C did not just wash their hands in the kitchen sink which was in the same room as R2. Following the fall, NA-B stated themselves, NA-C, and RN-D then decided to make sure the RN would be asked to sit with R2 if staff needed to leave her again instead of just leaving her unsupervised. NA-B stated nobody from management had told them that, it was just them working when it happened who decided that. NA-B reiterated a 1:1 means someone needs to always stay with the person and had that been done R2's fall was likely preventable. When interviewed on 3/24/26 at 8:03 a.m., NA-C stated they recalled R2 as being a fall risk and were assigned to R2 when she fell on 1/10/26. NA-C stated they were called to help with another patient by NA-B, so they moved R2 next to the door of that room and told R2 to stay there and they had come back. NA-C then went inside the other resident room and closed the door. When they opened it upon completion of care, R2 had wheeled herself back into the dining room. NA-C again told R2 to stay there and left to go dispose of trash and wash their hands down the hall while out of sight of R2. NA-C was washing their hands when suddenly RN-D called for help and R2 was on the floor. NA-C recalled R2 being very confused that night and stated they did not call for help prior to leaving R2 as they told R2 to wait there and would be right back. NA-C recalled R2 being a 1:1 as she had worked with her prior and she was a 1:1 then adding, We knew that [1:1]. The RN had told them R2 was a 1:1 that night, too, adding aloud, This patient is a 1:1. NA-C stated a 1:1 meant someone should stay with them at all times but again acknowledged leaving the patient quick to wash their hands when she fell. NA-C stated the group involved with the fall then discussed it and talked about how to prevent it again but nobody had discussed or provided re-education on a 1:1 and it's expectations since then though adding aloud, I can't recall that they talked about that. An interview was attempted with RN-D during the abbreviated survey; however, they were on leave and unavailable for interview per the campus administration. On 3/24/26 at 10:05 a.m., a group interview was held with registered nurse unit manager (RN)-B and the director of nursing (DON). RN-B explained someone's fall risk was assessed upon admission and then care plan interventions would be placed from that assessment. These interventions were kinda generalized until they learned more about the resident then more specific interventions would be identified. RN-B stated R2 was admitted with fractures from a fall in her right arm, and the new left elbow fracture happened from the fall on 1/10/26, with R2 possibly being on 1:1 that night due to being more busy and moving around more. It was not care planned but rather had just been nurse driven as an intervention. DON stated they felt there were different avenues someone could use if on 1:1 including just frequent checks versus constant supervision adding staff were trying our best to keep her in the line of sight they felt. DON stated there was not a specific policy or procedure for 1:1 to help define the exact expectations with it, which they had just talked with the administrator and identified as a takeaway from this situation. DON stated they felt the documentation listed in the progress notes and FSI meant to watch R2 closely but did not necessarily mean keeping constant eyesight of her. DON stated if R2 had been 1:1 like they'd expect for a suicide-risk (i.e., direct, constant supervision) then R2's fall was likely preventable but if it was just frequent checks like they felt this situation to be, then there was a chance a fall could still happen despite. Following the fall, some general education on teamwork had been sent to all staff members and RN-B stated they believed they discussed 1:1 expectation at a NA meeting since the fall and would provide that documentation. At 10:38 a.m., RN-B reviewed the agenda from their unit meeting (dated 1/29/26) which identified a discussion labeled, 1:1 activities / what is 1:1, and, Prevent fractures from self-transfers, with an attached sign-in sheet listing employee names and a X if attended. This listing had a total of 91 active employees (as of 1/29/26) but 51 of them did not have an X to demonstrate re-education on the topics. RN-B stated they recalled having discussion on 1:1 at the meeting and using teamwork to ensure supervision is provided when needed. RN-B acknowledged the multiple names on the listing without re-education and stated they were still trying to get some people caught up on it and working on a different system to get better attendance at the meetings. RN-B verified the nurses of the unit were not included in the re-education, either, since it was specific to NA staff members. When interviewed on 3/26/26 at 11:06 a.m., RN-C stated they were currently assigned to R2 and were aware R2 had fallen on the TCU prior and obtained an elbow fracture from it. RN-C stated if they directed a 1:1 for a patient then they expected the NA to have eyesight of them at all times. RN-C there had been no discussion of 1:1's or their expectation to the nurses on it recently to their recall adding, Not that I'm aware of. On 3/24/26 at 12:04 p.m., the DON and administrator were interviewed. DON stated they did not feel the language in the FSI, and progress notes meant a direct 1:1 needed prior to R2's fall but rather the documentation supported that was maybe a new intervention to do post-fall. DON stated the NA staff may have identified R2 was restless and needed more supervision on 1/10/26 and felt they could handle it themselves. DON reiterated they did not feel the language in the chart reflected a 1:1 was needed prior to the fall. The facility LTC (Long-term Care) Falls and Accidents policy, dated 10/2024, identified supervision defined as a determination based on the individual resident's assessed needs and identified hazards in the environment. This added, Adequate supervision may vary from resident to resident and from time to time for the same resident. The policy directed staff would be educated on preventing residents' falls and have access to the care plans for each resident. The resident would also be assessed for fall risk and based upon that, have individualized interventions in place to reduce the risk.

Based on interview and document review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program provided supervision for 1 of 1 infection preventionist (IP), to identify a thorough infection control surveillance program included surveillance of all employee illness. QAPI also failed to ensure employee surveillance was appropriately delegated to personnel in employee health (EH) who were not certified in infection control. This had the potential to affect all 74 residents. Refer to F880 and F882Findings include: Review of the current, facilities infection control surveillance for employees identified the facility utilized corporate employee health to track employee illness. The IP failed to have any oversight for employee illness and relied on corporate employee health (EH) to provide facility employee surveillance. There was no documentation to support the IP was made aware by EH daily of staff call-ins, had oversight to ensure staff would remain out of work, used that daily data to correlated staff illness to potential resident illness, and ensure staff were appropriately screened for their ability to safely return to work. In addition, QAPI failed to ensure EH had an employee certified in IP since they were delegated with monitoring employee illness. Interview on 12/2/25 at 4:10 p.m., with the infection preventionist (IP) identified employee's call central employee health (EH) when ill to report their symptoms, EH then provides the employee general guidelines of when they can return to work. The manager will get a call that the staff called in ill and when they can return to work based on the employee's illness. If employee heath identified a trend in employee illness, then EH would reach out to notify her so she could compare with the facility residents to see if there was any correlation. She revealed that she did not keep a record of employee illness only EH had that documentation. She was responsible for the resident surveillance at the facility and that EH tracked employee illness for the facility. She was not provided any type of spread sheet from EH with documentation of employee illness, their symptoms, and their return-to-work date, she was only called with trends that EH noted. Interview on 12/3/25 at 3:07 p.m., with the IP identified she does not monitor if the staff are following through with contacting EH when they are ill as that would be done by management. The manager was to receive an email related to the employee's illness and the manager was responsible to ensure employees followed any return-to-work guidance indicated by EH. She did not oversee employees as part of her surveillance and relied on department managers and EH to ensure staff illnesses were followed. The IP identified she only discussed or brought information to the QAPI meeting related to staff illness if there was something reported from EH, such as an outbreak. She had not brought information related to staff illness to the QAPI meeting. Interview on 12/3/25 at 3:46 p.m., with director of EH identified employees were to contact corporate EH when they were ill. A registered nurse (RN) would manage intakes from staff and was to have gone through an in-depth questionnaire with the employee and make recommendations according to Centers for Disease Control (CDC) and/or the Minnesota Department of Health (MDH). If needed, EH would follow up with staff members. EH was to notify the IP at the facility if they noted a trend or pattern with employee illnesses, but failed to have an ongoing, current method of communication for illness that was not identified to be a pattern or trend. If it was urgent, EH would call the IP directly, otherwise needed communication may be made via a text message or an email. The EH staff were not certified infection preventionists; however, the department did have an infectious disease physician who oversaw the program. The IP communicated any trends and/or patterns of resident illness with EH, to make them aware so they could monitor staff to see if any call-in symptoms correlated with resident illness. EH did not provide any type of surveillance or spreadsheets to the IP. Review of the QAPI minutes from January 2025 through November 2025 identified the IP was bringing overall (but not specific) resident illness reports to QAPI, however, no employee illness data was included in her reports. EH also attended QAPI. In:January, EH noted COVID, RSV and Norovirus continued to be on the rise (unknown if in the community or facility). Any and all illnesses were to be reported to EH.February, EH noted they were seeing staff continue to be positive for COVID and influenza throughout the system. There was no information on what the facility's staff illnesses were, any specific data noted, what goals were, or what action plans were made. March, EH noted staff were not compliance with the influenza vaccine and would be getting an email to complete. The IP noted there was a measles outbreak (unknown if in community or facility). She noted employee health was responsible to monitor audits on employee records on immunity.April, EH had no update. May, employee vaccinations were discussed, but it appeared to be corporate wide and not facility specific, as other states were mentioned in the report of employees. June, EH reported measle rates were increasing in South Dakota, and they were continuing an audit on employee vaccinations. They reported a large drop in employee illness. July, the IP noted an increase in respiratory illness on one unit that past month. EH made no mention of any staff illness, or the data was given to the IP to see if any correlation with resident illness occurred. August, the IP made no mention of any resident illness and EH made no mention of any staff surveillance. September, the IP noted a COVID outbreak began 9/11/25 related to a positive employee. EH noted an increase of respiratory illness among staff and encouraged the employee health line (used to report employee illness) for the return-to-work process and to follow infection control prevention. There was no indication QAPI nor the IP identified the concern with EH lack of delegated oversight in the potential for employees to return to work before being cleared or staff not reporting illnesses. October, EH reported no trends in employee illness, but failed to include any data to identify if enhanced surveillance was required of specific residents having been provided care by staff that were ill or if employees had followed policy and procedures and reported their illness upon onset of symptoms, had been restricted from work, or had specific guidance on when to return to work was appropriate. The IP reported 15 resident infections. Employee health provided no employee illness surveillance. Interview and QAPI review on 12/03/25 at 4:18 p.m. with quality assurance coordinator (QA)-A identified the IP was to give ongoing reports noting resident illness rates for identified infections at least quarterly. QA-A was unable to show evidence the IP was bringing any information forward regarding staff illness or that EH was monitored to ensure they were completed their delegated employee illness responsibilities appropriately. QA-A called the IP to ask if she had any reports from EH related to employee illness. The IP reported if there was a concern with staff illness, such as an outbreak, she could discuss that in QAPI, otherwise she did not bring any information regarding staff illness surveillance to QAPI. Interview on 12/3/25 at 5:15 p.m., with director of nursing (DON) identified the IP attended daily huddles and staff call ins were discussed at that time. She agreed there was a lack of documentation and oversight related to staff illness. She felt the information was there however, there was lack of documentation the IP was receiving and reviewing the information. She confirmed the IP was responsible for oversight of the infection prevention program and that was to include employee/staff surveillance. The undated, System Quality Plan identified management officials were responsible for improvement efforts. There was no mention in the plan of infection control surveillance, how QAPI was to provide oversight of the infection control program, ensure data submitted was analyzed, that appropriate delegation had occurred from the IP to EH, or that the IP provided oversight of EH in their monitoring of staff illness.

Based on interview and document review, the facility failed to have a current, ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that included all staff. This had the potential to affect all 74 residents. Refer to F882 and F868 Findings include: Review of facility infection control surveillance identified only resident illness surveillance had been completed at the facility. Interview on 12/2/25 at 4:10 p.m., with the infection preventionist (IP) identified employee's call central employee health (EH) when ill to report their symptoms, EH then provides the employee general guidelines of when they can return to work. The manager will get a call that the staff called in ill and when they can return to work based on the employee's illness. If employee heath identified a trend in employee illness, then EH would reach out to notify her so she could compare with the facility residents to see if there was any correlation. She revealed that she did not keep a record of employee illness only EH had that documentation. She was responsible for the resident surveillance at the facility and that EH tracked employee illness for the facility. She was not provided any type of spread sheet from EH with documentation of employee illness, their symptoms, and their return-to-work date, she was only called with trends that EH noted. Interview on 12/2/25 at 4:26 p.m., with director of nursing (DON) identified when a staff member called in for a shift the nurse would update the schedule online and then filled out a communication form that was turned into her to file in the employees personal file. Interview on 12/3/25 at 9:43 a.m., with licensed practical nurse (LPN)-A identified when a staff member called in for a shift the nurse filled out a communication form that included the date, the employee's name, and the issue for the call in, and if the staff need to contact EH. The nurse then notified the on-call manager and turned the communication form into the director. Interview on 12/3/25 at 9:45 a.m., with RN-A (the unit supervisor), identified if staff called in for work the nurse would contact her and she would assist with covering the shift. She ensured EH was contacted by the staff member by reaching out to EH herself and she notified HR. If the staff member had a doctor's note she would be responsible for scanning that and sending it to EH. Review of the Communication form (used by the charge nurses to give to the DON with absences from staff), and corresponding facility staff time-punches identified:-Nursing assistant (NA)-A had called in ill on 9/16/25. Staff documented on the communication form, that NA-A was directed by the nurse to contact EH after 8:00 a.m. that morning.-NA-B (who worked the night shift) had called in on 11/15/25, for symptom of diarrhea. Review of her time punches showed NA-B had in fact worked her shift and was not prohibited from work with her symptoms. NA-B also worked the next day on 11/16/25.-NA-C went home ill with symptoms of nausea and vomiting on 11/28/25. NA-C had left during her shift on 11/28/25. There was no indication of when NA-C was allowed to return to work as time punches were requested but not given.There was no mention of resolution of symptoms, if the facility had followed infection control standards for criteria in order to ensure staff were safe to return to work, or if they had been prohibited from work for an appropriate amount of time. Review of the employee health's (EH) staff illness spread sheet (only used by corporate and not available at the facility) identified on: -9/16/25, NA-A had reported to EH symptoms of cough, sore throat, fatigue, diarrhea, and vomiting, which began on 9/15/25. EH had noted NA-A had met criteria to return to work on 9/17/25, although it is unclear what criteria was used to make that determination.-11/15/25, NA-B was not mentioned in the data, and there was no documentation to support NA-B had ever called EH. There was also no indication the IP had followed up to ensure NA-B had followed facility protocol and advised EH of her illness.-11/28/25, NA-C called EH and reported symptoms of shortness of breath, headache, sore throat, runny nose/congestion, fatigue, and muscle aches which began on 11/26/25. EH advised NA-C she would be allowed to work 24 hours after improvement in symptoms and be fever free without use of fever reducing medication. There was no indication NA-C was instructed to call EH back upon improvement or resolution of symptoms to ensure she remained out of work for the appropriate time. Interview on 12/3/25 at 3:07 p.m., with the IP identified she does not monitor if the staff are following through with contacting EH when they are ill as that would be done by management. The manager was to receive an email related to the employee's illness and the manager was responsible to ensure employees followed any return-to-work guidance indicated by EH. She did not oversee employees as part of her surveillance and relied on department managers and EH to ensure staff illnesses were followed. The IP identified she only discussed or brought information to the QAPI meeting related to staff illness if there was something reported from EH, such as an outbreak. She had not brought information related to staff illness to the QAPI meeting. Interview on 12/3/25 at 3:46 p.m., with director of EH identified employees were to contact corporate EH when they were ill. A registered nurse (RN) would manage intakes from staff and was to have gone through an in-depth questionnaire with the employee and make recommendations according to Centers for Disease Control (CDC) and/or the Minnesota Department of Health (MDH). If needed, EH would follow up with staff members. EH was to notify the IP at the facility if they noted a trend or pattern with employee illnesses, but failed to have an ongoing, current method of communication for illness that was not identified to be a pattern or trend. If it was urgent, EH would call the IP directly, otherwise needed communication may be made via a text message or an email. The EH staff were not certified infection preventionists; however, the department did have an infectious disease physician, who oversaw the program. The IP communicated any trends and/or patterns of resident illness with EH, to make them aware so they could monitor staff to see if any call-in symptoms correlated with resident illness. EH did not provide any type of surveillance or spreadsheets to the IP. Interview on 12/3/25 at 5:15 p.m., with director of nursing (DON) identified the IP attended daily huddles and staff call ins were discussed at that time. She agreed there was a lack of documentation and oversight related to staff illness. She felt the information was there however, there was lack of documentation the IP was receiving and reviewing the information. She confirmed the IP was responsible for oversight of the infection prevention program and that was to include employee/staff surveillance. Review of 6/26/25, Infection Prevention Program and Authority policy identified infection preventionist was to implement infection prevention. The IP was to implement appropriate surveillance, prevention, and control measures when conditions exist that may spread and impact residents or employees. The function and duties included identification, maintaining surveillance, analyzing data, and implement corrective actions to minimize infections. Supervision of the infection control program included implementing precautions, hand hygiene, environmental cleaning, reviewing policies and procedures, oversight of surveillance, reporting and evaluation, consultation to staff on cleaning/disinfection procedures, new employee training, referring staff to EH for issues related to blood borne pathogens and staff exposures to those pathogens, tuberculosis (TB) control and the antibiotic stewardship program. A job description for the infection preventionist was requested but not provided.

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate oversight of the infection control (IC) program that included employee surveillance of all employees. This had the potential to affect all 74 residents. Refer to F880 and F868 Findings include: Review of facility infection control surveillance identified only resident illness surveillance had been completed at the facility. Employee surveillance had not been included. Interview on 12/2/25 at 4:10 p.m., with the infection preventionist (IP) identified employee's call central employee health (EH) when ill to report their symptoms, EH then provides the employee general guidelines of when they can return to work. The manager will get a call that the staff called in ill and when they can return to work based on the employee's illness. If employee heath identified a trend in employee illness, then EH would reach out to notify her so she could compare with the facility residents to see if there was any correlation. She revealed that she did not keep a record of employee illness only EH had that documentation. She was responsible for the resident surveillance at the facility and that EH tracked employee illness for the facility. She was not provided any type of spread sheet from EH with documentation of employee illness, their symptoms, and their return-to-work date, she was only called with trends that EH noted. Review of the Communication form (used by the charge nurses to give to the DON with absences from staff), and corresponding facility staff time-punches identified:-Nursing assistant (NA)-A had called in ill on 9/16/25. Staff documented on the communication form, that NA-A was directed by the nurse to contact EH after 8:00 a.m. that morning.-NA-B (who worked the night shift) had called in on 11/15/25, for symptom of diarrhea. Review of her time punches showed NA-B had in fact worked her shift and was not prohibited from work with her symptoms. NA-B also worked the next day on 11/16/25.-NA-C went home ill with symptoms of nausea and vomiting on 11/28/25. NA-C had left during her shift on 11/28/25. There was no indication of when NA-C was allowed to return to work as time punches were requested but not given.There was no mention of resolution of symptoms, if the facility had followed infection control standards for criteria in order to ensure staff were safe to return to work, or if they had been prohibited from work for an appropriate amount of time. Review of the employee health's (EH) staff illness spread sheet (only used by corporate and not available at the facility) identified on: -9/16/25, NA-A had reported to EH symptoms of cough, sore throat, fatigue, diarrhea, and vomiting, which began on 9/15/25. EH had noted NA-A had met criteria to return to work on 9/17/25, although it is unclear what criteria was used to make that determination.-11/15/25, NA-B was not mentioned in the data, and there was no documentation to support NA-B had ever called EH. There was also no indication the IP had followed up to ensure NA-B had followed facility protocol and advised EH of her illness.-11/28/25, NA-C called EH and reported symptoms of shortness of breath, headache, sore throat, runny nose/congestion, fatigue, and muscle aches which began on 11/26/25. EH advised NA-C she would be allowed to work 24 hours after improvement in symptoms and be fever free without use of fever reducing medication. There was no indication NA-C was instructed to call EH back upon improvement or resolution of symptoms to ensure she remained out of work for the appropriate time. Interview on 12/3/25 at 3:07 p.m., with the IP identified she does not monitor if the staff are following through with contacting EH when they are ill as that would be done by management. The manager was to receive an email related to the employee's illness and the manager was responsible to ensure employees followed any return-to-work guidance indicated by EH. She did not oversee employees as part of her surveillance and relied on department managers and EH to ensure staff illnesses were followed. The IP identified she only discussed or brought information to the QAPI meeting related to staff illness if there was something reported from EH, such as an outbreak. She had not brought information related to staff illness to the QAPI meeting. Interview on 12/3/25 at 3:46 p.m., with director of EH identified employees were to contact corporate EH when they were ill. A registered nurse (RN) would manage intakes from staff and was to have gone through an in-depth questionnaire with the employee and make recommendations according to Centers for Disease Control (CDC) and/or the Minnesota Department of Health (MDH). If needed, EH would follow up with staff members. EH was to notify the IP at the facility if they noted a trend or pattern with employee illnesses, but failed to have an ongoing, current method of communication for illness that was not identified to be a pattern or trend. If it was urgent, EH would call the IP directly, otherwise needed communication may be made via a text message or an email. The EH staff were not certified infection preventionists; however, the department did have an infectious disease physician who oversaw the program. The IP communicated any trends and/or patterns of resident illness with EH, to make them aware so they could monitor staff to see if any call-in symptoms correlated with resident illness. EH did not provide any type of surveillance or spreadsheets to the IP. Interview on 12/3/25 at 5:15 p.m., with director of nursing (DON) identified the IP attended daily huddles and staff call ins were discussed at that time. She agreed there was a lack of documentation and oversight related to staff illness. She felt the information was there however, there was lack of documentation the IP was receiving and reviewing the information. She confirmed the IP was responsible for oversight of the infection prevention program and that was to include employee/staff surveillance. Review of 6/26/25, Infection Prevention Program and Authority policy identified infection preventionist was to implement infection prevention. The IP was to implement appropriate surveillance, prevention, and control measures when conditions exist that may spread and impact residents or employees. The function and duties included identification, maintaining surveillance, analyzing data, and implement corrective actions to minimize infections. Supervision of the infection control program included implementing precautions, hand hygiene, environmental cleaning, reviewing policies and procedures, oversight of surveillance, reporting and evaluation, consultation to staff on cleaning/disinfection procedures, new employee training, referring staff to EH for issues related to blood borne pathogens and staff exposures to those pathogens, tuberculosis (TB) control and the antibiotic stewardship program. A job description for the infection preventionist was requested but not provided.

Based on interview and document review, the facility failed to ensure staff appropriately assessed, monitored, intervened, and notified the family in a timely manner after a fall for 1 of 1 resident (R1) resulting in a brain bleed and skull fracture causing serious harm and eventual death. The immediate jeopardy (IJ) began 9/15/25 at 10:23 p.m., when the facility failed to ensure staff appropriately assessed, monitored, and intervened after a fall for 1 of 1 resident (R1) who had an unwitnessed fall with visible facial bruising and facial structure abnormalities, that resulted in delayed medical examination by a physician and early treatment. R1 was finally transferred to the emergency room 9 hours post fall to the local hospital, where a brain bleed and skull fracture were discovered resulting in serious harm and eventual death. The facility administrator and director of nursing were notified of the IJ on 9/24/25 at 12:34 p.m. The facility had implemented immediate corrective action beginning 9/18/25 through 9/21/25, to prevent recurrence; therefore, the IJ was issued at PAST NON-COMPLIANCE. Findings include: The initial report to the State Agency (SA) identified on:1. 9/15/25 at 11:23 p.m., trained medication aide/nurse aide (NA)-A went to check on R1 and when she opened door to his room, he was found sitting on the floor in front of his recliner. The lights were on, and his walker was over by the closet. His face was bruised, purple, and he had swelling around his eyes. His nose was bruised and yellow. His fingers were covered with a small amount of red blood, and his thumb fingernail was broken at the tip. He had purple bruising and dry blood on the back of his hand. R1's brief was dry, and he denied having pain and hitting his head. He was alert and oriented to person and time. His neuros were reported as stable after the fall. Registered nurse (RN)-A removed his arm rest protectors from his recliner and educated R1 on using his breaks on his four-wheeled walker. There was no indication in the report staff had contacted a physician or family member for R1 immediately after the fall or sent R1 to the emergency room at the adjacent hospital for medical evaluation.2. 9/16/25 at 1:15 a.m., R1 began to report a headache and was given as needed (PRN) Tylenol 650 mg via standing orders. RN-A called the E-Care physician (on-call telemedicine physician) to report R1 now had a headache, was vomiting, had increased blood pressure (BP), and was noted to be shaking. The E-Care physician visited with R1 via telehealth (video over computer screen). R1 was vomiting into a trash can and complaining his head hurt. The E-Care provider recommended R1 take Zofran (anti-nausea medication) and wait for the Tylenol to kick in. R1 was noted to have vomited shortly after taking the Tylenol. There was no indication in the report, that the E-Care provider nor RN-A had identified an emergent situation that indicated potential head injury.3. 9/16/25 at 3:00 a.m., R1's oxygen level was identified to begin to drop between 86%-89% [oxygen saturation (SpO2)] (92% to 100% is normal range), which was reported to be not his baseline. RN-A then administered an Albuterol nebulizer (inhaled medication) treatment via standing orders at 3:34 a.m R1's oxygen increased to 90% SpO2 for 30 minutes but then reverted back to 86%-88% SpO2. RN-A called E-care back at that time to report change a in condition. R1 reported his headache pain was less painful, and he was no longer vomiting. The E-care provider then ordered a chest x ray STAT (immediately), a urinalysis specimen (UA) with culture, and some blood specimens and additional medication orders. There was no evidence that RN-A disclosed the previous E-Care physician's call, order changes, R1's recent fall, or identified the seriousness of the incident and the need to send R1 to the emergency room for in-person evaluation by a physician.4. 9/16/25 at 5:00 a.m., a nurse aide reported to RN-A that R1 had begun vomiting again. RN-A then called E-Care again requesting a computerized tomography (CT) scan of his head. The E-Care physician told RN-A since R1 was alert and could read questions (R1 had limited hearing so he was asked to read questions rather than hear them asked) used to assess his cognition, they did not believe R1 needed CT scan of his head and only gave order for an X-ray of his. RN-A then entered the orders from the E-Care physician. There was no mention in the report either the E-Care provider, nor RN-A had yet identified the seriousness of R1's condition.5. 9/16/25 at approximately 7:30 a.m., when R1's primary care physician (NP-C) arrived, he was notified of R1's fall and asked to evaluate R1. PCP directed staff to send R1 to the ER where a head CT was completed and it was noted there were bilateral skull fractures, bilateral brain bleeds, bilateral hemorrhagic contusions (bleeding and bruising) and a subarachnoid hemorrhage( bleeding in the space below one of the thin layers that cover and protect your brain) in the frontal and temporal (side) lobes and a right parietal intraventricular hemorrhage (bleeding in the cerebral ventricular system). Staff noted the call light was not sounding at the time of the fall. The facility identified R1's care plan had been followed. R1's 7/23/25, quarterly Minimum Data Set (MDS) assessment identified R1 was admitted in December 2022 with diagnoses of dementia, diabetes, anxiety, high blood pressure, insomnia, hearing loss, and anemia. R1's undated, current care plan identified R1 was able to dress himself however, staff were to assist as he allowed. R1 used bilateral grab bars to assist with mobility, positioning, and bed mobility. R1 used a four-wheeled walker and was independent with ambulation. R1 was at risk for falls and staff were to keep his room door open as much as possible, to monitor that his walker was near him, and that he had appropriate footwear on. Staff were to remind him to slow down when walking and check on him every 2 hours. R1's 9/15/25, Fall report identified at 10:23 p.m., a trained medication assistant/nursing assistant (NA)-A had opened the door to R1's room to check on him and found him sitting on floor in front of his recliner. The lights were on, and his walker was over by his closet. The arm rest protectors that were used on his recliner were found on the floor. R1's face was bruised, and he was noted to have swelling around his eyes and his nose was bruised and yellow. His fingers were covered with a small amount of blood, and his thumb nail was broken at the tip. R1 had denied hitting his head but could not explain why he fell. He was alert and orientated to person and time. His neurological assessment was noted to be within normal limits, and his call light was within reach. Interventions identified were to include hourly checks, discontinue arm rest protectors, and provide education to R1 to place his breaks on his walker when it was not in use. The on-call E-Care (telemedicine physician) was notified at 10:45 p.m R1's family member was documented as having been notified on 9/16/25 at 7:00 a.m., (8.5 hours later). R1's 9/15/25, Fall Scene Investigation Report (a huddle with staff on duty at time of fall) identified R1 had not utilized his breaks on his walker and did have shoes on at the time of his fall. The fall occurred next to a transfer surface, and the last time R1 was assisted to the restroom was on 9/15/25, at 8:20 p.m R1 was found by staff with facial bruising, had swollen eyes and nose, and had bloody fingers. R1's walker was across the room from him by the closet. Question number 4 on the form, noted: Did the resident hit head or have unwitnessed fall? The answer was yes. The form identified if the answer was yes, staff were to complete vitals (assessments of blood pressure, pulse, and respirations), and neurological (neuro) checks (assessment of pupils) per protocol at: A) every 15 minutes x 4, B) every 30 minutes x 2, C) every hour x4, D) every 4 hours x 6, then only vitals 2 x day x 3 days. R1's 9/15/25 through 9/16/25, neuro checks identified they were completed at:10:38 p.m., within normal limits. (WNL).10:53 p.m., WNL.11:08 p.m., WNL.11:23 p.m. WNL12:23 p.m., WNL, 1 hour later.1:23 a.m., R1 was documented as having a neuro change of a headache (HA).2:23 a.m., identified R1 had HA, nausea and vomiting (N&V).3:23 a.m., identified R1 continued to have a HA, nausea and vomiting (N&V).4:23 a.m., identified R1 continued to have a HA, nausea and vomiting (N&V).The form lacked evidence RN-A had perform 30-minute neuro checks after the 15-minute checks were completed after 11:23 p.m., x 2, per protocol. Interview on 9/22/25 at 1:00 p.m., with registered nurse (RN)-A identified NA-A found R1 on the floor during rounds, at approximately at 10:20 p.m. on 9/15/25. R1 was on the floor by his recliner and his walker was over by his closet. R1 had denied he fell, which was unusual for him as R1 had fallen before and gets mad if we find he has fallen. He was assessed and at the time, and his neuros and vitals were stable. E-Care (Nurse practitioner (NP)-A) was contacted by phone to report the fall and that R1 had facial bruising. Between 1:00 a.m. and 1:30 a.m., on 9/16/25, RN-A recalled R1 started to complain of a HA, and N&V at that time. She then gave R1 Tylenol and called E-Care and spoke to NP-B (different provider) to report his new symptoms. At that time, NP-B decided to see R1 via telehealth video conferencing. R1 complained of his head hurt and he was shaking at the time. RN-A was then directed by NP-B to give him Zofran. RN-A stated, I thought that was odd as R1 was shaking and his blood pressure was elevated. It was a very busy night, and I was overwhelmed. RN-A had another resident with an IV that was not working, and another resident on another unit, that she needed to straight catheterize (to assist with urination) for another nurse. RN-A called the hospital resource nurse (RN-H) from the adjacent hospital to come and help her with her duties. NP-B was called again when R1's oxygen levels dropped. RN-A stated she had just listened to NP-B and did what she said, as it was so busy that night. She had asked NP-B for a CT scan of R1's head which NP-B declined. NP-B was reported to decline RN-A's recommendation, as R1 had been able to read the questions RN-A had written out earlier as he was hard of hearing, and his headache had improved. NP-B ordered an X-ray of his facial bones and RN-A took him over to the adjacent hospital's radiology department for the X-ray. RN-A gave report to the oncoming day nurse, the nurse manager (RN-D), and the facility NP (NP-C), who happened to be at the facility early that day (at approximately 7:30 a.m., on 9/16/25). NP-C did assess R1 and had him sent over to the ER immediately. RN-A felt the reason she had not sent R1 over to the ER was because NP-B did not think he need to be seen at the time. RN-A was unaware, she could use her professional judgement to send R1 for medical evaluation. She thought she had to go through E-Care and get a physician's order to send a resident to the ER. After the fall, the facility did training with all the nurses, and she was made aware a nurse did not need an order to send a resident to the ER. R1 returned from the hospital later that morning and he passed away later that afternoon on 9/16/25. R1's 9/15/25 at 10:39 p.m., Avel Senior Care (E-Care), Change in Condition written by NP-A, identified RN-A reported R1 was found on floor with marked bruising on face, however, the resident denied hitting his face. It was unknown if R1 hit his head. Neuro assessment identified R1 was alert and orientated x 3 and able to read questions since he was hard of hearing. The NP-A's plan for a non-witnessed fall, was to initiate neuro checks and place him on a fall protocol. Even though he denied head trauma, NP-A ordered staff to monitor his neurological status frequently. NP-A provided the Senior Care Guidance to Monitor for Possible Head Injuries, form that identified signs and symptoms and provided guidance for staff on what to do:Signs and symptoms to watch for included: blacking out/loss of consciousness, headache, dizziness and/or vomiting, new or worsening confusion, trouble recognizing people, unusual sleepiness or difficulty waking up, unusual mood or behavior changes, new or worsening trouble with walking or talking, seizures, bruising behind the ears or around the eyes, and blood or clear drainage from the nose or ear.What to do: identified staff were to monitor the resident for 24-72 hours. It explained: Early on, there may not be symptoms. If any of these symptoms develop within 24 hours after a head injury, the resident should be urgently evaluated in the emergency room (ER) if that was consistent with their wishes. If a resident had not wanted to be transferred to the ER for evaluation, they should be urgently evaluated by [E-Care]. There was no indication NP-A had identified or followed the written guidance she gave the facility staff on the common lack of symptoms from a head injury as noted above, the facial bruising he already had at the time of the fall, or if she had asked R1 or his family if they desired for R1 to be seen at the ER. R1's 9/16/25 at 1:22 a.m., E-Care provider notification progress note, written by NP-B, identified RN-A called to report R1 was complaining of a headache, nausea, and vomiting. RN-A reported R1 had a fall yesterday. On provider video evaluation, R1 was visualized as awake, responded appropriately, displayed no weakness, followed commands and denied shortness of breath. R1 was anxious and nauseated. NP-B gave new orders for hydroxyzine HCI 25 milligrams (mg) take one tablet by mouth once a day at bedtime for anxiety, and Zofran 4 mg sublingual (SL) every 8 hours one time a day. The hydroxyzine 25 mg order was crossed out and noted (allergy, discontinue (dc)). NP-B also ordered was some blood specimen labs and a UA and urine culture. The order was not electronically signed by NP-B until 9/16/25 at 4:24 a.m. There was no indication in the progress note NP-B recognized R1's deteriorating condition as a sign of need for immediate evaluation in the ER. R1's 9/16/25 at 4:25 a.m., E-Care provider notification note written by NP-B, identified RN-A called to report resident now had hypoxia (lack of oxygen in the blood). RN-A reported R1's oxygen saturation (O2 sats) were at 90%. RN-A had given a nebulizer treatment however, R1's O2 sats remained at 90%. R1 still had nausea and vomiting. R1 was awake and denied pain, chest pain, or abdominal pain. The telehealth exam identified he was not in any acute distress. Orders were given to place R1 on oxygen at 2 liters (L) via nasal canula and titrate to keep O2 sats above 92%, get a stat (immediate) chest X-ray, albuterol nebs 2.5 mg every 6 hours as needed for shortness of breath, Ipratropium 0.5 mg every 6 hours as needed for shortness of breath, facial X-ray 2 views, and follow up with primary provider (NP-C) in the morning. The order was electronically signed later by NP-B 9/16/25 at 5:08 a.m. There was no indication NP-B identified during the call or telehealth assessment, that R1's condition was worsening or that he needed to be sent to the ER to be physically evaluated with a higher level of care. R1's 9/16/25 at 10:14 a.m., provider note by NP-C who identified R1 had been seen today (time unidentified on the note but reported by staff to be approximately 7:30 a.m.) at staff request, to follow up after an E-Care visit during the night due to a fall where the resident hit his head. There had been a facial X-ray done at this time. No CT scans were completed, and the resident had not been evaluated in the emergency department during the night. R1, while hard of hearing, was cognitively different than normal during the exam. He was unable to answer questions, and his responses are nonsensical at the time. R1's blood pressure was elevated that morning. Staff reported R1 was complaining of a headache, nausea, and vomiting during the night. NP-C assessed R1's head and face injury, and believed R1 needed a higher level of care and possible admission. NP-C consulted with the ER provider MD-B and gave a brief background of what had happened and recommended that R1 be seen in the emergency department. MD-B agreed, and nursing staff brought R1 over to the ER. Signed electronically by NP-C at 10:23 a.m. R1's 9/16/25 at 8:46 a.m., physician (MD-A)'s emergency department (ER) note identified the clinical impression by the ER physician was R1 suffered a brain bleed with skull fractures. R1's condition was listed as critical. R1 reported he tripped and fell last night. He had a mild headache but felt it would go away. He had no nausea, no neck pain, no extremity pain and was not on any anticoagulants upon admission. He was alert and oriented and his vital signs were normal. R1 was very hard of hearing but was able to answer questions appropriately. He has periorbital contusions (bruising) bilaterally, with no signs of entrapment. Facial bone computed tomography (CT) was negative. Non-contrast head CT showed multiple significant abnormalities. He had bilateral skull fractures, bilateral subdural hematomas (a pool of blood that can push on the brain), bilateral hemorrhagic contusions (bleeding with bruising) and subarachnoid hemorrhage (bleeding usually from a bulging blood vessel that bursts in the brain (aneurysm) that may lead to permanent brain damage or death if not treated). R1 had left to right subfalcine herniation of 8 millimeters in length (where part of brain tissue moves under a thin membrane that separates the two hemispheres of the brain). [A regional hospital] Neurosurgery was consulted and would accept R1 in a transfer. Keppra was given for seizure prevention, due to subarachnoid hemorrhage. Clinically, R1 declined while at the ER and was not as responsive. After extensive discussion with family, it was unanimously decided not to transfer for aggressive management at that time (related to his deteriorating condition upon his assessment in ER). They would like R1 to be started on hospice and return to the facility. Review of the 8/23/23, National Library of Medicine (NIH) article: Subfalcine Herniation, located at: https://www.ncbi.nlm.nih.gov/books/NBK536946/, identified herniation occurred when brain tissue was displaced within in the cranium. Initial presentation can be a headache. It is common to have headache, nausea, vomiting, or altered mental status. Treatment/management depends on the cause, with an attempt to decrease the intracranial (brain) pressure. Medical treatment may be medication or surgical. Surgical treatment could include ICP monitoring, external ventricular drain, craniotomy to remove a hematoma, or decompressive craniectomy. Brain herniation can cause severe clinical disability or death. Brain herniation is potentially reversible with appropriate and timely therapeutic interventions (by a medical provider). The patient and family should be thoroughly counseled about the possible treatment protocols to help in shared decision-making. A timely diagnosis and management will ultimately benefit the patient and improve the clinical outcome. Interview on 9/22/25 at 4:30 p.m., with NA-B identified she was working the night of 9/15/25, when R1 fell. NA-A had come to get her to assist with helping R1 up off the floor after the nurse was done assessing him. R1 was able to walk out to the TV room but he was a little more shaky than usual. R1's face was bruised, and his eyes were swollen, and a cold washcloth was placed over his eyes. In her opinion, R1 should have been taken over to the ER, even though he had denied he fell. When she returned to work the next day around 3:00 p.m., she assisted with repositioning R1 who at that time, was unresponsive. Interview on 9/22/25 at 4:40 p.m., with NA-A identified she had entered R1's room to check on him on the night of 9/15/25 and found him on the floor with his back against the recliner. R1's walker was across the room by his closet. His hat was on the floor and the closet door was open slightly. R1's right thumb was bleeding. Both of his eyes had bruising and looked baggy, like he had hit his face. R1's right hand was more shaky than normal. The nurse assessed R1, and he was assisted up and he was able to walk out to the TV room. RN-A called the E-Care physician, and they said if R1 was not complaining, he was okay, but she wished he would have been seen in the ER anyway. NA-A was worried about R1 when her evening shift ended. The nurse manager (RN-D) came out to speak to us the following evening on 9/16/25, as it was a heart-breaking event and R1 had passed away. She told staff If we needed, we could use the employee [assistance] program. There was a meeting the next day on 9/17/25, with some of the providers and they had some good ideas. The medical director was on the phone for the meeting. The meeting was about preventing future similar events. RN-D was aware NA-A was having a hard time with R1's death. NA-A reported she had asked RN-D, if she could have brought R1 over to the ER herself that night, and even if it was not going to help [R1], she would have felt better. RN-D had told her that technically she could take a resident to the ER, but the nurse should call [E-Care] first. Interview on 9/22/25 at 3:30 p.m., with licensed nurse (LPN)-B identified if a resident had a fall, the nurse would assess the resident and determine if additional treatment was needed. Depending on the nurse's assessment, the nurse may send the resident over to the ER for evaluation or may call the E-Care provider, if non-emergent, to obtain an order to send a resident to ER. A nurse did not need an order to send a resident to the ER if the nurse thought (used their professional judgment) they needed to be seen immediately. Further interview on 9/23/25 at 9:10 a.m., with RN-A, identified when E-Care was called, it took a while to get their notes back. She liked to double check the provider notes to make sure there were no changes from the oral orders. She noted she could have sent R1 over to the ER when he developed symptoms, but she understood she needed to call E-Care and go through them first. She did feel like R1 should have been sent to the ER, but she felt she needed an order to do that. Staff had to do as much as possible before sending someone to the ER. That was why they had E-Care. E-Care would assess so we are not sending residents over unnecessarily. The facility did do training that we do not need an order to send someone to the ER we can just send if we feel it is needed. She was offered to speak to someone if she needed as she reported she felt so bad about the outcome of this resident. Interview on 9/23/25 at 9:53 a.m., with medical director (MD-B) identified she had been notified of the incident. She revealed there were many parts contributing to the incident. MD-B was concerned how the providers (NP-A and NP-B) handled the situation and had referred one for peer review. She identified she supported a lot of long-term care facilities and had done education with nurses in the past, that they do not need a physician order to send someone to the emergency department. Unfortunately, there is a belief out there that they need an order, and they have a hard time sending someone to the ER without one. She would expect anytime there was something clearly alarming, the nurse would send a resident to the ER for an evaluation. They do not need an order for that. She had not spoken to the nurse on duty that night (RN-A) but felt bad for her as she felt RN-A likely thought she was doing the right thing by reaching out to E-Care for direction. E-Care did lay eyes on the resident. She had concerns about the decisions by E-Care that were made. MD-B felt the outcome would not have changed for R1 due to his significant fractures and the family choosing not to pursue aggressive treatment (after discovery of the fractures in the ER) however, she would have expected that conversation to have happened sooner than it did. She had completed a thorough review of R1's medical record and provider notes. The following day she participated in a meeting with the facility and discussed things that lead up to the event and what the facility could do to prevent events like this from happening again. Interview on 9/23/25 at 11:03 a.m., with director of nursing (DON) identified she had visited with RN-A and educated her that she could send a resident over to the ER anytime she had concerns. RN-A's intuition was that something was wrong, and she hoped now she would feel more empowered to follow her intuition in the future. She would expect a nurse to act on their assessments and critical thinking and send someone to the ER for evaluation if the nurse felt it was needed. She revealed it maybe hard for nurses to override [decisions by] a provider and send someone to the ER if that provider did not agree, but at times that might need to be done since the nurse's know the residents better, or if something was not right. She confirmed R1 should have been seen in the ER immediately but especially after he started to develop symptoms of headache, nausea and vomiting. All licensed nurses were retrained starting on 9/18/25, on E-Care and emergency room services, ARCC (Ask a question, make a request, voice a concern, use chain of command) and how to use ARCC. Interview on 9/23/25 at 3:53 p.m., with RN-G who was also the facility education nurse, identified she had been the nurse on-call the night of 9/15/25 into 9/16/25. She had not been called by RN-A to come in and assist her with anything. RN-A had not reached out to her to consult about R1's fall or any concerns she may have had about him developing symptoms. The facility had an internal departmental meeting anytime there was a fall with a major injury or if a resident was having multiple falls. These meeting were to discuss the fall or falls and determine a root cause. Training was provided to all the nurses following R1's event. We encourage our nurses to collaborate with each other all the time and encourage collaboration with the providers. Interview on 9/23/25 at 4:37 p.m., with licensed practical nurse (LPN)-A, identified he worked the night of R1's fall on a different unit. RN-A had come to the unit he was working on at around 3:00 a.m. or 4:00 a.m. to obtain Zofran from the emergency medication kit. RN-A had not asked him to assess R1 however, she had told him that R1 was having nausea and vomiting after having a fall. LPN-A revealed he had advised RN-A to send R1 to the ER because anyone having a fall and developing symptoms like that should be seen. Interview on 9/23/25 at 4:44 p.m., with RN-H (the resource nurse from the attached hospital) identified the facility had called and requested the resource nurse to come and restart an IV that was not working. RN-H reported no facility staff mentioned any other residents. She was just asked to start the IV on another resident. After that, she returned to the hospital. Later interview on 9/24/25 at 9:08 a.m., with the DON identified that the nurse managers all take call. Charge nurses (like RN-A) were able to call for any questions they may have. The facility had a system called Volt (an internal communication system). The nurses could communicate via text messaging or calling different staff through the Volt system. She was unaware RN-A thought she needed a physician order to send a resident to the ER for an evaluation until she had spoken with her. She was unaware that other staff on duty that night (LPN-A) had voiced concerns of R1 to RN-A and had advised they had felt R1 should have been sent to the ER for an evaluation. She also had not been made aware that NA-A had asked a nurse supervisor if they could have advocated for R1 and just have taken him over to the emergency room. A call was placed on 9/24/25 at 11:09 a.m., with a message left for MD-A but a call was not returned. The IJ that began on 9/15/25 was determined to be past noncompliance when it could be verified the facility took steps to correct the deficient practice prior to the survey by reviewing all fall related policies as noted and educating all licensed nursing staff to those policies. The May 2025, Fall Prevention and Management policy identified a fall risk assessment would be completed for each resident upon admission, re-admission, and quarterly. Residents determined to be at risk will have fall interventions incorporated into their care plan. After, a fall a post fall assessment would be completed to determine the root cause to prevent further falls. The nurse was to notify the physician and family at time of fall. The October 2024, LTC Falls and Accidents policy identified upon admission, re-admission, and quarterly the facility would assess fall risk, elopement risk, and other risk within the facility. The facility would implement interventions for any identified risk on the care plan. For a fall, the nurse was to immediately assess the resident for any injury. A head injury must include vital signs and neurological assessment at least every 4 hours x 4 and then daily for 72 hours. A fall must be investigated for root cause and individualize the residents care plan with interventions. The November 2024, Provider/Medical Services LTC policy identified for a resident that had a change in condition, the medical provider was to be contacted on the condition. For any life threatening or emergency, the resident was to be sent over to the ER for an evaluation. The facility had access to Avel (E-Care) services a telehealth-based system, which offered a virtual face-to-face visit. This system provided access to residents and providers to provide a medical evaluation, treatment and referral as appropriate. This system could be utilized for a change in condition in a non-emergent situation and accessed 24 hours a day with the resident's primary provider (PCP) being notified of the use of Avel virtual services and the resident's condition. The December 2024, Chain of Command and Administrative Call policy identified staff who have identified a problem situation would collaborate with their peers to determine the urgency of the problem. The responsible provider would be contacted for clarification. If the problem remained unresolved, the staff were to seek guidance of the LTC charge nurse. The charge nurse would contact the responsible provider. If the concern continues to be unresolved and there was an immediate risk to the resident care and safety, the charge nurse was to contact the LTC leader on-call if on a weekend, or the director of nursing on a weekday. The findings would be reviewed and if needed, the LTC leader on call or administrator would call for further clarification and discussion. If the issue remains unresolved, the administrator would be contacted and they would notify the chief medical officer, if needed, for assistance. The undated, E-Care and emergency room Services policy identified for a resident experiencing an injury or illness, the nurse was to assess and determine the best course of action for the resident. Staff were to address E-Care services with the resident and family. If staff were unable to contact family and/or resident was unable to make their needs known, staff had the right to send the resident to the emergency room. The nurse may contact E-Care for all non-emergent needs to confer with an on-call provider. The nurse had a right to utilize the emergency department based on their clinical judgement and assessment. A physician's order was not required to send a resident into the emergency room for evaluation. If a nurse was in doubt about whether to pursue further medical care, they were to collaborate with another nurse.

Based on observation, interview and document review the facility failed to appropriately discard personal protective equipment (PPE) after use inside the resident's room and perform appropriate hand hygiene with soap and water, and put on new gloves when carrying infection waste to the soiled utility room for 1 of 2 residents (R12) with a highly infectious disease (Clostridium Difficile (C-Difficile)). This practice had the potential to affect 8 of 73 residents who resided on the wing. Furthermore, the facility failed to ensure Enhanced Barrier Precautions (EBP) PPE use was followed for 1 of 1 resident (R19), who had an open scalp wound due to a drug resistent bacteria. That had the potential to affect 18 of 19 other residents who resided on that wing. The facility also failed to ensure gloves were discarded and hand hygiene occured after touching multiple surfaces and before administration of an eye ointment for 1 of 1 resident (R32) during medication pass observation. R12 Review of the 4/3/24, US Centers for Disease Control and Prevention (CDC) Transmission-Based Precautions guidelines, located at https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html, identified staff were to use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission by: 1) Using PPE appropriately, including gloves and gown. Staff (and visitors) were to wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning [putting on] PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the 3/5/24, CDC: C. Diff: Facts for Clinicians guidelines, located at https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html#:~:text=If%20a%20patient%20has%20had%20three%20or%20more,Reassess%20appropriateness%20of%20antibiotics%20in%20C.%20diff%20patients, identified: 1) C. diff sheds in feces. Any surface, device or material that becomes contaminated with feces could serve as a reservoir for the C. diff spores. C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. 2) Staff were to wear gloves and a gown when treating residents with C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 had moderate cognitive impairment and required extensive assistance with toileting hygiene. R12's Hospital Discharge Summary dated 9/30/24, identified R12 was hospitalized from 9/27/24 to 9/30/24, for sepsis (life threatening infection) secondary to C. difficile colitis (inflammation in the intestines). R12 presented from the facility with 1 to 2 weeks of diarrhea, and hospital stool studies were positive for C. difficile. Observation on 10/28/24 at 12:47 p.m., a Contact Enteric Precautions sign was posted on the outside of R12's door. Also outside R12's door was a container for PPE and a waste bin. Observation and interview on 10/28/24 at 12:54 p.m., with nursing assistant (NA)-C exiting R12's room identified NA-C removed their gloves and gown in the hallway outside R12's room into a waste bin. Without removing her PPE inside the room as appropriate or washing her hands, NA-C gathered the full bag of trash from the trash bin with her bare hands and disposed of it in the soiled utility room. NA-C exited the soiled utility room and used alcohol-based hand rub (ABHR) from the touch-less wall unit on her hands. When NA-C was asked if soap and water had been used after caring for R12, NA-C stated, No, I used sanitizer. NA-C further stated staff only needed to wash their hands with soap and water after hand sanitizer had been used 3 times. It was facility practice to have all PPE discarded outside a resident's room. Interview on 10/28/24 at 3:11 p.m., infection preventionist (IP) identified staff were expected to use soap and water for hand hygiene after caring for a resident with C. difficile, and because C. difficile was a spore releasing bacteria. Hand sanitizer would not kill the microbes completely as it does not kill the bacteria. Soap and water was most effective at prevention of transmission. Review of the 3/14/23, Nurse-driven Protocol for Screening hospitalized Patients for Clostridium Difficile Infections policy identified C. difficile spores could survive for long periods of time in the environment, and the bacteria could be transmitted to others through contact with the contaminated environment and equipment or indirectly on unwashed hands of health care workers. Review of the 11/21/23, Hand Hygiene policy identified staff were to complete hand hygiene with soap and water, not alcohol-based hand rub (ABHR), after caring for a resident with known C. difficile. 34083 R19 R19's 8/21/24, Significant change Minimum Data Set (MDS) assessment identified R19 had severe cognitive impairment, She required total assistance with activities of daily living (ADLS), and was transferred with a sling type lift. R19's printed diagnosis list identified aphasia (a language disorder that affects communication), a surgical wound (complex wound of head with avulsive loss of part of skull and cranial contents-non healing), osteomyelitis (bone infection) of the skull, hemiplegia (paralysis of one side of the body), diabetes, bowel and bladder incontinence, and had been admitted to Hospice services with a terminal diagnosis of respiratory failure with hypoxia. Observation on 10/28/24 at 3:15 p.m. of R19's door identified a bright green sign posted which identified she was on EBP. Staff and visitors must clean their hands before entering and when leaving the room. Providers and staff must also wear gloves and a gown for all the following high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care/use, wound care-any skin opening requiring a dressing, or therapy involving high-contact. Observation on 10/29/24 at 12:31 p.m. when trained medication aide (TMA)-A and nursing assistant (NA)-B retrieved the sling lift and prepared to transfer R19 from her recliner to her bed and then to check and change her incontinent brief. Both TMA-A and NA-B entered the room wearing gloves but no gowns, as indicated by the precautions listed on the door. NA-B retrieved the lift sling and with TMA-A's assistance, shifted R19 forward to place the sling behind her and then beneath her legs. R19 was resting her body against NA-B as she was shifted forward. TMA-A had visible contact against her uniform as she positioned the sling around R19. R19 was then transferred onto her bed. The sling was removed by turning R19 from side to side. NA-A removed R19's pants and change her wet brief . Both NA-A and TMA-A changed their gloves and R19 was redressed. Staff then left R19's room and performed hand hygiene. Interview on 10/29/24 at 12:41 p.m. with NA-B and TMA-A reported R19 was on EBP due to her open head wound and when asked about the sign posted on the door, both NA-B and TMA-A reported they should have been wearing gowns when they provided R19's personal care, but stated they had forgotten. Observation and interview on 10/29/24 at 12:51 p.m. with registered nurse (RN)-A identified staff should have been wearing a gown when transferring and performing brief changes. She reported the sign posted on the door identified both gown and gloves were to be used while providing cares. Interview on 10/29/24 at 1:35 p.m. with the infection preventionist reported EBP was to be in place for residents with any open wounds, lines, drains, with a history of a multi-resistant organisms (MDRO). Staff were expected to use appropriate PPE as indicated on the signage. She reported education on EBP's had been included in the May 24 annual in-service, and reviewed recently. Interview on 10/29/24 at 1:50 p.m. with the director or nursing (DON) confirmed her expectation was for staff to comply with use of PPE when performing personal care for a resident on EBP and that all staff had received training on infection prevention and EBP. Review of the November 2023, LTC-Transmission Based precautions (TBP) and enhanced barrier precautions (EBP) policy identified EBP was utilized when staff were providing high-contact resident care. EBP precautions were to be utilized when a resident had an MDRO with wounds that require dressings, indwelling medical devices such as a central line, a urinary catheter, a feeding tube or a tracheostomy (tube in throat used for breathing). A gown and gloves were indicated when assisting with dressing, bathing/showering, transferring, providing hygiene activities, changing linens, changing briefs or toileting, device care, wound care and therapy services. EBP were indicated to be used throughout a resident's stay in the facility unless the wound heals, the device is no longer used, and the IP had been consulted. 47497 R32 R32's October 2024, Medication Administration Record (MAR) identified R32 was to be administered erythromycin 0.5% ophthalmic eye ointment. Observation and interview on 10/30/24 at 8:12 a.m., with licensed practical nurse (LPN)-A during medication administration identified she put on gloves (donned) gloves, opened the drawer of the medication cart, removed R32's blister packs of medication, and placed them into a medication cup. With her gloved hands, LPN-A placed the blister packs into the drawer, opened another drawer and took out a tube that contained erythromycin (antibiotic) eye ointment. LPN-A then closed the drawer, locked the medication cart, and walked down to R32's room. LPN-A knocked on the door, opened it, sat the medication on the overbed table, and administered the eye ointment. LPN-A did not wash hands or change gloves prior to administering eye ointment after touching other surfaces. LPN-A agreed with the above findings and identified she should have removed her old gloves, washed her hands and donned clean gloves prior to administering R32's eye ointment. Interview on 10/30/24 at 4:54 p.m., with the director of nursing (DON) identified she would expect staff to follow infection control practices by donning clean gloves just prior to administering eye ointments. A policy related to administration of eye medication was requested, nothing was provided by the end of the survey.

Based on observation, interview, and document review, the facility failed to ensure appropriate infection control technique was followed during 1 of 1 meal service. This had the potential to affect all 20 residents residing on the Gardens unit. Findings include: Observation on 10/28/24 of the supper meal served on the Gardens unit identified at: 1) 5:30 p.m., it was noted The meal being served by cook-A. During serving of the meal, cook-A demonstrated multiple incidents of potential cross-contamination and lack of appropriate hand hygiene as he plated the meal for residents. Cook-A was noted to have facial hair that was uncovered as he was dishing food items from the steam table and moving about the kitchenette, obtaining various food items and placing them onto plates. 2) 5:32 p.m., cook-A returned to the steam table wearing the same gloves with which he had opened cabinets to retrieve serving items, and opened the refrigerator and freezer doors to obtain items to place onto trays. Upon returning to the steam table, cook-A placed a plate on the counter in front of the steam table, picked up a grilled cheese sandwich with his same gloved hands, place it onto the plate, used a knife to cut the sandwich, and separated the half's with his gloved hands. He then picked up a bowl and ladled soup into the bowl and placed it onto the plate between the sandwich halves. He then turned to a counter behind him and dished up coleslaw into a cup and placed it onto the tray. While still wearing the same gloves, cook-A opened the freezer, and moved a cardboard box with his gloved hand to obtain an ice cream sandwich. He then brought the sandwich to the serving line and placed it on the tray. The meal was then delivered to the resident by dietary staff. 3) 5:33 p.m., cook-A was still wearing his same contaminated gloves. Cook-A went to a cabinet, opened the cabinet, obtained a divided plate, placed it on the steam table and continued the same process. 4) 5:34 p.m., still wearing his unchanged gloves, he moved to a clipboard lying on the counter, and picked up a pen and made a notation. Still with no glove change or hand hygiene cook-A repeated the same process of handling sandwich's with his gloved hands, and then touching cabinets, the refrigerator and various other items on the counter. 6) 5:38 p.m. cook-A continued serving wearing his unchanged gloves, as he dished a bowl with [NAME] slaw with his thumb inside the dish coming in contact with the with [NAME] slaw, he wiped his hand on a napkin and turned to write a note on the clip board. 7) 5:40 p.m. cook-A picked up a small bowl, that had a black mark on the inside, he touched the black area, which did not rub off and stated it looked like ink, he set the bowl aside and continued to serve food , no hand hygiene or glove change. [NAME] A was also observed to be a wearing a braided bracelet on his right wrist, (uncovered by his glove), as he reached into the steam table to pick up sandwich's. 8) 5:48 p.m. cook-A continued serving the supper meal continuing the same repeated process with no glove change or hand hygiene performed. 9) 5:55 p.m. a resident indicated she did not want the meal being served and indicated she would like a cheese burger and chips. Cook-A removed his gloves, left the kitchenette and went to the main kitchen where he obtained a burger patty in a container. He returned to the kitchenette, put on new gloves without performing hand hygiene. He placed the burger patty to the microwave, reporting the temperature needed to be at 150 F for beef. Cook-A removed gloves while microwave the patty for the second time. When the microwave sounded he removed the burger from the microwave and checked the temperature which was at 145 F, cook-A again returned the burger to the microwave and heated again. On the third time microwave the burger the temperature was at 160 F, and cook-A applied gloves, retrieved a bun from a plastic package, opened the refrigerator and obtained a package of cheese slices, which he separated with his gloved hands and placed a slice on the burger patty. Cook-A again opened the refrigerator, picked up a bottle of catsup with his same gloved hands, squirted some on the burger and replaced the bottle in the the refrigerator and closed the door. Throughout the process of preparing the burger cook-A neither changed his gloves or performed any hand hygiene. Cook-A set the plate on the counter, opened a cabinet, and reached into a box to retrieve a package of potato chips which he opened and placed on the plate with the burger and served to the waiting resident. Cook-A then removed his gloves and indicated he was finished serving. Interview on 10/28/24 at 6:04 p.m. with cook-A identified he did not think he needed to use a facial hair covering because he kept his facial hair cut short. When asked about glove changing and hand hygiene he reported he did not realize he had not changed his gloves between tasks during the meal service when he needed to retrieve items not at the serving line. Cook-A reported he had received education on infection control practices, and reported he should have been changing his gloves and washing his hands between touching surfaces and food items. Interview on 10/29/24 at 8:32 a.m. with the dietary manager (DM) reported her expectation for a person serving food, to change gloves and perform hand hygiene when they touched food and then touched other items in the kitchen or area, and returned to touching food items. She also reported she was not aware of the need to cover facial hair. Review of the October 2024 LTC Food Safety and Sanitation Policy identified gloves were to be worn when handling ready to eat foods. Gloves were to be changed anytime a contaminated surface was touched with handwashing performed after removing the soiled gloves and prior to applying a new pair. Hair was to be restrained with hairnets, hats and/or beard restraints. Hair restraints were to be worn when preparing or serving of food items.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was provided to 1 of 1 resident (R21) prior to mealtime and during morning cares and required staff assistance. Findings include: R21's quarterly Minimum Data Set (MDS) identified R21's cognition was severely impaired, she had continuous inattention and disorganized thinking present. She required set up assistance with eating and was dependent on staff for all other cares. R21 was incontinent of bowel and bladder. R21 had diagnoses of Alzheimer's disease, dementia, anxiety, and depression. R21's 5/10/24, care plan identified she had difficulty making needs known and she was rarely understood. She has a diagnosis of Alzheimer's disease and and Vascular dementia. R21 required her food to be cut up and she needed staff assistance. The nurtion assessment noted resident should not have silverware. Interview on 10/28/24 at 4:21 p.m., with family member (FM)-D identified there were concerns R21 was not getting her fingernails trimmed. FM-D states that R21 ate with her hands and at times had been known to put her hands down her pants. Observation on 10/28/24 at 5:28 p.m., of staff assisting R21 identified R21 had come from the common area where she had been seated in the recliner. Her hands were on the recliner and then placed on the EZ stand by staff as they moved her to the wheelchair. R21 placed her hands on the wheelchair arms and was wheeled to the dining room table. There was no observation of hand hygiene assistance despite R21 touching the recliner, wheelchair, and table area. R21 was provided with a grilled cheese ripped into pieces along with a bowl of grapes. R21 used both hands to feed herself the sandwich pieces and eat the grapes. Intermittently, R21 was observed touching her wheelchair, pushing herself away from the table with her hands, then pushed back in by staff, where she resumed eating. While she ate, R21would set one hand on the tabe to rest and then would use that same hand again to feed herself. R21 alternates using each hand. R21 nails were observed to be longer that the finger and had some darker debris under the nails. It is unclear the dark debris was food particles or other contaminants. Observation on 10/29/24 at 12:58 p.m., R21 during meal service identified she was at the table using her hands to eat a take-out meal the facility ordered-in for residents. She had orange chicken and noodles. There were chunks of chicken all over her bib and it appeared she struggled to pick up the noodles as they were hard to pick up with her hands. There was no silverware there and no staff assisting. During an interivew with (NA)B 10/29/24 at 1:27 p.m., she shared that R21 is only allowed one dish as she will get confused and she is not provided with silverware.She is set up with the dish and R21 eats with her hands. Observation on 10/30/24 at 9:52 a.m., of nursing assistant (NA)-A completing morning cares with R21 in the bathroom where NA-A washed R21's face, her back, under her arms, and lastly her personal area. NA-A did not wash R21's hands during morning cares before leaving R21's bathroom and room. NA-A then proceeded to take R21 to the dining room for breakfast. NA-A obtained R21's breakfast and placed it in front of her at the table. She was provided scrammbled eggs, bacon, and a pastry with a glass of juice. R21 was encouraged to start to eat. No staff provided hand hygiene to R21 prior to her eating her meal. R21 was placed in her wheelchair and NA-A proceeded to assist with dressing, pulling her arms through the holes, but grabbing her hands. Once dressed, NA-A pushed R21 to dining room as R21 placed hands on the wheelchair arm rests. NA-A stated they wash wheelchairs once a week. Interview on 10/30/24 at 10:20 a.m., with NA-A revealed she normally only washed R21's hands with a wipe or washcloth after she eats as that is when R21 has dirty hands. NA-A confirmed she had not washed R21's hands during morning cares or prior to her being served her breakfast. Therefore, R21 went from bed, hands in sheets (which were changed while R21 was in bathroom), to dining room, to eating with her hands withouth having any hand hygiene. Interview on 10/30/24 at 3:21 p.m., with nurse supervisor (NS)-A identified her expectation was that staff would provide hand hygiene to residents who are dependent for cares, prior to meals, after toileting, and as needed throughout the day. Review of 11/21/23, Hand Hygiene policy identified staff were to encourage residents to perform hand hygiene before activities, before eating, and after using the rest room. R21 is dependent on staff for all ADL's.

Based on observation, interview, and document review, the facility failed to identify and implement interventions to prevent new pressure ulcer (PU) development for 1 of 1 resident (R61) who was at risk for PU upon admission. This caused actual harm when the facility failed to identify interventions to prevent new PU's to R61's heels and hip. Findings include: R61's: 1) 7/6/23, admission Minimum Data Set (MDS) assessment identified R61's cognition was severely impaired. R61 was dependent on staff for bed mobility, transfers, and toileting. R61 was identified as at risk for pressure ulcer (PU) development with no pressure ulcers present at that time. R61 had no venous or arterial ulcers, however, did have a skin tear. R61's skin and ulcer treatment included application of a nonsurgical dressing other than on their feet and application of ointment/medication other than on their feet. R61's diagnosis included atrial fibrillation, arthritis, osteoporosis, heart failure, hypertension, dementia, malnutrition or at risk for malnutrition, anxiety, depression, and psychotic disorder. 2) 9/27/23, quarterly MDS identified R61 continued to be dependent on staff for bed mobility, transfers, and toileting. R61 was identified as having a stage I or greater PU. R61 was at risk for PU development. R61 had an unhealed PU, and 1 unstageable PU. R61's skin and PU treatment included a pressure reducing device in chair, PU care, and application of ointment/medication, other than on their feet. R61's diagnoses included peripheral vascular disease (lack of blood flow to extremeties), atrial fibrillation (abnormal heart rhythm that affects blood circulation), congestive heart failure, degenerative joint disease, heart valve inadequacies (regurgitation), history of facial cancer, and knee and hip replacements. Observation on 11/28/23 at 12:10 p.m., R61 was seated in Broda wheelchair reclined with her feet elevated and a heel boot on her left foot. At 2:59 p.m., R61 was noted to be laying down in her bed positioned on her back side. At 5:06 staff entered room and assisted R61 up out of bed and back into her recliner. R61's facility wound assessments identified: 1) On 8/9/23, the left foot 2nd toe appeared as dried dark black/brown scab that measured 0.6 centimeters (cm) length x 1 cm width x 0.6 cm area and was classified as a PU, unstageable with wound bed eschar (dead tissue) at 100%, surrounding tissue noted to be dry, with brown staining, and a small amount of drainage. Staff were to apply a wound dressing and notify the physician (MD). Staff noted details of left 2nd toe remained the same on 8/16/23, 8/23/23, 8/30/23, 9/6/23, and 9/12/23. There was no mention of interventions put into place to prevent further skin breakdown as R61 was identified at risk for skin breakdown and now had additional heightened risk for other PU related to identified skin breakdown on left 2nd toe. 2) On 9/27/23, staff noted R61's left 2nd toe appeared as brown, measured 0.2 cm x 0.1 cm x 0.02 cm. Staff noted it was a PU, unstageable, with the wound bed 100% eschar. The surrounding tissue was dry, and had a scant amount of drainage. Wound dressings were to be applied. 3) On 10/3/23, the left 2nd toe had 2 areas. The top portion of 2nd toe measured 0.7 cm x 0.5 cm and the bottom portion of the 2nd toe measured 0.6 cm x 0.9 cm x 0.54 cm. They appeared as intact brown, yellow, unstageable PU, with the wound bed 40% slough and 60% granulated (healthy tissue). The surrounding tissue was noted to be dry, red, was boggy but had no drainage. Wounds were cleansed with betadine and dressing applied and secured with medical tape. There was no documentation R61's physician had been updated with the change in status of the left second toe or interventions were reviewed for appropriateness or additional interventions were identified for the remainder of R61's feet. 4) On 10/10/23, the left 2nd toe had 1 area that measured 0.8 cm x 0.5 cm x 0.40 cm. Staff did not document the appearance or stage of the PU, however, the surrounding tissue was noted to be dry and intact. A wound cleanser was used and the dressing changed to a debriding type dressing (alginate). Details of the left 2nd toe remained the same on the 10/17/23, 10/22/23, and 10/24/23. 5) On 10/21/23, staff identified an additional area of concern as R61 had a rash to their right upper shoulder, starting along the backside of the right side of the neck and down the right upper arm. The rash was not causing R61 discomfort and was to be re-assessed the next day. On 10/22/23, the rash had gotten larger with blisters present. Staff contacted R61's MD and the resident was seen via video with a diagnosis of shingles and medication was ordered. (R61 was placed into isolation in their room). 6) On 10/24/23 at 4:23 p.m., staff identified the left 2nd toe was a dry scab, measuring 0.5 cm x 0.6 cm x 0.30 cm, and the wound bed was 100% eschar. This measurement indicated a decrease in size from the morning measurement. No other interventions were placed at that time to protect R61's feet from new PU. 7) On 10/29/23, new bilateral heel wounds (PU) were identified. A right heel wound was noted that appeared dark reddish purple and measured 2.7 cm length x 2.7 cm width x 7.29 cm area. No drainage was noted. Staff placed an adhesive bandage on the right heel for protection and placed booties on heel and were to float the heels. The left heel was identified to have a wound that measured 2.7 cm x 2.7 cm x 7.29 cm also with a adhesive bandage placed on that heel for protection. Staff contacted R61's MD for a referral to wound care. Staff now began new interventions of booties on heels and were to ensure R61's heels were floated while in bed or a chair. R61 was noted as having displayed discomfort with the dressing change. 8) On 10/30/23, the right heel was identified as healed, however staff noted the area remained fragile and heel protectors were to still be in place. The left heel showed redness with purple area in the middle that measured 2.5 cm x 1.4 cm x 3.50 cm. The left heel was identified as a pressure wound a stage 2, with an Optifoam dressing to be applied and ensure heel protectors were in place. Staff noted redness on R61's left heel and measured the PU at 5 cm x 4 cm with a purple area in center of red area that measured 2.5 cm x 1.4 cm. R61's MD was updated on the new stage 2 pressure ulcer noted to the left heel, with a question if hospice referral would be appropriate. On 10/31/23, the provider responded R61 was not quite at a hospice level yet. 9) On 11/1/23, R61's left heel measurements remained the same. The left 2nd toe was identified as having 2 areas a scab below the right side of the 2nd toenail and a scab on the knuckle of the 2nd toe. The measurement was 0.4 cm x 0.3 cm x 0.12 cm, unstageable, with the wound bed 100% eschar, and a scant amount of drainage. The dressing applied was a Polymem dressing. R61 was noted as having displayed discomfort with the dressing change. A scab below 2nd toenail measured 0.4 cm x 0.5 cm. Another new area on the left side of foot was noted to be pink measuring 1 cm x 0.7 cm x 0.7 cm, classified as a stage 1 PU, and a Polymem dressing was applied. The facility reached out to wound care for assessment and treatment of R61's left 2nd toe, with an appointment made for 11/2/23. Review of wound care progress notes from nurse practitioner (NP)-G identified on: 1) 11/2/23, NP-G assessed R61's left foot wounds and identified a stage IV PU on R61's left 2nd toe and pressure injury of deep tissue to the left heel. NP-G noted R61 had a Polymem dressing to the left 2nd toe wound and an Optifoam dressing to the left heel. R61 was noted to have had a heel protector on. Following debridement NP-G identified the underlying tissue was consistent with a stage IV PU (full thickeness with muscle and bone exposure) noted to the dorsal (top) aspect of the left second toe that measured 0.9 cm x 1.0 cm x 0.1 cm. probing into the bone. The wound bed was 50% slough and 50% necrotic tissue. NP-G noted a deep tissue PU of the left heel. R61's skin was intact with non-blanchable (lack of blood flow) purple discoloration, measuring at 1.0 cm x 1.5 cm. NP-G's plan revealed R61 did have a stage IV pressure injury to left second toe with some bone exposed and surrounding redness. NP-G would need to order an MRI to further assess for potential osteomyelitis (sever bone infection). Treatment for second left toe was to be a debriding dressing of calcium alginate as a primary dressing covered with a Polymem dressing. The left heel was not open. She would continue to cover this area with Optifoam dressing and change the dressing every 2-3 days. R61 was to continue to use heel protectors and staff were to ensure regular pressure offloading practices. 2) On 11/15/23, NP-G re-assessed R61's non-healing foot wounds. Family was present and significantly concerned with the non-healing nature of the wounds. R61 was scheduled to see the infectious disease team later that day. NP-G noted a full thickness ulcer on R61's left second toe that measured 2.3 cm x 1.4 cm x 0.1 cm with deep probing to the bone. The wound bed is 100% necrotic tissue. NP-G also noted a full thickness wound to left heel that measured 2.5 cm x 3.0 cm x 0.1 cm. Necrotic tissue was covering the wound bed. R61 had moderate sanguineous (yellowish)drainage. NP-G had a discussion with the family the possibility of vascular (blood flow) studies however, family was unsure they wanted to move forward with that given her advanced age and demented status. There was concern for underlying osteomyelitis or worsening infection and NP-G noted R61 may be better off treated by the infectious disease team with an antibiotic. R61's family was more willing to accept the potential risks of antibiotic therapy versus any surgical procedure. It was explained to the family by NP-G that without proper treatment, there was a possibility the wounds could become worse, and they could certainly could lead to a life threatening infection (sepsis). R61 was fitted for a heel suspension boot to be used at all times to offload the heel wound and written instructions were provide for the facility. 3) On 11/20/23, NP-G assessed R61's left foot wounds. R61 had been seen last week by podiatry and infectious disease. The family decided to move forward with symptomatic treatment at this time and forgo any aggressive management. R61's left second toe PU measured 2.3 cm x 1.4 cm x 0.1 cm deep and was probing to the bone. The wound bed was 100% necrotic (dead) tissue. R61's left heel full thickness PU wound measured 2.5 cm x 3.0 cm x 0.1 cm deep. Dry necrotic tissue covered the wound bed. There were two new areas of non-blanchable, deep red discoloration areas noted to her outer and inner ankle. NP-G's plan was to continue with betadine to the left second toe and the left heel as well with an Optifoam dressing to the left heel after the betadine wash dried. Staff were to continue with R61's heel suspension boot and offloading practices like floating the heels. Further review of R61's wound assessments identified on: 1) 11/7/23, R61's left side of the foot was noted as healed. The left heel identified the center of wound was purple, and was boggy. The left heel measured 1 cm x 1.5 cm x 1.5, and an Optifoam dressing was applied. The left 2nd toe was identified as moist, measuring 1 cm x 0.7 cm x 0.7 cm, stage 4, with 25% of the wound bed as slough and 75% of wound bed being eschar. The surrounding tissue was macerated (white from moisture) with a small amount of drainage. Calcium alginate was applied followed by a Polymem dressing. R61 was noted to have discomfort with the dressing change. R61 was followed by wound care. 2) On 11/16/23, identified no assessment of left toe or left heel. Staff did note a new potential PU area on right lateral hip and it measured 0.9 cm x 0.3 cm x 0.27 cm. Staff classified the wound as a stage 2 PU. Dressing applied was Optifoam 4 x 4. An air mattress was now to be applied to R61's bed. 3) On 11/22/23, R61's right lateral hip had a scab that measured 0.5 cm x 0.2 cm x 0.10 cm. Staff noted the wound to be a stage 2 PU which they felt was improving. The left heel center of the wound was purple, and its edges were noted to be separating. The appearance was pink, purple, and boggy. The heel measured 3.5 cm x 3 cm x 10.5 cm and was classified as a stage 2 PU with small amount of drainage. An Optifoam dressing was applied. The left 2nd toe appeared moist, and measured 1 cm x 0.7 cm x 0.7 cm. and was noted to be a stage 4 PU. A small amount of drainage was seen. R61 had discomfort with the dressing change and was to be followed by wound care. R61's routine Skin Inspections dated 9/23/23, 10/14/23, 10/21/23, 10/28/23, 11/4/23, 11/11/23 and 11/27/23 had no identification of R61's wounds. R61's progress notes identified on: 1) 9/28/23, R61 was at risk for skin breakdown and had a unstageable pressure ulcer to her left 2nd toe. A barrier was applied as a preventative and now a cushion was to be used in R61's wheelchair. 2) 10/29/23, progress note identified communication to the provider that nursing noted areas on both of R61's heels that resemble deep tissue injury. The areas measured approximately 2.7 cm x 2.7 cm and were dark red/purple in color. Nursing requested a referral to wound care. The noted identified Optifoam had been placed on bilateral heels for protection, and booties were to be placed on heels and feet heels were to be floated on pillows. 3) 11/15/23, progress note identified the director of nursing (DON) spoke with family members who requested therapy to evaluate R61 for a different wheelchair, and they also requested a foot board for the wheelchair to support R61's legs. A fentanyl (narcotic pain patch) was requested to help with foot pain, and an air mattress was now to be placed on R61's bed. There was no indication the DON had identified preventative measures should have been placed to prevent other new or worsening pressure ulcers before they occurred. 4) 11/17/23, progress note identified R61 was on contact precautions related to MRSA culture from wound to the bone and being treated for osteomyelitis. R61's current care plan identified on: 1) 6/30/23, staff were to reposition R61 every 2 hours. The care plan lacked identification of the 8/9/23, of R61's unstageable pressure ulcer identified on R61's left second toe that was documented in the wound assessment section of the medical record, along with interventions to prevent worsening of that wound or prevention of additional PU. 2) 10/30/23, the care plan was updated and identified heel protectors were implemented to both heels while in bed and staff were to offload and float heels when able. There was no indication of interventions to prevent heel PU prior R61 acquiring their heel PU. 3) 11/13/23, the care plan was updated to include staff implemented contact precautions related to methicillin resistant staphylococcus aureus (antibiotic resistant organism) (MRSA) in R61's left 2nd toe. 4) 11/16/23, a care plan updated identified an air mattress was implemented due to R61's high risk for skin breakdown. There was no indication the facility proactively attempted to identify and implement interventions to prevent R61's heel and hip PU, nor how routine repositioning every 2 hrs was adequate to ensure R61 had properly offloaded their weight to ensure pressure reduction. R61's Tissue Tolerance assessments revealed on: 1) 6/30/23, the assessment identified after 2 hours of lying supine redness was noted on the coccyx with the intervention of repositioning put into place. The care plan identified repositioning every 2 hours however, the assessment had no mention how the facility determined a routine 2 hour repositioning was appropriated for a resident already at risk, nor if staff had identified the need for increased monitoring or repositioning. 2) 7/1/23, the assessment identified after 2 hours of lying supine areas of pressure had been observed on the coccyx with the same intervention of repositioning identified. The care plan remained the same with repositioning every 2 hours. There was no indication staff had identified increased repositioning was required as R61's 2 hour repositioning had not been adequate to prevent the area of pressure identified on the coccyx from occurring. 3) On 7/2/23, the assessment identified after 3 hours lying supine an area of pressure had been observed with redness noted on the coccyx with an intervention put in place to elevate with pillow and reposition. There was no mention of what staff were to elevate with a pillow. Interview on 11/27/23 at 4:28 p.m., with family member (FM)-E and FM-F reported R61 was admitted to the facility at end of June 2023, with no skin issues. By the end of August, R61 had developed a PU on her left second toe. FM-F stated they did not understand how R61 could come into the facility with no skin issues then develop a pressure ulcer. FM-E reported the facility did not do or have any treatments in place until November 2023. R61 had not seen podiatry or wound care until the wound turned almost black. At that time, the infectious disease (ID) physician extended R61's current antibiotic order until 12/15/23 and then planned to reassess. The ID physician advised the family the next step was amputation. FM-E and FM-F did not feel it was in R61's best interest to have the amputation. FM-F had met with the director of nursing (DON) at beginning of November 2023 and requested a foot cradle for the bed, a different wheelchair as R61's did not even have foot pedals and an air mattress for the bed. FM-F felt all of those interventions should have been done a couple months ago. FM-F and FM-E were concerned if R61 was actually being repositioned when family was not present. FM-E reported they had asked the facility about R61's left toe PU was getting worse and they were told when R61 had shingles she was not eating and her immune system was compromised, and that was the reason for the decline in her PU status. FM-F added if they had not spoken to the DON and had made suggestions for prevention of PU, R61 would not have the air mattress, foot cradle, or a new wheelchair. Interview on 11/28/23 at 3:38 p.m., with nursing assistant (NA)-D identified R61 came back from the local hospital yesterday with padded boots and white pads on her ankles. R61 was not to have the blankets touch her feet. NA-D was unsure how R61 developed her PU's but reported they had gotten worse. She had heard staff speak about her getting an amputation but was unsure if that was going to happen. NA-D reported if R61 was laying down staff were to only reposition her every 2 hours. She confirmed staff were to reposition R61 even if family was visiting. Observation and interview on 11/29/23 at 11:00 a.m., with registered nurse (RN)-C completing wound care treatments identified R61 was combative with the 2 nursing assistants, yelling and attempting to hit out. RN-C first removed a dressing from R61's buttocks and observed was a PU on R61's left buttocks cheek. RN-C cleaned the PU with normal saline, and measured it as 0.3 centimeters (cm) x 0.4 cm. RN-C then applied a new Optifoam dressing. RN-C reported R61's dressing changes typically occur in the evening, so she was unable to state if she felt the wound had improved or not. The right buttocks cheek was observed to have no reddened areas. The left second toe was cleaned with normal saline, measured as 2.3 cm x 1.3 cm. RN-C then applied betadine to the area and reported that the left second toe was to be left open to air. The right hip was observed to have a small scab that measured 0.3 cm x 0.6 cm. RN-C had cleaned the area and stated it would be left open to air. The left heel dressing was removed with a small amount of yellowish drainage noted on dressing. RN-C cleaned the area and measured the area as a whole measuring 4.3 cm x 3.4 cm. The inner opened area measured 0.6 cm x 2.4 cm. There was also an unstageable part covered in eschar measuring 3.9 cm x 2.9 cm. RN-C applied betadine and let that dry and applied another Optifoam dressing. RN-C identified on the left great toe a small scab that measured 0.3 cm x 0.4 cm. The right back side of R61's ankle had what appeared to be reddened skin resembling a rug burn or shearing that measured 0.2 cm x 0.6 cm. The left top portion of R61's ankle had a dressing RN-C removed. RN-C reported that this must be new. The area appeared to be reddened skin that measured 1.8 cm x 1.4 cm. Interview on 11/29/23 at 1:53 p.m., with director of nursing identified she was unable to find documentation that R61's MD had been update after the left 2nd toe status changed on 10/3/23 or that the care plan had been reviewed for appropriate interventions or needed revisions to prevent worsening of the current pressure ulcer or to prevent additional skin breakdown. She confirmed that the air mattress to R61's bed had not been implemented until 11/16/23 and that she had ordered a support device for R61's wheelchair however, that had not come in yet. She reported that she felt it was important to note that R61 had shingles diagnosed on [DATE], that potentially contributed to her decline. She confirmed that the facility should be communicating with R61's MD when a decline in wound status was identified and the resident's care plan should have been reviewed and revised as necessary. She revealed R61's tissue tolerance assessment identified concerns after 2 hours and that the facility implemented an every 2 hour repositioning when R61 first arrived. She further revealed if the tissue tolerance assessment identified after 1 hour a resident was red then staff should have reposition R61 hourly. She revealed the heel protectors were implemented on 10/30/23, the heel suspension boots on 11/15/23, a foot cradle for the bed was implemented and stated I don't know what else we could do. Interview on 11/30/23 at 8:45 a.m., with trained medication aid (TMA)-E identified R61 had never walked since admission. R61 was unable to move herself in her wheelchair and needed extensive assistance of staff since admission. TMA-E identified preventative measures in place for skin breakdown were reposition and toileting. TMA-E reported they thought R61 developed the heel ulcer after she had shingles in October 2023. Observation on 11/30/23 at 8:45 a.m., R61 was in bed sleeping, foot cradle in place, and was positioned with pillows on her left side facing the doorway. It was unknown if R61's heel boots were on or heels were floated in bed as she was covered up. Interview and observation on 11/30/23 at 8:54 a.m., with licensed practical nurse (LPN)-B in R61's room where R61 was lying in bed on her back slightly leaning more towards her left side. LPN-B identified wound rounds were completed weekly with measurements. R61 was known to be combative with cares. R61 used to use a standing lift but had further declined and now uses a total body lift. R61 then instructed LPN-B to leave her room. R61 was observed moving her feet up and down rubbing them while in her bed. Upon leaving the room, LPN-B reported that was how she believed R61 got her heel wound. Interview on 11/30/23 at 9:11 a.m., with nurse practitioner (NP)-G identified R61 was first seen on 11/2/23 for a stage 4 pressure ulcer on left second toe and a deep tissue injury on her left heel. NP-G reported the development of deep tissue PU's depended on each resident and their co-morbidities. R61 did not have good vascular status (blood flow to her limbs) and that increased her risk of acquiring a PU. NP-G reported R61 had even developed a new wound between weekly visit confirming she was prone to skin breakdown. When residents are at risk for skin breakdown, she typically recommended heel suspension boots. She reported there were concerns for osteomyelitis (bone infection) however, R61's family did not want to pursue aggressive measures related to her not being a good surgical candidate. Family also felt R61 would not tolerate a PICC line (IV line used to get antibiotics directly into the blood stream near the heart). NP-G reported there were definitely things [interventions] that should have been put in place prior to R61 acquiring new PU. The family was made aware that R61 could become septic (life threatening infection if not treated) related to not wanting to do any interventions other than oral antibiotics. NP-G revealed that every 1 to 1.5 hour repositioning would be ideal as every 2 hour repositioning for a resident who was a known PU risk was not appropriate. She agreed the facility should have anticipated R61's needs and identified and implemented interventions to try and lower her risk of new PU development. Observation and interview on 11/30/23 at 10:46 a.m., of R61 who was seated in recliner, reclined with feet elevated and heel boot on. FM-E reported there have been multiple times when FM-E had to request staff to reposition R61. FM-E further reported that R61 did not receive a boot to suspend her heel until she was seen by podiatry and reported R61 did not have any foot pedals for her wheelchair for the first 5 months until occupational therapy finally assessed her for wheelchair positioning. R61's 11/22/23, occupational therapy evaluation identified a referral was made for an evaluation for optimal positioning while in recliner and wheelchair for skin integrity and comfort. The therapy note identified R61 was found to have a ROHO cushion that was flat noted in wheelchair. A replacement cushion, low profile was provided. Therapy also provided a dycem cushion for recliner. There was no indication that therapy had been consulted for positioning upon admission or when PU had been discovered. R61's 11/15/23, Infectious Disease (ID) visit note identified left second toe with osteomyelitis with associated cellulitis (skin infection). Family was present and discussed the chances of a cure might be hampered by multiple variables including poor vascular supply and age. A discussion on side effects of antibiotic and after a full explanation of the clinical scenario a decision was made to proceed with antibiotic therapy. The left foot medial heel ulcer was assessed also. R61's case was extensively discussed with family members. A MRI, vascular study was offered but declined by family and decision to only treat with antibiotic was made given her advanced age and dementia. A follow up appointment on 11/27/23, identified a concern for osteomyelitis with a recommendation for MRI or bone scan to evaluate. It was noted that family declined the desire to have R61 go through a MRI, vascular studies or source control (e.g amputation). the ID planned to treat R61 with Docycycline (antibiotic) 100 mg twice a day until 12/13/23 then follow up in 2 weeks as an outpatient. Review of June 2023, Skin Condition Identification and Prevention Program policy identified residents would be assessed for risk of pressure ulcer development or presence of pressure ulcers upon admission. The facility will implement interventions to prevent pressure ulcer development and/or treat current pressure ulcers. For residents who have been identified as having a pressure ulcer upon admission interventions will be implemented to promote healing. Residents who develop a pressure ulcer after admission, the facility will reevaluate prevention intervention for appropriateness of preventative measures. The facility was to document pressure ulcers weekly by the type of injury, the stage, measurements, describe the wound bed, describe the wound edges, any drainage, any pain and progress towards healing. There was no indication PU should be assessed more frequently as needed to ensure worsening did not occur. If a resident has a pressure ulcer not showing evidence of progress within 2-4 weeks the resident and interventions should be reassessed. The facility was to implement a baseline care plan within 48 hours that included preventative measures based or the residents risks and needs that were identified such as repositioning, pressure relieving devices, moisture barriers, and nutritional needs with measurable goals identified. The policy further provided references for prevention, assessing, staging, and types of interventions the facility could use. The pressure ulcer development reference identified the provider and the wound care team should be notified of a new pressure ulcer development for an assessment. The facility was to notify the MD if no evidence of healing occurred in 2-4 weeks. The policy references included performing a tissue tolerance test and how to conduct the test. For example if a resident that had remained in the same position for 2 hours developed any areas of redness the test should be stopped as the resident would require repositioning at an interval of every hour.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to have evidence of a Performance Improvement Project (PIP) which identified facility specific high risk or problem-prone areas, develop an action plan to correct the identified areas of concern, and to ensure the committee participated in the development and oversight of the systems. This had the potential to affect the quality of care and quality of life for all 72 residents in the facility. Findings include: Interview and record review of minutes with the Quality Assurance (QA) coordinator, for the last 3 quarters; March 16, 2023; April 20, 2023; May 18, 2023, June 15, 2023, July 20, 2023; September 21, 2023, and October 19, 2023, identified the facility had failed to identify facility specific problems or areas of concern, develop action plans, and implement systems with documented QAPI committee oversight. Interview on 11/28/23 at 2:15 p.m., with the QA coordinator reported QA education is provided to all staff annually by online education related to generic QAPI programs and not to the faciliy's QAPI program itself. Managers were encouraged to take facility specific QAPI information from the score card to their staff meetings and it was also available to staff online in the facility SharePoint document. She reported there was no documentation to identify if information had been provided by the department managers to their staff. Interview on 11/28/23 at 3:30 p.m., with the director of nursing (DON) reported she included QAPI as an agenda item on her monthly staff meetings. She reported she reviewed any areas of concern she was aware of but did not have any information on PIPS or areas of concern outside of the nursing department. Interview on 11/29/23 at 9:30 a.m. with registered nurse (RN)-C reported there was some review of QAPI at staff meetings, but there had not been specific discussion on PIP projects, facility identified areas of concern or action plans put in place. Interview on 11/29/23 at 3:46 p.m., with the QA coordinator and the interim administrator reported she had spoken with other supervisors about the process used for taking minutes and there needed to be more detail on areas of discussion and any projects put into place. The QA coordinator reported the facility developed a plan at the beginning of the physical year and then items could be added as they were identified. She voiced agreement there was no documented evidence of the process included in the QAPI minutes and facility specific concerns along with the action plan should be identified. When asked about the alleged incident of drug diversion she confirmed the incident had not been brought to QAPI as an area of concern and it should have been with development of an action plan with QAPI oversight. The interim administrator reported his agreement that work needed to be done to ensure identified areas of concern were discussed with development of a plan of action and documentation in the QAPI minutes. Review of the QAPI Plan 2023 - 2024, approved by the Quality Committee of the Board of Directors August 28, 2023, identified the facility would put in place systems to monitor care and services, drawing data from multiple sources. It included performance indicators to monitor a wide range of care processes and outcomes and review findings against benchmarks/goals the facility had established for performance. It included tracking, investigating, and monitoring adverse events each time they occurred, with development of action plans implemented. Targets for performance in areas being monitored were to be set by the QAPI team, with monitoring of the facility's progress. The QAPI team was to organize a PIP team who was entrusted to investigate a problem area and produce plans for correction and/or improvement to be implemented. The progress and results of the PIP teams work was to be reported to the QAPI committee on a regular basis.

Based on interview and document review, the facility failed to perform antibiotic stewardship to include antibiotic use protocols and a system to monitor antibiotic usage and determine if the prescribed antibiotics resolved the identified infectious process for 22 of 72 sampled residents (R2, R6, R7, R10, R11, R13, R21, R22, R28, R36, R37, R38, R43, R47, R53, R61, R167, R267, R268, R269, R270, and R271) identified in the facility's infection control surveillance. This had the potential to affect all 72 residents who were or may receive antibiotic therapy in the future. Findings include: Review of the September, October, and November 2023 infection control (IC) surveillance identified for the month of: 1). September 2023, 8 residents were receiving antibiotic treatment (R10, R13, R22, R167, R268, R269, R270 and R271). R167 was identified as receiving an antibiotic but there was no additional information included. There was no indication staff had re-assessed the resident's following completion of the therapy or notified their physicians to identify if symptoms had resolved or there was a need to change the medication or continue treatment for a specific period. 2). October 2023, 4 residents were identified as receiving antibiotic treatment (R6, R37, R53, and R267), R267 was listed on the tracking form as infectious Disease but there was no follow up or documentation to identify the source of infection. There was no indication staff had re-assessed the resident's following completion of the therapy or notified their physicians to identify if symptoms had resolved or there was a need to change the medication or continue treatment for a specific period. 3). November 2023, 10 residents were identified on the tracking as receiving antibiotic therapy ((R2, R7, R11, R21, R28, R36, R38, R43, R47 and R61). There was no indication staff had re-assessed the resident's following completion of the therapy or notified their physicians to identify if symptoms had resolved or there was a need to change the medication or continue treatment for a specific period. Interview and document review on 11/27/23 at 1:02 p.m. with the infection control practioner (IP) reported she received a daily report of any new antibiotics started within the last 3 days and utilized (Theradoc-a computer-based resource that identified labs, antibiotic orders, etc. and populated to a surveillance dashboard for review). The IP reported she looked at antibiotic initiation to determine if it met Loeb criteria and documented on her spreadsheet. According to the IP Employee illness was monitored by a nurse at another facility who screened and determined the appropriate action based on signs and symptoms (S/S) reported. She received a report via email to update on the action taken with the employee. When asked about the incidents of Sepsis the IP reported she was aware of the occurrence and the facility had a form Situation, Background, Assessment and Recommendation (SBAR) staff were to complete and fax to the doctor when a resident was having S/S, but she identified staff were not consistent with completion of the form. Completion of the form caused a trigger on the electronic system to perform an assessment and notify the provider but that was not consistently completed. Interview on 11/29/23 at 8:53 a.m., with the Quality Assurance Coordinator (QA) identified she felt it would be appropriate to have documentation of resolution of a person who had been receiving antibiotic treatment regardless of whether the course of treatment was initiated in the facility or in the hospital. Interview on 11/29/23 at 9:30 a.m., with registered nurse (RN)-C reported when an antibiotic was started on the unit, she notified the director of nursing (DON), and a 48-hour time out would be completed and documented in the record. The facility also performed a 72 hour hold with the hope the culture/sensitivity (C/S) had returned and at that time the MD or NP was notified for any updates or changes in orders. RN-C reported when a resident returned from a hospitalization , she made certain there was an end date for the antibiotic, but relied on the MD or NP to make any documentation related to resolution of the condition that indicated the need for antibiotic treatment. RN-C identified nursing did not do any routine follow up or documentation unless the antibiotic was started in the facility. Interview on 11/30/23 at 10:30 a.m. with the DON identified her expectation for antibiotic stewardship to be followed according to the policy and documentation should be complete to identify all areas on the spread sheet. She also identified all antibiotics should be tracked regardless of initiation in or out of the facility. Review of the November 2023 Long Term Care Antibiotic Stewardship policy identified outcomes were to be monitored related to the use of antibiotics was to include tracking multi-drug resistant organisms and Clostridiums difficile. Review the list of antibiotics ordered for residents to determine if treatment guidelines were followed. Track antibiotic use in the facility monthly to review for patterns of use, days of therapy and to determine the impact of antibiotic stewardship interventions. Reporting of antimicrobial use as well as resistance was to be reported to the Quality Assurance and Performance Improvement (QAPI) committee quarterly. Education was to be provided to nursing and clinical staff at least annually with the goal of antibiotic stewardship interventions.

Based on observation, interview and document review the facility failed to follow manufacture's instructions for cleaning and disinfecting 2 of 2 Master Care Air Jetted tubs located on the First floor. This had the potential to affect 24 of 34 residents, ( R1, R3, R4, R5, R8, R11, R12, R13, R15, R17, R18, R21, R23, R24, R27, R33, R35, R36, R37, R41, R46, R47, R51, and R60) who utilized the two tubs. The facility also failed to ensure staff followed policy and procedure for donning and doffing personal protective equipment (PPE) following use with a resident who was on precautions and failed to sanitize a Hoyer lift following use with a resident on contact precautions. Findings include: WHIRLPOOL TUB Observation and interview on 11/29/23 at 10:44 a.m., with trained medication aid (TMA)-D who performed cleaning and disinfection the Master Care Aire Jet tub following completion of a resident bath. TMA-D reported she had completed her last bath for the day and would complete the cleaning and disinfection process. She then pointed to the instruction sheet posted on the side of the mirror across from the tub and pointed out a competency form posted on the wall beside the tub and stated she followed the directions. TMA-D applied gloves, and goggles, went to the side of the tub unit, picked up the sprayer located on the front of tub and sprayed the interior surface of tub and the surfaces of the bath chair with Master Care Classic cleanser and disinfectant. After she sprayed the solution over the interior surfaces of the tub and chair, she closed the drain and turned on the water to fill the tub. She then picked up a long handled scrub pad and brushed the tub and chair as the tub was filling with water to the level covering the seat of the bath chair. TMA-D did not add more of the Master Care Classic solution and reported it was on the surface of the tub and chair and mixed with the water to disinfect the surfaces. She turned on the tub jets at 10:48 a.m. and reported they were allowed to run for 10 minutes to disinfectant all surfaces. Two black jets were noted in the bottom of the tub and circulated the water over the interior surfaces of the tub and chair. TMA-D continued to brush surfaces of tub for another minute and then removed pad and disposed into the trash. She reported a new pad was used each time the tub was cleaned. TMA-D removed her gloves, washed her hands and continued to put away supplies in room and stated she had to wait for 10 minutes to allow the tub to be disinfected. At 10:55 a.m., TMA-D turned off the jets and opened the drain and allowed the water and disinfectant to drain from tub. When asked about the amount of disinfectant and water in the tub she reported she was not aware of how much disinfectant she had sprayed in the tub as she didn't measure it, and she was not aware of how much water the tub held, or the amount of water needed to cover the seat of the bath chair. Review of the Master Care direction sheet with TMA-D located on the wall identified 2 ounces of disinfectant was to be diluted in 1-2 gallons of water and then brushed over all surfaces and allowed to remain wet for 10 minutes. TMA-D reported there was a lot more water in the tub than the 1-2 gallons and she thought there was probably 2 ounces of disinfectant because she had sprayed everything well. She reported she had been trained to clean and disinfectant the tub as she had demonstrated, but agreed the ratio of water to disinfectant was not as directed on the instruction sheet. Interview on 11/29/23 at 10:19 a.m., with nursing assistant (NA)-C reported she also provided tub baths in the jetted tubs and utilized the same process for spraying disinfectant on the interior surfaces and chair, scrubbing the surfaces with the pad, then filling the tub with water to cover the bath chair seat. NA-C reported she was not aware of the recommended dilution that was listed on the Master Care direction sheet and identified she was not aware of how much disinfectant/cleaner was sprayed into the tub, but confirmed filling the tub to the level of the bath chair seat was more than the 1-2 gallons directed. Interview on 11/29/23 at 2:52 p.m. with the infection preventionist reported her expectation for staff to follow manufacture recommendations for the dilution ratio of disinfectant to water for cleaning/disinfection of the jetted tubs. Reported she was aware of staff completing a competency for providing tub baths and that included cleaning and disinfection. She reported she was not aware the manufacture's directions were not being followed and was an infection control concern she would need to follow up on. Interview on 11/30/23 at 10:15 a.m., with the director of nursing (DON), identified her expectation for the manufacture's recommendations for tub cleaning and disinfection to be followed and voiced agreement that filling the tub over the level of the bath chair seat was much more than the recommended 1-2 gallons of water. Review of the Master Care MB-80 R operation manual identified the tub capacity was 45 gallons of water and water level covering the seat of the bath chair came half way up surface of the tub. The directions for disinfection listed to add 2 ounces of disinfectant solution per gallon water, wet all surfaces thoroughly, and allow to remain wet for 10 minutes and then remove excess liquid. Review of the Master Care Integrity Bath cleaning and disinfecting competency form identified, when there was approximately one gallon of water and disinfectant in the foot well, shut off dispensing by turning knob upright. Use the long handed brush, to thoroughly scrub the inside surfaces of the bath, transfer chair, belts and pads Open the drain and allow the disinfectant to remain for full contact time of 10 minutes per manufacture recommendations. Once the contact time was reached, turn on flush water (turn knob left) to run water through the disinfecting lines in the dispensing box and thoroughly rinse all cleaned components of the tub and transfer chair. A policy for use of the Master Care jetted tub was requested but not provided. 39988 PPE Observation and interview on 11/28/23 at 5:32 p.m., of nursing assistant (NA)-A and NA-B who donned gloves and yellow gowns before entering R61's room. R61 had a sign on the door that identified contact precautions. NA-A and NA-B reported that R61 had an infection in a wound and that staff had to don personal protective equipment (PPE) when performing cares. NA-A and NA-B transferred R61 with a mechanical Hoyer lift (full body lift) into the bed to check and change incontinent product. R61 was incontinent of bowel. R61 was combative with the staff during the task. NA-A removed the soiled incontinent product, cleaned R61's peri area and placed a new incontinent product on R61 without changing gloves. NA-A and NA-B then transferred R61 into her recliner in her room with NA-A still wearing the same gloves. NA-B removed the garbage bag from the trash can that contained the soiled incontinent product and replaced with a new bag before exiting the room. NA-A pushed the mechanical Hoyer lift out of the room and down the hall to a small alcove and parked it all while wearing the same gloves and the yellow gown. NA-A then walked farther down the hall still wearing the yellow gown and soiled gloves to the nurse's station where she removed the gown and soiled gloves. NA-A then used hand sanitizer on her hands and walked into the dining area. NA-A reported that she did not take her soiled gloves nor her yellow gown off in the room because NA-B had just changed the garbage and she did not want to put her dirty gown and gloves in there. NA-A confirmed that she had not sanitized the mechanical Hoyer lift after parking it in the small alcove. NA-A agreed that her PPE should have been removed prior to leaving the room and that the mechanical lift should have been disinfected immediately after use with someone on contact precautions.

Based on observation and interview the facility failed to ensure the steam table where resident meals were served had a sneeze guard to protect food from being contaminated by nearby staff. This had the potential to effect all 12 residents who ate in the Gardens dining area. Findings include: Observation on 11/27/23 at 12:21 p.m., in the Garden dining area identified a steam table against the wall. The steam table lacked a sneeze guard to help reduce the risk of contamination from nearby staff or residents, and there was no separation device used to keep staff or residents any distance away. Dietary aide (DA)-A was observed facing the steam table and dishing food onto plates and placing on a cart, either he or a nursing assistant would take the cart and pass to the residents. Other staff were observed standing near the steam table while DA-A was dishing food. Interview on 11/29/23 at 1:57 p.m., with administrator identified he was not aware that they needed a sneeze guard but agreed that this could pose a risk for contamination. He identified that going forward they would ensure a steam table with a sneeze guard would be used. Review of the 10/17/22, facility provided LTC Food Safety and Sanitation Policy identified the facility would establish and maintain sanitary standards of cleanliness and food handling practices. They would evaluate practices of food handling to meet sanitary standards.

Based on observation, interview and record review the facility failed to ensure the hot steam table was separated from the resident's area in 1 of 3 kitchenettes observed (Gardens resident dining area) placing residents at risk for potential burns. Findings include: Review of current resident's roster residing in the Gardens wing of the facility identified 19 resident total, with 14 residents identified with cognitive impairment and 2 at risk for wandering with Wander Guard devices in place. Observation on 11/27/23 at 12/21 p.m., in the Gardens kitchenette dining area identified a steam table used to hold food at a hot holding temperature while serving residents was against the wall. The steam table and surrounding area lacked any barrier between it and the residents. Observation on 11/27/23, at 12:44 p.m., dietary aid (DA)-A shut off steam table and left area, no other staff were present. Steam table remained very hot to touch. The Garden's dining area was open to resident common areas lacking any barrier or door to ensure resident could not wander into the area. Interview on 11/27/23 at 1:15 p.m., with DA-A identified that he had not received any special instructions or training related to safety with residents and the hot steam table. He said the nursing assistants watch the residents during mealtime to make sure they don't get to close to the steam table. The other dining rooms have a barrier between residents and the steam table, and he was not sure why they did not have one in the gardens dining room but thought it might be the lack of space. DA-A identified that he always makes sure to shut off the steam table before he leaves, and he agreed that it takes a while for it to cool off. Interview on 11/29/23 at 1:57 p.m., administrator agreed with the above finding and agreed the lack of a barrier between residents and the steam table places residents at risk for being burned. He identified that going forward he would always expect a barrier be in place to ensure the safety of residents. A policy was requested related to steam tables but none was provided.

Based on interview and document review, the facility failed to ensure resident cardiopulmonary Resuscitation(CPR) orders were consistent throughout the medical record for 1 of 16 residents reviewed (R3) and ensure staff were knowledgeable as to where to identify documents in order to prevent discrepancies. Findings include: R3's current, [DATE], physician orders identified on [DATE], an order for Do Not Resuscitate (DNR) was entered. R3's current, undated face sheet also reflected the DNR status. R3's current, undated care plan identified R3 was a DNR as of [DATE]. R3's current, Physician Orders for Life Sustaining Treatment (POLST) identified he was to receive CPR in an emergency. Interview on [DATE] at 3:57 p.m., with registered nurse (RN)-C, identified if R3's heart stopped she would start CPR because I know from memory, .he is a full code (CPR). RN-C reviewed chart and identified R3 is a DNR. RN-C then looked at the signed POLST and identified it said he was to have CPR. Interview on [DATE] at 4:15 p.m., with RN-B identified if R3's heart stopped she would check the face sheet for the code status order. RN-B identified she did not know how to pull up the signed POLST or advanced directive in the medical record. Interview on [DATE], director of nursing (DON) agreed that the medical record and the POLST did not match, and she was not sure why. She identified that she could not determine what the correct code status order should be, and she would have to follow up with the family to find out what their wishes were and get a new POLST completed and signed by the physician. Review of the facility's [DATE], Code Status/Resuscitation policy identified they would periodically review CPR status with the resident or responsible representative at least quarterly and with any significant change in the resident's condition.

Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status and needs for 1 of 1 resident (R48) reviewed for elopement. Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated the resident had moderate cognitive impairment and had a Wander Guard elopement bracelet to be used daily. The MDS further indicated diagnoses of Alzheimer's disease. R48's face sheet printed 11/30/23, included diagnoses of dementia with Lewy bodies (abnormal deposits of a protein in the brain causing sleep, behavior, cognition, and movement disorders) and psychotic disorder with delusions and hallucinations. R48's care plan dated 5/25/22, indicated R48 had a problem for elopement and was at risk for elopement related to dementia and ability to ambulate independently. R28 was not at risk for elopement at that time, which was also dated 5/25/22 with status of active and frequency listed as PRN (as needed). R48's elopement assessment dated [DATE], indicated R48 was at low risk for elopement. R48's updated elopement assessment on 11/11/23, completed by licensed practical nurse (LPN)-A indicated R48 was then at risk for elopement and there was to be a Wander Guard in place and checked daily. A nursing aide care sheet, last revised 11/28/23, indicated R48 had dementia and a Wander guard. On interview and observation on 11/27/23 at 5:47 p.m., family member (FM)-A indicated R48 wanders a lot and at times is really confused. FM-A stated he is often here throughout the day and into the evening as he is concerned what could happen to R48. FM-A indicated they don't have a bracelet on her anymore. R48 did not have a Wander guard on her wrists, ankles, or wheelchair. During observations on 11/28/23 at 3:18 p.m., 11/29/23 at 8:10 a.m., and 11/30/23 at 8:10 a.m., R48 was observed to not have a Wander Guard on their person or wheelchair. On interview 11/30/23 at 8:14 a.m., trained medication assistant (TMA)-A indicated R48 used to wander around the facility frequently and try to go up the elevators or outside but hasn't tried to leave in a very long time. TMA-A indicated she no longer has a Wander guard on and thinks the nurse took it off at least a week ago. On interview 11/30/23 at 8:21 a.m., registered nurse (RN)-A, also identified as nursing supervisor, indicated R48 has not tried to elope in a very long time and is not a high risk for elopement anymore. Upon review of recent elopement assessment dated [DATE], RN-A indicated the Wander guard was removed 5/3/23, when she was assessed as low elopement risk. RN-A indicated she doesn't believe the assessment on 11/11/23 was accurate because R48 has not made any attempts over the past six months to elope. RN-A added when R48 first came to the facility she was in a different mental state and has shown improvement since that time. On interview 11/30/23 at 9:25 a.m., the director of nursing (DON) indicated R48 was not physically able to wander around the facility anymore and agreed with RN-A that the 11/11/23 assessment was not accurate and R48 is not at high risk for elopement at this time. The DON stated when care plans are inactivated, like R48's, it says PRN (as needed) in the intervention. The DON stated the nursing assistant care sheet, care plan and assessment should all indicate R48's the same accurate status and interventions for elopement. On interview 11/30/23 at 10:19 a.m., LPN-A indicated she doesn't remember doing the assessment, but if her assessment indicated high risk and a Wander guard she would have verified the Wander guard was on R48's wrist, ankle or wheelchair. LPN-A indicated R48 does wander aimlessly on the ground floor but hasn't attempted to leave the facility or go on the elevators in a long time. A policy and procedure for assessments, care plans or elopement was requested, and none was received.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R16) received assistance with hand splints to prevent worsening of contractures. Findings include: R16's Diagnosis Report printed 11/29/23, included diagnosis of vascular dementia (problems in the blood supply to the brain leading to tissue death), and rheumatoid arthritis (chronic inflammatory disease that affects the joints). R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. The MDS further identified R16 required partial to moderate assist with transfers, and was dependent on staff for toileting and dressing. The MDS also included functional limitation of range of motion with impairment on one side upper extremities. R16's care plan dated 1/2/20, indicated R16 requires assistance with most of her activities of daily living and uses adaptive equipment. Interventions included R16 is to wear a brace on right arm, hand and wrist after range of motion. R16 is to wear orthotic (brace) for 2-3 hours at a time as she tolerates. Check for any redness or pain while she has orthotic on. R16's Nursing Assistant Care Sheet, last revised 11/17/23, indicated use of EZ Stand (strap/stand device used to lift someone from a seated position) but did not include use of a splint or orthotic device. An occupational therapy treatment encounter dated 12/28/22, by certified occupational therapy assistant (COTA)-B indicated R16 had orthotic on for 2.5+ hours this morning per staff. COTA educated staff on ensuring patient has no redness or pain during and after wearing the brace. Staff and patient agreeable to completing range of motion and orthotic wear schedule. Staff agreeable to check for redness/pain and to encourage patient to wear for 2-3 hours at a time as patient tolerates. Patient will be discharged . During observation and interview on 11/17/23 at 4:58 p.m., R16 had a visibly contracted (shortening and hardening of muscle) right 4th and 5th finger with the 2 fingers bent straight downwards towards her wrist. There was no splint on her right hand. R16 stated she is unable to move her 4th and 5th fingers and she once wore a splint but doesn't anymore. R16 indicated she isn't sure why they quit putting the splint on her right hand. R16 stated she spent months trying to get her fingers to work again, but she just can't move them now and stated they are stuck. A splint was present in a basket holder in her room window on the ledge. During observation on 11/28/23 at 12:49 p.m., R16 was in the dining room getting assistance with eating. No splint was present on her right hand. During observation and interview on 11/28/23 at 2:20 p.m., registered nurse (RN)-B indicated R16 used to have a splint for her right hand and is unsure if R16 is refusing or if staff are not putting it on. R16 did not have a splint on her right hand. RN-B asked R16 to move her right 4th and 5th fingers and R16 stated they don't move and was unable to move them. R16 indicated she wasn't sure if a splint would work on her hand as she can't move her fingers. RN-B pointed towards R16's window and indicated the splint is in the basket holder on the ledge. During interview on 11/28/23 at 2:23 p.m., trained medication aide (TMA)-B indicated she tries to put the splint on R16's right hand but some days she gets upset and doesn't allow staff to put it one. TMA-B indicated she refused today and was yelling at staff earlier. TMA-B indicted she generally will try a couple times every day and if R16 refuses she documents refused. TMA-B added R16 can not use her right hand to grasp the EZ-stand handles. During observation on 11/29/23 at 7:52 a.m., R16 remained in bed. No splint was present on R16's right hand. Splint remained in basket holder on window ledge. During interview on 11/29/23 at 8:20 a.m., TMA-C indicated R16 will sometimes wear her splint and other times she refuses. TMA-C indicated they complete range of motion to her R16's hand daily. Brace documentation included: (documentation was completed 1-2 times daily) June 1-30, 2023: no documentation 10 times. Brace on 13 times and brace off 21 times. Refusals documented 0 times July 1-31, 2023: no documentation 11 times. Brace on 13 times, brace off 34 times. Refusals documented 0 times. August 1-31, 2023: no documentation 9 times. Brace on 15 times, brace off 35 times. Refusals documented 0 times. September 1-30, 2023: no documentation 9 times. Brace on 19 times, brace off 24 times. 1 refusal due to pain documented. October 1-31, 2023: no documentation 14 times. Brace on 18 times, off 19 times. Refusal 2 times. November 1-28, 2023: no documentation 12 times. Brace on 12 times, off 22 times. Refusal 1 time. During observation and interview on 11/29/23 at 1:08 p.m., registered nurse (RN)-A, also identified as supervisor, assessed R16's right hand. RN-B indicated she hasn't seen it for awhile but R16 had a stroke that affected her right side but she doesn't believe the fingers have changed since she last evaluated her right hand. R16 did not have a splint on her right hand and splint remained in basket holder on window ledge. During interview on 11/29/23 at 1:34 p.m., the director of nursing (DON) indicated if R16 refuses to wear the splint it should be documented as refused. The DON confirmed the plan of care for R16's splint has not been documented as R16 wearing the splint but was unsure if she has been actually wearing the splint or not. The DON indicated she will request an occupational therapy evaluation. During interview on 11/29/23 at 2:49 p.m., occupational therapist (OT)-A indicated she was seen by OT in December 2022 for assessment and treatment for her right hand and fingers. OT-A indicated R16 was to wear her splint 2 to 3 hours per day, check for redness and then put splint back on. OT-A indicated she received a request from DON to assess R16 fingers and right hand which she assessed as tighter than previous but was able to move R16's fingers and get them stretched to normal position. OT-A indicated if R16 is refusing to wear her right wrist brace, OT should be notified, which OT-A confirmed has not occurred. A OT evaluation and plan of treatment dated 11/29/23, for R16 included at baseline R16 has limited wrist extension and tightness for MP (medial phalangeal), PIP (proximal inter-phalangeal joint) and DIP (distal inter-phalangeal joints), (hinge joints between the phalanges {digital bones in the hands} of the finger that provide flexion towards the palm of the hand). R16 within 4 weeks will demonstrate improved tolerance to wear orthotic for a least 4-6 hours per day monitoring for redness for maintaining joint mobility. On 11/29/23, passive range of motion (PROM) was completed but orthotic unable to be assessed today due to patient leaving for another appointment. An OT note dated 11/29/23, at 3:03 p.m. included: Evaluation for R16's right upper extremity, use of orthotics and reported decreased ability to participate in feeding and drinking when when she is drowsy but can do it independently when she is alert. She had previous care provider plan completed for use of Comfy orthotic 2-3 hours at a time during the day checking for redness and use of sheepskin palm protector at night with exercises. Staff reported that they have attempted to put on orthotic but she declines. At this time, skilled OT services are warranted for PROM, orthotic use and wearing. OT provided gentle PROM with tightness present. The use of the Comfy orthotic was not attempted today as R16 left for another appointment. A policy and procedure was requested for splint/orthotic use and none was received.

Based on interview and document review, the facility failed to ensure development of comprehensive care plans were developed and implemented for each resident, included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs and include services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 16 of 18 sampled residents (R3, R4, R5, R11, R20, R31, R41, R42, R43, R50, R54, R56, R57, R121, R122, and R127). This had the potential to affect all 69 residents. Findings include: R5's current, undated care plan identified R5 was admitted to the facility in November, 2021 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], anxiety disorder, . R5's care plan identified problems noted for bladder incontinence, communication and cognitive concerns, was a fall risk, was on hospice, was on a constant carb diabetic diet, chronic pain, psychosocial well-being/mood, activities, medication side effects, and skin integrity. R5 had little to no specific person-centered goals or interventions identified on the care plan according to existing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's current, undated care plan identified R3 was admitted to the facility in July, 2017. R3's care plan identified problems noted for psychosocial well being, Activities of Daily Living (ADL) status, bowel and bladder incontinence, communication and cognitive ability, fall risk, oral and respiratory status, blood sugar status, nutrition, pain, activity involvement, was at risk for medication side effects, and skin integrity. R3 was at risk for side effects from [CONDITION(S)] drug use related to behaviors, however no interventions were placed on the care plan specific to R3.R3 also had contractures and the need for restorative therapy was also not noted on the care plan. Throughout R3's care plan, R3 had little to no specific person-centered goals or interventions identified according to existing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R41's current, undated care plan identified R3 was admitted to the facility in October, 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 had little to no specific person-centered goals or interventions identified on the care plan according to existing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R56's current, undated care plan identified R56 was admitted to the facility in [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had identified problems of ADL status, catheter use, ostomy care, communication and cognitive ability, fall risk, nutritional status, chronic pain, psychosocial well-being, activity involvement, skin integrity. R56 was noted to have a suprapubic (tube placed in opening into bladder through stomach) catheter with interventions to clean and change the catheter bag monthly. The care plan also had a discrepancy and noted R56 was to have her Foley (tube inserted into urethra, then into the bladder) flushed twice per day. Staff were to place a pad under R56 if it leaked. There was also a notation to cath secure change however, there was no indication what that meant or how staff was to ensure her catheter remained secured to her leg. R56 had little to no specific person-centered goals or interventions identified on the care plan according to existing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R31's [DATE], quarterly Minimum Data Set (MDS) identified she had intact cognition with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31 was to have had extensive assistance of 2 staff for transfers between surfaces and required the use of a wheelchair. Observation on [DATE] at approximately 9:45 a.m. identified R31 was being transferred with nurse aide (NA)-H identified she was in process of performing a pivot transfer to R31. NA-H was observed grabbing onto the back side of R31's elastic waistband pants, and pivoting R31 from her wheelchair to a chair without use of a gait belt. R31's current, undated care plan identified R31 was admitted to the facility in [DATE]. R31 was at risk for falls as evidence by a history of falls, impaired balance, [CONDITION(S)], urinary tract infections, and impaired mobility. There were no interventions identified on the care plan reflective of her MDS assessment. R31 had a problem noted with Activities of Daily Living (ADL) and required assistance with ADL's. R31 was noted to transfer/pivot with use of a gait belt and a walker. There was no mention R31 required 2 staff for safety. Review of the [DATE],current nurse aide (NA) care plan identified under the section Care Plan/Special Needs/Special Diet the only notation for NA staff was that she likes makeup and recliner. Her ADL's were listed as A1 (assistance of 1). There was no indication why the nurse aide care plans did not contain critical elements of resident care needed or why it had not been revised recently. Interview and observation on [DATE] at 10:00 a.m. with the administrator and director of nursing identified all residents were to have gait belts in their rooms for potential transfers. Both agreed NA-H should have used the resident's gait belt. The administrator and DON agreed there was the potential for harm for an accidental fall due to staff not using the appropriate equipment. The administrator was unsure why the nurse aide care plans were not up to date or reflective of what resident's care was required but did acknowlege their current computer software was not friendly to long term care (LTC) use and was not able to be resident specific. Both agreed care plans failed to detail resident specific needs. R11's undated care plan failed to identify safety measures for behaviors of anxiety with agitation, attempted elopement, wandering and self-transfers with resulting falls. R11 also had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 had signed provider orders for [MEDICATION(S)] for his anxiety, [MEDICATION(S)] for pain, Insulin for diabetes, and [MEDICATION(S)] for pain. His medications were not identified on the care plan with monitoring for potential side effects. R42's current undated, care plan identified R42 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's care plan identified problems of Alzheimer's dementia, fall risk with a history of falls prior to admission which resulted in a left [CONDITION(S)] with surgical repair, activity involvement, nutritional status with offer preferred supplement for weight loss and wound healing, and at risk for pain evidence by a history of venous stasis ulcers, and arthritis in her shoulders. The care plan also listed R42 was receiving hospice services. R42 had little to no specific person-centered goals or interventions identified on her care plan according to existing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R50's current undated, care plan identified R5 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R50's care plan identified problems with skin integrity, risk for skin breakdown due to immobility, history of pressure ulcers, history of skin grafts, contractures, noncompliance with repositioning at times, [MEDICATION(S)] and [CONDITION(S)] sites, nutritional status-with offered high protein snacks related to his wounds and needed encouragement to eat, at risk for pain but and listed on scheduled pain medication, but no non-pharmacological interventions listed, and psychosocial wellbeing/mood identified. Throughout R50's care plan, R50 had little to no specific person-centered goals or interventions identified according to his specific diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R121's undated, care plan identified R121 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R121 had experienced an injury of unknown origin with bruising under his left arm pit that extended to his chest area and under his right upper arm. R121 was developing increased weakness and it was thought the bruising was a result of use of and EZ stand lift and not being able to support his weight on his legs. R121's current, undated care plan identified problems of communication ability/cognition, ADLs, bowel, and bladder incontinence, fall risk, psychosocial wellbeing/mood, chronic pain, and nutritional status. Throughout R121's care plan, R121 had little to no specific person-centered goals or interventions identified according to his specific diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R122's, undated care plan identified R122 was admitted to the facility on [DATE] and discharged on [DATE], following an extended hospitalization . R122 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R122's care plan identified problems of ADLs, bladder incontinence, communication ability, fall risk, acute/chronic pain, psychosocial wellbeing/mood activity involvement, and medication side effects. R122 had little to no specific person-centered goals or interventions identified on the care plan according to existing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R127's undated care plan identified R127 was admitted to the facility on [DATE] and died on [DATE]. R127's discharge summary listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R127's care plan listed problems of ADLs, bowel and bladder incontinence, communication/cognition ability, fall risk, activity involvement, anticoagulant therapy, blood sugar status, respiratory status, and hospice care. R127 had little to no specific person-centered goals or interventions identified on the care plan according to existing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R20's [DATE], significant change Minimum Data Set (MDS) assessment identified severe cognitive impairment with inattention and disorganized thinking. R20 had verbal, physical and other behaviors during the assessment period. R20 required extensive assist with cares, R20 took an antipsychotic 6, antianxiety 2, and pain medication 4 of the 7 look back period. R20's undated, care plan identified Communication deficit as evidenced by advanced dementia with moderate cognitive losses, problem understanding others, and was mostly non-verbal. The goal was to maintain communication and cognition. Interventions identified care conference as needed, family notification as needed, BIMS interview as needed, communication as needed, nurse observation as needed, notify provider of critical results as needed, and hearing aid/glasses's every 12 hours. The care plan further identified fall risk as evidenced by history of falls, impaired balance, hypertension medication, impaired mobility, and impaired cognition. The goal was to prevent falls and injury. Interventions included balance and functional range of motion as needed and fall risk assessment as need. Psychosocial well being and mood was identified as a problem as evidenced by withdrawal from care and activities, grief over loss of status, daily routine is very different from prior pattern in community, and strong identification with past. The goal was to establish own goals, strong identification with past, and maintain mood. Interventions included an individual abuse prevention plan, alcoholic beverages as needed, [CONDITION(S)] assessment as needed, staff observation as needed, social service assessment as need, [CONDITION(S)] screen as needed, PHQ-9 as needed, Behavior/mood observation every 12 hours, elopement risk as needed, AIMS assessment as needed, and behavior/mood assessment every 12 hours. R20's care plan lacked individualized interventions for staff to follow to ensure communication to meet needs, to prevent falls, and to identify if R20 was displaying any target behaviors as there were none identified. Interview on [DATE] at 1:45 p.m., with registered nurse (RN)-A identified R20 had been seen by psych for medication adjustments related to his physical behaviors. She revealed side effects of medication were being monitored and agreed that the target behaviors were not identified on the care plan but staff charted any behaviors that occurred. Review of [DATE], Behavior health note by psychiatric provider identified R20 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R20 behaviors had been physical aggression to staff, raising hands and shake fist at caregivers, shoved staff, poked staff in eye, punched staff in face, kicked at wife. None of this information had been identified on R20's care plan. R54's [DATE], significant change MDS assessment identified moderate cognitive impairment. R54 required extensive assist with cares and transfers. R54 had history of falls, took daily diuretic, and had occasional pain. R54's undated, care plan identified fall risk as evidenced by history of falls, impaired balance, [CONDITION(S)] drugs, hypertension medications, diuretic medication, impaired mobility, and impaired cognition. The goal was to prevent falls and injury. Interventions included balanced and functional range of motion as needed and fall risk assessment as needed. The care plan identified chronic pain as evidenced by peripheral vascular disease, and [CONDITION(S)]. The goal was to be free from pain and residents to have acceptable level of pain. Interventions included pain interview as needed and pain assessment as needed. R54's care plan lacked individualized interventions to prevent falls and to minimize pain for staff to follow. R43's [DATE], annual MDS assessment identified severe cognitive impairment with inattention and disorganized thinking. R43 required extensive assist with cares and was identified to have had 2 or more falls. R43 took a daily antipsychotic, antidepressant, and a daily hypnotic. R43's undated, care plan identified a communication deficit as evidenced by [CONDITION(S)] dementia with moderate to severe cognitive losses's, was able to make self understood but sometimes talked nonsensical, his orientation fluctuated, he had problems understanding others, and memory impairments. The goal was to maintain communications and cognition. Interventions included care conference summary as needed, family notifications as needed, BIMS interview as needed, communication as needed, nurse observation as needed, notify provider with critical results as needed, hearing aide and glasses's every 12 hours. The care plan identified elopement as a problem with wander guard placed related to ability to wander, cognitive loss and desire to go outside. The goal was R43 will not leave facility unattended. Interventions included wander guard alarm check daily using wander guard pocket reader and elopement risk as needed. R43's care plan lacked individualized interventions for staff to follow to ensure communication to meet needs and initialized interventions to prevent elopement. R4's care plan dated [DATE], indicated R4 had a concern for bladder and bowel due to frequent incontinence of urine. Interventions included recording R4's output and scanning R4's bladder as needed. R4 had a risk for falls related to a history of falls with an injury, impaired balance, the use of [CONDITION(S)] and high blood pressure medications, and impaired mobility and cognition. Interventions included balance/functional range of motion (ROM) daily and keeping R4's bed at a level so R4 could sit on the edge of the bed at a 90-degree angle with her feet flat on the floor to allow for a safe transfer from bed. The care plan lacked interventions related to R4's fall while using the restroom unattended, R4 not activating her call light, and attempting to self-transfer. R57's quarterly Minimum Data Set (MDS) dated [DATE], indicated R57 had severe cognitive deficits. R57 required supervision of one staff for eating and extensive assistance of two staff for all other activities of daily living (ADLs). R57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's Care Area Assessment (CAA) dated [DATE], indicated R57 triggered for cognitive loss/dementia, due to Alzheimer's and dementia, instructing a continuation of the item on R57's care plan. R57 triggered for communication secondary to being hard of hearing and instructing a continuation of the item on the care plan. R57 also triggered for mood state due to a history of depression, instructing a continuation of the item on the care plan. R57's care plan dated [DATE], indicated R57 was at risk for a communication deficit related to hearing loss, difficulty making himself understood and understanding others and declining cognition. Interventions included notifying a provider with critical results as needed, MDS nursing observations as needed, completing a Brief Interview for Mental Status (BIMS) as needed, notifying family as needed, and completing a care conference summary as needed. The care plan lacked resident-centered interventions to assist, maintain, or improve R57's communication deficits. The care plan also indicated R57 was at risk for psychosocial well-being evidenced by withdrawal from activities, grief over loss of roles/status, daily routine very different from prior pattern in the community and having a strong identification with the past. Interventions included visiting with R57 about past agricultural business and discussing his memory book and pictures. R57's care plan further indicated R57 had a deficit related to activities due to a lack of interest. Interventions included daily activity review, an activity evaluation, MDS preferences to be reviewed as needed, and a spiritual assessment to be completed. The care plan lacked indications of R57's preferences for activities or an individualized plan to increase R57's involvement in activities. R57 had respiratory concerns related to OSA and using a [CONDITION(S)]. Interventions included putting the [CONDITION(S)] on every night and cleaning it weekly. No other interventions or instructions regarding the use of the [CONDITION(S)] machine were indicated. R57's care plan also indicated R57 was at risk for psychosocial wellbeing. Interventions included monitoring R57 for side effects related to the use of Seroquel; however, R57 was no longer taking the antipsychotic medication. The care plan lacked evidence R57 had been evaluated for dementia to develop a resident-centered plan to decrease R57's repetitive behaviors and lacked indication that R57 was taking [MEDICATION(S)] (an anti-convulsant used also as an antipsychotic) or interventions to monitor for side effects related to the medication. Review of the [DATE], Facility Wide Risk Assessment identified the facility provided person centered care. Staff were to find out the resident's likes and dislikes and what makes for a good day and incorporate that information into the care planning process and to to ensure staff had the information. Review of [DATE], Care Planning policy identified a person centered care plan would recognize what was important to the resident with regard to daily routines and activities, what supports the resident required, and having an understanding of the resident' life prior to residing in the nursing home.

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R3) with failed to ensure 1 of 1 resident received a Pre-Admission Screening and Resident Review (PASARR) Level II to ensure coordination of mental health services. Findings include: Review of the 7/24/17 (PASARR Level I) identified it was done prior to R3's admission. R3 was noted to have a diagnosed mental illness of Bipolar disorder, depression, anxiety disorder and personality disorder. There was no indication upon admission to the facility an addition assessment occurred. R3's current, undated care plan identified she had an entry for Psychological Well Being/Mood related to a diagnoses of anxiety and depression, loss of independence, and chronic pain. There were no personalized interventions listed other than R3 was to maintain mood and maintain interests in previous activities. There was no mention of R3's diagnoses of Bipolar disorder, depression, anxiety disorder and personality disorder or how staff were to care for her and ensure she received professional services. R3's 2/9/22, annual Minimum Data Set, Section D-Mood identified R3 had little interest in doing things, felt down, depressed or hopeless, Had trouble falling or staying asleep, felt tired or had little energy, had poor appetite or was overeating, had trouble concentrating on things, moved or spoke slowly that other people had noticed, or was fidgety or restless with a total severity score of 15, indicating she had moderately severe depression. Interview on 10/24/22 at 7:15 p.m. with R3 identified she has been depressed. Since at least 4 to 5 moths ago, she felt like she wasn't getting the proper care but acknowledged she does see a mental health professional after she had requested it. They were working on getting her medications straight. Interview on 10/26/22 at 5:00 p.m. with the administrator identified she agreed R3 needed to have a PASARR Level II re-assessed in order for staff to develop a thorough care plan so the facility social worker and contracted mental health providers had provided additional care for R3 after admission and when R3's mood decreased. Review of the current, 7/3/19, Preadmission Screening and OBRA, at https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_000814, identified if the OBRA Level I screening indicated a person had a diagnosis or suspected diagnosis of developmental disabilities or related conditions, he/she also must receive an OBRA Level II evaluative report before he/she can be admitted to an MA-certified nursing facility (NF). If a person experiences a significant change of condition, the lead agency must complete a new OBRA Level II evaluative report. (Note: At the federal level, these evaluations are called resident reviews.) A significant change was noted as a major decline or improvement in person ' s status that: 1) Will not normally resolve itself without staff intervention or standard disease-related clinical interventions, and the person cannot prevent the decline (i.e., not considered self-limiting) 2) Affected more than one area of the person ' s health status 3) Required multidisciplinary review and/or revision of the person ' s care plan. No policy related to PASARR Level II screening was provided by the end of survey.

Based on observation and interview the facility failed to ensure daily nurse staffing information was posted on each of the 2 floors of the facility in a visible prominent place readily accessible to visitor and resident within the nursing home. This had the potential to affect all 69 residents and visitors who wanted to review this information. Interview on 10/25/22 at 2:19 p.m., with trained medication aide (TMA)-D identified that there was no posting of staff on duty anyplace for residents or visitors to view. That information was only accessible on the computer. She was unaware if any paper form with that information was posted in the building. Interview on 10/25/22 at 2:20 with registered nurse (RN)-E identified that nurse staffing information was located on the computer and then on weekends it is on paper. She was unaware if any paper form was posted in the building that showed nurse staffing information. Observation on 10/25/22 at 2:32 p.m., daily nursing staff posting was found by the elevators to go down to the lower level hanging on the wall at wheelchair height below a poster along with several other papers which were all on hooks in a clear plastic protective sleeve. This location was straight down the hall from the entrance to the building located by a conference room. From the front door entrance both resident living quarters where located to the right of the main entrance and then divided into 2 hallways of resident rooms. The nursing staff posting was not visible to resident or visitors unless they went to the elevator and looked through the multiple items hanging on the wall. There was no posting of nurse staffing located in the lower level which also had 2 divided areas of resident rooms. Interview on 10/25/22 at 2:29 p.m., with administrator agreed that the staff posting was not placed on both floors of the building. Observation on 10/26/22 at 9:04 a.m., of the staff posting located by the first floor elevators was dated 10/25/22 from yesterday and not current. There were no other postings observed on either floor of the building. Observation on 10/27/22 at 9:19 a.m., unable to locate any nurse staff posting for the day on lower level. On first floor next to elevators is the staff posting in a clear plastic protective sleeve hanging on the wall at wheelchair height that has current date on it. Interview on 10/27/22 at 12:41 p.m , with family member (FM)-C identified she was unaware of any type of information being posted in the building like that and stated that would be kind of nice to know. Interview on 10/27/22 at 12:43 p.m., with FM-D identified they had no idea that there was any type of information about how many staff were working and had never seen anything like that before. Interview on 10/27/22 at 3:52 p.m., with director of nursing (DON) agreed that the staff posting was not visible and prominent to visitors or residents in its current location. She confirmed there had never been staff posting located on the lower level as it had only been placed by the elevators. She confirmed the current location was not by the entrance and agreed visitors and residents would not know where to even look for if they wanted to review. A policy for nursing staff posting was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure residents were protected from physical abuse when a nursing assistant struck 1 of 1 residents (R2). This resulted in an immediate jeopardy (IJ) situation with the potential to effect all 19 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) residents residing on the Meadows unit. The IJ began on 4/12/19, when nursing assistant (NA)-A struck R2 in the chest, and the facility failed to ensure all residents residing on the Meadows unit were protected from NA-A, who was allowed to continue working unsupervised after striking R2 in the chest. The facility administrator was notified of the IJ on 4/19/19, at 4:32 p.m. which was identified as a pattern (K) The IJ was removed on 4/22/19, at 4:00 p.m. but non-compliance remained at the lower scope and severity of E, no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: R2's quarterly Minimum Data Set ((MDS) dated [DATE], identified R2 had severe cognitive impairment with decreased decision making skills. R2 required extensive assistance with transfers and had daily verbal and physical behaviors. The MDS identified [DIAGNOSES REDACTED]. R2's care plan dated 2/7/19, identified R2 required the assistance two staff for transfers and cares. R2 had known behaviors of hollering, throwing items, grabbing at staff, and making sexually inappropriate comments. Staff were to respond to R2's hollering as soon as possible to assess his needs of toileting, wanting to eat, change his position, and assess for pain. This usually stopped R2's hollering and disruption to others. If R2 appeared unapproachable, staff were to provide R2 with a safe place and re-approach later. There was no mention how staff were to handle aggressive behaviors if exhibited while staff were performing necessary care. The facility investigation dated 4/13/19, 8:20 a.m. identified the report was made by registered nurse (RN)-A. The event date recorded was 4/12/19, at 8:30 a.m. R2 was aggressive toward staff during morning cares. NA-A reported the incident to RN-A around 10:00 a.m. NA-A had tapped R2 on shoulder and stated to R2 to please to not hit us (staff). We are trying to help you. Later on in the shift around 7:00 p.m. NA-B reported NA-A's tap was more like a slight karate chop. RN-A indicated she would continue to monitor R2 for redness/bruising and had none noted at that time. RN-A's immediate action was identified as having a conversation with staff and included it was wrong to take out aggression towards a resident, no matter the situation. RN-A documented she would continue to monitor staff interaction with R2 throughout the weekend. Follow up documentation marked on the report was Supervisor notified?: No. Family notified: No. Contact the provider (R2's physician (MD)): No. Further information documented family had been notified the following day on 4/13/19 at 8:47 a.m. There investigation lacked how the facility was protecting R2 and the other residents on the unit from NA-A. A State Agency (SA) report dated 4/15/19, identified the SA was notified on 4/15/19, at 11:15 a.m. The date of incident was identified as 4/12/19, at 6:00 p.m. The report identified the following: Resident was struck by staff after he had hit out at her per typical behaviors and staff reportedly put hand/arm up, in reaction, which caused resident to be struck as well. This was reported by staff involved as well as another staff in room assisting with cares. Family Aware. Nursing assistants had reported this to nurse, who contacted administrator. Reported to local law enforcement and nurse states VA (vulnerable adult report) filed. In follow up today, its noted that VA was not submitted per protocol-she was unable to log on to (SA) site and when submitting facility quality risk management report, she included (SA) email which she understood was going to be reported to state as VA this way. The Marshall police department report dated 4/15/19, identified the following: - The police were called to the facility on [DATE], at approximately 10:49 a.m. for a staff to resident incident. Officer (O)-A was notified by dispatch he could call the facility and contact registered nurse (RN)-A. O-A called RN-A who reported R2 had dementia and often was assaultive to staff. RN-A stated R2 struck one of the staff members (NA-A). NA-A had struck R2 back somewhere between his neck and shoulders. RN-A had checked on R2, and he was fine. NA-A was being monitored and not going into R2's room. RN-A had notified her supervisor and completed the reporting to the State Agency. RN-A was asked to complete a written statement to be included with his case file. At 3:00 p.m. that same day, O-A went to the facility to pick up RN-A's statement. Upon arrival O-A spoke with RN-A who reiterated R2 was becoming increasingly more combative to staff. O-A asked to speak with R2, but was told R2 would likely not provide an accurate detail of the incident due to his dementia. NA-A had self- reported to RN-A and advised her she struck R2 as a reaction of R2 striking her. NA-B and trained medication aide (TMA)-A had also been in the room at the time of the incident. All 3 staff were currently on shift. O-A asked to speak with them individually. RN-A's written statement identified she had reported the incident to the facility administrator. - NA-B was interviewed by O-A and reported TMA-A was also in R2's room getting his morning medication ready. NA-A and NA-B had been getting R2 up for the day and providing morning cares. R2 had a history of [REDACTED]. NA-A was positioned on R2's right side, and NA-B had been on his left. R2 was being combative at NA-A and NA-B and hitting out at them. NA-B observed NA-A hit back at R2 in the upper chest area. NA-B believed her actions were instinct. NA-B believed if newer staff (NA-A) had further training (with residents with behaviors), staff's instinct to strike back when hit by a resident could be managed better. NA-B had worked at the facility for [AGE] years and reported he had been hit by residents many times. NA-B reported he knew to keep his distance from R2 so he would not get hit. NA-B reported to O-A NA-A hit R2 with more than a light hit, but not full force. NA-B reported R2 apologized as if he knew he was doing something wrong. - O-A interviewed NA-A at that time. NA-A was willing to speak with the officer freely. NA-A reported she had been quite upset about the incident and the reporting that has resulted. NA-A indicated she was in R2's room getting him up for the day. NA-B and TMA-A also were present in the room. TMA-A was getting R2's morning pills ready. Immediately after the incident TMA-A had assisted NA-A and NA-B by trying to hold R2's hands. R2 had been in bed. NA-A and NA-B were in the process of cleaning R2 up, which he didn't like. R2 would often wet or defecated in his briefs so staff would have to clean him up. R2 was known not to like it and often put his fists up and tried to hit at staff. NA-A was on R2's right side using a warm wash cloth to clean R2's private area. As she was doing this, NA-A reported R2 hit her in the throat and it startled her. She had a reflex reaction and hit R2 with the palm of her hand on his upper right shoulder. NA-A reported she had not hit R2 very hard and was just trying to keep his arm away from her. R2 would usually keep fighting with his hands and fists and staff would continue to clean him. NA-A stated she had been hit multiple times by R2, but never in the throat. NA-A was worried about the situation and had not intended to hurt R2. NA-A stated it had been a reflex reaction. NA-A reported R2 would often show staff his fists as if to threaten he was going to hit them. NA-A admitted to showing R2 her fists in return and would say something to the effect of She can show her fists as well. NA-A reported she would never hit R2 in that situation, but rather showed him his threats to staff were not okay. NA-A had been employed at the facility for two years. - O-A spoke with TMA-A. TMA-A heard R2 hit NA-A, but had not witnessed it. It had sounded like a slap or a punch that connected with a person's skin. TMA-A reported R2 normally would put his fists up as he had not liked his morning cares. NA-A had informed TMA-A R2 had hit her in the front of the neck and NA-A reacted by hitting R2 back. That surprised her as she did not hear a second hit. NA-A's neck was red at the time. TMA-A knew NA-A had reported the incident to her supervisor. TMA-A reported NA-A was kind of jumpy when R2 struck her in the neck related to past spousal abuse from NA-A's husband. - O-A identified the case should be sent to the Detective's Division for review. O-A identified he was unaware whether action had been taken to protect R2 from further harm. The facility schedule for 4/7/19, through 4/20/19, identified NA-A worked 4/12/19, 4/13/19 and 4/14/19. During interview on 4/18/19, at 11:36 a.m. nursing supervisor (NS)-B stated she first found out about the incident on 4/15/19. NS-B followed up with the administrator and RN-A who was on duty that day. RN-A had stated the incident was reported to her by NA-B at end of his shift on 4/12/19. NA-A had already gone home for the day at that time. RN-A had not notified the administrator until 4/13/19. At that time, the administrator instructed RN-A to contact law enforcement and submit a report to the State Agency. NA-A could remain on the schedule, but was not to work independently. NS-B logged into the state reporting website and found RN-A had not filed a report, as previously stated, so she immediately filed a report on 4/15/19. NS-B stated the investigation interviews by the facility were completed on 4/15/19. NA-A was placed on suspension on 4/15/19, by the administrator at that time. NA-A continued to work at the facility on 4/12/19, 4/13/19, and 4/14/19. Her understanding was NA-A did not work with R2 over the weekend and either RN-A or RN-C supervised NA-A on a 1:1 basis with the other residents. NS-B's expectation was to immediately report the incident according to facility policy. During interview on 4/18/19, at 2:44 p.m. NA-A stated on 4/12/19, R2 was hooked up to a mechanical lift and she was standing in front of the lift when R2 struck her in the neck. NA-A stated, as a reflex, she struck R2 in the upper arm by R2's shoulder. NA-B was standing in front of lift and trained medication aide (TMA)-A was trying to get R2's medication ready to give R2. NA-A did not think TMA-A saw what happened.Once TMA-A was aware of what happened, TMA-A tried to grab and hold R2 hands to prevent R2 from lashing out so R2 wouldn't hit at staff NA-A stated she frequently worked with R2 and had been hit by R2 several times. When R2 hit NA-A, it was sudden, in her neck and so strong it was shocking. NA-A stated she was startled and reacted. NA-A reported R2 will threaten staff by holding his fist up like he is going to hit someone. NA-A mirrored R2's actions before and has held up her firsts and shook them back at R2. Some days R2 had no behaviors and was in a good mood NA-A received no direction from RN-A after she reported what happened. NA-A continued to work with R2 and remained working independently with other residents. R2 continued to be combative that day. RN-A did have someone work with NA-A when she worked with R2 but she did not have any monitoring by anyone when she worked with other residents, nor was she told someone had to be with her. NA-A had previous training on abuse, reporting, and working with resident with dementia and behaviors. NA-A stated it would be nice to have more training. NA-A verified she did not have a another staff assigned to work with her on 4/12/19, 4/13/19 and 4/14/19 when she worked. During interview on 4/18/19, at 3:12 p.m. NA-B stated he was in R2's room when NA-A struck R2 during morning cares. NA-A was in front of R2 on the right side and when NA-A was bending down R2 struck NA-A sideways in the neck. NA-A raised her arm with open hand and struck R2 back in chest. NA-B reported it might of been reaction, but felt NA-A needed better training. NA-B reported the incident to RN-A on duty about one-half hour to forty-five minutes after it happened. NA-B also identified anytime NA-A worked with R2, NA-B needed to be in the room as he required 2 staff for assistance. NA-B indicated he was not instructed to work with NA-A for residents who only required one staff for cares. On 4/13/19, the police came to the facility to talk to staff regarding the event on 4/12/19. NA-B felt NA-A tried to minimize what happened on 4/12/19. During interview on 4/19/19, at 8:51 a.m. TMA-A stated she was in the room when NA-A struck R2 but did not actually witness it. TMA-A heard what sounded like someone hitting skin. She believed the noise she hear had to be when R2 struck NA-A. TMA-A saw a red spot on NA-A's neck, after NA-A stated R2 hit her. TMA-A said NA-A reported she was scared that R2 was really going to hurt her. TMA-A has been hit by R2 and saw other staff get hit by R2. TMA-A never saw anyone else react to R2 aggressive behaviors in the manner NA-A had. TMA-A stated was directed by RN-A there needed to be another person in the room when NA-A was providing care to R2, but not if NA-A was providing cares to the other 18 residents on the unit. On 4/19/19, at 9:00 a.m. the medical director (MD) stated he was verbally notified in a round about way on 4/15/19, about the incident. MD was told NA-A had struck R2 after being struck by R2 during cares. MD's expectation was the facility staff were to follow policy and procedure for reporting and keeping residents safe. MD stated R2 had a history of [REDACTED]. MD expected the facility to suspend staff suspected of abuse immediately and throughout the investigation until it could be determined if abuse occurred. When interviewed on 4/19/19, at 9:22 a.m. director of nursing (DON) stated she was not available on 4/12/19, and had not been notified of the incident. The administrator notified on 4/13/19, the day after the incident. The administrator directed RN-A to call law enforcement and have someone work along side of NA-A for the remainder of the weekend. DON stated staff were expected to report sooner. Normally, facility process was to protect residents by suspending the person immediately until an investigation was completed. Direction was given to the nurse by the administrator that NA-A was not to work with R2. During record review, She discovered NA-A had continue to work with R2 after the incident. NA-A had self-reported the incident to RN-A on Friday 4/12/19. RN-A had inappropriately supervised NA-A, and allowed NA-A to continue to work unsupervised. The DON stated NA-A was instructed to have someone with her at all times when providing cares. NA-A had been terminated as of 4/18/19. DON stated RN-A was on duty 4/13/19, and 4/14/19, and had not followed facility policy and procedure. During interview on 4/19/19, at 2:04 p.m. administrator stated she was notified about the incident the morning of 4/13/19, by RN-A. She was told R2 hit NA-A, and NA-A hit R2 back. Her understanding was the incident occurred just before NA-A finished her shift on 4/12/19. RN-A stated a witness said it was more than a tap. The administrator walked RN-A through making a report to the State Agency. She directed RN-A, NA-A should not work unless she can be with someone all the times, and to call the police because it was an assault. The administrator expected staff were to call the police immediately. Staff failed to immediately begin the process according to policy, if abuse was suspected to have occurred. During interviews with staff on 4/15/19, the administrator discovered staff's versions of events had not been corroborated by one another. NA-A was suspended at that time. The facility Adult Abuse Prevention Plan dated 1/19, defined abuse as a willful infliction of injury, unreasonable confinement, intimidation, or punishment, resulting in physical harm, pain, or mental anguish. Staff may be suspended or terminated in situations involving severe abuse / or neglect on part of the caregiver. The facility would provide for immediate safety of the resident. The IJ that began on 4/12/19, was removed on 4/22/19, at 4:00 p.m. when it was able to be validated the facility had established and implemented their removal plan by educating all nursing staff, suspending identified staff from resident care, and reviewing and updating policies.

Based on interview and document review, the facility failed to appropriately assess, monitor, and intervene for 1 of 1 resident (R2) who sustained an unwitnessed fall with facial fractures resulting in serious harm and eventual death. Additionally, 2 of 2 residents (R1 and R3) whom sustained an unwitnessed fall did not receive consistent neurological monitoring from nursing staff. The survey resulted in an Immediate Jeopardy (IJ) at F684 J- isolated related to the facility's failure to appropriately assess, monitor, and intervene, with immediate risk to resident health and safety. The IJ began on [DATE] at 7:15 p.m. the facility administration were notified of the IJ on [DATE] at 4:35 p.m. Non-compliance remained at the lower scope and severity of G, actual harm, that was not Immediate Jeopardy. The IJ that began on [DATE] was removed on [DATE] at 1:35 p.m., when it could be verified by observation, document review and staff interview, the facility had implemented their plan of correction by educating and training all nursing staff, and reviewing and updating policies. Findings include: R2's significant change Minimum Data Set (MDS), dated [DATE] identified R2 had [DIAGNOSES REDACTED]. The MDS also identified R2 required extensive assistance for walking in her room and down the unit at that time. R2's [DATE], care plan identified R2 was a do not resuscitate (DNR) and had not wished to receive feeding tubes, IV fluids, mechanical breathing assistance, or cardiopulmonary resuscitation. The care plan identified R2 was steady on her feet for transfers, required only 1 assist for ambulation and required either a cane or walker. R2 was at risk for falls due to dementia and her inability to recall safety. If R2 was unsteady or weaker, staff were to offer assistance. R2's nutrition goal was to maintain weight with no significant weight loss. R2's nursing progress notes revealed on [DATE]: (1) At 7:25 p.m., R2 fell on her face at 7:15 p.m., and had a laceration to the bridge of her nose with crooked in appearance. Her top and bottom lips were swollen, she had a forehead hematoma (large collection of blood under skin) and knee bruising to both knees. Her oxygen saturation of her blood (SPO2) was 95% (normal ,[DATE]%). Her Glasgow Coma Scale (GCS) at that time was 15, identifying mild head injury. Her pupils were sluggish (normal reaction to light is brisk) and 3 millimeters (mm) in size, immediately after the fall R2 had no facial pain, but complained of right shoulder pain. R2's blood pressure (BP) was ,[DATE] millimeters of mercury (mm/hg) (normal ,[DATE] mm/hg). The Family, telemedicine (e-LTC) and hospice were notified of the fall. There was no mention staff identified R2's sluggish pupils as a concern for head trauma even though this was a change from her baseline (MONTH) (YEAR) neurological assessment which identified her pupils normal reaction to light was brisk. (2) At 7:40 p.m., R2's pupils remained sluggish and her GCS was again 15. (3) At 7:45, R2's family member (FM) was contacted about the fall and a request was made for R2 to see the medical doctor (MD) through tele-medicine (e-LTC) for potential X-rays needed. The FM advised nursing Yes, we need to fix what we can and keep her comfortable. (4) At 7:45 p.m., staff documented R2 was found on floor in hallway outside her room earlier at approximately 7:15 p.m. Staff had been in her room [ROOM NUMBER] minutes earlier and had helped R2 to bed. There was no indication R2 exhibited any abnormal behavior immediately before her fall that was reported by nurse aides (NA) to the nurse on duty. (5) At 7:55 p.m., R2's pupils remained sluggish. (6) At 8:10 p.m., R2 was resting and medications were given. No neurological (neuro) checks were performed at that time. (7) At 8:33 p.m., e-LTC was contacted regarding R2's fall via telephone only. No video assessment was completed. (8) At 9:00 p.m., R2 was sleeping. No neurological checks were completed. (9) At 10:00 p.m., R2 responded to pain in her shoulder. Staff noted they spoke with the X-ray department. X-ray department advised nursing the x-rays would not reveal any internal injuries from a fall to the face, and a CT should be ordered. The e-LTC provider was called and a recommendation made to forego the Ct scan as R2 had pain with movement in her shoulder which could wait until the morning. There was no indication staff notified the e-LTC MD about R2's abnormal sluggish pupils, decreased level of consciousness (L[NAME]), or lack of pain with potential nasal fracture. R2 only responded to touch and pain during this time. (10) At 10:23 p.m., R2 was able to consume 600 milliliters (ml) of fluid. No neuro checks were documented as performed at that time. Staff were to give R2 pain medication every 2 hrs as needed, and check on her frequently. (11) At 11:00 p.m. R2 was sleeping. There was no indication staff woke R2 to appropriately assess her neurological function. Pain medication was given for moaning with movement. R2's nursing progress notes revealed on [DATE]: (1) At 12:05 a.m., R2 was resting. No neurological checks were noted at that time. (2) At 3:50 a.m., almost 4 hours later, staff documented R2 was responsive to pain and was given additional pain medication. No neurological checks or physical assessment were documented as performed. (3) At 10:42 a.m., 7 hours later, staff identified hospice registered nurse (RN)-B advised facility nursing staff she had transported R2 to the emergency department per FM's request and was looking for a medication list for R2. At that time, an unidentified ER nurse came to the facility requesting a medication list, advanced directives, code status, and power of attorney (POA) information. Staff provided the ER nurse with the requested information. (4) At 10:45 a.m., staff documented R2 had passed away in the ER at 9:38 a.m. R2's [DATE] midnight, e-LTC documentation identified the provider, doctorate of nurse practitioner (DNP)-C identified R2 was not seen via camera video assessment. DNP-C diagnosed R2 with unspecified fall, unspecified injury of the nose, and pain in her right shoulder. DNP-C documented she called the facility and spoke with registered nurse (RN)-A, who reported family requested X-rays of R2's nose. Discussed calling hospice regarding goal of obtaining X-ray since treatment will most likely not change other than immobilization. Hospice nurse, RN-B spoke with FM and identified they were okay with not obtaining X-rays, however they would like R2's nose straightened manually. FM had wanted a shoulder X-ray and immobilization. DNP-C recommended R2 be seen by a provider in person for re-alignment. If FM wanted an accurate diagnosis, a head CT would be needed of R2's face. DNP-C identified R2 had an unwitnessed fall where resident probably hit her head, may have a broken nose, and hurt her right shoulder. R2 had hit her head on the railing in the hall and landed face down. Her face and knees hit the floor first before the rest of her body. DNP-C reported neuro's were within normal limits for R2. DPN-C's documentation identified R2 had hit her head, had a swollen bump over her right eye, and her lips and nose were swollen as well. R2's knees were swollen and bluish in color. Staff were ordered to follow facility fall protocol with vitals and neuro's. Fall was not related to R2's hospice [DIAGNOSES REDACTED]. There is no mention RN-A reported R2's abnormal neuro's or the extent of potential injuries and seriousness to DNP-C. R2's [DATE], 2:09 p.m. hospice note identified R2 was at the lunch table when RN-B arrived at the facility. R2's SPO2 was 94%, RR at 18, and BP was ,[DATE]. R2 was able to make her wishes known to lie down at that time. No abnormalities of R2's health were noted. R2's [DATE], 8:08 a.m. hospice note identified RN-B had been notified [DATE] at 8:00 p.m. of R2's fall. RN-B notified the family of a nose and shoulder injury. FM wanted R2's nose straightened. The e-LTC advised RN-B R2's nose could be straightened in the morning. RN-B noted she had arrived at the facility earlier that a.m. and found R2 in bed with some blood on her cheek which appears to be coming from her mouth. R2 had snorous respirations and was very pale. R2's fingers were dusky. RN-B measured R2's SPO2 with her O2 monitor and found R2's SPO2 was at 17%. She then retrieved the facility's SPO2 monitor which calculated R2's O2 at 30%. RN-B placed a nasal cannula on R2's mouth and administered 5 L oxygen. RN-B placed a call to R2's FM and advised her of R2's health deterioration. FM wanted R2 to be seen immediately in the ER. R2 was discharged from hospice and transported to the ER. R2's [DATE] ER record indicated she was brought to the ER: (1) At 7:28 a.m., by RN-B after RN-B had arrived at the facility that morning. RN-B checked R2's SPO2 and identified as 35% on room air. RN-B notified FM of R2's condition and FM told RN-B to take R2 off hospice and bring R2 to the ER. Upon arrival to the ER, R2's SPO2 was 34% on 5 liters (L)/minute (min) of oxygen via mask. ER staff noted bruising around both eyes and behind R2's left ear with an abrasion (scrape) to her right forehead and shoulder. R2's vital signs were identified as temperature, 99.5 degrees Fahrenheit (F) (slightly elevated), heart rate (HR) 81 beats per minute (bpm), a fast respiratory rate of 24 breaths per minute (bpm) (normal ,[DATE] bpm), and a lowered BP of ,[DATE] mm/hg. R2's GCS was 3, identifying severe neurological damage if less than 8. An IV was started, and R2 was seen by the physician (MD)-A at 7:35 a.m. (2) At 7:35 a.m., R2's oxygen was increased to 15 L/min and her SPO2 increased to 68%. After IV initiation, R2's BP increased to ,[DATE]. Staff attempted to wake R2 using a sternal (chest bone) rub in attempt to wake or get a response from R2. R2 made no response. (3) At 7:40 a.m., R2's GCS remained at 3, with her pupil diameter smaller at 2 mm and sluggish. R2 remained unresponsive at that time and displayed agonal breathing (abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, and accompanied by strange vocalizations and involuntary muscle jerking). R2's skin was dusky and cool to the touch. (4) At 7:45 a.m., R2 was started on a Bi-Pap machine (pushes air into lungs to assist with breathing). R2's SPO2 increased to 72%. R2's HR was 78 bpm and her BP was ,[DATE]. Her GCS and pupil reaction remained unchanged. (5) At 8:03 a.m., R2 was positioned to sitting up in bed to attempt to increase her SPO2. R2's SPO2 increased to 88%, BP increased to ,[DATE], but her GCS and pupil reaction remained the same. (6) At 8:10 a.m., R2's SPO2 increased to 92%. The director of nursing (DON) for the facility was called regarding potential comfort care for R2. (7) At 9:18 a.m., R2 was switched to another breathing machine, a more aggressive (AVAP) as her SPO2 declined to 60 %. (8) At 9:32 a.m., staff documented R2's continuing decline in SPO2, in spite of the use of an AVAP machine. (9) At 9:33 a.m., R2's HR was abnormally low at 55 bpm, her respirations decreased to 4 bpm, and her SPO2 was at 53%. There was no change to her GCS. (10) At 9:34 a.m., R2's heart rate went to asystole (absence of heart beat). (11) At 9:38 a.m., R2 was pronounced dead. Interview and document review on [DATE] at 8:00 a.m., with RN-A identified she was the nurse on duty who assisted R2 on [DATE] after her fall. R2 had walked out into the hallway and fell face first at approximately 7:15 p.m RN-A performed an immediate assessment on R2. Her face was banged up. R2's neuro's immediately after the fall were sluggish. Staff were to perform neuro's every 15 min x 4, every hour x 4, then every 4 x 6. RN-A had thought R2's sluggish neuro's were her normal. Staff would check back in electronic medical record at the previous neuro documentation to see if anything had changed. RN-A identified on [DATE], a neuro assessment was performed on R2 and her pupils were brisk at that time. RN-A agreed sluggish pupils would not be normal for R2. RN-A had not performed neuro checks according to policy as R2 was sleeping at times and she had not wanted to wake her. RN-A agreed that was not according to facility policy. Staff wouldn't normally wake residents if they appeared to be sleeping. RN-A was unsure how staff would be able to determine a decrease in level of consciousness or changes to neuro status without performing appropriate assessments. E-LTC would be responsible to order X-Rays if needed after a fall. RN-A brought the e-LTC monitor into R2's room for DNP-C to do a visual assessment. DNP-C declined. DNP-C went off the report from the nurses who made the assessment. RN-A was not sure if she advised DNP-C about the potential severity of R2's injuries or abnormal neuro status. In the past, e-LTC would need to give orders to take a resident to the ER for evaluation. R2's family member had requested the facility take R2 to (ER) to straighten her nose. RN-A wasn't sure why staff had not taken R2 to the emergency room that night for assessment of her nose at the family's request. DNP-C felt the shoulder X-ray could be completed in the morning. R2 was moaning with movement and had had a snoring breathing pattern that was not her normal throughout the night of [DATE]. RN-A was unaware R2 had the potential for facial fractures that could cause a brain bleed. RN-A was unsure if the director of nursing (DON) had been called right away after the fall. RN-A stated the facility had a post fall huddle a few days later and went over the events of the fall. No re-education was given at that time. RN-A agreed potential facial fractures would be an emergent situation, now that she looked back at the events surrounding R2's fall. Interview on [DATE] at 9:10 a.m. with the DON regarding R2's fall identified staff were to call her if a significant injury happened at the facility. She was not notified of R2's fall until the next day after R2 went to the ER. If a resident was on hospice, typically the hospice MD-B (also the medical director) is called but he was on vacation at that time, so staff called the e-LTC. E-LTC is contracted for urgent care needs only. Her expectation staff were to perform assessments as dictated in the policy. Staff should have woken R2 to perform neuro assessments. Staff were to use critical thinking in assessment of injuries and identify abnormal vita signs and potential serious injuries. Staff should have communicated the potential seriousness of R2's injuries to the MD and family so all options were given to make the best judgement on care of a resident. The DON performed a post fall huddle and went over the events of R2's fall with staff. Her expectation was hospice should have been alerted to the seriousness of R2's injuries to determine what may need to be done with higher level of care. The DON had set expectation of vitals and policies and procedures were to be followed, but had not re-educated the nursing staff on communication, clinical assessment or policies and procedures. She planned on addressing this individually with staff at a later date. The nurse practitioner (NP) who worked for the MD also reviewed R2's chart and had serious concerns of how staff handled the situation. RN-A advised the DON because R2 was hospice, her fall was not serious. The DON agreed R2's fall was an emergent situation and should have had immediate evaluation. Interview on [DATE] at 11:20 A.M., with the emergency room doctor (MD)-A, regarding the events surrounding R2's fall. MD-A agreed if e-LTC would have visually assessed the resident, they could have seen the potential extent of her injuries. Facial fractures commonly have no pain associated with them as nerve damage is common. MD-A suspected a brain bleed, but was not sure if it was related to Alzheimer or the fall. If R2 had no symptoms or abnormalities immediately before the fall, he would associate the bleed with the injury vs Alzheimers. MD-A stated staff should have taken R2 to the ER immediately for evaluation of her obvious facial fractures. There may have been preventative measures ER staff could have taken to prevent the death of R2 if caught early. MD-A agreed staff failed to recognize the serious extent of R2's injuries, causing delay in treatment. Interview on [DATE] at 11:42 a.m., with RN-B (hospice nurse) regarding R2's fall. RN-B had seen R2 earlier that day on [DATE]. R2 was alert, but confused related to Alzheimers. That was her normal. R2 was placed on hospice related to her nutritional decline earlier that month. RN-B was notified of a probably nose fracture and a potential shoulder injury. RN-B was not made aware of the extent of R2's facial injuries or her abnormal neuro's and vital signs. She spoke with the e-LTC doctor, who reported R2's shoulder x-ray could wait until morning. R2 should have been seen in person at the ER to assess and manually straighten R2's nose. RN-B was not aware the facility staff had not taken R2 to the ER for evaluation. R2's fall injuries were not related to her Alzheimers disease process. RN-B was never advised of the seriousness of R2's injuries that included orbital (eye) bruising with the high potential of facial fracture, R2's hematoma, or abnormal vitals. RN-B arrived to the facility early on [DATE] as another hospice resident had passed away. RN-B came to see how R2 was doing and found her to have ineffectual snored breathing and was pale in color. She immediately assessed R2 and took her SPO2. When her machine said R2 had 17% SPO2, she retrieved the facility monitor. That was a bit higher but seriously low. RN-B immediately called R2's FM and conveyed the seriousness of the situation. At that time, R2's FM decided to remove R2 from hospice and have her transferred to the ER for evaluation. R2 died shortly after in the ER. Had RN-B known the potential seriousness of R2's injuries and abnormal vitals, she would have recommended immediate evaluation at the ER. Interview and competency document review on [DATE] at 12:30 p.m. with RN-D regarding RN-A's competencies and training identified staff meetings and training were held every month. RN-A had not attended either (MONTH) of (MONTH) 2019 trainings as she usually had not attended onsite trainings as she works nights. RN-A was required to sign an email stating she read the training that was provided. No competencies or training were done for RN-A related to falls since (MONTH) (YEAR). RN-E had not had any current fall and injury prevention. her last training was on [DATE]. The IJ that began on [DATE] was removed on [DATE] at 1:35 p.m., when it could be verified by observation, document review and staff interview, the facility had implemented their plan of correction by educating and training all nursing staff, and reviewing and updating policies related to emergency procedures, signs and symptoms of head injury, and fall prevention. R1's [DATE], Significant Change (SC) MDS identified she was severely cognitively impaired and totally dependent on staff for mobility. R1 had an unwitnessed fall on [DATE]. She was found lying on her left side of her body on the fall matt beside her bed. R1 pointed to the other side of the room and said red drawer. R1 denied pain at that time. R1's first 4 neuro assessments were performed the first hour at approximately every 15 min followed by every hour x 4. R1's neuro's after 2:30 a.m. were not performed until 10:30 a.m. the next day 8 hours later as R1 had been asleep. R3's quarterly [DATE], MDS assessment identified she had mild cognitive impairment and would forget things easily and had a history of [REDACTED]. R3 had an unwitnessed fall on [DATE] at 3:40 a.m. R3 stated she was reaching for her call light that was not beside her in bed, but left in the recliner. R3 had a touchpad call light on her railing, but had forgotten to use it. R3's neuro's were completed at 3:40 a.m. and again at 3:55 a.m. and 4:10 a.m. At 4:23 a.m. and 5:25 a.m., staff noted R3 was resting and had not performed any neurological assessment as indicated per policy for an unwitnessed fall until 6:25 a.m Neuro's were then checked at 7:40 a.m. and 8:40 a.m., and not checked again until 12:35 p.m. later that day. The last neuro check was at 4:30 p.m. Interview on [DATE] at 11:15 a.m. with the DON identified she agreed R1 and R3's neuro checks for unwitnessed falls were not completed according to policy and procedure. She agreed nursing staff were not completing these timely or were not performing the assessments if residents were sleeping and should have. Neuros should be completed initially, then every 15 minutes x 4, then every 1 hour x 4 and every 4 hours x 6. This information was not written into any facility policy or procedure, but was expected to be performed as a nursing standard. Review of the (MONTH) (YEAR) Fall Prevention and management policy identified nursing staff were to follow the post fall process map. An assessment of a resident was to include vitals signs and neuro checks if a resident struck their head or it was an unwitnessed fall. The nurse was to notify the family and physician of the fall, sequence of events, and patient condition. There was no mention of how long or at what interval neuro assessments were to be made. Review of the [DATE], Avera Senior Care Services Agreement identified e-LTC was to be used for urgent care services 24 hours per day/7 days per week /365 days per year. The facility and e-LTC agreed to collect and provide current vital signs for residents. E-LTC was to participate in a video encounter when requested by the Avera RN. the RN was to provide an accurate, brief synopsis of the presenting problem, including vital signs that will allow the MD to triage. Review of the undated Physician/medical Services LTC algorithm identified e-LTC was to provide services for residents when the MD or his designee were not onsite. A change in a resident's medical condition requiring physician information identified emergent, life-threatening medical conditions were to be evaluated in the ER immediately.

Based on document review and interview, the facility failed to ensure necessary nursing care and services were provided for 1 of 1 resident (R128) reviewed with a history of acute [MEDICAL CONDITION] and pneumonia. This resulted in actual harm for R128, who required emergency room (ER) care at the local critical access hospital (CAH) and subsequent transfer and admission to an acute care hospital. Findings include: R128's face sheet, identified R128 was admitted to the facility 4/9/15. R128's hospital discharge summary included [DIAGNOSES REDACTED]. An incident report related to an allegation of neglect for R128 had been submitted by the facility to the State Agency (SA) on 4/13/15 which indicated, Resident was admitted from Avera McKennan hospital on [DATE]. On the morning of 4/10/15, staff nurse entered room and found resident to be lethargic, bi-pap at bedside was not on. Resident 02 SATs (oxygen saturation level) at that time were 65% and patient was responsive to stimuli only. Physician here and transferred to ER for further treatment. The facility's investigative report dated 4/17/15 included: Discussion held with nursing staff who admitted resident on 4/9/15. It was verbally reported from Avera Mckennan nurse that the resident was to wear a Bi-pap with oxygen at night. This was reported on to the night nurse by both the charge nurse as well as the unit LPN from the shift. Residents (sic) wife brought the bi-pap in from home to be utilized and the machine was present at bedside. Discussed with nurse who worked the night shift in regards to the use of the bi-pap and he confirmed that he was not given the report that the resident was to use bi-pap and the bi-pap was available but he did not place it on the resident during his shift. There were no vital signs documented per protocol for this resident and scheduled neb (nebulizer) treatment was not administered in a timely manner by the nurse providing care. Disciplinary action has been completed with this employee leading to termination of employment for failure to follow the plan of care for this resident. The resident was transferred to Sioux Falls after the ER visit on the morning of 4/10/15 and admitted to their hospital for further care. Expectation of all staff is to read and understand the plan of care for the residents which they are responsible to provide care for. During interview with the director of nursing (DON) on 12/17/15 at 10:51 a.m., the DON stated R128 was discovered with a low oxygen saturation on the morning of 4/10/15. The DON verified the bi-pap had not been on and that staff had responded immediately by sending him (R128) to the ER for evaluation. The DON stated because it was morning time R128 would not necessarily have needed to have the bi-pap machine on when it was discovered by staff. The DON stated, I feel like the staff responded appropriately at the time of the incident by sending him to the ER. The DON stated that through her investigation on 4/13/15, it was determined the bi-pap had not been used for R128 the night of 4/9/15 so she'd filed a report to the SA because the nurse failed to follow the resident's plan of care. The DON stated she was unable to conclude whether or not having the bi-pap machine caused the low oxygen saturation due to R128's condition.

Based on staff interview and document review, the facility failed to provide appropriate [MEDICAL CONDITION] care for 1 of 2 residents in the sample (R45) reviewed for [MEDICAL CONDITION] care. This resulted in harm for R45. Findings include: Staff changed R45's [MEDICAL CONDITION] and reinserted a smaller size tube than what was prescribed. The stoma shrunk and the resident later required a surgical revision of the stoma to accommodate the use of the physician ordered [MEDICAL CONDITION]. R45 was admitted to the facility on [DATE] after suffering respiratory arrest. The resident was admitted on mechanical ventilation. According to the resident's plan of care dated 1/5/12, staff in an acute care hospital attempted to wean R45 from the ventilator prior to her admission to the nursing home, but these attempts were unsuccessful. The resident was entirely dependent on the ventilator for her respirations. Review of the medical record revealed a history and physical dated 12/14/11 that included the following information: "Today the technician from the home medical goods came by to make a [MEDICAL CONDITION] change, which is routine for R45, as she has a permanent [MEDICAL CONDITION]. Unbeknownst to the technician, apparently (nursing home) staff had placed the smaller Shiley [MEDICAL CONDITION] a day and a half ago when they were apparently cleaning her [MEDICAL CONDITION]. This accidental downsizing allowed the stoma to close down somewhat to a smaller size. When the technician went to insert the 6-French [MEDICAL CONDITION], which was the Shiley type, he was unable to successfully pass it because the stoma had shrunk and the tracheal rings were too tight. There was some minor trauma with a small amount of bleeding. Because of the trauma, the area became [MEDICAL CONDITION] and the technician was unable to get the #4 Shiley back in." The report continued that the surgeon and respiratory therapy were summoned to R45's room, where a still smaller (3.5)endotracheal tube was inserted and the resident was ventilated with an AMBU bag. At this point it was determined that the airway was inadequate because of the small size endotracheal tube and that a surgical revision of the stoma was necessary. R45 was transported to the hospital emergency department for set up of an intravenous line and administration of anti-anxiety medications. She was then taken to an operating room where a surgical revision of the stoma was performed, which involved cutting through one of the tracheal rings and expanding the size of the [MEDICAL CONDITION]. This allowed for insertion of a 6.0 French cuffed [MEDICAL CONDITION]. R45 was admitted to the intensive care unit for further monitoring after the surgical intervention. She returned to the nursing home the next day. Review of the nurses' notes dated 12/13/11 revealed only that the [MEDICAL CONDITION] had been changed by a nurse without incident. The vice president of resident care services was interviewed on 1/25/12, at 11:45 a.m. She confirmed that the incident occurred as stated in the above referenced hospital report. She stated that the incident was reviewed and a root cause analysis had been completed. She stated that the internal investigation had determined that the wrong size [MEDICAL CONDITION] set was in the resident's closet. They were unable to determine if the set had come with the resident when she was admitted from another hospital, or if the medical supply staff had stocked the wrong sized set in the resident's closet. The investigation did identify that the nurse who had inserted the wrong sized tube had not checked to ensure that she was inserting the correct size tube. The vice president of resident care services stated that all nursing staff who work on that unit had been re-trained and competency tested on all aspects of [MEDICAL CONDITION] care. In addition policies and procedures had been revised.