Every finding on record at Avera Sunrise Manor

Based on interview and record review the facility failed to develop a policy for oversight for disciplinary actions for 1 of 1 nursing assistant (NA-A) who had multiple coachings, an action plan, and was subseqently terminated following an alleged incident of alleged abuse. Findings include: Review of 3/29/25, report to the State Agency (SA) identified the DON was notified that an incident had occurred where NA-A had hit R8 in the stomach 3/27/25. The DON assessment of R8 was completed with no visible signs of injury to R8, no pain cues, and no change in behavior was noted. An investigation started. R8's 2/11/25, Significant Change, Minimum Data Set (MDS) assessment identified R8 had a severe cognitive deficit with continuous inattention and disorganized thinking. She had an altered level of consciousness and was dependent on staff for all her cares. R8 was on scheduled pain medication and had no indicators of pain displayed. R8 was identified to have a life expectancy of 6 months or less and was receiving hospice services. R8 had diagnoses of dementia, chronic osteoarthritis, peripheral vascular disease, chronic obstructive pulmonary disease (disease affecting breathing), high blood pressure, difficulty swallowing, and was receiving hospice services. R8's care plan identified R8 was at risk for abuse as a vulnerable adult due to impaired cognition, impaired mobility, and impaired communication. She had severe cognitive impairment and was unable to participate in the assessment as she rarely or never understood and would reply nonsensically. R8 was noted be a Gem Level (mental test to determine stage of dementia) of level Amber/Ruby indicating: 1) R8 had the mental capacity of a 2-7 year old. 2) The environment could drive her reactions without awareness of safety. 3) Residents in this stage may enter into other people's space or cross boundaries as they attempt to meet their own needs being totally unaware of the intrusion. 4) Care could be refused if seen as threatening, due to differences in perspective and ability compared to ours. 5) R8 could experience struggles to understand instructions or gestures and a resident may be able to pick up and hold objects but will not necessarily know what to do with the object. R8 occasionally had behaviors of not wanting to give the staff kitchen utensils to wash. She did not like things taken away from her. She occasionally refused cares and staff were to explain what they were doing prior to attempting task to reduce behaviors. Historically R8 had behaviors of swinging at staff during cares or toileting, and staff needed to be mindful of this and redirect or re-attempt as she allowed. Interview on 3/31/25 at 12:31 p.m., with the director of nursing (DON) identified she had been at the facility the morning of 3/29/25 and had worked a couple hours before returning home. She was called back to the facility and arrived around 2:10 p.m She was informed by staff that NA-A had hit R8 in the stomach on 3/27/25. She had not been made aware of the incident prior to 3/29/25. Review of the facilities ongoing investigation documentation identified on 3/29/25, the DON had interviewed staff, obtained statements, had assessed R8, reviewed and confirmed staff schedule and assignment sheet. The DON notified the ombudsman, initiated re-training on abuse policy, contacted the police department, and set up additional training related to abuse and reporting. The DON interviewed and received the following statements by staff identifying: 1) NA-B (staff who reported to the DON on 3/29/25) reported NA-C (who witnessed the abuse by NA-A) advised her on 3/27/25 NA-A had hit R8 in the stomach. NA-A was reported to have told R8 you don't hit my baby. NA-C told NA-B she reported the incident to the nurse that day. 2) NA-C (witness to the abuse) reported she was assisting NA-A with R8's cares and R8 had reached for NA-A's shirt. NA-A told R8 you do not grab my child and then, with a closed fist, hit R8 in the bladder area of her abdomen. 3) NA-A stated R8 had her in the stomach. NA-A had told R8 not to hit her baby. NA-A denied she hit R8 back. 4) LPN-A (charge nurse on duty on 3/27/25) identified she had no knowledge of the incident. She denied NA-C had reported the abuse from NA-A to R8 on 3/27/25. On 3/31/25, the DON continued interviews with other staff and residents. On 4/1/25, NA-A was given a termination notice and on 4/2/25, NA-C was given a termination notice. Interview on 4/2/25 at 1:08 p.m., with NA-C identified on 3/27/25, after the evening meal around 7:00 p.m., she was assisting NA-A with R8's cares when R8 reached for NA-A. NA-A said to R8 don't hit my kid! and with a closed fist, hit R8 in the bladder area of her abdomen. NA-C reported she did not see R8 hit NA-A, she only saw R8 reach for her. NA-C found the charge nurse (LPN-A) around 8:30 p.m., and reported what had happened. However, she noted she was unsure if the LPN-A heard what she was saying as the nurse was flustered because she had to take over passing medication to residents. She did not work on 3/28/25 but had picked up a shift on 3/29/25 and spoke to the DON. She was unaware she should have told the DON right away on 3/27/25. She thought that she had done the right thing by telling LPN-A at the time it occurred. R8 reacted to the incident by yelling out NO, STOP!. R8 showed no signs of distress after the incident. Interview on 4/2/25 at 2:34 p.m., with NA-B identified on 3/29/25, she was sitting at the nurse's station desk with NA-C talking. NA-C mentioned she had worked with NA-A on Thursday 3/27/25. While assisting R8 to bed on 3/27/25, R8 had tapped NA-A in the belly who was pregnant. NA-A told R8 you don't hit my baby and then proceeded to hit R8 in the stomach 3 times with a closed fist. She asked NA-C if she had reported the incident, and she said she had. NA-B told the DON about her discussion with NA-C about an hour later, when the DON came to the facility. NA-B stated she had never seen NA-A hit anyone, but she was not a gentle person but not rough. NA-A was known to be disrespectful and would tell residents No when they wanted to use the bathroom. Both NA-A and NA-C were newer staff and had only worked a couple months. She had reported to the charge nurse about NA-A being disrespectful previously, and was advised by the nurse NA-A was meeting with the DON about once a week about her attitude already. To her knowledge, NA-A had worked alone as a nurse aid even after reports of negative behavior and was not monitored by other staff or management to her knowledge or observations. Review of NA-A's employee file identified NA-A had coaching with the DON on 1/23/25, 2/4/25, 3/6/25, 3/8/25, and 3/13/25 related to: 1) Communication with peers, 2) Providing assistance to co-workers 3) Time management. 4) Failure to answer call lights. 5) Spending a significant amount of time at the nurses' station when call lights or alarms were sounding. 6) Not passing supplies. 7) Leaving rooms dirty with laundry on the floor, leaving dirty commodes in rooms and garbage in the room, and not cleaning up foul odor of urine on residents. 8) A resident report of not assisting them with toileting needs when asked with other staff. 9) Finding resident in tears for not being assisted. Further review of the coaching in NA-A's employee file note on 3/20/25, an action plan had been put into place due to the above identified issues. NA-A was to demonstrate immediate and sustained improvement in overall performance to avoid further corrective action that included the following. NA-A was to: 1. Check in with the charge nurse at the beginning of her shift, mid shift and before she leaves and provide feedback on what she has completed and if she needs any assistance. 2. Only sit at the desk when charting and prioritize patient care including call lights over charting. 3. Communicate with co-workers and respond over the walkie appropriately. 4. Ensure rooms were cleaned and stocked after assisting residents. 5. Communicate with residents that she will get assistance and be back if she cannot assist them at the time the call light is sounding. 6. Work with co-workers and charge nurse as part of a team and communicate if she needs assistance or has questions. 7. Accept accountability for upholding all facility standards. 8. Be encouraged to utilize the Employee Assistance Program ([NAME]) as necessary. NA-A's file had no mention of how the facility was going to monitor NA-A performance/progress to ensure the previous mentioned concerns had been corrected prior to the incident, or supervise NA-A to ensure residents were safe and appropriately cared for when known behaviors and neglect of duties were identified by the facility. Interview on 4/2/25 at 3:51 p.m., with the DON identified NA-A had worked a total of 5 days between the action plan being implemented on 3/20/25 and the date of the incident on 3/27/25. The DON followed up with NA-A's progress of her action plan verbally with nurses and NA-A. She had no documentation to support she provided oversight to ensure NA-A had been making progress with her action plan and no further incidents of potential abuse or neglect would occur. She would have only documented the progress of the action plan if NA-A had not been doing what she was supposed to be doing. Interview on 4/3/25 at 9:26 a.m., with medical director identified he was made aware of the incident that occurred with NA-A and R8. He was unaware NA-A had performance concerns prior to the incident with coaching and an action plan in place. He revealed that the facility had a good process in place related to abuse identification and training but there was always room for improvements. There were staff challenges due to turnover at times and there maybe an additional training needed more frequently for staff that could be helpful and he would discuss that with the administration and the DON. He agreed NA-A should have been supervised when behaviors with her care of residents had been identified in order to potentially prevent the incident on 3/29/25. Review of the 11/27/23, Corrective Action policy identified corrective action was implemented to improve an employee's job performance or conduct. This type of action would be implemented as a means to inform the employee of the unacceptable behavior or job performance. The policy identified a process of first coaching an employee, then a verbal warning, then a written warning which identified the facilities expectations of the employee in an action plan. A corrective action beyond verbal had to be approved by HR prior to taking action. The manager and/or HR would complete an investigation prior to implementing any corrective action and any action beyond a verbal warning must be signed by the manager and the employee and given to HR to be filed in the employee's personnel file. The policy further identified reasons for immediate dismissal of a position which included neglect or abuse. There was no indication of how an employee action plan would be monitored to ensure progress towards improvement or how the facility would provide oversight for staff identified as having conduct or job performance concerns. Review of the October 2024, Vulnerable Adult Abuse Prevention Plan identified residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. The facility must ensure all alleged violations of abuse, mistreatment, neglect, and misappropriation were immediately reported to the administrator and a thorough investigation completed. The results of the investigation would be reported to the administrator and other officials in accordance with State law within 5 working days and if alleged violation was verified appropriate corrective action would be taken.

Based on interview and document review, the facility failed to notify the ombudsman of facility initiated discharges for 3 of 3 residents (R1, R10, and R17) who were discharged to the hospital. Findings include: R10's current diagnosis list included chronic kidney disease stage III, congestive heart failure (CHF), high blood pressure (HTN), and her hospital discharge summary identified she was hospitalized with influenza and pneumonia with CHF exasperation. R10's condition continued to decline with increased signs and symptoms and on 2/22/25 her family requested she be transferred to the emergency department (ED) for further evaluation. The MD was updated and provided orders for the transfer by emergency medical services (EMS). R10 was admitted to acute care on 2/22/25 and returned to the skilled nursing facility on 2/25/25. Review of R10's medical record failed to include any indication the Ombudsman had been notified of the discharge due to hospitalization. R17's medical record diagnosis list included, HTN, diabetes, Hashimoto's thyroiditis, history of a stroke, hallucinations, psychotic disorder due to medical condition with hallucinations, chronic anticoagulation, morbid obesity, hypercalcemia, osteoarthritis, CKD, and Parkinson's disease. R17 was hospitalized [DATE] -8/16/24 and her discharge summary identified she was admitted to acute care with diagnosis of Pneumonia and Urinary Tract infection (UTI). R17 was treated with antibiotics and returned to the skilled nursing facility. Review of her medical record failed to identify notification of the Ombudsman of R17's discharge to acute care hospitalization. Interview on 4/2/25 at 8:08 a.m., with the director of nursing (DON) reported she had spoken with the social services designee who confirmed the facility had not been reporting discharges due to hospitalization to the Ombudsman. She further reported she was not aware she was supposed to report hospital related discharges when the resident was expected to return to the facility. Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 3 of 3 residents (R1, R10, and R17) reviewed for hospitalizations and/or discharges. This had the potential to affect all 36 residents who resided in the facility as the facility identified they were unaware of the requirement. Findings include: R1's 3/16/25, discharge return anticipated Minimum Data Set (MDS) assessment identified R1 had an unplanned discharge to an acute care hospital. R1's face sheet identified she had been admitted to the facility in March of 2023. R1's hospital discharge summary identified she admitted to the hospital on [DATE] and was discharged back to the facility on 3/18/25. Interview on 4/2/25 at 12:00 p.m., with the social service designee reported she had not notified the ombudsman of R1's discharge. She was not aware they were required to notify the ombudsman of residents who were expected to return following a hospital admission. Interview on 4/2/25, at 12:20 p.m., with the director of nursing identified she was also not aware that the facility was required to notify the ombudsman of residents who where expected to return following a hospital admission. She reported they did not have a policy that specifically identified the facilities responsibilities related to reporting discharges to the ombudsman. A policy was requested for Ombudsman notification of discharge, but not provided by the end of the survey period.

Based on observation, interview and document review the facility failed to protect 1 of 1 resident (R8) from abuse. Findings include: Review of 3/29/25, report to the State Agency (SA) identified the DON was notified that an incident had occurred where NA-A had hit R8 in the stomach 3/27/25. The DON assessment of R8 was completed with no visible signs of injury to R8, no pain cues, and no change in behavior was noted. An investigation started. R8's 2/11/25, Significant Change, Minimum Data Set (MDS) assessment identified R8 had a severe cognitive deficit with continuous inattention and disorganized thinking. She had an altered level of consciousness and was dependent on staff for all her cares. R8 was on scheduled pain medication and had no indicators of pain displayed. R8 was identified to have a life expectancy of 6 months or less and was receiving hospice services. R8 had diagnoses of dementia, chronic osteoarthritis, peripheral vascular disease, chronic obstructive pulmonary disease (disease affecting breathing), high blood pressure, difficulty swallowing, and was receiving hospice services. R8's care plan identified R8 was at risk for abuse as a vulnerable adult due to impaired cognition, impaired mobility, and impaired communication. She had severe cognitive impairment and was unable to participate in the assessment as she rarely or never understood and would reply nonsensically. R8 was noted be a Gem Level (mental test to determine stage of dementia) of level Amber/Ruby indicating: 1) R8 had the mental capacity of a 2-7 year old. 2) The environment could drive her reactions without awareness of safety. 3) Residents in this stage may enter into other people's space or cross boundaries as they attempt to meet their own needs being totally unaware of the intrusion. 4) Care could be refused if seen as threatening, due to differences in perspective and ability compared to ours. 5) R8 could experience struggles to understand instructions or gestures and a resident may be able to pick up and hold objects but will not necessarily know what to do with the object. R8 occasionally had behaviors of not wanting to give the staff kitchen utensils to wash. She did not like things taken away from her. She occasionally refused cares and staff were to explain what they were doing prior to attempting task to reduce behaviors. Historically R8 had behaviors of swinging at staff during cares or toileting, and staff needed to be mindful of this and redirect or re-attempt as she allowed. Interview on 3/31/25 at 12:31 p.m., with the director of nursing (DON) identified she had been at the facility the morning of 3/29/25 and had worked a couple hours before returning home. She was called back to the facility and arrived around 2:10 p.m She was informed by staff that NA-A had hit R8 in the stomach on 3/27/25. She had not been made aware of the incident prior to 3/29/25. Review of the facilities ongoing investigation documentation identified on 3/29/25, the DON had interviewed staff, obtained statements, had assessed R8, reviewed and confirmed staff schedule and assignment sheet. The DON notified the ombudsman, initiated re-training on abuse policy, contacted the police department, and set up additional training related to abuse and reporting. The DON interviewed and received the following statements by staff identifying: 1) NA-B (staff who reported to the DON on 3/29/25) reported NA-C (who witnessed the abuse by NA-A) advised her on 3/27/25 NA-A had hit R8 in the stomach. NA-A was reported to have told R8 you don't hit my baby. NA-C told NA-B she reported the incident to the nurse that day. 2) NA-C (witness to the abuse) reported she was assisting NA-A with R8's cares and R8 had reached for NA-A's shirt. NA-A told R8 you do not grab my child and then, with a closed fist, hit R8 in the bladder area of her abdomen. 3) NA-A stated R8 had her in the stomach. NA-A had told R8 not to hit her baby. NA-A denied she hit R8 back. 4) LPN-A (charge nurse on duty on 3/27/25) identified she had no knowledge of the incident. She denied NA-C had reported the abuse from NA-A to R8 on 3/27/25. On 3/31/25, the DON continued interviews with other staff and residents. On 4/1/25, NA-A was given a termination notice and on 4/2/25, NA-C was given a termination notice. Observation on 3/31/25 at 11:34 a.m., R8 was seated at dining room table with staff sitting next to her for lunch. She was alert and looking around room. R8 did not appear to be in any distress. Observation on 4/1/25 at 8:32 a.m., R8 was seated at a table with staff next to her assisting her with breakfast. R8 did not appear to be in any distress. Interview on 4/2/25 at 1:08 p.m., with NA-C identified on 3/27/25, after the evening meal around 7:00 p.m., she was assisting NA-A with R8's cares when R8 reached for NA-A. NA-A said to R8 don't hit my kid! and with a closed fist, hit R8 in the bladder area of her abdomen. NA-C reported she did not see R8 hit NA-A, she only saw R8 reach for her. NA-C found the charge nurse (LPN-A) around 8:30 p.m., and reported what had happened. However, she noted she was unsure if the LPN-A heard what she was saying as the nurse was flustered because she had to take over passing medication to residents. She did not work on 3/28/25 but had picked up a shift on 3/29/25 and spoke to the DON. She was unaware she should have told the DON right away on 3/27/25. She thought that she had done the right thing by telling LPN-A at the time it occurred. R8 reacted to the incident by yelling out NO, STOP!. R8 showed no signs of distress after the incident. Interview on 4/2/25 at 2:34 p.m., with NA-B identified on 3/29/25, she was sitting at the nurse's station desk with NA-C talking. NA-C mentioned she had worked with NA-A on Thursday 3/27/25. While assisting R8 to bed on 3/27/25, R8 had tapped NA-A in the belly who was pregnant. NA-A told R8 you don't hit my baby and then proceeded to hit R8 in the stomach 3 times with a closed fist. She asked NA-C if she had reported the incident, and she said she had. NA-B told the DON about her discussion with NA-C about an hour later, when the DON came to the facility. NA-B stated she had never seen NA-A hit anyone, but she was not a gentle person but not rough. NA-A was known to be disrespectful and would tell residents No when they wanted to use the bathroom. Both NA-A and NA-C were newer staff and had only worked a couple months. She had reported to the charge nurse about NA-A being disrespectful previously, and was advised by the nurse NA-A was meeting with the DON about once a week about her attitude already. To her knowledge, NA-A had worked alone as a nurse aid even after reports of negative behavior and was not monitored by other staff or management to her knowledge or observations. Review of NA-A's employee file identified NA-A had coaching with the DON on 1/23/25, 2/4/25, 3/6/25, 3/8/25, and 3/13/25 related to: 1) Communication with peers, 2) Providing assistance to co-workers 3) Time management. 4) Failure to answer call lights. 5) Spending a significant amount of time at the nurses' station when call lights or alarms were sounding. 6) Not passing supplies. 7) Leaving rooms dirty with laundry on the floor, leaving dirty commodes in rooms and garbage in the room, and not cleaning up foul odor of urine on residents. 8) A resident report of not assisting them with toileting needs when asked with other staff. 9) Finding resident in tears for not being assisted. Further review of the coaching in NA-A's employee file note on 3/20/25, an action plan had been put into place due to the above identified issues. NA-A was to demonstrate immediate and sustained improvement in overall performance to avoid further corrective action that included the following. NA-A was to: 1. Check in with the charge nurse at the beginning of her shift, mid shift and before she leaves and provide feedback on what she has completed and if she needs any assistance. 2. Only sit at the desk when charting and prioritize patient care including call lights over charting. 3. Communicate with co-workers and respond over the walkie appropriately. 4. Ensure rooms were cleaned and stocked after assisting residents. 5. Communicate with residents that she will get assistance and be back if she cannot assist them at the time the call light is sounding. 6. Work with co-workers and charge nurse as part of a team and communicate if she needs assistance or has questions. 7. Accept accountability for upholding all facility standards. 8. Be encouraged to utilize the Employee Assistance Program ([NAME]) as necessary. NA-A's file had no mention of how the facility was going to monitor NA-A performance/progress to ensure the previous mentioned concerns had been corrected prior to the incident, or supervise NA-A to ensure residents were safe and appropriately cared for when known behaviors and neglect of duties were identified by the facility. Interview on 4/2/25 at 3:51 p.m., with the DON identified NA-A had worked a total of 5 days between the action plan being implemented on 3/20/25 and the date of the incident on 3/27/25. The DON followed up with NA-A's progress of her action plan verbally with nurses and NA-A. She had no documentation to support she provided oversight to ensure NA-A had been making progress with her action plan and no further incidents of potential abuse or neglect would occur. She would have only documented the progress of the action plan if NA-A had not been doing what she was supposed to be doing. Interview on 4/3/25 at 9:26 a.m., with medical director identified he was made aware of the incident that occurred with NA-A and R8. He was unaware NA-A had performance concerns prior to the incident with coaching and an action plan in place. He revealed that the facility had a good process in place related to abuse identification and training but there was always room for improvements. There were staff challenges due to turnover at times and there maybe an additional training needed more frequently for staff that could be helpful and he would discuss that with the administration and the DON. He agreed NA-A should have been supervised when behaviors with her care of residents had been identified in order to potentially prevent the incident on 3/29/25. On 4/2/25 at 8:48 a.m., an attempt was made to contact NA-A and a voice mail was left to return the call with no response. On 4/2/25 at 8:50 a.m., an attempt was made to contact LPN-A. A voice mail was left to return the call but there was no response. Review of the 11/27/23, Corrective Action policy identified corrective action was implemented to improve an employee's job performance or conduct. This type of action would be implemented as a means to inform the employee of the unacceptable behavior or job performance. The policy identified a process of first coaching an employee, then a verbal warning, then a written warning which identified the facilities expectations of the employee in an action plan. A corrective action beyond verbal had to be approved by HR prior to taking action. The manager and/or HR would complete an investigation prior to implementing any corrective action and any action beyond a verbal warning must be signed by the manager and the employee and given to HR to be filed in the employee's personnel file. The policy further identified reasons for immediate dismissal of a position which included neglect or abuse. There was no indication of how an employee action plan would be monitored to ensure progress towards improvement or how the facility would provide oversight for staff identified as having conduct or job performance concerns or identify if the employee was at risk of neglect or abuse to residents and when to act upon such actions. Review of the October 2024, Vulnerable Adult Abuse Prevention Plan identified residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. The facility must ensure all alleged violations of abuse, mistreatment, neglect, and misappropriation were immediately reported to the administrator and a thorough investigation completed. The results of the investigation would be reported to the administrator and other officials in accordance with State law within 5 working days and if alleged violation was verified appropriate corrective action would be taken.

Based on interview and document review, the facility failed to provide a written copy of the bed hold notice for 1 of 3 residents (R)1 who transferred to the hospital. Findings include: R1's 3/16/25, discharge return anticipated Minimum Data Set (MDS) assessment identified R1 had an unplanned discharge to an acute care hospital. R1's face sheet identified she had been admitted to the facility in March of 2023. R1's hospital discharge summary identified she admitted to the hospital on [DATE] and was discharged back to the facility on 3/18/25. R1's 3/16/25 nursing progress note identified she had been transferred to the hospital for evaluation. The progress note made no mention that a bed hold had been offered to R1 or a resident representative. Interview on 4/2/25 at 12:20 p.m., with the director of nursing identified she agrees with the above finding and would expect staff would offer a bed hold when a resident is being transferred out to the hospital. She reported they had an agency nurse on that day, and she may not have understood the process. Review of the February 2025, facility Bed Hold Policy identified they would provide residents the opportunity to leave the facility for various types of leaves and be given opportunity to keep their long-term care bed. Staff will provide a written notice which will be presented to the resident or representative at the time of transfer.

Based on interview and record review the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours a day, 7 days per week, for 2 of 168 days reviewed. This had the potential to affect all 29 resdients. Findings include: Review of the facility schedules from 10/1/23 through 3/17/24, identified there was no RN coverage on 12/10/23 and 3/3/24. Interview on 4/1/24 at 6:21 p.m., with the director of nursing (DON) identified she only has 1 full time RN at the facility other than herself and the case manager. At times the facility use the adjoining hospital's RN for coverage. The hospital RN was not physically present in the facility, and took call only. They do check in a couple times and the staff are able to reach out to the hospital RN if they need anything. Interview on 4/2/24 at 10:57 a.m., with administrator confirmed that the facility had on occasion used the hospital RN for coverage. He understood the expectation to have 8 consecutive hours of RN coverage daily, however, they have not had any applicants and have not been able to fill the position. The facility is offering a sign on bonus as well as a recruitment bonus. They are advertising on several web-based platforms and locally in newspapers. They have been working with the local area college nursing program but have not had any results. A facility policy for RN coverage was requested however, nothing was provided by end of survey.

Based on interview and record review, the facility failed to ensure the contracted pharmacist, in conjunction with the facility, had a method to ensure resident's physicians acted upon pharmacy recommendations for 1 of 5 residents (R21) reviewed for unnecessary medications. Findings include: R21's 4/1/24, Patient Health Summary report identified R21 had diagnoses of anemia, generalized anxiety disorder, major depressive disorder in partial remission, chronic colitis (irritation in intestines causing pain), chronic obstructive pulmonary disorder (COPD) (lung disease affecting breathing) with asthma, restless leg syndrome, high blood pressure, acute and chronic respiratory failure with hypoxia (severely low blood oxygen levels), diabetes mellitus type 2, low thyroid disorder, insomnia, back pain, and arthritis. R21's 3/19/24, quarterly Minimum Data Set (MDS) identified R21 cognition was intact. R21 was independent with toileting and transfers. R21 had no behaviors present and experienced shortness of breath with exertion, when sitting at rest, and when lying flat. R21 had oxygen therapy and routinely took an antipsychotic, anti-anxiety, anti-depressant, diuretic, opioid, anti-platelet, and hypoglycemic. R21 had no gradual dose reduction (GDR) attempted for her anti-psychotic and no GDR had been documented by the physician as clinically contraindicated. R21's 4/1/24, current physician orders identified Ability 0.5 milligram (mg) every day (an antipsychotic medication), lorazepam 0.5 mg four times a day as needed (PRN) for anxiety, and trazodone 50 mg at bedtime PRN for insomnia. R21's care plan printed 4/2/24, identified psychosocial wellbeing deficit related to daily routine was different from prior pattern in community, R21 used medications for comfort. R21 had behavior deficit related to accusatory behavior, mood deficit related to negative comments, repetitive questions, anger with self and others, withdrawal from activities, and sad or worried facial expressions. R21's Consultant Pharmacist's Medication Regimen Reviews for December 2023 through March 2024 identified: 1) On 12/11/23, the form identified R21 had an order for PRN trazodone. Recommendation included PRN psychoactive medication must be limited to 14 days except, if the physician believes it is appropriate for the PRN order to be extended beyond 14 days. When extending a PRN psychoactive medication order the physician must document rationale for continued use and indicate the duration in the residents medical chart. There was no evidence the physician acted on the pharmacist's recommendation. 2) On 2/12/24, the form identified the pharmacist made the same recommendation as the previous month for the physician to document rationale for continued use and indicate the duration for the PRN psychoactive medication. There was no evidence that the physician acted on the pharmacist's recommendation. 3) On 3/5/24, the form identified R21 had an order for Abilify 0.5 mg (an antipsychotic medication). Recommendation made was to trial a gradual dose reduction or document if it would be clinically contraindicated. There was no evidence that the physician acted on the pharmacist's recommendation. Interview on 4/3/24 at 7:56 a.m., with director of nursing (DON) confirmed that R21's medical doctor (MD)-A had not acted on the pharmacist recommendation for the last 3 months. She revealed she thought MD-A had renewed the PRN order for trazodone every 14 days however, that had not occurred, and the last time MD-A renewed the PRN trazodone order was back in January. Interview on 4/3/24 at 10:54 a.m., with medical director (MD)-B identified his expectation was that pharmacy recommendations would be addressed timely. The facility was actively working on changing the process to make sure that pharmacy recommendations are going out on the day they are provided to the facility and acted on. He revealed unfortunately this was not a new concern and he was working on identifying the barriers to see why pharmacy recommendations were not being addressed or addressed timely. Interview on 4/3/24 at 11:15 a.m., with consulting pharmacist (PharmD) identified when a provider does not follow up on a recommendation, he first reaches out to nursing staff to see that the provider received the recommendation. If the provider was given the recommendation but did not act on it, he reported he would resend the same recommendation for a couple months unless it was something that needed immediate attention. He confirmed that R21's had a PRN trazodone and PRN Ativan order and both needed documentation for a rationale for continued use and an indicated duration beyond 14 days. He further, confirmed that MD-A had not responded to the recommendations for December 2023 through March of 2024, and it was stressful for the facility. Review of the September 2023, LTC Pharmacy Consultant Expectations-System Standard policy identified the services were in collaboration between the providers, the facility staff, and the pharmacist to meet the resident needs. The consulting pharmacist would assist the facility with pharmaceutical services to meet the resident's needs, assist with best practices and regulatory requirements. The pharmacist will discuss with attending physicians any identified problems of an immediate nature, provide reports to the director of nursing, communicate, and resolve identified issues related to pharmaceutical needs. The pharmacist will complete monthly medication regimen reviews of each resident and address identified irregularities and document on a written report.

Based on interview and record review, the facility failed to ensure as needed (PRN) psychoactive medications were not given without a rationale for continued use and indicated specific duration for 1 of 5 residents (R21) to prevent potential unnecessary medications. Findings include: R21's 4/1/24, Patient Health Summary identified R21 had diagnoses of anemia, generalized anxiety disorder, major depressive disorder in partial remission, chronic colitis, COPD with asthma, restless leg, hypertension, acute and chronic respiratory failure with hypoxia, diabetes mellitus type 2, hypothyroidism, insomnia, thoracic spine pain, and arthritis. R21's 3/19/24, quarterly Minimum Data Set (MDS) identified R21 cognition was intact, R21 was independent with toileting and transfers. R21 had no behaviors present. R21 had shortness of breath with exertion, when sitting at rest, and when lying flat. R21 had oxygen therapy and routinely took an antipsychotic, anti-anxiety, anti-depressant, diuretic, opioid, anti-platelet, and hypoglycemic. R21's care plan printed 4/2/24, identified psychosocial wellbeing deficit related to daily routine was different from prior pattern in community, R21 used medications for comfort. R21 had behavior deficit related to accusatory behavior, mood deficit related to negative comments, repetitive questions, anger with self and others, withdrawal from activities, and sad or worried facial expressions. R21's 4/1/24, current physician orders identified lorazepam 0.5 mg four times a day PRN for anxiety last renewed on 1/15/24, and trazodone 50 mg at bedtime PRN for insomnia last renewed on 1/15/24. R21's January, February, and March of 2024 medication administration recorded identified: 1) lorazepam 0.5 mg four times a day as needed had been used in January 34 time, February 34 time, and March 33 time. 2) trazodone 50 mg at bedtime as needed had been used in January 25 time, February 28 time, and March 26 times. R21's 2/12/24, Consultant Pharmacist's Medication Regimen Review identified the pharmacist had reminded R21's medical provider that psychoactive medication must be limited to 14 days except, if the physician believes it is appropriate for the PRN order to be extended beyond 14 days. It noted when extending a PRN psychoactive medication order the physician must document rationale for continued use and indicate the duration in the resident's medical chart. There was no evidence in the pharmacist note that a documented rationale was obtained even though the medication had continued to be administered to prevent potential unecessary medication use. Review of 1/13/24, progress note identified a message had been sent to R21's medical provider questioning if he would like to continue R21's orders of lorazepam 0.5 mg four times a day PRN and trazodone 50 mg at bedtime PRN for an additional 14 days. The 1/15/24, provider progress note back to the facility identified yes please. The note lacked rationale for the continued use of either PRN medication or a indicated duration for the PRN medication. There was no evidence in the progress note that a documented rationale was obtained even though the medication had continued to be administered to prevent potential unecessary medication use. Interview on 4/3/24 at 7:56 a.m., with director of nursing (DON) revealed that R21's medical doctor (MD)-A had not renewed R21's orders for lorazepam 0.5 mg PRN or trazodone 50 mg PRN since 1/15/24. She was unaware that MD-A had not been renewing the PRN orders every 14 days. She further confirmed that MD-A had not acted on the pharmacist recommendation in February of 2024 to document the rationale for both PRN medications and document a duration for the orders. Interview on 4/3/24 at 10:54 a.m., with medical director (MD)-B identified his expectation was that the regulation requirements were followed and if PRN psychotropic medications had specific documentation requirements that would be followed. He further identified pharmacy recommendations should be addressed and addressed timely. The facility was actively working on changing the process to make sure that pharmacy recommendations are going out on the day they are provided to the facility and acted on. He revealed unfortunately this was not a new concern and he was working on identifying the barriers to see why pharmacy recommendations were not being addressed or addressed timely. Interview on 4/3/24 at 11:15 a.m., with consulting pharmacist (PharmD) identified when a provider does not follow up on a recommendation, he first reaches out to nursing staff to see that the provider received the recommendation. If the provider was given the recommendation but did not act on it, he reported he would resend the same recommendation for a couple months unless it was something that needed immediate attention. He confirmed that R21's had a PRN lorazepam and PRN trazodone order and both needed documentation for a rationale for continued use and an indicated duration beyond 14 days. He further, confirmed that MD-A had not responded to the recommendations for December 2023 through March of 2024, and it was stressful for the facility. A policy for PRN psychoactive medications was requested but not provided. Review of February 2024, Antipsychotic Medication Management policy identified PRN use of antipsychotics which were limited to 14 days. If an antipsychotic PRN was to be renewed a direct examination was needed by the provider with a rationale identified in the medical record. There was no mention of other psychoactive PRN medications in this policy.

Based on observation, interview, and record review the facility failed to ensure frozen raw meat and cooked meat were thawed in separate containers as not to cause potential cross contamination. In addition they failed to ensure test strips used for chemical sanitation were not expired. This had the potential to effect all residents residing in the facility. Observation on [DATE] at 10:44 am in the facility kitchen identified a packaged raw turkey and fully cooked turkey both sitting in a sink touching each other with a stream of water running over the raw turkey to thaw. Interview on [DATE] at 10:45, with (cook)-A identified this is a normal routine, after the frozen meat is partially thawed they place it in a container and it is moved to the refrigerator. She agreed that thawing raw meat and fully cooked meat together in the same container could have the potential to cause cross contamination. Observation on [DATE] at 11:00 a.m., identified test strips hanging near the dishwasher, used to ensure the appropriate level of chemical sanitation for the dishwasher had expired on [DATE]. Interview on [DATE] at 10:55 a.m., with the dietary manager identified the fully cooked turkey breast was to be used for sandwich meat, it was her expectation that cooked meat and raw meat be thawed separately and identified they would discard the fully cooked turkey breast. She agreed that the test strips used for the dishwasher had been expired and should have been replaced. Review of the current, undated thawing frozen foods safely policy identified facility would prevent cross contamination by not mixing raw food items in the same sink or container.

Based on observation, interview and document review the facility failed to ensure expired medication was removed from 2 of 2 medication carts and not administered to 6 of 6 residents (R4, R6, R21, R24, R26 and R27). Findings include: Observation and interview on 8/1/23 at 3:30 p.m., with registered nurse (RN)-A and RN-B during review of the two medication administration carts identified outdated medications had not been removed from the medication administration carts when the documented expiration dates had occurred and had resulted in expired medication being administered to residents. 1.) R4 had orders for Tylenol 325 milligrams (mg) 2 tablets every (Q) 4 hours (H) as needed (PRN) The expiration date on the bubble package card was 6/9/23 and the medication administration record (MAR) identified one dose had been administered after the expiration date on 6/20/23. 2.) R6 had orders for Loperimide 2 mg PO Q6H PRN x 7 days. The expiration date on the card was 1/19/23 and the medication order identified it had been discontinued 8/28/22 but remained in the medication cart. 3.) R21 had orders for Loratadine 1 tablet PO Q Day (D) PRN. The expiration date on the card was 9/26/21 and the MAR identified one dose was administered after the expiration date on 5/8/22. The medication card remained in the medication cart. 4.) R24 had orders for Tylenol 500 mg PO Q8H PRN. The expiration date on the card was 5/30/23 and the MAR identified one dose administered after the expiration date on 6/13/23. 5.) R26 had orders for Tylenol 500 mg PO four times daily (QID) PRN. The expiration date was 5/25/23 and doses were administered from the card on 6/4/23, 6/6/23 and 6/22/23. 6.) R27 had orders for Tylenol 325 mg 2 tablet PO Q6H PRN. The expiration date was listed as 5/9/23 and medication was administered from the card on 5/27/23, 5/30/23, 6/3/23, 6/5/23, 6/17/23, 7/28/23 and 7/30/23. Interview on 8/1/23 at 3:40 p.m. with RN-A reported the expired medications should have been removed from the cart when they reached the expiration dates. She also identified when staff administered medications, they should be checking the expiration date on the package in addition to the order and not administering the medication if it was outdated. Interview on 8/1/23 at 4:33 p.m., with the director of nursing (DON) reported she was not aware the medication carts were not being checked routinely for outdated medication and had assumed it was being done at the end of each month when medication cards were exchanged. A policy for medication storage was requested but not provided by the end of the survey period.

Based on interview and document review, the facility failed to ensure 5 of 5 residents (R11, R12, R15, R17, and R27) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 30 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose Review of 5 sampled residents for vaccinations identified: 1) R27 was admitted in October 2015. R27 received his PCV-13 on 2/10/15 and his PCV-23 on 5/19/09 (age 75). There was no documentation to support R27 had been offered the PCV-15 or PCV-20 to ensure he was updated with current CDC guidance for vaccines. 2) R11 was admitted in July 2022. R11 received her PCV-13 on 3/27/15 and her PCV-23 on 10/01/15 (age 76). There was no documentation to support R11 had been offered the PCV-15 or PCV-20 to ensure she was updated with current CDC guidance for vaccines. 3) R12 was admitted in June 2022. R12 received her PCV-23 on 6/26/12 (age 74) and her PCV-13 on 6/22/15 (age 77). There was no documentation to support R12 had been offered the PCV-15 or PCV-20 to ensure she was updated with current CDC guidance for vaccinations. 4) R15 was admitted [DATE]. R15 received her PCV-13 on 3/26/21. There was no documentation to support R15 had been offered the PCV-20 or the PPSV-23 to ensure she was updated with current CDC guidance for vaccines. 5) R17 was admitted [DATE]. R17 received her PCV-13 on 5/28/15 and her PPSV-23 on 4/27/07 (age 77). There was no documentation to support R17 had been offered the PCV-15 or PCV20 to ensure she was updated with current CDC guidance for vaccines. Interview on 8/3/23 at 11:45 a.m., with director of nursing identified she was responsible for ensuring residents were offered updated vaccinations per CDC guidelines. The DON had not realized there were updates to the CDC guidelines for Pneumovax and agreed staff should have clear direction on what vaccinations to offer and/or administer. Review of the current, undated immunization policy identified the facility was to follow CDC recommendations for the pneumococcal vaccinations and included a link to assist staff to the most updated CDC vaccination recommendations. 38687

Based on observation, interview and document review the failed to dilute medication per manufactory guidelines and include those directions on the medication order and label for 1 of 1 resident (R24). Findings include: Observation and interview on 8/2/23 at 8:12 a.m., with trained medication aide (TMA)-A as she prepared to administer Potassium Chloride Oral Solution which was highlighted on the bottle as 40mEQ (milliequivalents per liter) per 15 ml(millimeter). Directly below the highlighted area a bolded box listed the instruction to dilute prior to administration. R24's medication record (MAR) listed an order for potassium chloride oral solution 40 meq by mouth (PO) at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. and the dose instruction listed 15 ml. TMA-A checked the MAR, removed the bottle of Potassium Chloride solution from the medication cart, compared the bottle to the computer MAR, picked up a clear plastic medication cup and filled it to the 30 milliliter (ml) mark with the potassium liquid, and reported that was 30 ml. She then retrieved a second medication cup and poured 10 ml into that cup and reported that was 40 ml and picked up the two cups to take to R24. TMA-A was stopped and asked to recheck the order again and to look at the label on the bottle. It was pointed out on the MAR the dose instruction of 15 ml and the bottle which listed the concentration as 40 mEq per 15 ml. Interview on 8/02/23 at 8:18 a.m. with TMA-A reported she made an error in dispensing R24's Potassium. She reported she had prepared to administer 40 ml instead of 40meq as identified on the order. TMA-A reported she would have administered the medication if she had not been interrupted with correction by the surveyor. She reported she had been off for a couple weeks and this was a new medication for her, and she had misread the label. TMA-A reported she had not attempted to dilute the medication prior to administration because R24 did not want it diluted in water or juice and that was his right. She reported she was not aware if the consultant pharmacist was aware of the medication not being diluted or if it had been brought to the attention of the doctor. Review of the Pharmacy Monograph (A written document that reflects the quality attributes of medicines approved by the U.S. Food and Drug Administration) Potassium Chloride (English) Information last revised December 2022, Copyright (c) 2023 First Databank, Inc., How To Use: To prevent stomach upset, you must first mix your dose of potassium with a glass (4 to 8 ounces/120 to 240 ml) of cold water or juice as directed by your doctor. Manufacture's patient instructions listed on the bottle of Potassium Chloride identified a warning: WARNINGS DO NOT ADMINISTER FULL STRENGTH. SOLUTION MAY CAUSE GASTROINTESTINAL IRRITATION IF ADMINISTERED UNDILUTED. R24's current signed medication orders listed an order for potassium chloride oral solution 40 meq by mouth (PO) at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. and the dose instruction listed 15 ml Interview on 8/2/23 at 10:15 a.m. with the consultant pharmacist reported he reviewed medications at the facility monthly. He identified that a dose of 2.5 times the ordered dose (100 mEq instead of the ordered 40 mEq) had the potential to be a significant medication error if given repeatedly dependent on the resident's blood potassium level. He reported he did not believe a single dose would have caused side effects, but it would depend on the individual resident. He reported he received a checklist of facility education needs biannually and he would review it with the director of nursing (DON) with medication safety included. The pharmacist identified liquid potassium was supposed to be diluted in 6-8 ounces of water or juice because of gastric irritation, and that information should have been included in the pharmacy label when it was dispensed. If the resident was requesting the medication not be diluted, then the doctor should have been updated and a possible alternative medication provided. Interview on 8/2/23 at 11:00 a.m., with the DON reported her expectation that the 6-rights of medication administration were to be followed according to the facility medication administration policy. She reported TMA-A had been trained on the administration of medications which included pills, liquids, creams, etc. and she would be following up with education review to ensure competency. Review of TMA-A's personnel file identified she completed her TMA training on December 11, 2017 and received a certificate of course completion from Minnesota [NAME] Community & Technical College. The checklist identified completion of competency requirements for routes of administration of medications. Review of the May 2023 policy Medication Orders and Administration-LTC identified medications orders were to specify the name, strength, dose, time or frequency, route of administration, length of therapy if appropriate. Altered medications required review by the pharmacist for appropriateness and alternate medication recommended with a physician order.

Based on interview and record review, the facility failed to identify the appropriateness for continued use of an antibiotic for 1 of 1 resident (R19). Findings include: R19's 7/20/23, quarterly Minimum Data Set (MDS) identified R19's cognition was moderately impaired. R19 had a diagnosis of heart failure, high blood pressure, diabetes, dementia, parkinsons, and anxiety. No diagnosis of infections were listed on the MDS. R19's 9/12/18, Infectious Disease (ID) follow up appointment summary provided by the facility identified R19 had left knee septic arthritis. The ID recommendations were to continue cephalexin 500 milligrams (mg) twice daily given that his inflammatory markers were normal this would be the appropriate suppressive dose. R19 was to monitor for toxicity from cephalexin such as C. difficile colitis, and to follow up with ID in one year as he came from a home environment. R19's undated care plan printed on 8/2/23, had no indication that staff were to monitor for signs of toxicity that may be caused by long term use of an antibiotic or symptoms of infection. R19's 8/23/19, letter from ID physician identified the ID was unable to reach him and instructed R19 to contact him as soon as possible to continue his care. There was no indication R19 had ever followed up with the ID to discuss the need to continue the antibiotics. R19's 4/1/19, Consulting Pharmacist's Medication Regimen Review idntified R19 was taking cephalexin 500 mg twice daily. The diagnosis for this medication should be clarified if taking chronically and a stop date should be entered into the medical record. The primary physician answered the recommendation stating it had already been addressed and long term use was indicated. There was no indication the primary physician identified what the long term use was. Interview on 8/1/23 at 1:49 p.m., with director of nursing (DON) identified they had not followed up with ID since R19 was admitted to the facility and had not completed any labs to determine if the infection was still present or if there was a need to continue with the antibiotic. DON revealed she did not know about the request from infectious disease for a follow up visit or the pharmacy recommendation until surveyor requested the information during this annual survey. Interview on 8/1/23 at 1:30 p.m., infection preventionist identified the facility should have followed up with ID, she stated she thought having the primary physician review the medications was enough. Interview on 8/1/23 at 2:22 p.m., with certified medical assistant (MA) for the ID doctor identified they would have expected the facility to contact the ID for a follow up. It is actually shocking that he has been on the cephalexin for five years and nobody has requested a follow up visit with us. R19 should have been re-evaluated for the need to continue with this antibiotic. Review of the facilities March 2023, Antimicrobial stewardship policy identified the facility would monitor the use of antibiotics. The facility will implement interventions focused on shortening the duration of antibiotic courses and identify ways to perform post-prescription review such as antibiotic time out.

Based on observation, interview and document review, the facility failed to ensure 2 of 2 medications were properly administered according to manufacturer's guidelines resulting in a medication error rate of 8.0% for 2 of 25 opportunities of medication administration. Findings include: Observation, interview, and document review on 8/2/23 at 7:52 a.m., with trained medication aide (TMA)-A as she prepared and administered R2's Synthroid 0.88 micrograms (mcg) by mouth (PO) as he finished eating his breakfast. Review of the physician's order on the Medication Administration Record (MAR) identified the medication was to be administered before food was eaten. Review of the Food and Drug Administration guidelines identified Synthroid (thyroid medication) was administered as a single daily dose, preferably one-half to one-hour before breakfast. Interview on 8/2/23 at 8:00 a.m., with TMA-A reported she was aware the physician's order directed R2's Synthroid was supposed to be administered before breakfast or food eaten, but he didn't want to be woke up to take his medication, so it was given with his other medications at breakfast time. She reported she had not thought about reporting this to the charge nurse for discussion with the physician and possibly changing the order. Observation and interview on 8/2/23 at 8:12 a.m., with trained medication aide (TMA)-A as she prepared to administer Potassium Chloride Oral Solution which was highlighted on the bottle as 40mEQ (milliequivalents per liter) per 15 ml(millimeter). Directly below the highlighted area a bolded box listed the instruction to dilute prior to administration. R24's medication record (MAR) listed an order for potassium chloride oral solution 40 mEq by mouth (PO) at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. and the dose instruction listed 15 ml. TMA-A checked the MAR, removed the bottle of Potassium Chloride solution from the medication cart, compared the bottle to the computer MAR, picked up a clear plastic medication cup and filled it to the 30 milliliter (ml) mark with the potassium liquid, and reported that was 30 ml. She then retrieved a second medication cup and poured 10 ml into that cup and reported that was 40 ml and picked up the two cups to take to R24. TMA-A was stopped and asked to recheck the order again and to look at the label on the bottle. It was pointed out on the MAR the dose instruction of 15 ml and the bottle which listed the concentration as 40 mEq per 15 ml. Interview on 8/02/23 at 8:18 a.m. with TMA-A reported she made an error in dispensing R24's Potassium. She reported she had prepared to administer 40 ml instead of R40 as identified on the order. TMA-A reported she would have administered the medication if she had not been interrupted with correction by the observing surveyor. She reported she had been off for a couple weeks and this was a new medication for her, and she had misread the label. TMA-A reported she had not attempted to dilute the medication prior to administration because R24 did not want it diluted in water or juice and that was his right. She reported she was not aware if the consultant pharmacist was aware of the medication not being diluted or if it had been brought to the attention of the doctor. Review of the Pharmacy Monograph (A written document that reflects the quality attributes of medicines approved by the U.S. Food and Drug Administration) Potassium Chloride (English) Information last revised December 2022, Copyright (c) 2023 First Databank, Inc., How To Use: To prevent stomach upset, you must first mix your dose of potassium with a glass (4 to 8 ounces/120 to 240 ml) of cold water or juice as directed by your doctor. Manufacture's patient instructions listed on the bottle of Potassium Chloride identified a warning: WARNINGS DO NOT ADMINISTER FULL STRENGTH. SOLUTION MAY CAUSE GASTROINTESTINAL IRRITATION IF ADMINISTERED UNDILUTED. R24's current signed medication orders listed an order for potassium chloride oral solution 40 mEq by mouth (PO) at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. and the dose instruction listed 15 ml Interview on 8/02/23 at 10:15 a.m. with the consultant pharmacist reported he reviewed medications at the facility monthly. He identified that a dose of 2.5 times the ordered dose (100 mEq instead of the ordered 40 mEq) had the potential to be a significant medication error if given repeatedly dependent on the resident's blood potassium level. He reported he did not believe a single dose would have caused side effects, but it would depend on the individual resident. He reported he received a checklist of facility education needs biannually and he would review it with the director of nursing (DON) with medication safety included. The pharmacist identified liquid potassium was supposed to be diluted in 6 - 8 ounces of water or juice because of gastric irritation, and that information should have been included in the pharmacy label when it was dispensed. If the resident was requesting the medication not be diluted, then the doctor should have been updated and a possible alternative medication provided. Interview on 8/2/23 at 11:00 a.m., with the DON reported her expectation that the 6-rights of medication administration were to be followed according to the facility medication administration policy. She reported TMA-A had been trained on the administration of medications which included pills, liquids, creams, etc. and she would be following up with education review to ensure competency. Review of the May 2023 policy Medication Orders and Administration-LTC identified medications orders were to specify the name, strength, dose, time or frequency, route of administration, length of therapy if appropriate. Altered medications required review by the pharmacist for appropriateness and alternate medication recommended with a physician order.

Based on interview and document review the facility failed to ensure a level II Pre-admission Screening and Resident Review (PASRR) was completed for 1 of 1 resident (R6) who received a new diagnosis of Schizoaffective disorder-depressive type. Findings include: R6's electronic Admission Record identified R6 was admitted [DATE], with diagnoses of dementia, seizure disorder, physical deconditioning and depression. R6's admission Minimum Data Set (MDS) assessment identified in section A 1500 Pre-Admission Screening she had been evaluated by Senior Linkage with a Pre-Admission Screening (PAS I) dated 3/17/22 OBRA: which listed - It appears this person does not need an OBRA Level II assessment. R6's 12/19/22 physician recertification visit identified Geriatric psych had been consulted for management of her medications but did not include a diagnosis of Schizoaffective disorder. On 2/2/23 R6 was seen via two-way audiovisual telecommunication by the psychiatric nurse practioner who identified R6 met the criteria of Schizoaffective disorder, Depressive Type. Her notes also identified R6 had previous psychiatric diagnoses of generalized anxiety disorder, moderate recurrent major depression, organic personality disorder, dementia, major depressive disorder, recurrent and severe with psychotic features, dependent personality traits,and borderline intellectual functioning. Interview on 8/2/23 at 9:41 a.m., with the social services designee (SSD) reported she thought the facility was called from Senior Linkage if a resident needed an additional screening. The SSD reported she was not aware of the need to update Senior Linkage when a resident had a new psychiatric diagnosis so that a screening for additional services could be determined. She reported she had thought this was all taken care of before the resident was admitted since the facility received a screening at the time of admission. Interview on 8/02/23 at 1:08 p.m., with the director of nursing (DON) reported she was not aware of the need for a PASRR level II screening to be completed when a resident was given a new psychiatric diagnosis or the county needed to be notified to complete the screen to determine if additional services were indicated. The DON reported R6 did have new psychiatric diagnoses and the county had not been notified or a PASRR II screen completed. A PASRR policy was requested, however none was provided at the end of the survey.

Based on interview and document review the facility failed to ensure timely reporting of an allegation of potential neglect for 1 of 1 resident (R133) to the administrator and State Agency (SA) occurred immediately but no later than 2 hours after an unwitnessed fall. Findings include: Review of the 6/10/21 at 3:27 p.m., report to the SA identified R133 had an unwitnessed fall on 6/5/21 at approximately 10:25 a.m. in the facility solarium. R133 had been found on laying on her left side with blood on her head and in her hair. R133 was identified as a resident in end stages of dementia and did not communicate efficiently. Staff were unable to complete a full range of motion assessment as R133 complained of pain. R133 was sent to the emergency department (ED) for evaluation. The report noted it was possible the care plan had not been followed. Review of the 6/15/21 at 12:21 p.m., 5 day report to the SA identified R133's care plan was updated to identify R133 was not to be left alone in the solarium after a root cause analysis was performed by the interdisciplinary team. Staff were updated to changes on the care plan. Interventions on the care plan at the time of the fall were deemed appropriate. There was no mention the facility investigation identified reporting to the administrator and the SA was delayed by 5 days and was not within 2 hours for potential neglect of care. R133's 5/17/21, quarterly Minimum Data Set (MDS) identified R133 had severely impaired cognition. R133 displayed continuous behaviors of inattention and disorganized thinking. R133 required extensive assist of 2 staff for bed mobility and toileting, extensive assistance of 1 staff for transfers and locomotion. R133 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 5/5/22 at 11:33 a.m., with nursing assistant (NA)-C identified R133 normally was kept close to the nurses station in order to give her things to do to keep her busy and for staff to keep an eye on her. NA-C revealed R133 did not have a lot of falls and had been on hospice for a long time. Interview on 5/6/22 at 10:12 a.m., with licensed practical nurse (LPN)-A identified R133 was unable to ambulate and used a wheelchair. R133 had a tendency to bend over while in her wheelchair and attempt to pick things up off of the floor. R133 was on hospice and had been for about a year. Interview on 5/6/22 at 10:46 a.m., with registered nurse (RN)-A identified R133 had fallen in the solarium and suffered a laceration to her head. R133 had been sent over to the emergency room for evaluation. RN-A identified that the director of nursing normally does the SA reporting but all nurses are trained to file a SA report. Interview on 5/6/22 at 1:59 p.m., with the facility administrator identified he agreed the facility had not followed policy and procedure and immediately inform him of R133's unwitnessed fall resulting in an ED visit. He had reviewed the fall information and made the decision to file a SA report on 6/7/21, 2 days after the fall, but the report to the SA report was delayed further and not reported until 6/10/21, 5 days after the fall. His expectation was staff were to inform him immediately and a report to the SA was to be filed immediately but no later than 2 hours for any allegation of potential neglect or abuse. He agreed that there had been a potential for neglect as there were initial questions as to the care plan being followed. It was later discovered the care plan had been followed, but he agreed the investigation did not discover reporting had been delayed for the allegation. He noted staff needed further training on reporting to the administrator and SA timely. Review of the 3/22, Vulnerable Adult Abuse Prevention Plan policy identified all allegations of potential neglect were to be reported immediately, but no later than 2 hours to the administrator and SA.

Based on observation, interview and document review the facility failed to provide adequate supervision for 1 of 1 resident (R1) who eloped through 1 of 3 dining room outer emergency exit doors (labeled door #10). The facility also failed to secure 2 of 3 emergency exit doors (#10 and #11) which were not under direct supervision by staff at all times. Findings include: R1's 7/10/21 at 8:16 a.m., State Agency (SA) report identified R1 had exited the building through the unsecured emergency exit door labeled #10, located on the north side of the dining room. The door opened onto a paved area connected to the staff parking lot and hospital ambulance entrance. Nursing assistant (NA)-A had her back to the door as she conversed with dietary aide (DA)-A when an unidentified resident alerted staff, R1 had gone out the door. NA-A responded by going to the emergency door, discovering R1 was outside on the cement walkway and returned her to the building. Both the interim director of nursing (IDON) and charge nurse were notified of the incident. R1 had a WanderGuard device on her ankle. During examination of the 3 dining room doors, it was discovered neither door #10 or #11 were equipped with WanderGuard monitors. Both of the exit doors were designed to be opened with a key. Door 10 was unsecured and had a key left in the lock. A sign posted to the right side of door #10, beneath a fire alarm, identified the door was to only release upon activation of the fire alarm. The IDON initiated an investigation and identified R1 had exited the building following performers who had finished a music activity that day and the door remained unlocked. The performers had left and no staff were outside when R1 exited the building. In checking the remaining 2 doors, it was discovered #11 also had a key left in the locks to allow easy opening of the exit doors. R1's 6/8/21, quarterly Minimum Data Set (MDS) assessment indicated R1 had severe cognitive impairment, required limited assistance with dressing, toileting, personal care, and was independent with ambulation. R1's diagnoses included Alzheimer's dementia with behaviors, depression, anxiety, and [CONDITION(S)]. R1's gait was noted as steady and she was able to walk rapidly as she wandered throughout the facility. R1's current, undated care plan identified R1 had problems with short and long-term memory, had impaired decision making and problems understanding others. Her behaviors were identified as wandering, being intermittently verbally abusive, physically abusive, socially inappropriate and resistive to cares. Staff identified R1 had safety concerns of wandering into other resident rooms and subsequent interaction with other residents. Staff were to provide hourly rounding to monitor R1's safety and provide supervision. The care plan failed to identify R1's potential for elopement, until after the incident, even though R1 had a history of wandering throughout the facility and previously attempted to follow or assist other persons as they were exiting the building. Observation and interview on 7/19/21, at 2:20 p.m. of R1 with NA-A identified R1 was seated in the lounge area working on a puzzle. R1 responded to a greeting, but then looked away and did not respond to attempts to interview. NA-A identified R1 was able to respond to simple questions at times, but was not able to have a conversation. NA-A reported R1 would become verbally abusive toward staff when they attempted to redirect her from an other resident's rooms and she had issues with short and long-term memory. Interview on 7/19/21 at 2:23 p.m. with NA-A identified she was talking with a dietary aide (DA)-A on 7/9/21 at 4:25 p.m. with her back to the dining room when a resident (unknown) called out, R1 had walked out one of the 3 doors. NA-A identified she ran to the unlocked door, opened it and discovered R1 standing on the walkway facing the building. She was able to bring R1 back into the building and had her sit across the dining room with other residents who were visiting. NA-A identified the performers had exited through door #10 following the activity and the door remained unlocked. NA-A thought R1 was outside less than a minute as she responded immediately when the resident called out. NA-A identified the emergency exit doors were to be locked, with the key stored in the lock box located beside the door. She identified emergency exit door #10 had been utilized for exiting with residents going on outings due to ease of exiting the building through a single door. R1 had a WanderGuard monitoring device located on her right ankle, but the emergency exit doors did not have wander guard monitors in place which normally alarm and temporarily lock the doors if a resident attempted to exit. Interview on 7/19/21 at 2:38 p.m., with the Activity Director (AD) identified the previous director of nursing ( DON) had initiated the use of the emergency exit for loading and unloading residents going to and from outings due to convenience of only having to transport residents through one door, rather than double doors that were WanderGuard monitored. Following the elopement of R, the dining room is no longer being utilized unless for emergency as it is an egress door. The key for the emergency exit door #10 and #11 had been left in the lock for convenience. Interview and photographic document review on 7/19/21 at 2:59 p.m., with the IDON identified she was notified by NA-A of R1 exiting the building. She responded immediately and performed an assessment of R1 which did not reveal any injuries. The IDON identified keys were present in the locks of both emergency exit door #10 and #11 located in the dining room and provided photos of the locks and doors. The IDON immediately removed the keys from the locks of both door #10 and #11 and secured them in her office. She then provided re-education to all staff of the elopement policy itself, however had not utilized monitoring to ensure no doors were intentionally left unlocked. The IDON identified she had completed an assessment to ensure the WanderGuard protected doors were functioning on 7/9/21 at 3:00 p.m. The DON agreed the doors were designated as emergency exits, were being utilized and kept unlocked for staff convenience, and not adequately supervised. Interview on 7/19/21 at 3:05 p.m., with the administrator identified he was not certain why keys had been left in the locks of the emergency exit doors, but agreed it was a safety concern and should have been caught on environmental rounds. Observation on 7/19/21 at 3:15 p.m., identified R1 walking independently in the hall as unidentified staff redirected her from walking toward the door which connected to the hospital, with the offer of a snack. Interview with the maintenance supervisor on 7/20/21 at 9:33 a.m., identified the emergency exit doors located in the dining room were checked monthly with scheduled fire drills to insure release of the locking mechanism at that time, but were not included on routine safety rounds. Maintenance employees A & B were interviewed at 10:06 a.m. and identified keys for the emergency exit doors located in the dining room had always been kept in the actual door lock for as long as [they] could remember. Interview on 7/20/21 at 11:14 a.m., with NA-B identified R1 wandered through out the facility and at times would pack her clothes and attempt to leave the building questioning staff why the doors would not work, when her wander guard engaged. Review of the June 2021, Safety Reporting and QM/RM Notifications policy identified the purpose to identify residents who had elopement and/or wandering behavior and to avoid incidents. An occurrence of an event included to be identified for safety included elopements and structural breeches such as doors being propped open or malfunctioning. Quality coordinators were to track trends and report data monthly via quality scorecards and quality meetings.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 1 of 3 residents (R2) who had planned interventions for drinking with assisted devices, but were not performed as a result of 1 of 1 staff (nursing assistant (NA)-A) choosing to disregard the care plan, resulting in 2nd [MEDICAL CONDITION] R2. Findings include: Review of the 5/20/20, report filed to the State Agency (SA) identified at 3:15 p.m., R2 was given a cup of hot coffee while in her bed with the head of bed elevate. R2 spilled her coffee affecting the right side of her chest and her right hip. The spilled coffee resulted in a second degree burn to her right hip area. R2 was identified to have severe cognitive impairment with limited range of motion (ROM) in her right upper extremity and required extensive assistance with bed mobility. Review of the 5/25/20, 5-day facility investigation report submitted to the SA identified R2 had requested and received a cup of coffee while in bed with the HOB elevated. She was left unsupervised and had spilled the coffee on her chest and right side which resulted in the hot coffee pooling to right hip and thigh area. The report identified staff did not implement R2's current care plan which indicated R2 required lids on a specialized cup. The care plan further identified the resident was not to receive food or fluids while in bed related to her [DIAGNOSES REDACTED]. The report identified R2's care plan included fluids that were hot were to be covered. The report identified NA-A had been re-educated and understood that the resident should be up in a chair for all meals and snacks. The report further identified that R2 had four areas of redness approximately 6 centimeters (cm) by 2 cm and an area where a blister had popped but the skin remained intact. Review of the facilities 5/20/20, Investigation Documentation, identified R2 had been given a hot cup of coffee in an uncovered Styrofoam cup by nursing assistant (NA-A) while in bed and NA-A then left the room. The investigation documentation identified within minutes NA-A heard yelling and re-entered R2's room. The hot coffee had spilled down the front of R2's clothing and pooled inside her brief on the right hip area. She had sustained a 2nd degree burn to her right hip. R2's 3/14/20, quarterly Minimum Data Set (MDS) identified R2 had severe cognitive impairment and severe decision-making skills. R2 required extensive assistance of two staff for transferring, bed mobility, and toileting. The MDS identified she was independent with set up for eating. R2's [DIAGNOSES REDACTED]. R2's 3/20/20, care plan identified on 9/30/19, R2 was to utilize adaptive equipment related to her decline in activities of daily living (ADLs). She was to have an adaptive cup with handles and lids, a lipped plate, built up silverware, and dycem under her plate to hold in place. This setting was to be placed on a bedside table raised to fit her height. Other interventions that had been in place since 7/31/19, included liquids were to be covered. If liquids were too hot, water was to be added. R2 was not to have food or liquids while in bed. R2 had a history of [REDACTED]. Review of R2's undated nursing assistant (NA) care sheet identified R2 was to have cups with handles. R2 was not to eat in bed and had to be in her wheelchair (WC) in an upright position for all meals. Observation on 5/26/20 at 9:24 a.m., identified R2 shared a room with another female resident. R2 was observed in her WC watching television seated in front of a bed table with two Styrofoam cups with lids and straws. R2's room was located at the end of a hallway and when observed staff were not present. Additional observation at 12:00 p.m., R2 was eating lunch in the dining room with a two handled covered adaptable cup with hot tea and built up silverware with a divided plate to assist her to eat independently. Interview on 5/26/20 at 10:00 a.m., with NA-C identified at meal time room trays are distributed by NA's. Staff were to have the resident out of bed and in a chair or their WC with a table in front of them. The NA's will then call down to the kitchen to set up the meal trays for staff to deliver to resident room. NA-C identified our process is to get four people up and served at a time. NA-C identified if there is an incident or accident they are to stay with the person and call for help. The nurse would be called into the room to assess the resident. Nursing is responsible for completing a report and contacting the doctor and family. Interview on 5/26/20 at 10:40 a.m., with registered nurse (RN)-A identified to be the charge nurse on the afternoon of 5/20/20. She had been called into R2's room around 3:00 p.m., found R2 in bed with HOB elevated and her top was wet from spilled coffee. RN-A identified R2's top was removed and the skin assessed. R2's skin on the upper half of body was intact with no redness or signs of trauma. At the time of the skin assessment staff had went to change R2's brief and a burn to the right hip and thigh area was identified. The hot liquid had pooled in the brief causing reddened areas and a blister. The blister was intact at that time and the area was left open to air. R2 was then kept off of her right side to avoid pressure to the area. RN-A identified she had been called into the room within minutes of the incident. RN-A identified NA-A reported R2 requested to stay in bed for her coffee and snacks. NA-A had elevated R2's head of bed and gave her a cup of coffee in a Styrofoam cup that did not contain a lid. NA-A left the room to finish passing snack cart and within 5 minutes heard the call for help. NA-A communicated to RN-A she had went back into room and discovered the spilled coffee. The physician was contacted as well as R2's son. RN-A identified R2 does have periods of forgetfulness, but was able to identify she had spilled the coffee on herself. Interview on 5/26/20 at 10:58 a.m., with dietary manager (DM)-D identified the care plan will list adaptive equipment for the resident. If there is not a care plan for adaptive equipment then the resident would receive liquids in a heavy weight disposable cup with a lid. The snack cart is set up by dietary and will have the adaptive equipment placed on the cart. The cart will also have the heavy weight disposable cups for those residents who do not require adaptive equipment. The NA assigned to pass the snack cart is responsible for knowing the care plan and what adaptive equipment a resident is to use. The DM-D identified she was not aware of the incident until she read the progress notes and then spoke to the charge nurse. Observation on 5/26/20 at 12:17 p.m., with NA-B and NA-C of R2's right hip and thigh area revealed an open area approximately the size of a 50 cent piece where a blister had opened. A scant amount of yellow drainage had been noted on her brief. Approximately 1 to 2 inches below that area were 2 small intact reddened areas. Interview on 5/26/20 at 2:06 p.m., with NA-A identified on 5/20/20, she had passed snack chart that afternoon. R2 was still in bed at snack time and requested her snack and hot beverage while in bed. NA-A identified she elevated head of bed, then gave her a hot beverage in a Styrofoam cup with no lid. NA-A then left the room to go to the next room and within minutes heard R2's roommate yell for assistance. NA re-entered room to discover R2's shirt was wet. She then got a towel that was in the room and placed it between the wet shirt and resident's skin. She then identified she left the room to get the charge nurse to come and assess her. No redness was noted on the upper part of R2's body but when they went to change the bedding the redness of the hip was discovered. NA-A identified the area was just really red and at that time there were no blisters or bubbles. NA-A identified there had not been an adaptive cup on the snack cart that day. NA-A confirmed instead of taking the time to go back into the kitchen to get the adaptive cup she used what was available on the cart, disregarding R2's care plan. Interview on 5/26/20 at 2:21 p.m., with administrative assistant (AA)-B identified it was her responsibility to update the NA care sheets. AA-B identified R2's care plan had been updated on 5/20/20. AA-B identified R2 is not new to the facility and prior to the 5/20/20 update the care plan had identified R2 was to have an adaptive cup with handles and lid. The care plan also had identified R2 needed to be out of bed related to history of spilling food. The expectation would be staff caring for the resident needed to know what is on care plan. NA's are to be carrying care sheets with them and be able to pull out of their pocket to review when in question. Interview on 5/26/20 at 4:00 p.m., with director of nursing (DON) who identified at the beginning of each shift NA's are expected to obtain a care plan sheet for the area they are working. Her expectation for staff would have been to have read and understood care plan. She would expect staff to make sure they have the adaptive equipment needed for the resident and if not, residents were not to be given substitutes that may cause harm. The DON identified NA-A had been verbally counseled after incident on 5/20/20 by charge nurse. She also followed up with NA-A that day and provided some feedback on the same information the charge nurse had provided to her. DON identified that NA-A understood the policy and procedures. DON identified that everyday at 2:00 p.m. we have a conversation with the day and afternoon shift to follow up on any changes and incidents that may have happened. DON identified she will be having staff training on 5/27/20 to re-educate all staff. She was unable to provide written documentation on the re-education provided to NA-A. Interview on 5/26/20 at 4:15 p.m., with Administrator identified he was aware of the incident and did not have any addition information to add. Review of the 9/2019, Vulnerable Adult Abuse Prevention Plan, identified the residents have a right to be free from neglect. Neglect was defined as a failure of the facility and it's employee's to provide services that are necessary to avoid physical harm.

Based on observation, interview and document review the facility failed to implement source control masking of staff or visitors, or policies specific to personal protective equipment (PPE) or isolation precautions required for potential or suspected COVID-19 resdients or staff in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guideline for COVID-19. This had the potential to affect all 30 residents. Findings include: Observation on 4/8/20 at 9:00 a.m., upon entrance to the facility, identified neither nursing nor non-nursing staff were utilizing source control source control masks as they performed duties on the nursing unit. Observation and interview on 4/8/20 at 9:30 a.m., with the director of nursing (DON)-B identified staff were not utilizing source control masks unless they were to assist a resident on isolation. The facility did have an ample supply of PPE available including masks, gowns and gloves. The DON-B identified one resident, (R1) who had been admitted on [DATE] following hospitalization and was placed on isolation in a private room for 14 days as a precautionary measure. The DON saw no reason for staff to utilizing appropriate PPE when entering R1's room even though R1 was placed on isolation. All residents were screened for temperature and oxygen saturation on a daily basis, with any deviation from their base line reported to the physician. No residents had signs and symptoms of COVID-19 in the facility. Interview on 4/8/20 at 10:45 a.m., with registered nurse (RN)-A identified there were source control masks and additional PPE available on the door of the utility room of each wing, but staff were not utilizing source control masks at the present time. Observation and interview on 4/8/20 at 10:45 a.m., of a family member (FM)-A who entered the unit from the connecting hospital hall. FM was not wearing a source control mask and identified herself as R2's FM. FM-A had entered through the clinic door, and had been screened for temperature and other symptoms of COVID-19. FM-A was there to visit R2 who was on hospice. FM-A identified neither she nor her children had received education or been requested by staff to wear a mask while in the facility since 1/6/20 R2's date of admission. FM-A visited daily and her children visited frequently. Observation and interview on 4/8/20 at 11:00 a.m., of nursing assistant (NA)-A responded to R1's call light and provided personal care to R1 without wearing a mask or gown as required for a resident on transmission based precautions NA-A identified she had not been educated on a need to utilize source control masks upon entering the facility, nor donning appropriate PPE when providing resident care for a resident on isolation for potential COVID-19. R1's current baseline care plan identified R1 was on isolation/quarantine for 14 days. Type identified was isolation, No PPE unless sx (symptomatic). There was no indication what type of isolation or direction for staff of what R1's isolation precautions were for potential COVID-19. R1's 4/8/20, hospital [DIAGNOSES REDACTED]. Observation on 4/8/20 at 11:20 a.m., with RN-A identified she entered R1's room and retrieved a urine sample from the bathroom. RN-A had not worn a mask or gown as part of TBP for potential COVID-19. RN-A identified R1 was placed on isolation for a period of 14 days as a precaution following hospitalization . Although R1 was on isolation, staff were not utilizing PPE when entering the room to provide cares as R1 was not currently symptomatic. On 4/8/20 at 11:45 a.m., unidentified several unidentified NA were passing lunch trays to residents in their rooms. NA's were wearing gloves, but not source control masks as they entered and exited each resident room. Interview on 4/8/20 at 12:04 p.m., DON-B identified the facility did not have an adequate supply of PPE as of the past week to provide 24/7 availability for all staff. The facility had received supples on 4/7/20 and the plan was to distribute on 4/10/20. Due to having the supplies available the DON identified the Infection Control Practitioner (IP) from the regional office had directed them today to go ahead and distribute source control masks to their staff on the afternoon of 4/8/20. There was no mention of distributing source control masks to visitors. Further interview on 4/10/20 at 2:44 p.m., DON-B identified the facility had received a box containing 50 source control masks on 4/1/20, and had masks to be used for PPE on each hall on the PPE supply rack. R1 had been placed in isolation following hospitalization for a 14 day period as a COVID-19 precaution. R1 had no signs/symptoms so it was not considered necessary for staff to utilize PPE of source control masks or gowns when entering R1's room to provide care. DON-B was unaware of the requirement of all staff to wear source control masks while in the facility, but thought the provision of isolation was a facility precaution. Review of the December 2018, Isolation for LTC (long term care): Standard Precautions and Additonal Transmission Based Precautions policy were to be implemented for known, suspected or incubating infections for the protection of residents, visitors and staff from potential exposure. Airborne precautions are indicated for infectious diseases that were transmitted by airborne droplets. Respiratory protection identified only necessary personnel were to enter the room, and masks, gowns and gloves were to be worn. A specific policy/procedure addressing the COVID-19 precautions was requested but not provided.

Based on observation and interview, the facility failed to ensure 1 of 1 hand rail located at the facilty entrance was in good repair and safe for resident, employee, and visitor use. This the potential to effect all residents, employees and visitors. Findings include: On 8/17/19, at 1:37 p.m., observation of the facility's entrance identified a hand rail was crooked and unstable. The railing was located on an incline along a sidewalk leading to the faciltiy entrance. Further observation identified the rail posts were heavily rusted. Several rail posts that held the railing were rusted completely through. The railing was loose and was unable to support weight with light contact. During observation of the railing and interview with maintence worker (M)-A on 8/22/19, at 1:30 p.m., M-A verified the railing was loose and in poor repair. M-A stated the railing was an ongoing problem. Ice on the sidewalks caused the metal to deteriorate. Brackets were placed on the rail posts about a year and half ago. M-A was unsure how long the railing had been in disrepair and was unaware it had gotten as bad as it was. The maintenance team was short staffed and very busy. There was no routine maintenance checks for railings, and he had not heard any complaints about the rail being loose. M-A was in agreement that the railing was a safety issue and had discussed concerns with the maintenance director and was told replacing the railing was very expensive and not within the budget. On 8/22/19, at 4:28 p.m., during observation and interview, the administrator verified the railing was a safety issue due to disrepair and stated the facilty was planning to build a new facility, and had a tight budget. He was unaware of the rusted unstable railing because he never used the Sunrise Manor entrance to enter the facilty. No routine checks of exterior structures were scheduled by maintenance personnel and stated repair or replacement of the railing was going to be a priority do its instability. There was no policy provided related to facility upkeep and safety provided at the time of the survey.

Based on interview and document review, the facility failed to ensure the facility's Grievance policy and procedures were implemented to ensure verbal concerns of care expressed by 1 of 1 resident (R11) were reported, documented and reviewed. Findings include: On 8/21/19 at 1:35 p.m., family member (FM)-A contacted surveyors with concerns about R11's care. FM-A visited R11 at least 2-3 times per week and was no longer confident staff ensured R11's personal hygiene and toileting needs were met. During the past few months, FM-A observed R11 had increased confusion, and had increased difficulty managing personal hygiene and incontinence. On most visits, R11 had a strong urine odor, long whiskers (greater than in inch), and wore the same clothing. Additionally, R11 had a history of [REDACTED]. When FM-A assisted R11 in the bathroom, her incontinence pads were saturated with urine. FM-A verbally communicated the concerns to registered nurses (RN)-A, RN-B, other charge nurses, and several nursing assistants (NA)s during her visits. Additionally, the concerns were verbally communicated to the care conference team at care conferences. FM-A continued to observe R11 with urine odor, whiskers, and wearing the same clothing during visits after communicating the concerns. FM-A recalled on 6/6/19, FM-A went on a week-long vacation. On the last visit before leaving, R11 was wearing pants with a small blood stain on them, and FM-A tried to remove the stain. Upon return from the vacation, FM-A was surprised to see R11 wearing the same clothing. R11 had two baths per week, and staff were supposed to change R11's clothing at bath time. FM-A reported her concern to RN-A, and also contacted the director of nursing (DON). FM-A was unable to speak directly with the DON, but left a voice message and requested a return call. FM-A never received a response from the DON. FM-A was familiar with the grievance policy, but was unsure where complaint forms were located in the facility to complete a form, and had not provided a written complaint to the facility about R11's ongoing care concerns. Review of R11's quarterly minimum data set ((MDS) dated [DATE], identified R11's cognition was intact. R11's [DIAGNOSES REDACTED]. The MDS indicated R11 required limited assitance of one staff for dressing and toileting, and extensive assistance of one staff for personal hygiene. R11's quarterly MDS on 6/21/19, identified intact cognition. Her Brief Interview for Mental Status (BIMS) score was 14, which was lower than her score of 15 on 3/24/19, and indicated R14 required supervision of one staff for dressing and limited assistance of one staff for toileting and personal hygiene. R11's care plan dated 7/2/19, identified a slow decline in cognition. R11 had short and long term memory problems, and impaired decision making. Staff were to cue her for cares and were directed to reapproach or seek assistance from other staff memebers when R11 refused cares. Interventions for activities for daily living (ADL)s were not included in the care plan. R11's bowel and bladder incontinence interventions were not included in the care plan. R11's nursing assistant care sheet provided on 8/19/19, indicated R11 ambulated independently with a walker and required extensive assistance of one staff for personal cares. Staff were directed to check for incontinence and offer R11 the toilet three times per shift. Staff were to report refusals to the charge nurse. R12 was independent with supervision for dressing. Staff were instructed to shave R11 on bath days on Sunday and Wednesday and were to remove laundry every night and dress R11 with fresh clothing every day. Staff were to follow her back to her room after supper and for HS cares. The care sheet indicated R5 also used a protective absorbent pad on her recliner. R11's Care Conference notes on 10/11/18, identified FM-A was present at the meeting. R11 was incontinent of bladder, and required staff to assist her with toileting needs. There was not documentation related to FM-A's care concerns. R11's Care Conference Notes on 4/2/19, identified FM-A was present at the meeting. The care conference team agreed her physical status declined and she was at risk for falls. R11 toileted independently. R11 also was more sleepy and tired. There was not documentation related to FM-A's care concerns. R11's Care Conference Notes on 7/2/19, identified FM-A was present at the meeting. R11 had incontinence changes and required assitance from staff to wipe. R11 was also noted to have increased unsteadiness in her gait. There was not documentation related to FM-A's care concerns. R11's progress notes were requested from (MONTH) 2019, to (MONTH) 2019. No progress notes were provided. During interview, the social service designee (SSD)-A on 8/22/19, at 9:21 a.m., stated if care concerns were reported to staff during care conferences, the DON was notified so concerns would be addressed. SSD-A was not aware of any processes in place for recording family complaints. Care conference notes were posted in a communication book at the front desk to provide nursing assistants (NA)s updated information regarding reported concerns and changes in care plans. SSD-A was unsure who was responsible to ensure concerns and complaints were followed. Charge nurses and NAs were expected to report identified concerns to the DON and if there were repeated concerns identified, it would be addressed during interdisciplinary team meetings (IDT) to identify further actions to correct concerns. On 8/22/19, at 9:40 a.m., registered nurse (RN)-B stated when family or residents expressed concerns, if she was able to deal with the concern, she would. If it was an issue she was she was unable to take care of, the DON was notified. When family concerns were brought to the charge nurse during the shift, NAs were notified of concerns and changes to the plan of care. The concern was also put in the communication binder for future shifts to review. On 8/22/19, at 9:45 a.m., trained medication aid (TMA)-A stated when family members brought a concern to her, she would help the person with the concern and direct them to the charge nurse to document concerns. When concerns were urgent, the DON was notified. On 8/22/19, at 11:13 a.m., RN-A identified the process to address family concerns at care conferences was for the charge nurse at the care conference to provide education and communicate care needs to the NAs verbally and through writing in the facility communication book, then place information on daily resident care sheets. The DON was always notified about family and resident concerns brought up during conferences. RN-A attended R11's care conferences and was aware of FM-A's concerns. Additionally, FM-A had discussed her concerns during routine visits. RN-A was aware FM-A contacted the DON regarding R11 wearing the same clothing after a week-long vacation, and was aware FM-A was frustrated by the lack of facility response about the concerns. RN-A verified she provided the DON information about FM-A's concerns but had not documented the concerns in the electronic documentation system or in progress notes to indicate the concerns were addressed. On 8/22/19, at 11:38 a.m., the DON stated if concerns were presented to staff by a family member, they were expected to document the complaint into the electronic complaint system. If the concern required follow-up it would be investigated. The DON stated she was not made aware of any concerns and stated she would have absolutely followed policy to ensure concerns were addressed and indicated concerns entered into the system were reviewed by top management and were reviewed on a daily basis. The DON was not concerned about having no grievances, complaints or resident notifications since (YEAR), because management was not able to follow concerns that were not reported. During interview on 8/22/19, at 4:41 p.m., the administrator verified grievances were under- reported in the facilty. The management team was responsible to monitor the grievance process and the facility's quality assurance committee was supposed to track facilty grievances. Grievances were difficult to monitor and track by the quality assurance committee due to under- reporting. the administrator stated prior to the implementation of the new electronic medical record system on 8/1/19, all staff were provided training on how to electronically report grievances. Review of the facility's Grievance Policy with a revision date of 11/2017, indicated a grievance was defined as any expression of dissatisfaction with care or a service that is brought forward by the customer or the customer's representative that is not resolved on the day the grievance was received. The facility's quality committee was responsible for ensuring grievances were reviewed and resolved. Customer grievances received by a leader/employee were documented in the QM/RM module in the electronic medical record on the date the grievance was received. A resident had the right to file a grievance orally and/or in writing, without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has or has not been furnished, staff behavior, and other concerns regarding their long term care stay. At the time the grievance was received, the complainant was informed of the review/investigation process and time frames. The grievance was to be reviewed and responded to within a timely manner, but no longer than 30 days. Review of the facility's Patient Grievance/Complaint by Location summary and General Patient Notifications by Location on 8/21/19, identified no complaints or patient notifications were documented for R11. Additionally, the most recent grievance, complaint and notification submitted on the facility's electronic electronic documentation system was dated 11/29/18. A request for written complaint documents provided by residents, employees, and resident representatives was requested. The director of nursing (DON) on 8/21/19, at 3:30 p.m., stated no written documents were available. The DON verified all grievances and concerns were documented electronically.