Every finding on record at Benedictine Health Center

Based on interview and document review, the facility failed to ensure the medical provider was updated in a timely manner about worsening edema which needed additional nursing interventions to manage for 1 of 3 residents (R1) reviewed who had heart failure. R1 developed edema in their legs which caused the nurses to place Tubigrips (a compression-style device) on them, however, the medical provider was not immediately updated about this.Findings include: R1's hospital Discharge summary, dated [DATE], identified R1 had been treated for an acute condition of acute blood loss anemia, along with multiple other medical conditions including high blood pressure, chronic heart failure, atrial fibrillation (irregular heartbeat), and diabetes mellitus. R1 was discharged with a Foley catheter in place to the care center for short-term rehabilitation. R1's medications were listed which identified he consumed torsemide (a diuretic medication) 20 milligrams (mg) twice daily. R1's next appointment was scheduled for 5/8/26 with the provider. The section labeled, Condition on Discharge, identified his vital signs which included a weight of 212.1 pounds (lbs), and a physical exam identified, Mild pitting edema in BLE [both legs]. R1's progress notes, dated 5/4/26 to 5/9/26, identified the following information: On 5/4/26, R1 was admitted to the care center from the hospital. R1 was alert and oriented and recorded with, HRIR [heart rate, irregular], trace edema BLE, +PP [pedal pulses] . R1's lung sounds were clear, but he had shortness of breath at rest.On 5/7/26, R1 remained at the care center following hospitalization for anemia and heart failure. The note recorded, Edema: Yes, with more dictation reading, 2-3 + to BLE. R1 did not have any obvious weight gain or loss, and the nurse wrote a nursing order for Tubigrips, and to elevate his affected extremities. The note was authored by registered nurse (RN)-C. On 5/8/26, R1 continued to have edema present which was recorded, 2-3 + to BLE.R1's Search Vitals Results, dated 5/4/26 to 5/8/26, identified R1's recorded daily weights collected at the care center. These were: 5/4/26 - 198.8 lbs5/5/26 - 201.0 lbs 5/6/26 - 202.3 lbs 5/7/26 - 202.2 lbs 5/8/26 - 202.8 lbs R1's First Eldercare admission Regulatory Visit note, dated 5/8/26, identified R1 was seen by the medical provider. R1 was identified to have heart failure and R1 stated he is doing well today. R1 denied chest pain but acknowledged chronic shortness of breath ongoing. A physical exam was recorded which identified, Extremities: . swelling of his [BLE]. The note did not address whether the Tubigrips were present or not.R1's medical record lacked evidence that the medical provider was contacted on 5/7/26 about the increased edema despite the nursing staff deciding to implement a new treatment (i.e., the Tubigrips) to help reduce it and improve the condition. When interviewed on 5/27/26 at 12:46 p.m., licensed practical nurse (LPN)-A stated the care center often had patients with heart failure and the monitoring for each person depended on the specific physician orders they came with or had. LPN-A stated Tubigrips would sometimes be used to help control edema as they didn't require a physician order to use. LPN-A stated the typical threshold for notification to the medical provider about heart failure or potential fluid overload was not based on edema but rather on their weight being elevated over a certain threshold (i.e., 3 lbs in 24 hours/5 lbs in a week) adding this was a general rule. LPN-A stated residents with edema should be monitored at least daily for the edema but there was no specific order set to record the monitoring being completed. LPN-A stated if edema was concerning, or if the medical provider was updated about it, that information should be written in a progress note. On 5/27/26 at 1:07 p.m., a telephone call was made to RN-C. A return call was received at 3:30 p.m., and RN-C recalled R1 as having increased edema in his legs on 5/7/26. RN-C stated R1 often did not like to lay down and was often up in his wheelchair so they thought adding Tubigrips would be helpful for the increased swelling. RN-C was asked when to notify the provider about increased edema and responded, That is a good question. RN-C explained the prompt to notify the provider was typically done off their weight status and not specifically for just increased edema. RN-C stated any notification to the provider would have been documented in the progress notes and expressed they did not recall placing a note for the physician or calling them on 5/7/26. RN-C reiterated they just felt the edema was from him sitting often and thought, Let's see how these [Tubigrips] work the next day or so. RN-C stated if R1's weight had been more drastically elevated along with the edema; it would have prompted an immediate telephone call to the provider. On 5/27/26 at 1:41 p.m., nurse practitioner (NP)-A stated they worked for the service R1 had been under while at the care center, however, they had not personally seen him so could not answer specific questions about his care. NP-A stated R1 remained in the hospital and discussed the current standard-of-care for heart failure is to do a daily weight and place the patient on a low sodium diet. NP-A stated it would be appropriate to update the provider at the first sign of increased swelling or edema as that was an indication something is not right. On 5/27/26 at 2:36 p.m., the director of nursing (DON) and registered nurse unit manager (RN)-B were interviewed. DON stated all nurses were aware to complete a daily check of edema for a patient with heart failure but, in general, edema was not specifically tracked in the medical record. If a nurse noticed increased swelling in the legs, then the nurse should review the previous charting to determine if the edema was more or less than previous shifts. RN-B explained a Tubigrip was like a sleeve and were able to be placed with a simple nursing order. DON verified the application of Tubigrips would be considered a form of treatment and felt the nurses could update the provider even simply as placing a note in their folder for the next rounds if the physician was scheduled to be there soon. However, if they were needed to be used for several days in a row, then a telephone call to the provider would be appropriate. RN-B stated they felt immediate notification to the provider would only be considered for emergent items or updates. DON and RN-B verified there was nothing recorded in the medical record to demonstrate the medical provider was contacted on 5/7/26 when the edema was identified as worse and a new form of treatment was started by the nurse. RN-B stated they felt any increase of edema should be relayed to the provider and added going from a 'trace' to 2-3+ of edema in a few days period was on paper a significant increase. A facility Change in Condition, Resident Examination and Evaluation policy, dated 11/2025, identified a resident examination and evaluation would be completed upon admission, with a change in physical function, or with an acute change of condition. The policy added, When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and [will] notify the resident/resident representative. A procedure was listed which directed to contact the medical provider for abnormalities including changes in physical status from baseline and a need to alter treatment significantly. The notification was to be recorded in the medical record. However, the policy lacked any definitions on what was considered a need to alter treatment significantly or what the facility defined as 'immediately.'

Based on observation, interview, and document review, the facility failed to ensure infection control interventions were implemented during an outbreak of SARS-CoV-2 (COVID), according to nationally recognized standards of practice such as Centers for Disease Control and Prevention (CDC) guidelines, including contact tracing and testing of staff and residents per guidelines. In addition, the facility staff failed to utilize proper personal protective equipment (PPE) while caring for COVID-positive residents and ensure that equipment was properly sanitized following use in a COVID-positive resident room. The deficient practice resulted in an immediate jeopardy (IJ), when 19 of 96 residents (R72, R94, R65, R84, R31, R20, R41, R61, R69, R81, R13, R106, R109, R39, R64, R90, R29, R51, R110) tested positive for COVID, three of the COVID positive residents were subsequently hospitalized (R69, R72, R94) and 11 facility staff tested positive. In addition, the facility failed to ensure a resident catheter bag was appropriately concealed and not in contact with the floor for 1 of 1 resident (R5) reviewed for catheter cares.The immediate jeopardy began on 12/4/25, when appropriate infection control interventions, including contact tracing and testing of staff, were not implemented to reduce the spread of COVID in the facility. Further observations were completed and indicated that facility staff were not properly utilizing PPE while caring for COVID-positive residents or sanitizing reusable medical equipment after use with COVID-positive residents. The immediate jeopardy was identified on 12/17/25. The administrator, nurse consultant (NC)-B, and director of nursing (DON) were notified of the IJ at 6:00 p.m. on 12/17/25. The immediate jeopardy was removed on 12/17/25. However, non-compliance remained at a pattern scope and severity with potential for more than minimal harm that is not immediate jeopardy (level E). Findings include: The Centers for Disease Control and Prevention guidance titled Infection Control Guidance: SARS-CoV-2 (COVID) dated 6/24/24, indicated for nursing homes that if they had a single new case of COVID for any healthcare provider (HCP) or resident, it should be evaluated to determine if others in the facility have been exposed. The guidance indicated that the facility should approach the outbreak investigation with either contact tracing or use a broad-based approach. The guidance indicated that a broad-based approach was preferred if all potential contacts cannot be identified or managed with contact tracing, or if contact tracing failed to halt transmission. The guidance indicated COVID testing should be performed for all residents and HCPs identified as close contacts or on the affected unit(s) if using a broad-based approach. The guidance indicated testing should be completed for all residents and HCPs who had close contact or were on the affected unit immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases are identified during contact tracing, strong consideration should be given to shifting to a broad-based approach if not already being performed. The guidance indicated broad-based testing should be continued on affected units or facility-wide, every three to seven days until there are no new cases for 14 days. A memo (memorandum) dated 12/12/25, was addressed to skilled nursing facility associates, residents, and visitors. The memo indicated that the facility was experiencing an outbreak of COVID-19 on the third floor and that the facility was taking immediate steps to mitigate the spread of the virus. The memo indicated source control measures (surgical masks) were implemented throughout the third floor. The memo indicated masking would be implemented for all associates who work on the third floor, and residents would be encouraged to wear masks when they are outside their rooms. The memo indicated group activities, services, and communal dining would be limited during that time. The memo encouraged visitors to wear masks and practice good hand hygiene. A memo dated 12/15/25, was addressed to skilled nursing facility associates, residents, and visitors. The memo indicated that the facility was experiencing an outbreak of COVID-19 and was taking immediate steps to mitigate the spread of the virus. The memo indicated source control measures (surgical masks) were implemented throughout the facility. The memo indicated masking would be implemented for all associates, and residents would be encouraged to wear masks when they are outside their rooms. The memo indicated group activities, services, and communal dining would be limited during that time. The memo encouraged visitors to wear masks and practice good hand hygiene. Residents Who Tested Positive for COVID The Preventive Health Care Report dated 12/1/25 to 12/17/25, identified the following residents tested positive for COVID:- On 12/10/25, R72 on the third floor.- On 12/11/25, R94 on the third floor.- On 12/12/25, R65 on the third floor.- On 12/13/25, R84 on the third floor.- On 12/14/25, R31 on the second floor and R20, R41, and R61 on the third floor. - On 12/15/25, R69 and R81 on the second floor- On 12/16/25, R13, R106, R109, and R39 on the second floor and R64 and R90 on the third floor- R29, R51, and R110 were not included in the report. R29's progress note dated 12/13/25 at 11:03 p.m., identified R29 had tested positive for COVID. R29's face sheet dated 12/19/25, identified R29 resided on the third floor. R51's progress note dated 12/15/25 at 3:51 a.m., identified R51 had a moist cough with slight wheezing heard in the lungs bilaterally. The note indicated R51 was swabbed and tested positive for COVID. R51's face sheet dated 12/19/25, identified R51 resided on the third floor. R110's progress note dated 12/14/25 at 1:47 p.m., identified R110 had tested positive for COVID. R110's face sheet dated 12/19/25, identified R110 resided on the second floor. COVID Positive Residents hospitalized R69's progress notes included the following:-12/15/25 at 1:40 p.m., identified R69 had chills and increased confusion. R69 was tested for COVID and was positive. -12/15/25 at 11:55 p.m., identified R69 stated he did not feel well, had an occasional dry cough, and weakness/fatigue. The note indicated R69 also had increased confusion.-12/16/25 at 2:25 a.m., identified R69 was weak and could hardly get out of bed.-12/16/25 at 2:00 p.m., identified R69 was transferred to the hospital for increased delirium, four unwitnessed falls in the last 24 hours, weakness, and a COVID-positive status. R69's face sheet dated 12/19/25, identified R69 was diagnosed with dementia, heart disease, and unspecified convulsions. R72's progress notes included the following:-12/10/25 at 8:07 p.m., identified when R72 had returned from dialysis (a medical treatment that filters blood when the kidneys fail), he had reported increased respiratory symptoms, shaking, chills, general malaise, fatigue, and reported not feeling well. R72 was found to be COVID-positive after testing. The note indicated R72 had several outside of the facility appointments in the recent past, and the facilities would be updated accordingly. The note indicated nursing leadership was notified, and R72's respiratory status had been quite compromised.-12/15/25 at 7:31 p.m., R72 stated he did not feel well and had increased shortness of breath. On assessment, R72 had extremely coarse lung sounds on the left side, and the provider was notified, who recommended the resident be admitted to the hospital. R72 eventually agreed to hospital admission and was sent to the hospital. R72's face sheet dated 12/19/25, identified R72 was diagnosed with kidney failure with a dependence on dialysis, heart failure, diabetes, and a heart arrhythmia (irregular heartbeat). R94's progress notes included the following:-12/11/25 at 1:16 p.m., identified R94 had tested positive for COVID.-12/15/25 at 11:04 a.m., identified R94 had an out of reference electrolyte imbalance with a critical low sodium level, and the resident was sent to the hospital for evaluation. -12/16/25 at 7:58 a.m., identified R94 was admitted to the hospital for a diagnosis of a low sodium level and pneumonia. R94's face sheet dated 12/19/25, identified R94 was diagnosed with acute transverse myelitis (inflammation of the spinal cord, which can cause loss of sensation, movement, and bladder control), vomiting/diarrhea, and malnutrition. Employees Who Tested Positive for COVID Employee Information Line Listing dated 12/17/25, identified the following:-Cook (C)-A had a positive COVID test on 12/4/25.-Nursing assistant (NA)-A had a positive COVID test on 12/11/25 and last worked on 12/10/25. The listing indicated NA-A became symptomatic on 12/11/25 and reported the illness on 12/15/25. Per an email on 12/16/25 at 3:31 p.m., when asked what department COVID-positive staff members worked for, the administrator indicated NA-A worked on the third floor. -Dietary aide (DA)-B had a positive COVID test on 12/13/25.-Registered nurse (RN)-A had a positive COVID test on 12/14/25.-RN-B had a positive COVID test on 12/15/25.-Unknown department supervisor (ADS) had a positive COVID test on 12/15/25.-DA-A had a positive COVID test on 12/15/25.-NA-B had a positive COVID test on 12/15/25.-NA-C had a positive COVID test on 12/15/25.-RN-C was reported to have COVID on 12/15/25, but the listing did not indicate what date RN-C tested positive.-laundry aide (LA)-A had a positive COVID test on 12/17/25. Staff Interviews During an interview on 12/17/25 at 9:13 a.m. with the infection preventionist (IP)-C (a registered nurse) and licensed practical nurse (LPN)-A:-The IP-C stated C-A had tested positive on 12/4/25. IP-C stated she would have expected the culinary director to complete symptom screening with the staff members who were in close contact with (C)-A, but she did not believe any testing or anything formally was completed after (C)-A had tested positive on 12/4/25. The IP-C stated she would have to check with the culinary director, who was out sick with COVID, to see if any further infection control measures were taken in the kitchen with this incident of COVID. -The IP-C stated the first positive resident case of this outbreak in the facility had been on 12/10/25 and was R72. LPN-A stated R72 frequently had appointments outside of the facility, including dialysis, but was isolated to his room while at the facility. IP-C stated she had decided to complete contract tracing with symptom-based testing, so testing was only completed for residents or staff members who had symptoms of COVID. IP-C stated that contact tracing had been completed after R72 tested positive, but she did not keep records of this contact tracing. LPN-A stated R72's health had been very compromised before contracting COVID and confirmed R72 resided on the third floor. LPN-A stated no other residents were in close contact with R72. IP-C stated she would have to consult the staff schedule to see what staff members would have been in close contact with the resident. The IP-C stated all staff members in close contact with R72 had been notified of their contact, but she thought testing had only been completed if staff members had symptoms of COVID. The IP-C stated she only had a record of staff testing if the results of the test were positive for COVID. The IP-C stated she was unsure off the top of her head how often serial testing would have been completed for staff members. The IP-C confirmed that serial testing had not been occurring for residents and staff members who didn't have symptoms of COVID, as symptom-based testing was occurring.-The IP-C stated the second staff member to test positive for COVID during this outbreak was DA-B on 12/13/25, who worked in the dietary department. The IP-C stated she would again have to check with the culinary director to see if contact tracing had been completed but believed it had been. The IP-C stated the next staff COVID case was RN-A on 12/14/25, and she believed NA-A tested positive on 12/15/25. -The IP-C confirmed R94, who resided on the third floor, had tested positive for COVID on 12/11/25. The IP-C confirmed R65, who resided on the third floor, had tested positive for COVID on 12/12/25. At 9:46 a.m., the director of nursing (DON) entered the conversation. The IP-C stated she believed that they recognized the facility had an outbreak on the third floor on 12/12/25 and sent out a memo to residents, staff, and visitors. All 13 total positive resident cases (R72, R94, R65, R84, R29, R20, R61, R41, R31, R110, R51, R81, R69) from 12/10/25 to 12/15/25 were reviewed with the IP-C. The IP-C stated at that time the facility continued to complete contact-based tracking and testing, as they did after R72 tested positive for COVID until 12/14/25, when they had the first case on the second floor, as all prior cases were on the third floor. The IP-C stated they declared a facility-wide outbreak on 12/14/25 and started facility-wide testing on 12/16/25. The IP-C stated that after all staff and resident cases until 12/14/25, they had completed contact tracing and completed symptom-based testing but would have to check with other staff members to see if they kept records of this contact tracing. The IP-C stated she would have preferred facility-wide COVID testing be started on 12/15/25, but due to time limitations caused by the recertification survey, that did not happen. -The LPN-A stated that three residents who had a diagnosis of active COVID had been admitted to the hospital. LPN-A stated R94 had been admitted to the hospital with critical labs and was diagnosed with pneumonia. LPN-A stated R72 had a history of pleural effusions and had been hospitalized for this recurring condition. LPN-A stated R69 had also been hospitalized , but she was not sure what for. During an interview on 12/17/25 at 10:56 a.m., housekeeper (HK)-A stated this morning was the first time she had been tested during this outbreak and had previously been told she would need to test if she was symptomatic. HK-A added that if there were an outbreak, they would be notified by email, and she did get that email yesterday. During an interview on 12/17/25 at 10:59 a.m., NA-F stated she tested yesterday or Monday, but hadn't tested yet today. NA-F provided she only worked on this unit, and it didn't have any COVID, but she did know there was an outbreak, and she needed to wear a mask. NA-F added there was a self-testing station in the education room, which was always there for self-testing, and then staff would write in the logbook. NA-F stated she had received an email yesterday about needing to test when she came to work. During an interview on 12/17/25 at 11:03 a.m., wellness assistant (WA)-A stated she mainly worked on the second floor. WA-A stated it was mandatory to test at work this morning and had also tested herself at home last Thursday or Friday because she had been around a resident she knew to be COVID positive, and she wanted to test herself. Her home test was negative. During an interview on 12/17/25 at 11:06 a.m., NA-I stated she had worked on the third floor last Thursday. NA-I stated she tested herself for COVID for the first time last night at home after she found out there was COVID in the building, and NA-I confirmed no one had reached out to her before this to complete COVID testing. NA-I confirmed she had tested negative for COVID and had no active symptoms. During an interview on 12/17/25 at 11:07 a.m., social worker (SW)-A stated she tested this morning, because it was required upon arrival. SW-A stated she was aware of this as of yesterday when she got an email. SW-A added she worked full-time with all floors and hadn't tested prior to today. During an interview on 12/17/25 at 11:09 a.m., HK-B stated he tested this morning because it was mandatory, before this, it was just based on symptoms or if he had been around one of the positive residents. HK-B added there was a self-testing station, if their result was negative, they signed their name and date. If they had a positive result, they would need to follow a link in the email he received about the outbreak. During an interview on 12/17/25 at 11:12 a.m., NA-H stated he had worked with R72 on the day that R72 had first tested positive for COVID last week. NA-H stated he hadn't been wearing a mask when working with R72 before R72 tested positive on 12/10/25. NA-H stated he had tested himself when he got home from work that night, and then the facility had him test himself again when he got to work the next morning on 12/11/25. NA-H confirmed he had not completed any further COVID testing between 12/11/25 and 12/17/25, as no one had told him to. NA-H stated he had not had any symptoms of COVID, and his tests had been negative. During an interview on 12/17/25 at 2:56 p.m. with the IP-C, NC-B, and the administrator, NC-B stated the facility did not have documentation of source tracing/contract tracing, notification of exposed staff, or documentation of negative staff COVID tests. NC-B stated that when the facility had one or two positive COVID cases, they would use contact tracing, and then based on their policy and clinical judgement, they could choose between the three options of contact tracing, unit-based testing, and facility-wide testing. NC-B stated one factor that went into deciding to switch to a facility-wide outbreak on 12/14/25 was having positive COVID cases on multiple units. NC-B stated that due to delays related to the recertification survey, facility-wide testing was started on 12/16/25. During an interview on 12/18/25 at 11:26 a.m., the medical director (MD) stated that when the first staff member tested positive in the kitchen on 12/4/25, he would have expected the other staff members who were in close contact with the positive staff member to be tested for COVID. The MD stated he thought it was unlikely the positive COVID case on 12/4/25 was linked to the first resident case on 12/10/25. With 12/10/25 being considered the first COVID case, the MD stated he would expect that when another positive was found, the facility would go into a facility-wide outbreak and would expect all facility staff and residents to be tested for COVID. The MD stated that a resident at the facility testing positive for COVID would increase the risk of hospitalization and the need for emergency care. The MD stated that COVID can lead to pneumonia for residents and confirmed that electrolyte imbalances can be related to hydration status with nausea and vomiting. The MD stated that health-wise, this population did not have a lot of resilience and confirmed that when a resident got sick with COVID, it could lead to changes in their mental status, weakness, and delirium. The MD stated that he was not aware of COVID having any effect on pleural effusion recurrence. The facility's COVID-19 Policy Manual dated 11/13/25, indicated under the heading Symptom and Contact-Based Testing that residents and staff members who develop COVID symptoms, had close contact (within six feet of positive person for greater than or equal to 15 minutes over a 24 hour period), or had a higher-risk exposure where the eyes, nose, or mouth were exposed to material potentially containing COVID should be tested for COVID. The manual then had a heading titled Outbreak Investigation Testing with instructions to implement when one resident or staff member had newly tested positive and was in the community during the infectious period. The manual indicated the facility had three options for how to conduct outbreak testing:-contract tracing testing where all staff members who had a higher risk exposure with a COVID-positive individual, and all residents who had close contact with a COVID-positive individual were tested.-Unit-based testing where all staff and residents were tested based on assignment and locations-facility-wide testing where all staff members and residents at the facility were tested. The policy then indicates if positive results were confirmed, continue bi-weekly testing of all previously negative residents and staff based on the outbreak testing option chosen until there were no new cases for at least 14 days. The policy indicated that if contact-based testing was being utilized, testing was recommended immediately (but not earlier than 24 hours after exposure) and if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day zero), day three, and day five. A complete list of all residents and staff members who tested positive during the covid outbreak as of 12/19/25 was requested and not received. Infection Control Observations R69's Face sheet no date, identified R69 had diagnoses which included convulsions, dementia, hypertension, hyperlipidemia, anxiety, insomnia, pain, depression, and difficulty walking. R69's quarterly MDS dated [DATE], identified he was usually understood and was able to understand, was moderately cognitively intact, and was independent with activities of daily living. R69's nursing notes dated 12/17/25 at 4:55 p.m., identified R69 tested positive for COVID 19 on 12/15/25. During an observation on 12/16/25 at 12:04 p.m., NA-D donned personal protective equipment (PPE) and entered R69's room with a vital sign machine. Affixed to R69's door was a droplet/contact precautions sign due to R69's COVID positive status. On 12/16/25 at 12:06 p.m., NA-D exited R69's room and brought the vital sign machine to a spot near the medication cart. During an interview on 12/16/25 at 12:14 p.m., NA-D verified she did not sanitize the vital sign machine after leaving R69's room. During an interview on 12/18/25 at 12:52 p.m., the DON verified equipment brought into isolation rooms (droplet/contact) should absolutely be sanitized to prevent any transmission of virus or bug. Resident Care Equipment dated 6/2017, identified Each community will protect against indirect transmission, which is the transfer of an infectious agent through a contaminated intermediate object, through decontamination of an object rendering it safe to use. In addition, the policy identified as a general reminder, Associate providing care will disinfect equipment prior to removal from a room of a resident in Contact Precautions. R109's care plan dated 12/16/25, indicated active COVID-19 infection care plan. Interventions included maintain isolation precautions/procedures per facility policy. R109's COVID-19 test completed on 12/16/25, indicated a result of positive. R81's care plan dated 12/15/25, indicated active COVID-19 infection care plan. Interventions included maintain isolation precautions/procedures per facility policy. R81's COVID-19 test completed on 12/15/25, indicated a result of positive. On 12/16/25 at 12:37 p.m., RN-D was observed entering R109's room. A disposable gown, gloves, and disposable eyeglasses were worn by RN-D. RN-D also had on a non-form fitting surgical mask instead of an N95 mask. The isolation sign R109's door indicated PPE including a gown, gloves, eye wear and a N95 mask was needed for any person entering the room. During an interview at 12:44 p.m., RN-D stated R109 was on quarantine because of a positive COVID-19 test and was currently symptomatic. RN- D confirmed a N95 mask was not on when entered R109's room but should have been. On 12/16/25 at 12:48 p.m., NA-E was observed entering R81's room. A disposable gown, gloves, and disposable eyeglasses were on NA-E. NA-E also had on a non-form fitting surgical mask instead of an N95 mask, The isolation sign on R81's door indicated PPE including a gown, gloves, eye wear and a N95 mask was needed for any person entering the room. During an interview on 12/16/25 at 12:52 p.m., NA-E confirmed an N95 was not on while in R81's room. NA-E stated the floor had run out of N95 masks earlier that day and did not realize they had been restocked. During an interview on 12/16/25 at 12:54 p.m., IP-C stated a N95 was needed to be worn along with the gown, gloves, and eyewear when going into a COVID-19 positive resident room because a regular surgical mask would not protect the person and would increase the risk of spread of the COVID-19 virus. During an interview on 12/16/25 at 1:16 p.m., the DON stated an expectation staff would wear the appropriate PPE, which included gloves, gown, eyewear and an N95 mask when going into a COVID-19 positive resident room. A surgical mask was not an appropriate mask to wear into a COVID-19 positive resident room to protect the staff member from possibly getting and transferring COVID-19 to other people in the building. On 12/17/25 at 11:18 a.m., one cook and three culinary aides were observed in the kitchen area in close proximity of each other without source control masks in place. During an interview on 12/17/25 at 11:21 a.m., the assistant culinary director stated the culinary staff had been informed all staff had to wear source control surgical mask at all times while in the facility to help decrease the risk of spread of the COVID-19. Management from each department were responsible to make sure staff wore their masks while in the department. The culinary department currently had 4 staff members out with COVID-19. The immediate jeopardy that began on 12/4/25, was removed on 12/17/25 when the facility implemented an infection control plan to minimize the spread of COVID, which included resident COVID testing twice a week or if having symptoms, all staff COVID tested before their shifts, and sanitizing all shared resident equipment. Staff were provided education regarding the infection control procedures, such as COVID testing protocols, PPE use, and sanitizing shared equipment. Catheter Observation R5's quarterly Minimum data set (MDS) dated [DATE], indicated R5 was cognitively intact with the diagnoses of chronic respiratory failure with hypoxia, obstructive and reflux uropathy and urine retention. The undated, facility provided document titled Observation Detail Report identified R5 had an indwelling catheter. The note section dated 6/3/25, identified R5 had a history of urinary tract infections, but had not had one in the last 30 days. A 11/21/25, note indicated R5's catheter was in place due to obstructive and reflux uropathy with urinary retention. Daily and PRN catheter care was being done along with monthly catheter changes. R5's Care plan last updated on 12/15/25, identified R5 as being on enhanced barrier precautions to minimize the risks of/and prevention of infections related to their indwelling catheter. R5's Physician Order Report: 6/10/25 to 12/19/25, identified an order: per urology change catheter every four to six weeks, once a day on the 20th of every month. R5's Medication and Treatment record dated 12/1/25 to 12/19/25, included documented entries of routine Foley care completion each shift. During an observation on 12/15/25 at 3:30 p.m., R5 was in bed. R5's catheter bag was directly on the floor by the foot of the bed on R25's left side. R25's shared bathroom had an unlabeled graduated cylinder sitting on back of toilet below the flush handle. Two bins were stacked on the floor between the wall and the toilet with an unlabeled bedside urinal in one of the bins. During an observation on 12/16/25 at 3:10 p.m., R5 was in bed. their catheter bag was located in the same place directly on the floor. The blue drainage spout was in direct contact with the floor. During an observation on 12/17/25 at 2:25 p.m., R5 was in bed, their catheter bag was directly on the floor in the same location as before. During an interview on 12/19/25 at 9:05 a.m., registered nurse (RN-E) stated she had just been in R5's room and RN-E confirmed R5's catheter bag had been directly on the floor at the foot of R5's bed. RN-E stated R5's catheter bag should not be on the floor because of the risk for contamination which put R5 at a higher risk for infection. RN-E stated they would be placing R5's catheter bag in a dignity bag for cleanliness/infection prevention and resident dignity. During an observation on 9/19/25 at 9:20 a.m., R5's catheter bag was at the left foot of the bed directly on the floor. During an interview on 12/19/2025 at 9:52 a.m., the director of nursing (DON) stated catheter bags should be concealed in a dignity bag and attached to the bed or chair at a level below the bladder. As an infection prevention measure, catheter bags should not be directly on the floor due to the risk of contamination from contact with the floor. The facility policy Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) dated 2017, identified complications associated with CAUTI could result in resident decline in function and mobility, hospitalizations, and increased mortality, prevention is key. The policy instructed to ensure the catheter bag was always hanging below the bladder and not to touch the catheter drainage bag with the collection container when emptying the catheter. The peri-urethra should be cleaned regularly with mild soap and water and then rinsed. The policy did not address catheter contact with the floor or other potentially contaminated objects or surfaces.

Based on observation, interview, and record review the facility failed to ensure the proper labeling of medications and the removal of expired medications and supplies occurred in two of two medication rooms and 3 of 6 medication carts. This deficient practice had the potential to impact all residents who received supplies and medications from reviewed medication rooms and carts.Findings include:During a medication pass observation on 12/17/25 at 7:36 a.m., trained medication administrator (TMA-B) pulled medications for administration to R21. Medications included Mucinex. TMA-B reviewed the Mucinex box they had pulled for administration and confirmed the Mucinex had expired. TMA-A stated the medication should have been pulled from the cart when it expired. TMA-A removed the box and then administered R21 Mucinex from a non-expired medication card.The third-floor medication cart identified as norther lights cart was reviewed on 12/17/2025 at 9:32 a.m., with licensed practical nurse (LPN-B). LPN-B confirmed the following findings: Drawer one contained an insulin syringe which had been opened but not dated. A second insulin pen wad dated, but the date was unreadable. Drawer two contained a stock medication acid reducer famotidine, expiration date July 2025. Drawer four contained a discharged resident's inhaler and a box of expired Mucinex. LPN-B pulled the expired medications from the cart for disposal. LPN-B stated medications like insulin, inhalers and eye drops needed to be dated when opened because the expiration date of the medication changed when it was opened. The expired medications should have been pulled from the cart when the medications expired.A partial review of the third-floor medication room was completed on 12/17/25 at 9:40 with LPN-B. Expired insulin syringes and 3 sets of expired blood culture bottles were found in the medication room. During a follow-up review of the third-floor medication room on 12/17/25 at 10:59 a.m., the director of nursing (DON) confirmed two partial boxes of 100-unit insulin syringes had expired on 9/20/25. The DON removed the supplies from the medication room and stated they expected staff to be checking dates on supplies and medications and removing them from stock when expired. A review of the 2nd floor medication room and blood draw supply was completed on 12/17/25 at 10:16 a.m., with the director of nursing DON. The DON confirmed and removed a box of safety needles that had expired on 2/28/25. The DON confirmed and removed the following expired resident labeled supplies from the intravenous supply cart: two expired central line dressing kits, several expired iv positive pressure caps, multiple expired picc plus stat locks, and expired guardiva dressings. The DON stated the supplies belonged to a resident who had been discharged . The DON confirmed the lab cart in the lab storage area was used by facility staff to draw labs at the facility. The supplies were also used by one of the hospitals that drew labs at the facility as well. The DON performed an expiration date spot-check of lab tubes on the cart and confirmed approximately 25 tubes had expired between the dates of 6/30/25 and 10/31/25. The DON then reviewed the supply cabinet and found multiple green top tubes had expired on 10/31/25, and two partially full packs of yellow top tubes had expired on 11/30/25. The DON removed the expired lab tubes from supply and stated they would expect staff to routinely review and remove expired lab supplies from carts and storage areas to prevent the use of expired supplies on patients. The DON confirmed it was the responsibility of the facility to order lab supplies. The third-floor medication cart identified as Superior Waters was reviewed on 12/17/25 at approximately 11:30a.m., with TMA-B. TMA-B confirmed the following findings. The cart contained expired insulin syringes, and the following current resident expired medications: hydrochloride cream expired 11/2025, nystatin power expired 11/2024, two hydrocortisone creams expired 1/2025 and 11/2025, and an open bottle of nitroglycerin 0.5 mg labeled discard after 3/18/25. The cart also contained one partially used Ozempic pen and one glargine insulin pen. Both pens were not labeled with the date first opened. TMA-B stated expired medications should be removed from the cart. They did not give insulin as a TMA, but they knew medications like insulin, inhalers, and eye drops were supposed to be labeled with the date when they were opened.A second-floor medication cart review was completed on 12/18/25 at 12:27 p.m., with registered nurse (RN-E). Cart drawer four contained medications of a resident who had been discharged from the facility on 12/1/25. There was also a current resident's inhaler that had been opened but not dated. RN-E stated things like inhalers and eye drops should be dated when opened. RN-E reviewed the fill date and admit date for the resident and dated the inhaler. RN-E stated it was the responsibility of everyone on the cart to make sure medications were labeled correctly, not expired, and for current residents only.During an interview on 12/18/25 at 1:30 p.m., LPN-A stated RN-E was the point person for medication rooms and medication carts. They believed RN-E performed outdate audits and so did the consulting pharmacy service. Beyond that it was a shared responsibility of anyone working on the cart to make sure that discharged resident's medications and expired medications/supplies were pulled from carts and medication rooms. LPN-A confirmed insulin pens, eye drops, and inhalers should be labeled with the date opened. During an interview on 12/19/2025 at 8:57 a.m., the DON stated they expected only properly labeled current resident non-expired medications and supplies to be stored in medication carts and med rooms. Carts and med rooms should be checked by staff for expired medications and supplies, and proper labeling throughout the work shift. Expired and discharged patient medications/supplies should be removed for proper disposal when found. The facility policy Medication Storage in the Facility Storage of Medications dated 3/17, directed outdated medications are to be immediately removed form inventory and disposed of. The nurse will check the expiration date of each medication before administering it.The facility policy Medication Labels Policy dated 12/17, did not address procedure for dating multidose medications once used.A facility policy on insulin administration/insulin pens was requested but not received.The policy Specific medication Administration Procedures Injectable Medication Administration dated 8/18, instructed staff administering an injectable medication to check the medication for expiration and to write the date opened and expiration date on the vial according to the table of shortened expiration dates for expiration date to use.

Based on observation, interview, and document review, the facility failed to ensure a dignified dining experience was provided for 1 of 11 residents (R16) observed during dining while staff stood next to them while assisting them with eating.Findings include:R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 had diagnoses which included Alzheimer's disease, dementia, and diabetes mellitus. R16's MDS identified R16 was generally understood and could understand and was severely cognitively impaired.R16's group sheet no date, identified R16 required set up with cues and encouragement for meals and hydration.During an observation on 12/17/25 at 11:24 a.m., in the safe harbor dining room, there were 11 residents seated at four different tables.At 12:28 p.m., the covered food cart arrived on the unit and the meals were delivered to the seated residents.At 12:37 p.m., trained medication aide (TMA)-A was observed standing next to R16 and assisting her with eating.During an interview on 12/17/25 at 12:49 p.m., registered nurse (RN)-E stated she would expect all staff to sit in a chair next to a resident to help them with eating.During an interview on 12/18/25 at 1:00 p.m., the director on nursing (DON) verified all staff assisting a resident to eat should be seated for face-to-face contact. The DON stated it was not dignified to stand over a resident while helping them with their meal.The policy Assistance with Meals dated 2/2018, identified Residents who cannot feed themselves will be assisted with attention to safety, comfort and dignity.

Based on observation, interview, and record review, the facility failed to promote resident choice to refuse when medication was hidden in food for 1 of 5 (R46) residents reviewed for resident rights. In addition, the facility failed to ensure 1 of 2 residents (R34) with a vision deficit was assisted in selecting menu choices when they were unable to do so independently. Findings include: R46: R46's Resident Face Sheet printed 12/19/25, indicated R46 was his own responsible party. R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 had moderate cognitive impairment. Diagnoses included dementia, encephalopathy, and epilepsy. R46's care plan dated 7/23/25, identified R46 was non-complaint and refused medications at times. Interventions included accept resident right to refuse and show respect for resident decisions and to notify provider and hospice if medications refused. R46's care plan dated 6/26/25, indicated psychotropic medication was used and to administer per provider orders. R46's Hospice order dated 8/8/25, indicated okay to hide medications in food if needed. R46's progress notes were reviewed and indicated the following: - - 11/1/25, refused nighttime medications. Resident suspicious of hidden blueberries in his drink. - - 10/2/25, nighttime olanzapine again crushed and hidden in his coffee per order. - - 10/1/25, nighttime olanzapine crushed and hidden in his coffee per order. - - Orders to crush and hide medications in food appeared to be working well. R46's COVID-19 test consent form dated 12/16/25, was signed as a verbal consent given by R46. During an interview on 12/17/25 at 2: 48 p.m., registered nurse (RN)-F stated if a resident refused medications staff should come back and reattempt to administer the medications at another time. If the medications were still refused, then the refusal would be documented because residents had a right to refuse medications. Medications would never be hidden in food and the resident not told about the medications unless there was a provider order okaying the action. RN-F stated R46 had an order from hospice to hide medications in food so R46 would take them. RN-F stated R46 was his own responsible party and decision maker. During observations on 12/18/25 at 9:36 a.m., RN-D was observed crushing R46's medications and mixed them in a bowl of hot cereal. RN-D was then placed the bowl of hot cereal, with medications mixed in it, back on the food cart with the other resident meal trays. During an interview on 12/18/25 at 10: 38 a.m. the hospice registered nurse (HRN) stated hospice had provided an order on 8/8/25 that indicated it was okay to hide medications in R46's food and not tell him they were there. R46 had a history of refusing medications when he was told he was getting them, and the hospice agency and facility did not want him to refuse the medications. During an interview on 12/18/25 at 10:48 a.m., RN-D confirmed she had mixed crushed medications and hid the medications with hot cereal so R46 would not be aware they were there. The tray was then placed back on the food cart for somebody to deliver to R46's room. R46 would always refuse medications when administered to him and told they were medications to take. The facility did not want R46 to refuse the medications, so an order was obtained to mix medications with food when needed. R46 did not have a power of attorney and was his own person regarding decision making. R46's spouse had removed herself completely from R46's medical record. RN-D stated all residents, even confused/dementia residents who are their own person have the right to refuse medications. During an interview on 12/18/25 at 1:77 p.m., RN- G stated all residents, who were their own responsible party, or resident representative would have the right to refuse any treatment or cares, which included medication administration. There would need to be special steps taken before medications would be hidden in food and the resident not told about them. RN-G was unsure what steps would need to be taken During an interview on 12/18/25 at 3:48 p.m., the director of nursing (DON) stated residents, and resident representatives had the right to refuse any cares or treatment offered. R46 had no court orders in place that allowed the facility to give medications to R46 without telling him first and having the ability to refuse medications. Staff were expected to allow resident to refuse cares or treatments, document the refusals, and notify the provider of refusals. Facility policy Resident Rights and Notification of Resident Rights last reviewed 8/28/25, indicated a copy of the resident bill of rights was given to all residents at time of admission. One of the 45 resident rights included the right to refuse treatment.

Based on observation, interview, and record review the facility failed to ensure adequate privacy was in place prior to and after 1 of 1 resident (R75) had requested privacy measures be implemented for privacy during toileting and self-cares performed in bed.Findings include: R75's quarterly Minimum Data Set (MDS) dated [DATE], indicated R75 was cognitively intact with the diagnoses of multiple sclerosis, paraplegia, neuromuscular dysfunction of bladder, and constipation.R75's Care plan last updated 11/18/25, included interventions for bowel toileting program and resident self-performed intermittent catheterization. R75's care plan did not address R75's 's privacy needs during self-care activities and/or bed pan use.R75's Physician Order Report: 1/1/22 to 12/19/25, included the following orders:Resident is okay to perform self-catheterization for neuromuscular dysfunction of the bladder.It is okay to leave medications at bedside for R to self-administer.Fleets enema once daily as needed rectal route for constipation. Ok for self-administration.A progress note entry made by licensed practical nurse (LPN-A) In R75's electronic medical record (EMR) included: Resident requested a privacy curtain. Resident feels that anyone could open their door and enter their room violating their privacy. Resident does have extensive toileting needs which does warrant increased privacy and validate this concern further - writer did let R75 know a request had been made.During an interview on 12/15/25 at 6:37 p.m., R75 stated because of MS, they had to have their bladder catharized, and they also had to use fleets enemas for constipation. They were able and preferred to do their own intermittent self-catheterization and administration of enemas which they did while in bed. R75 explained both tasks required them to open their legs wide apart, and this was very uncomfortable to do without having privacy between their bed and their room door. Without a privacy curtain, when their door was open, their bed was in full view. Staff did knock, but if they were performing selfcare and staff had to come in, as they did, R75 was completely exposed to everyone in the hallway. R75 stated they had asked multiple staff multiple times for a privacy curtain between the door and their bed, but nothing had been done. They could not recall everyone they spoke with but did remember talking to the nurse manager licensed practical nurse LPN-A. R75 stated they had tried to position their belongings as a shield, but it really was not adequate to protect them from being viewed from door/hallway. An observation confirmed R70 was viewable from the doorway/hallway when R75's door was open.During a follow-up interview on 12/18/25 at 11:14 a.m., R75 was in bed. R75 stated having a curtain or barrier was a matter of dignity and privacy nobody would want to have. It felt pretty awful to be in bed all exposed and afraid the door would open and expose them every time they performed self-care. They didn't feel it was too much to ask for something to protect them from being exposed when their room door was opened. During an interview on 12/18/25 at 11:59 a.m., the administrator and licensed social worker (LSW-B) were present. LSW-B stated they had just had a care conference with R75, and they didn't think that a privacy issue had been brought up. The administrator privacy curtains were not normally provided in single rooms, however their double rooms required privacy curtains so those were in place in all of their double rooms. The administrator did recall R75 had asked for a privacy curtain, and R75's request had been discussed, but with R75 having a single room the curtain had not been pursued. The administrator stated if it was something R75 wanted they and LSW-B could work with R75 on it. During an interview on 12/18/2025 at 1:27 p.m., LPN-A confirmed they had met with R75 a few months ago and at that time R75 had requested a privacy curtain or a shield of some sort for their room. LPN-A stated they had put the interaction in a progress note and reported it on to R75's care team for follow-up. LPN-A stated they didn't know the outcome of the privacy request but knew the administrator had been looped in by the care team. On 12/18/25 at 2:06 p.m., LSW-B reported a trifold curtain had been taken out of their office and placed at the door in R75's room, so now R75 had a privacy barrier in place. The facility policy Resident Rights and Notification of Resident Rights dated 8/28/25, identified residents had the right to respect, dignity, and privacy.The facility provided copy of the Minnesota [NAME] of Rights Minnesota Nursing Home and Boarding Care Home dated 12/4/15, sub-heading Treatment Privacy outlined residents shall have the right to respectfulness and privacy as it relates to their medial and personal care program. Privacy shall be respected during toileting, bathing, and other care activities of personal hygiene, except as needed for resident safety or assistance.

Based on observation, interview, and record review the facility failed to ensure residents were free of chemical restraints and utilized/documented nonpharmacological interventions prior to administering as needed psychotropic medications. The facility also failed to have a stop date for as needed psychotropic medications that were past 14 days and did not have a stop date documented. This effected 2 of 6 (R46, R69) residents looked at for unnecessary medications. Findings Include: R46: R46's quarterly Minimum Data Set, dated [DATE], indicated R46 had moderate cognitive impairment. Diagnoses included dementia, encephalopathy, and epilepsy. R46's care plan dated 12/8/25, indicated a psychosocial well-being concern related to potential for trauma related to my past military service and may become agitated or aggressive. Interventions included send to emergency room, notify hospice, analyze key times, places, circumstances, triggers and what de-escalates triggers. A care plan dated 6/26/25 indicated the use of psychotropic medication use which included risperidone, olanzapine and lorazepam. Interventions included monitor target behaviors daily. The care plan lacked what target behaviors to monitor for and what non-pharmacologic interventions to attempt prior to administering psychotropic medication. R46's Physician Order Report printed 12/19/25, indicated on 12/8/25 olanzapine 10 milligrams (mg) twice a day by mouth was started. Target behaviors were dementia with other behavioral disturbance, non-pharmacologic interventions included non-judgmental care and empathetic listening. On 6/25/25, lorazepam 1mg every 4 hours as needed (PRN) by mouth was started for anxiety/agitation. R46'S medication administration record (MAR) for December indicated Lorazepam was administered on the following dates with the following reasons: - 12/7/25 at 5:10 p.m., with prn reason of other. - 12/12/25 at 7:08 p.m., with reason of anxiety - 12/13/25 at 6:23 p.m., with reason of anxiety/agitation - 12/14/25 at 6:14 p.m., with reason of anxiety/agitation R46's MAR lacked any other documentation related to specific triggers that occurred to require the need to administer PRN psychotropic medications or what non-pharmacological interventions were attempted prior to administering medication. R46's progress notes were reviewed for the month of December and identified on 12/7/25 at 2:05 p.m., a male resident had entered R46's room. R46 proceeded to backhand the other resident on the left ear. The two residents were separated; a stop sign strap was placed on R46's doorway to prevent further entries without invitation. R46's progress notes lacked any other specific documentation related to triggers the resident had or nonpharmacological interventions attempted prior to administered lorazepam. During an interview on 12/17/25 at 2: 48 p.m., registered nurse (RN)-F stated prior to PRN psychotropic medications being issues there should be triggers observed from the resident and non-pharmacological interventions need to be attempted. Everything observed and attempted should be documented in the medical record, either in the MAR or the progress notes. RN-F indicated she had just arrived to work when R46 struck the other resident. Both residents were separated and taken to their own rooms. A stop sign was placed on R46's room right away and he was calm after that. RN-F stated R46 had remained calm after the incident, but an as needed lorazepam was still administered at 5:10 p.m., just in case and to head off any possible behaviors later that shift. RN-F stated that several times it is difficult to get R46 to take PRN psychotropic medications like lorazepam when he is in the middle of a behavior who several nurses, including me, would go ahead and given an Ativan in the evening before behaviors occurred and to keep him from having possible behaviors. Staff have not talked about a scheduled order for Lorazepam because the current order works. During an interview on 12/18/25 at 2:08 p.m., RN-G stated PRN medications should only be given when true behaviors/triggers are witnessed and only after non-pharmacological interventions were attempted first. If the non-pharmacological interventions work, then PRN medication should not be administered. Behaviors/triggers would then be documented either in the progress notes or the MAR, if medication was given. The non-pharmacological interventions would be documented in the progress notes. PRN psychotropic medication should never be administered just because, or to make a nurse's job easier. During an interview on 12/18/25 at 3:48 p.m., the director of nursing (DON) stated an expectation all nursing staff would document behaviors, nonpharmacological interventions and medication usage in the medical record. PRN psychotropic medications would only be used if needed and not for staff convenience. Facility policy related to PRN psychotropic medication was requested but not received. R69: R69's Face Sheet dated 12/19/25, identified R69 had diagnoses which included convulsion, dementia, anxiety, insomnia, pain, and depression. R69's quarterly Minimum Data Set (MDS) dated [DATE], identified R69 received antipsychotics, antidepressants, antiplatelets, and anticonvulsants medications. R69's care plan dated 9/16/25, identified mood state, interventions included medications as ordered, pharmacy consult monthly and as needed, observe for side effects of psychotropic medications and changes in mood. In addition, R69's care plan dated 6/4/25, identified he received psychotropic medications, interventions included to administer medications as ordered and to monitor for target behaviors. R69's Physician Order report dated 12/16/25, identified R69 received the following medication: lorazepam 0.5 milligram (mg) twice a day as needed for anxiety, with a start date of 12/2/25 and no end date. Consultant Pharmacist report no date, but signed by provider on 12/8/25, did not address the need for a stop date for the as needed lorazepam. On 12/28/25 at 12:48 p.m., the director of nursing (DON) reviewed R69's electronic medical record and verified R69's as needed lorazepam order had no end date. The DON verified all as needed psychotropic medications required a start date and an end date. On 12/19/25 at 11:48 a.m., consultant pharmacist (CP)-F responded with the following email: Yes. For a resident prescribed PRN lorazepam (Ativan), an initial stop date of 14 days following initiation is recommended. At that time, the prescribing provider should evaluate the resident's use, clinical response, and ongoing need for therapy. Based on this assessment, the provider may determine an appropriate continuation plan and, if warranted, establish a subsequent stop date that does not exceed 180 days. The facility policy Psychotropic Medication Use dated 9/7/23, identified the following: PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending providers evaluate the resident for the appropriateness of that medication.

Based on observation, interview, and document review the facility staff failed to have qualified staff administer medications to a resident. This effected 1 of 1 (R46) resident reviewed for medication administration. Findings include: R46's quarterly Minimum Data Set, dated [DATE], indicated R46 had moderate cognitive impairment. Diagnoses included dementia, encephalopathy, and epilepsy.R46's care plan dated 6/26/25, indicated R46 received high risk medications. Interventions included administer medications per MD order and observe for side effects of medications.During observations on 12/18/25 at 9:36 a.m., registered nurse (RN)-D was observed crushing R46's medications and mixed them in a bowl of hot cereal. RN-D was then placed the bowl of hot cereal, with medications mixed in it, back on the food cart with the other resident meal trays. During observations on 12/18/25 at 9:48 a.m., the registered dietician (RD) was observed delivering R46's tray to the room and placed on the bedside table. R46's was observed to be asleep so RD left the tray on the bedside table and did not wake R46 up to educate on the medications or verify the right resident was getting the right medications. During an interview on 12/18/25 at 10:48 a.m., RN-D stated medication should only be gathered and administered to residents by a trained medication aide (TMA), licensed practical nurse (LPN), or RN. TMA's, LPN's, and RN's are the only staff members that are trained and qualified to gather and administer medications to residents appropriately and safely. Any other staff members would not have training on the 5 rights (right patient, right medication, right time, right dose and right route). Without that training residents would be at an increased risk of adverse effects from medications given to them.During an interview on 12/18/25 at 11: 52 a.m., the registered dietician (RD) stated she would assist at mealtimes to pass the trays more timely. The RD did remember passing R46's breakfast tray this morning. The RD was aware, based on care plan, R46 had medications hidden in their food and that medication might be on the breakfast tray when delivered. There was no verification prior to passing the tray to see if medications were present. The RD stated only staff members trained in medication administration should pass trays when medications are mixed with the food. The RD acknowledged she had no training in medication administration prior to that and did not have an understanding of accurate and safe medication administration policies.During an interview on 12/18/25 at 1:42 p.m., nurse assistant (NA)-E stated the staff who worked the cart would mix R46's medications with the food on the tray and then place it back on the food cart to be administered by somebody else. NA-E stated she had delivered R46's tray many times to his room with medications mixed with the food and left the food tray and medications in the room for R46 to take at a later time. NA-E confirmed she had no specialized training as a TMA to pass medications and understand the medication administration policies.During an interview on 12/18/25 at 3:48 p.m., the director of nursing (DON) stated only TMA's, LPN's and RN's had the appropriate training to gather and administer medications appropriately and safely. No other staff should be gathering or administering medications to residents.Facility policy Administering Medications last revised 8/31/23, indicated medications would be administered by licensed nurses (LPN, RN) or as otherwise delegated, trained associates (TMA). Medications would be administered following the 6 Rights of medication administration:a. Right Residentb. Right Medicationc. Right Dosed. Right Timee. Right Routef. Right Documentation

Based on observation, interview and document review, the facility failed to ensure morning cares including oral cares were completed for 1 of 3 residents (R62) reviewed for activities of daily living (ADLs), and who were dependent on staff for assistance with ADL cares.Findings include:R62's quarterly Minimum Data Set (MDS) dated [DATE], identified R62 had Alzheimer's disease and dementia. In addition, R62's MDS identified she required partial to moderate assistance with ADL cares.R62's group sheet undated, identified R62 required substantial assistance of one for dressing and substantial assistance of one for oral hygiene.R62's care plan dated 8/29/25, identified a self-deficit with bathing, grooming, and oral cares. Interventions included extensive assist of one to assist with bathing. The care plan did not address oral care.During a continuous observation on 12/17/25 starting at 7:41 a.m., and ending at 10:55 a.m., nursing assistant (NA)-F assisted R62 with clothing choices, put Tubigrips (a brand of elastic bandage) on her legs, gripper socks, pants, and shoes. NA-F rang the call light for help (NA)-G entered and assisted NA-F with a brief change, they then assisted R62 into a wheelchair, NA-F combed R62's hair and she was brought to the dining room for breakfast.-at 9:03 a.m., R62 remained in the dining room at the table, she was done with breakfast.-at 9:10 a.m., R62 talked about leaving staff asked her if she wanted to go the exercise group, she declined. No staff offered to bring her to her room to brush her teeth after breakfast.-at 9:28 a.m., staff brought R62 to the exercise activity.-at 9:43 a.m., staff brought R62 to the dining room for a manicure.-at 10:08 a.m., R62 went into her room alone.During an interview on 12/15/25 at 1:47 p.m., family member (FM)-E stated they did not think R62's teeth were being brushed twice a day.During an interview on 12/17/25 at 10:30 a.m., NA-F stated there were two NAs from 6:00 a.m. to 10:00 a.m., and offered that it was hard to get everything done for residents. NA-F stated morning cares included getting the resident's brief changed and dressed. NA-F stated completion of oral care was dependent on if they had time, otherwise oral care should be done after breakfast. NA-F verified she did not complete oral care for R62 during morning cares or after breakfast.During an interview on 12/17/25 at 10:55 a.m., trained medication aide (TMA)-A stated they could use more help, verified they can't get morning cares completed with one- and one-half nursing assistants.During an interview on 12/17/25 at 12:51 a.m., registered nurse (RN)-E stated the staffing was one TMA and one- and one-half NAs. The one half NA was scheduled from 6:00 a.m. to 10:00 a.m RN-E verified morning cares included face washing, hand washing, oral care, clean clothes, and peri-cares. RN-E stated she would expect this to happen every morning. During an interview on 12/18/25 at 12:52 a.m., the director of nursing (DON) stated he would expect staff to follow the group sheet for cares. The DON verified face washing, hand washing, oral care, toileting, and incontinence cares were all part of morning and evening cares. The DON verified it was important to provide oral care to help residents keep the teeth the have. The policy Activities of Daily Living dated 6/2021, identified the following, Residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility. The policy identified hygiene as bathing, dressing, grooming, and oral care.

Based on observation, interview and record review the facility failed to ensure a locked door on the secure memory care unit had a functioning alarm to prevent residents at risk for elopement from leaving unobserved. This affected 1 of 2 residents (R100) reviewed for elopement risk. Findings include:R100's admission Minimum Data Set (MDS) dated [DATE], identified R100 had diagnoses which included macular degeneration (an age-related eye disease that damages the macula, causing loss of sharp, central vision needed for reading and driving), hearing loss, and cognitive communication deficit. In addition, R100's MDS identified he was severely cognitively impaired, had behaviors, and wandered. R100's MDS identified a wanderguard was in use daily.R100's care plan dated 12/12/25, identified R100 had cognitive loss with exit seeking behavior. Interventions included to distract with activities and a secure memory care unit with specialized programming. R100's care plan also included behavioral symptoms, wandering towards doorways and elevators. Interventions included to approach from the front, walk in step with him before redirecting, wanderguard use, and to provide comfort measures for basic needs (snack, redirection, activities).R100's group sheet undated identified he wandered but was easily distracted.R100's nursing progress notes dated 12/14/25 at 3:13 p.m., Resident exit seeking. Resident got through back door. Back door alarm is broken. Resident able to get through without code. Staff redirected resident and then he continued to exit seek down the other hallway. Writer let nurse know.R100's nursing progress note dated 12/5/25 at 10:27 p.m., identified the following: He is wearing a wanderguard on his left ankle, as he attempts to get on the elevators and leave the unit at times.Behavior monitoring sheets:12/6/25 at 1:07 p.m., Pt has been wandering consistently throughout the day, both exit seeking and general wandering. Several other pts reported seeing him try to come into their rooms. Have been keeping a watchful eye on him, he has tried to open the doors to the stairwell and almost snuck on the elevator behind a visitor (does have a wanderguard on).During observations on the memory care unit on 12/15/25 between 12:05 p.m., and 7:00 p.m. the back door alarm was not heard to alarm despite dietary staff using that entrance/exit. During an observation on 12/16/25 at 2:04 p.m., R100 was observed pushing the back door to the memory care unit open, he was able to get part way out of door before the director of nursing (DON) saw him and pulled his wheelchair back into the unit. No alarm sounded.During an observation and interview on 12/17/25 at 8:33 a.m., maintenance worker (MW)-B was observed working on the back door to the memory care unit. MW-B stated he'd heard that morning that the alarm was not working. MW-B verified the door was not alarming or locking. MW-B verified staff had placed a chair in front of the exit and he was working on putting an audible alarm on the door, he stated he did not know how long it had not been working (locking or alarming). During an interview on 12/17/25 at 8:46 a.m., registered nurse (RN)-E stated she was not sure how long the door had not been locking, then said Saturday but she had learned it was not functioning on Monday, and she informed the administrator. RN-E stated they were just keeping a close watch on the door.During an interview on 12/17/25 at 2:00 p.m., environmental services director (EVS)-G stated the door (back exit to the memory care unit) had not been locking since the end of November. He was not sure how maintenance staff had been informed the door was not alarming on 12/17/25. EVS-G verified there was a chair in front of the door and stated it was not okay to place a chair in front of an exit door. EVS-G verified if a resident got through the door, they could potentially exit the building (they would have to take an elevator to the first floor) and no alarms would sound at the first floor exit to the outside of the building.During an interview on 12/17/25 at 2:21 p.m., trained medication aide (TMA)-A stated she was not sure how long the back exit door to the memory care unit had not been working locking or alarming. TMA-A stated they were told to watch more closely and count their residents.During an interview on 12/17/25 at 1:01 p.m., RN-E stated they had been instructed to place a cart in front of the back exit door. RN-E verified there was a hallway that led to an elevator that went to the third floor or down to the first floor where there was an exit to the outside of the building.During an observation on 12/17/25 at 1:11 p.m., with EVS-G were able to exit the memory care unit, get on the elevator, take it to the first floor and go out a door to the outside of the building.During an interview on 12/18/25 at 2:32 p.m., the administrator and executive director verified the back door to the memory care unit was not locking, they also verified it was not acceptable to place furniture in front of the door as a deterrent to residents using it due to safety concerns. They verified the staffing level for the unit was not changed while they were waiting for parts to fix the door.The policy Elopement dated 10/14/22, identified the purpose was To provide a safe and least restrictive environment for residents. To maintain the safety of residents who are at risk of wandering and/or active elopement. In the post-investigation section questions that needed to be asked and answered were: a. Were the alarm systems working properly?b. Were all internal and external doors visually checked?c. Were there any deficient practices or system failure?The policy did not specifically address the memory care unit and safeguards in place for residents.

Based on observation, interview and document review, the facility failed to ensure the nursing staff posting included the facility name and was updated with changes in staffing. In addition, the facility included the director of nursing and the nurse managers (who were not responsible for direct resident care) in the total hours worked. This had the potential to affect 96 residents and their visitors.Findings include:On 12/15/25 at 4:22 p.m., the hours posted were as follows: Staffing Hours report for Nursing at Duluth-SNF dated 12/15/25, census was listed as 93. The posting was in sections nursing assistant and trained medication aide totaling 93.25 hours. Section for licensed practical nurse totaling 32 hours. Section for registered nurse included the clinical managers (two), the director of nursing and two registered nurses with the total hours as 40. The director of nursing and the clinical manager hours were included in the total hours for nursing care.A review of the DON's job description dated 2/2019, identified they were responsible for leading, planning, supervision to provide effective nursing services. In addition, to provide administrative and clinical leadership.A review of the clinical manager's job description dated 2/2019, identified the clinical manager is a clinically competent registered, professional nurse who assumes accountability and responsibility for a particular unit of resident/patient and the direct care staff. Effectively manages the care process of the residents/patients by coordinating and overseeing the provided care and competency of those entrusted with the responsibility. The job description identified the role as supervision.On 12/18/25 at 1:39 p.m., the director of nursing (DON) verified the staffing hours were posted daily but no changes were made on the posted sheet for residents and visitors. The DON stated those changes were noted elsewhere. The DON verified his hours as well as the clinical manager hours were included in the total worked hours for direct care. The DON also verified the actual name Benedictine Living Community of the facility was not part of the posting, instead the name was listed as Nursing at Duluth-SNF.On 12/18/25 at 2:11 p.m., the human resource director (HRD)-K stated she was making the nursing schedule for now. HRD-K stated they did not know why the name of the facility wasn't on the posting for nurse staffing. HRD-K verified changes were not made on the actual posting for residents and visitors to see. HRD-K verified the DON, and the clinical managers daily responsibilities did not include direct resident care.The Staffing and Daily Work Assignments dated 9/2018, did not address the daily nurse staff posting but did however, identify licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.The annual facility assessment dated 8/2025, in the section on Staffing Plan identified the director of nursing and the nurse managers as other nursing personnel (e.g., those with administrative duties).

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R1) was free from sexual abuse when nursing assistant (NA)-A entered R1's room with his genitals exposed to R1 and proceeded to hold R1's hand while holding his genitals in his other hand. This had the potential to result in serious psychosocial harm for R1.The IJ began on 10/22/25, at approximately 5:00 a.m., when NA-A entered R1's room and sexually abused R1. NA-A exposed his genitals to R1 through his unzipped pants and held R1's hand with one hand while holding his genitals in his other hand. The administrator and the director of nursing (DON) were informed of the IJ on 10/29/25, at 3:36 p.m. The facility had implemented corrective action to prevent recurrence by 10/22/25, therefore, F600 is being issued at past non-compliance. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. Diagnoses included hemiplegia (paralysis or weakness of one side of the body), dysphagia (difficulty swallowing), and aphasia (difficulty with communication).R1's care plan dated 10/22/25, identified R1 was vulnerable to abuse from others and needed assistance to remain safe in the facility. The care plan also indicated R1 believed sexual trauma had been experienced. R1's vulnerabilities included physical limitations, hemiplegia and hemiparesis after a stroke, and communication deficitsA Nursing Home Incident Report to the State Agency (SA) dated 10/22/25, identified R1 had reported to licensed practical nurse (LPN)-A, that NA-A had placed R1's hand on or around NA-A's genital region.The facility investigation file indicated NA-A was interviewed by the director of nursing (DON) on 10/27/25 at 8:33 a.m. During the interview NA-A told the DON between 5:15 a.m. and 5:30 a.m., he had gone into R1's room to empty the catheter bag. NA-A's genitals were outside of his pants. He went up and said goodbye to R1 while holding R1's hand in one hand and his exposed genitals in the other hand. The file indicated NA-A reported R1's hand did not touch his genitals while out of his unzipped pants.During an interview on 10/29/25 at 9:03 a.m., communicating via a letter board, R1 identified that NA-A came into the room on the morning of 10/22/25 and his pants were unzipped. NA-A's genitals were exposed outside of the zipper where R1 could see it. NA-A then grabbed R1's hand and held it around NA-A's genital region and skin to skin contact was made. R1 was tearful as she spelled out the answers to the questions. The interview was assisted by LPN-A, who also confirmed the understanding of what R1 was communicating.During an interview on 10/29/25 at 9:25 a.m., LPN-A stated R1 had reported the initial concerns to him. LPN-A stated he could tell there were issues with R1 and asked if something was wrong. R1 shook her head yes. LPN-A asked if there was a staff issue and R1 proceeded to spell out the word report. When asked if R1 wanted to report a staff member R1 shook her head yes. LPN-A proceeded to leave R1's room and went to the nurse manager. LPN-A, registered nurse (RN-A) and the social services designee (SSD) all went into R1's room together. RN-A asked R1 what was wrong and R1 spelled out zipper. LPN-A stated after hearing the word zipper he stepped out of the room.On 10/29/25, RN-A was on vacation and unable to be interviewed.During an interview on 10:29 a.m., SSD stated LPN-A, RN-A and the SSD went into R1's room to talk about what needed to be reported. RN-A asked R1 what was wrong and R1 spelled out the word zipper. R1 reported she had been inappropriately touched by NA-A during cares. SSD stated R1 reported NA-A physically moved the hand to make contact with NA-A's genitals. NA-A was not clothed and skin to skin contact had happened. R1 had also reported to SSD NA-A had used her hand to touch and perform sexual acts with his genitalia but penetration had not occurred. R1 was tearful throughout the entire interview.During an interview on 10/29/25 at 12:46 p.m., the DON stated everything happened on 10/22/25 around 5:15 a.m. The incident was reported as soon as he found out about it. All staff reported they did not go in the room with NA-A, but review of the cameras confirmed NA-A had entered R1's room around 5:15 a.m. on 10/22/25. The DON confirmed NA-A reported the genitals were outside his unzipped pants and that he had held R1's hand while holding his genitals outside of his pants with NA-A's other hand. NA-A reported he did not touch his genitals with R1's hand.During an interview on 10/30/25 at 8:30 a.m., NA-A stated he had entered R1's room on 10/22/25 at approximately 5:15 a.m. His genitals were exposed to R1 outside his pants when entering the room. NA-A then proceeded to hold his genitals on one hand while grabbing R1's hand with NA-A's empty hand. NA-A did not touch his genitals with R1's hand.The facility's Abuse Prevention Plan last revised 7/21/22, indicated the definition of abuse included the willful infliction of unreasonable confinement, intimidation or punishment of which resulted in physical harm, pain or mental anguish. This included sexual and mental abuse. Sexual abuse was defined as the non-consensual sexual contact of any type with a resident.The past noncompliance IJ began on 10/22/25. The IJ was removed and the deficient practice corrected on 10/22/25, when NA-A was suspended and later resigned. The facility conducted an investigation which included other resident interviews and staff interviews (no further incidents of abuse were found), and re-training was completed at that time for all staff related to abuse and was confirmed through review of education and signed attendance sheets showing all staff received training. The abuse policy was also reviewed as part of the investigation.

Based on observation, interview and document review, the facility failed to report an injury of unknown origin to the State Agency (SA) immediately, but not later than two hours, for 1 of 4 (R1) residents reviewed for resident safety. Findings include: On 5/12/25 at 12:30 p.m. a facility reported incident (FRI) submitted to the SA by the facility administrator indicated on 5/11/25, at 4:00 a.m. R1 had a new bruise to her right under arm. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of stroke, hemiplegia and hemiparesis (paralysis) of her right dominant side, and impaired cognition following cerebral infarction (stroke). The MDS indicated R1 had moderate cognitive impairment and required extensive assistance by staff for bed mobility and transfers. The MDS further indicated R1 was taking anticoagulant and antiplatelet medications (both medications prevent blood from clotting). R1's care plan dated 5/8/25 directed two staff to assist with transfers, using a mechanical lift. The care plan directed 1-2 staff to assist with bed mobility. R1's care plan directed staff to investigate any allegations of suspected abuse, neglect, or exploitation. R1's skin check assessment dated [DATE] lacked indication of bruising. On 5/11/25 at 5:12 a.m. a progress note indicated R1's right arm had fresh swelling and bruising, from armpit to just above her elbow. Swelling included entire length of arm. R1 denied an injury, and stated she could not recall if her arm had been injured. On 5/11/25 at 12:20 p.m. a progress note indicated R1 had a large bruise of her right upper arm with swelling from shoulder throughout arm, hand, and fingertips. R1 was unable to raise her right arm. Bruise of lateral side of right breast outlined, and R1 reported subtle pain of area only when palpated. Surface over front of shoulder was hard and raised. R1 reported tenderness to site when palpated. The on-call nurse was informed. Bruise measured 15.1 centimeters (cm) x 18.8 cm. On-call provider notified. On 5/12/25 at 10:14 a.m. a progress note indicated R1 had extensive dark bruising on her right breast, and right arm from elbow to shoulder. R1's upper chest/collarbone on the right side were not bruised, but very swollen and firm. R1 denied injury of any kind. Provider updated and ordered R1 be sent to the emergency room. On 5/13/25 at 9:30 a.m. a progress note indicated R1 reported to the hospital the cause of her injury was a fall on Thursday (5/8/25) and a transfer on Friday (5/9/25) that went bad, and she also asked staff if the devil did this to her. R1 did not have dementia and experienced forgetfulness and confusion at baseline. On 5/15/25 at 12:03 p.m. R1 stated, The hospital told me I got beat up, but she was unable to identify whom may have hurt her. R1 then denied anyone hurt her, denied any falls, and stated she just woke up with the bruises to her right arm. During an observation on 5/15/25 at 12:05 p.m. R1's right upper arm had discoloration extending from the armpit throughout the lower arm and hand on the medial (side closest to the body) side, which ranged in color from dark to light purple, with some shades of yellowish green. On 5/15/25 at 1:05 p.m. registered nurse (RN)-A stated R1's bruising was first noticed on 5/11/25 at 5:00 a.m., but not reported to the SA until 5/12/25. She first saw R1's bruise on 5/12/25. Most of the bruise was a deep dark purple at that time. The injury was reported to the nurse on-call on 5/11/25. The injury should have been reported to the SA within one hour. On 5/15/25 at 1:26 p.m. trained medication aide (TMA)-A stated he notified the on-call nurse of R1's bruise on 5/11/25 around 11:00 a.m. On 5/15/25 at 1:38 p.m. licensed practical nurse (LPN)-A stated TMA-A notified the on-call nurse of R1's bruise on 5/11/25. The policy was to notify the on-call nurse right away, and follow directions when there was a new bruise or injury. On 5/15/25 at 1:57 p.m. LPN-B stated she was the on-call nurse on 5/11/25. She was informed of R1's bruise by TMA-A on 5/11/25 at 11:55 a.m. She did not remember if she instructed TMA-A to inform the director of nursing (DON) of R1's bruise. The policy was to notify the administrator, DON, provider, and family when there was a injury of unknown source. The SA was to be notified within 24 hours. On 5/15/25 at 2:32 p.m. the administrator stated she was informed of R1's bruise on the morning of 5/12/25. The administrator stated she filed the report with the SA on 5/12/25. The administrator stated immediate education was provided to staff to report injuries of unknown origin immediately. The facility Abuse Prevention Plan dated 7/22 identified an injury should be classified as an injury of unknown source when both of the following criteria are met: 1) The source of the injury was not observed by any person or the source of the injury could not be explained; and 2) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time of the incidence of injuries over time. The policy directed if the event that caused the suspicion involves abuse or results in serious bodily injury, the individual is required to report the suspicion to the state immediately, but not later than 2 hours, after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report to the state no later than 24 hours after form the suspicion.

Based on observation, interview, and record review the facility failed to ensure proper glove use and hand hygiene was performed during incontinence care for 1 of 4 (R3) residents reviewed for incontinence care. Findings include: R3's care plan revised 11/1/23 indicated R3 needed total assistance with personal hygiene. On 12/19/23 at 1:06 p.m., trained medication aide (TMA)-A and nursing assistant (NA)-A were observed sanitizing hands and placing gloves on at R3's bedside. TMA-A opened R3's soiled incontinent brief and cleansed R3's peri-area. TMA-A turned R3 and NA-A cleansed R3's buttocks. N-A then removed R3's soiled incontinent brief. NA-A removed her soiled gloves, and without completing had hygiene, donned clean gloves. NA-A then placed a clean incontinent brief under R3. TMA-A and NA-A removed their gloves and did not perform hand hygiene. NA-A turned R3 on her left side, and TMA-A placed a pillow under R3's under left arm, and under legs and neck. R3 was covered with a sheet and NA-A placed the call light under R3's left hand. At 1:17 p.m., TMA-A was observed leaving R3's room without completing hand hygiene. TMA-A went to the medication cart, drank out of a bottle which was on the medication cart, and dispensed medications without completing hand hygiene. TMA-A entered a room and gave a resident medications. TMA-A left the room and sanitized her hands. At 1:29 p.m., TMA-A stated, I sanitize my hand after taking off my gloves every time. On 12/19/23 at 1:47 p.m., NA-A stated, I do hand hygiene when I take my gloves off. On 12/20/23 at 10:01 a.m., with gloved hands, TMA-B and NA-B removed the straps on R3's incontinent brief. TMA-B cleansed R3's peri- area. NA-B turned R3 to her left side, and TMA-B cleansed R3's buttocks. TMA-B removed R3's soiled incontinent brief. TMA-B removed her soiled gloves, and without performing hand hygiene, donned clean gloves. TMA-B placed a clean incontinent brief on R3, removed her gloves and washed her hands. TMA-B stated, Normally I would hand sanitize or use soap and water before putting new gloves on. NA-B stated, I should have sanitized my hands but did not see hand sanitizer. Every time I remove my gloves, I should sanitize my hands. On 12/20/23 at 2:39 p.m., licensed practical nurse (LPN)-A stated if a staff member removed their soiled gloves, they should be doing hand hygiene before applying clean gloves or doing any other tasks. On 12/20/23 at 3:40 p.m., the administrator stated staff were expected to do hand hygiene whenever they were taking off their gloves. The facility policy Hand Hygiene dated 6/2017 directed hand hygiene should be performed before and after direct resident contact, before and after assisting with personal cares, and after removing gloves.

Based on interview and document review, the facility failed to conduct ongoing surveillance for the infection control program to ensure tracking and trending of infections and illnesses in the facility. This deficient practice had the potential to affect all 87 residents currently residing in the facility. Findings include: A line list regarding resident infection and symptom surveillance was requested from 9/1/23 through 10/18/23, but was not provided. During an interview on 10/19/23 at 10:14 a.m., infection preventionist (IP) stated the only thing the IP kept track of were the residents on antibiotics. IP did not keep track signs and symptoms of infection, labs completed. The IP did not keep track of staff or residents that had symptoms of illnesses to look at trending or symptom analysis to prevent a potential outbreak. The IP relied on the nurses to let her know when more people were getting sick and if an outbreak occurred. During an interview on 10/19/23 at 11:12 a.m., registered nurse (RN)-B stated they kept track of antibiotics to make sure labs were tracked. They did not keep track of illness trends or infection trends to prevent an outbreak, the IP was suppose to do that. During an interview on 10/19/23, at 1:45 p.m., director of nursing stated the IP was responsible to keep track of all infections and symptoms for trending and analysis to prevent possible outbreaks before they occurred. The facility policy Surveillance dated 6/17, identified infection control included ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks, to reduce morbidity and mortality and to improve resident health status. It is a necessary component of effective infection prevention and control in any healthcare setting.

Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R30, R49, R71, R73) reviewed for immunizations. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of diabetes mellitus and hyperlipidemia. R30's undated immunization record, identified R30 received pneumococcal polysaccharide (PPSV23) on 5/18/07, and the pneumococcal conjugate vaccine (PCV13) on 10/13/00. R30's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R30 or 30's representative. R49's quarterly MDS dated [DATE], identified a diagnosis of dementia. R49's undated immunization record, identified R49 received the PPSV23 on 1/10/17 and the PCV13 on 5/4/19. R49's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R49 or R49's representative. R71's quarterly MDS dated [DATE], identified diagnoses of dementia and diabetes. R71's undated immunization record, identified R71 received PPSV23 on 12/19/03. R71's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R71 or R71's representative. R73's quarterly MDS dated [DATE], identified diagnoses of dementia and diabetes. R73's undated immunization record, identified R18 received PPSV23 on 6/14/17. R73's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R73 or R73's representative. During an interview on 10/19/23 at 10:18 a.m., infection preventionist (IP) stated she just began to talk with the medical director about the new PCV20 immunization and had not started to immunize residents. During an interview on 10/19/23, at 1:18 p.m., corporate registered nurse stated all facilities were given clearance and should have began offering the PCV20 vaccine. During an interview on 10/19/23 at 1:24 p.m., director of nursing (DON) stated the IP was responsible for verifying all residents were up to date with their vaccinations, which include the PCV20. The facility policy Pneumococcal Vaccine for Residents dated 3/18/22, identified PCV20 pneumococcal vaccines would be offered to each resident according to the current recommendations from the CDC. The CDC guidance dated 2/9/23, identified, adults 65 and older have the option to get PCV20.

Based on observation, interview and document review, the facility failed to ensure timely repositioning was offered for 1 of 6 residents (R74) reviewed for pressure ulcers. Findings include: R74's quarterly Minimum Data Set (MDS) dated [DATE], identified R74 had severe cognitive impairment and required moderate to maximum assist with activities of daily living (ADLs). Diagnoses included congestive heart failure, kidney disease, diabetes, and venous insufficiency. R74 had one stage three pressure ulcer (full thickness loss of skin) and and was at risk for further development of pressure ulcers. R74 was dependent on staff to roll side to side in bed. R74's care plan dated 9/5/23, identified R74 was at risk for alteration in skin status. Interventions included a turning and repositioning program to turn side to side and change positions every two to three hours. On 10/17/23 at 12:00 p.m., R74 was assisted to eat her lunch by nursing assistant (NA)-A while lying in bed, on her back. The head of the bed was elevated and R74 was covered with a bright green blanket. R74 was still wearing a hospital gown and stated she did normally get up in her wheelchair but had not felt like it today. During continuous observation on 10/17/23, from 12:00 p.m. to 3:15 p.m. R74's position had not changed and she continued to lie on her back with the head of her bed elevated, intermittently watching television in her room or sleeping with her chin resting on her chest. Staff did not interact or offer to reposition R74 or enter R74's room during the three hours and fifteen minute continuous observation. On 10/17/23 at 3:15 p.m., surveyor intervened NA-A stated he and NA-B assisted R74 with incontinence care before lunch and had boosted her up in her bed; however, they had not positioned her on her side at that time. NA-A and trained medication assistant (TMA)-A assisted R74 to turn on her right side and assisted to change her incontinence brief, which was soiled due to a bowel movement. R74's back and buttocks were deep red in color with deep creases and wrinkles from the bed sheets visible. R74's coccyx was excoriated with multiple surface abrasions. TMA-A completed peri care and asked R74 if she would like to lie on her side, which R74 was agreeable to. She was easily positioned on her left side, with no complaints of discomfort. During observation of wound care treatment on 10/18/23 at 9:30 a.m., registered nurse (RN)-I changed R74's dressing to her coccyx. After removing R74's large adhesive butterfly dressing and cleaning peri area, R74's coccyx and buttocks were noted to be deep red in color with several small open areas and an excoriated appearance. RN-I stated it did appear to be more irritated and it was possible lying in the same position on her back the day before could have contributed to the increase redness and excoriated appearance. R74 was to be turned and repositioned every two hours. RN-I was not sure if that was indicated on R74's plan of care, but turning and repositioning every two hours was the usual practice for any residents who had pressure ulcers. He had noticed a decline with R74's wounds. R74 was seen by the wound clinic in September and she had another appointment with the wound clinic on 10/19/23. When interviewed on 10/19/23 at 1:30 p.m., director of nursing (DON) indicated she was informed R74 was not repositioned timely on 10/17/23. It was important to complete timely turning and repositioning to maintain skin integrity and to prevent further deterioration of her current pressure ulcer. The facility's undated policy Prevention and Treatment of Skin Breakdown identified maintenance of intact skin was integral to resident health and wellness. Care and services would be delivered to maintain skin integrity and promote skin healing if skin breakdown should occur. A resident centered care plan would be implemented for skin risk with interventions based upon areas of risk, resident assessment, Braden evaluation score of 15 or less, clinician assessment, and evaluation and resident preferences. If a resident was admitted with impaired skin integrity or a new pressure injury or wound developed, the licensed nurse would evaluate current pressure reduction interventions and revise the resident centered care plan.

Based on observation, interview and document review, the facility failed to provide a restorative range of motion program for 1 of 4 residents (R14) reviewed for range of motion and who was assessed as needing a range of motion program to promote mobility. Findings include: R14's significant change Minimum Data Set (MDS) dated [DATE], identified R14 had severe cognitive impairment. R14 required extensive assistance with activities of daily living (ADLs), was dependent on staff to transfer, and was unable to ambulate. R14's care plan dated 8/23/23, identified R14 required extensive assist of two for bed mobility, a ceiling lift was used for transfers and R14 was unable to ambulate. R14 was at risk for decline in her range of motion (ROM) related to diagnoses of hemiplegia (paralysis of one side of the body) and gait abnormality. A goal was identified to maintain or improve R14's ROM for three months. Interventions included to complete bilateral exercises two times per day, six days a week. Monitor and document participation in exercises and a quarterly review by a registered nurse. R14's Occupational therapy (OT) note dated 8/16/23, identified OT provided right upper extremity passive range of motion (PROM) to R14 and were unable to range R14's right elbow as it was in hyperextension. OT discussed a restorative program for PROM and R14 agreed. R14's Therapy Communication to Nursing Form dated 8/18/23, identified R14 was to be followed by restorative nursing to complete supine PROM exercises six time per week. R14's Physical Therapy Discharge Summary dated 8/22/23, identified skilled physical therapy (PT) services were provided with a focus to improve safety with functional mobility tasks and to setup up a restorative nursing program. R14 was discharged with a restorative nursing program established for bilateral lower extremity PROM. Prognosis to maintain her current level of function was good with strong family support and consistent staff follow through. OT Discharge Summary dated 9/21/23, identified a PROM to R14's right upper extremity had been established. Prognosis to maintain her current level of function was good with consistent staff follow through. On 10/16/23 at 6:40 p.m. R14 was seated in her wheelchair in the dining room. R14's right arm was lying limply, wedged tightly between her body and the wheelchair arm rest. R14 had no positioning devices, and no visible contractures were noted. On 10/17/23 at 9:30 a.m., nursing assistant (NA)-A was assisting R14 with her morning cares and transfer out of bed. After providing assistance with dressing, NA-A assisted R14 to her wheelchair using a ceiling lift. No PROM or ROM was provided to R14 during completion of morning cares. During interview on 10/18/23 at 1:50 p.m., registered nurse (RN)-I stated they added a restorative nursing program to R14's care plan after RN-I received a communication note from therapy to start ROM exercises in August. Review of restorative nursing flow sheets revealed no exercises had been documented as completed in the months of September or October for R14. R14's last quarterly review was 9/22/23, and RN-I would have reviewed the restorative aides documentation at that time, as well as have recorded how often R14 had completed her exercise program. RN-I thought maybe the restorative NA was having difficulty completing his documentation of exercises. During interview on 10/18/23 at 2:45 p.m., NA-E stated ROM exercises were not recorded for R14 because NA-E never assisted R14 with exercises. When NA-E came on shift R14 was always up in her wheelchair and she needed to be lying down to do the ordered ROM. NA-E received the Therapy Communication form for R14 on 8/18/23, but had not added her to his daily restorative schedule. NA-E notified RN-I several times that NA-E had not started R14's exercise program yet and RN-I was aware of this issue. NA-E always notified RN-I when NA-E was unable to see a resident for exercises. During interview on 10/19/23 at 1:30 p.m., director of nursing (DON) stated they identified R14 was not getting restorative nursing and her care planned exercises were not being done. DON was aware NA-E was not able to get to all of his assigned patients for restorative exercises and leadership was working to resolve the issue. Nursing assistants did not perform ROM exercise for residents during care, but that was something the DON was considering. The facility could be doing a better job at providing restorative nursing program to their residents. When it was assessed a resident needed assistance with ROM it was important it was provided to maintain the resident's current level of function and to avoid contractures and decline in condition. The facility policy Restorative Nursing Program dated 6/9/20, identified its purpose was to promote an optimal level of physical, mental, and psychosocial functioning in alignment with a resident's individual goals. The RN would document the individualized restorative nursing program including initiation of nursing assistant documentation and care plan problem, goals and approaches in the medical record. Associates administering the restorative interventions would be trained on the interventions assigned to them. An RN would provide oversight to the program to ensure the restorative interventions were being implemented as planned. The RN would document at minimum quarterly the program evaluation, including the progress, lack of progress and changes to the restorative care plan.

Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 4 residents (R7) reviewed for weight loss. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had no cognitive impairment, required setup and clean up assistance with eating, and did not have a weight loss of 5% or greater in the past month. R7's Mini-Nutritional assessment dated [DATE], identified R7 consumed a regular, heart healthy, low carbohydrate diet with fair intake of 50 to 75% of meals. A weight loss was identified of 2.2 to 6.6 pounds in the past three months. R7's weights varied greatly and would continue to monitor his weight and intakes per facility protocol. R7's care plan dated 9/27/23, identified R7 had a nutritional deficit related to R7's progressive weight loss and variable weight pattern. A goal for R7's nutrition was to have a stable weight pattern. Interventions identified R7 would like to use a select menu to choose his daily food choices and he would be provided three meals per day and snacks. On 10/17/23, at 4:00 p.m. R7 was seated in his wheel chair in his room, watching television with a bedside table in front of him. An unopened candy bar rested on the table. R7 stated he did not like the meals he was served at the facility. A couple of weeks ago, staff had told R7 they were going to give him a menu to make meal choices from, but they never did. R7 was served lasagna for his lunch and he did not eat it because he did not like it. R7 did not know what the alternative menu choice was that day but he was sure he would have liked it better than the lasagna he had been served. R7 identified he liked to eat hamburgers, hot dogs, bratwurst, cauliflower, and broccoli. R7 thought he would eat better if he received the food he liked. On 10/18/23, at 2:00 p.m. the dietary manager (DM) stated they were aware R7 was having weight loss. On the last progress note DM reviewed, R7 had lost 15 pounds. R7's meal intake ranged 25 to 50%. They tried a med pass supplement last week but it had been poorly accepted so they stopped it. DM personally talked with R7 about the menu and one time DM went in and tried to assist R7 to fill out R7's choices for the week. R7 completed one day of choices and would not complete more days. There was a weekly menu available to all residents when they requested it. Residents filled out their choices for the week and that was turned into dietary. It would be very difficult to provide a menu with choices daily, for residents. The facility did a weekly menu that was turned in on Sundays. R7's weights fluctuated and nursing was looking into determining the most accurate method to obtain R7's weight. R7's physician was notified of R7's progressive weight loss as well. R7's recorded weights from 6/20/23 to 10/16/23, identified the following: - 6/20/23, R7 weighed 242.6 pounds (lbs). - 7/24/23, R7 weighed 238.6 lbs, a 4 lbs wt loss. - 7/31/23, R7 weighed 229.6 lbs, another 9 lb wt loss in one week. A reweigh to verify the significant weight loss in one week was not recorded. - 8/21/23, R7 weighed 239.4 lbs. - 9/20/23, R7 weighed 223 lbs, a 16 lb wt loss in one month. - 9/25/23, R7 weighed 217 lbs, another 6 lb wt loss in one week. A reweigh to verify the significant weight loss in one week was not recorded. - 10/2/23, R7 weighed 206 lbs, a 11 lb wt loss in one week. A reweigh to verify the significant weight loss in one week was not recorded. - 10/9/23, R7 weighed 219.6 lbs, a gain of 10 lbs in one week and similar to his weight recorded on 9/25/23. A weight loss of twenty-three pounds was documented for R7 in a four month period of time. R7's Physician Progress Note dated 9/29/23, identified R7 was seen by his primary physician during rounds. The physician identified nursing identified a slight decrease in R7's weight and initiated a med pass supplement to address the weight loss earlier that week. R7's medical record was reviewed and lacked any evidence R7 had been comprehensively reassessed or evaluated for his continued weight loss. After refusing med pass there was no evidence care plan interventions were implemented or screening was implemented to help prevent or slow the continued weight loss. When interviewed on 10/18/23, at 7:30 a.m. cook (CK)-A stated she never saw menu preferences menus filled out for R7. CK-A was not sure if R7 just did not want to fill out selections but the kitchen never received a preference menu for R7. When interviewed on 10/18/23, at 10:20 a.m., nursing assistant (NA)-C stated she never asked a resident if they needed assistance to make meal preferences for their weekly meals. When interviewed on 10/18/23, at 11:55 a.m. NA-F stated she helped residents to fill out their menu choices if they asked, but it was usually family who helped the residents with their menu. NA-F thought it was dietary staff that passed out menus to each resident, as NA-F did not. During telephone interview on 10/19/23, at 1:00 p.m. registered dietician (RD)-A stated they were following R7 during their weekly weight tracking meetings. The nurse manager would know more about what was being done with the variable weights, in assuring accuracy of the weight. RD-A knew the dietary manager tried to assist R7 with making choices on a weekly menu but that did not work. R7 refused supplements. RD-A made the recommendation to get R7's provider involved to rule out a medical reason for R7's weight loss. They noted the variable weights and kept hoping the weight loss was not accurate and the next obtained weight would not indicate a loss. It would be an important first step to verify the accuracy of R7's weights as they varied so dramatically from week to week. When interviewed on 10/19/23, at 2:30 p.m. the director of nursing (DON) stated the facility had weekly weight tracking meetings and R7's weights were discussed weekly. The DON verified there was no consistent follow up being done to ensure interventions were implemented consistently. The facility policy Weight Monitoring and Documentation dated 8/19, indicated the facility must ensure a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that it was not possible. Each resident's weight would be monitored and fluctuations of 5% or greater in one month or 10% or greater in six months would be assessed and appropriate individualized dietary interventions and documentation would be implemented. Licensed nursing staff were to verify the accuracy if there were weight changes. Re-weighs were recommended for residents with a five pound or greater weight change.

Based on observation, interview and document review, the facility failed to respond in a timely manner to resident call lights to ensure activities of daily living (ADL)'s including personal cares and toileting was provided to maintain respect and dignity for 3 of 3 residents (R12, R9, and R7). Findings include: R12's quarterly minimum data set (MDS) assessment dated [DATE], indicated R12 was cognitively intact. R12 needs extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. R12 is always continent of bowel and bladder. R12 has anxiety disorder and mood affective disorder. R12's care plan reviewed/revised 5/24/23, indicated R12 was able to communicate needs. Continent of bowel and bladder but requires assistance of 1 staff related to impaired mobility and transfer assistance on and off toilet. R12 would be able to call for assistance with toileting needs. During an interview on 6/1/23 at 3:05 p.m., R12 stated I must wait for an hour and a half about every day. I had an accident in the evening the day before yesterday because I could not hold my bowels any longer. I have had to throw my underwear away because of the accidents. After telling the staff and going to resident council meeting talking about the call lights being an issue there has been no improvement in my case. I still must go in the hall and yell sometimes so someone will come before I have an accident. I am frustrated, I can't do it myself, but I wouldn't have accidents if someone would come and help me. I am up half the night worried who is going to come in and take care of be because they are so short staffed. I have become very depressed because the call light is not even worth using as no one comes for a very long time. R12's 14-day call light report titled; Resident Incident Details Report dated from 5/19/23-6/1/23 indicated the following: 12 times with call light was on over 30 minutes. 4 times with call light on over 45 minutes 5 times with call light on over one hour 5 times with call light on over one hour and half, and on 5/23/23 at 5:39 a.m., call light was on for duration of 2 hours and 14 minutes R9's quarterly MDS assessment dated [DATE], indicated R9 was moderately cognitively intact. R9 needed extensive assistance from staff with bed mobility, dressing, eating, toilet use, personal hygiene, and was totally dependent on staff for transfers. R9 was always incontinent of bowel and bladder. R9 has quadriplegia, unspecified progressive quadriparesis and anxiety disorder. R9's care plan reviewed/revised 4/17/23, indicated R9 was able to communicate needs. Activities of daily living functional status indicated functional incontinence related to muscular weakness. Staff would anticipate needs and toilet every 2 hours and as needed to help R9 remain free of skin breakdown and respect R9's dignity. R9 required extensive to total assistance of 1-2 staff with toileting needs. During an interview on 6/2/23 at 11:30 a.m., R9 stated I put my light on because I need to use the bathroom. I can make it without having an accident in my brief if someone comes but if they do not come and I must wait I will go in my brief. I wait a half hour at minimum. I get upset because it goes through my pants and then I must still sit in my urine and wait for someone to come. I send my soiled clothes home for my husband to wash, and it is embarrassing. It makes me feel depressed when I don't get out of my room for a walk with my husband because we are waiting for someone to come help me to the bathroom for so long that I then need to be changed due to having an accident. R9's 14-day call light report titled; Resident Incident Details Report dated from 5/19/23-6/1/23 indicated the following: 19 times with call light on over 30 minutes. 8 times with call light on over 45 minutes 10 times with call light on over one hour 2 times with call light on over one hour and half, and on 5/20/23 at 0:47 a.m., call light was on for duration of 1 hour and 46 minutes 5/24/23 at 11:44 a.m., call light was on for duration of 1 hour and 47 minutes 5/27/23 at 7:43 a.m., call light was on for duration of 1 hour and 47 minutes R7's quarterly MDS assessment dated [DATE], indicated R7 was cognitively intact. R7 needed extensive assistance from staff with bed mobility, dressing, toilet use, personal hygiene, and was totally dependent on staff for transfers. R7 was always occasionally incontinent of bowel and bladder. R7's care plan reviewed/revised 5/24/23, indicated R7 was able to communicate needs. Activities of daily living functional status indicated functional incontinence related to muscular weakness. R7 would verbally ask for assistance. R7 required extensive assistance of 1 staff and ceiling lift with toileting needs. R7's face sheet dated 6/2/23, indicated the following diagnoses: acquired absence of right leg below knee, acquired absence of left leg above knee, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder and major depressive disorder. During an interview on 6/1/23 at 12:05 p.m., R7 stated, I have had to wait for an hour and a half for someone to come. I have had accidents in my pants due to my call light not being answered just this week. I need help using the urinal or I will make a mess and it gets all over and I feel embarrassed. I am not a baby, but I have to go to the bathroom in my pants because no one comes when I call with my light. I am resident counsel president, and we talk about this all the time in our meetings, we have had administration present for the meetings, and they are aware of our concerns, but nothing has been done or said to us about how they are going to help fix the problem. R7's 14-day call light report titled; Resident Incident Details Report dated from 5/19/23-6/1/23 indicated the following: 5 times with call light was on over 30 minutes. 1 time with call light on over 45 minutes 3 times with call light on over one hour During the following 3rd floor observations: -on 6/1/23 at 12:26 p.m., the call light for room [number] had been on for 35 minutes. -6/1/23 at 12:33 p.m., the call light for room [number] had been on for 30 minutes. -6/1/23 at 2:16 p.m., the call light for room [number] had been on for 1 hour and 18 minutes. During an interview on 6/1/23 at 2:26 p.m., licensed practical nurse (LPN)- A stated 10-15 minutes is the longest we would want to see a call light on for. LPN-A was updated of the observed call light and verified room [number] call light had been on for a 1 hour and 28 minutes and is unacceptable. During the following call light observations on the 3rd floor: -6/2/23 at 6:56 a.m., room [number] had been on for 40 minutes. -6/2/23 at 11:44 a.m., room [number] had been on for 31 minutes. -6/2/23 at 11:48 a.m., room [number] had been on for 33 minutes. During an interview on 6/1/23 at 2:20 p.m., R11 stated at times they must wait for 2 hours before staff answer the call light. R11 indicated the staff would tell R11 not to feel bad if R11 had to go to the bathroom in their pants. Staff has told R11 it is okay because staff cannot come in time because they are busy. On 6/1/23 at 3:27 p.m., nursing assistant (NA)-A stated the longest they had seen a call light on for was an hour and a half. NA-A said it is hard when taking care of 7-8 people who need you all at once and you are the only one working the hallway. NA-A said some residents yell quite often about not getting to them in a timely manner. NA-A has had a few residents have bowel movements or have urinated on themselves a couple of times because staff could not get to them in time. On 6/1/23 at 5:38 p.m., LPN-B stated, I have had residents complain about waiting too long to go to the bathroom and then having an accident and needing to be cleaned up, some of them feel humiliated. On 6/1/23 at 5:49 p.m., trained medication assistant (TMA)-A stated, I have had continent residents have the call light on and tell me they had an accident before I could get to them a handful of times a week. Some of the residents get upset and cry because they were incontinent. On 6/1/23 at 5:58 p.m., NA-B stated, residents that are continent have an accident at least once a week due to the call light not being answered fast enough. During an interview on 6/2/23 at 11:54 a.m., family member (F)-A stated, This last Sunday when I got here the call light read it was going off for 1 hour and 40 minutes. When I went into her room there was urine and brown liquid all over the floor around R9's wheelchair. Once someone came in, they threw a pad on her wheelchair cushion and said they would wash it later. I have been here when R9 has had to wait up to 3 hours for someone to help her to the bathroom. We started going to resident council meetings and facility staff stated to call the nurses station if your call light does not get answered. We have contacted the ombudsman and they don't even get responses back from the facility. On 6/2/23 at 11:28 a.m., the ADON stated a call light should be answered within 3-5 minutes. We have staff that are of color and some of our residents refuse to let people of color care for them so they will wait and have accidents. We have had residents who need two staff to assist them with toileting and at the time the resident needs to use the bathroom we only have one staff member available so sometimes those residents will have accidents. On 6/2/23 at 2:44 p.m., the administrator stated a call light could be on up to 30 minutes, but the light needs to be answered as soon as possible. We have residents who do not like to work with specific staff so those call lights might be on longer, but it is expected as soon as staff are able the call light needs to be answered. Residents have brought to my attention about the call light wait times. The administrator verified there is an issue with call light wait times and has updated a few residents what the facility is working on to improve call light wait times. A facility policy titled Activities of Daily Living (ADL) dated 6/2021, indicated residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication, and mobility. A facility policy for call lights was requested not received.

Based on interview and document review, the facility failed to follow care plan interventions of tilting wheelchair when not eating or in activities to prevent a fall for 1 of 3 residents (R1) reviewed for accidents. This practice resulted in harm when R1 was left unattended sitting upright in her wheelchair resulting in a fall, R1 sustained a injury to her forehead and required sutures as a result of the fall. Finding Include: R1's Face Sheet printed [DATE], indicated R1's diagnoses included cerebral atherosclerosis, [CONDITION(S)] with behavioral disturbances and peripheral vascular disease. R1's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had severe cognitive impairment and required extensive assistance of staff for all activities of daily living (ADLs). R1's care plan dated [DATE], indicated R1 was at risk for falls. Interventions to prevent falls included tilt wheelchair when not eating or in an activity. R1's progress note dated [DATE], at 10:49 a.m. indicated R1 was found on the floor with a large laceration to the right forehead. Bleeding was difficult to control so R1 was sent to ER for sutures and evaluation. R1's progress note indicated R1 was at her normal baseline for her mental state and physical state prior to leaving for hospital. R1's progress note dated [DATE], at 12:43 p.m. indicated the facility investigation showed R1's wheelchair was left in the upright position when not at mealtime or activity. R1's progress note dated [DATE], at 10:08 a.m. indicated R1 had a significant change with TIA/Stroke like symptoms that included mumbled and slurred speech, unable to answer questions, pupils were pinpoint and unresponsive. There was an obvious left sided facial droop. R1's provider note dated [DATE] indicated R1 had acute onset of stroke-like symptoms, gazing to the right and murmuring on [DATE]. Provider notes indicated R1 was kept comfortable and was becoming less responsive. Further, Provider noted the neurological assessment indicated perceived left [CONDITION(S)]-paralysis of limbs on the left side of the body and left facial droop. During an interview on [DATE], at 11:02 a.m. registered nurse (RN)-B after the fall. RN-B stated R1 was at her normal baseline for mental and physical well-being, which included eating and drinking small amounts, talking short sentences, and always asking to go to the bathroom. RN-B stated he saw R1 on [DATE], and R1 remained at baseline. RN-B said R1 had a large bump over the right eye but R1 denied having a headache and pupils were equal. RN-B stated he was notified on [DATE], R1 had a change of condition. RN-B stated when he arrived, R1 was in bed with a right deviated gaze and left sided weakness. RN-B stated those were signs of a possible stroke or other neurological condition. RN-B stated he felt the possible stroke could be related to the recent fall with head injury due to the timing of the fall related to the change of condition. During an interview on [DATE], at 1:31 p.m. nurse assistant (NA)-A stated staff had group sheets and care plans to review prior to providing resident care. NA-A stated [DATE] was on her second day working. NA-A had a mentor working with her and remembered going over the care sheets for the residents they were assigned, However, R1 was not on their assignment. NA-A stated the director of nursing (DON) asked her to assist R1 with eating on a different hallway that morning. NA-A stated when she entered R1's room to assist her R1's wheelchair was in the upright position and the meal tray was in front of her. NA-A stated when R1 was finished eating, NA-A left R1 her in the upright position and left the room. NA-A stated she had not checked the group sheets or ask other staff about R1 before assisting her. NA-A stated she was unsure who sat R1 in the upright position prior to her entering the room. During an interview on [DATE], at 1:40 p.m. nurse practitioner (NP)-C stated she saw R1 on [DATE], and R1 was currently at her baseline. NP-C stated she saw R1 on [DATE] and R1 had a left facial droop, slurred speech, and eye deviation. NP-C stated R1 was showing signs of somebody who had a possible significant stroke. NP-C said the fall could have contributed to the severe stroke-like symptoms on [DATE], and to R1's death on [DATE]. During an interview on [DATE], at 2:06 p.m. RN-A stated she was responsible for keeping the group sheets up to date anytime there was a change, a new group sheet was printed and distributed. RN-A stated she entered R1's room when notified and witnessed R1 on the floor. RN-A stated other than lots of blood, R1 was at her baseline. RN-A completed the investigation after the fall. RN-A stated R1's wheelchair was supposed to be leaned back when not eating or in an activity. R1 was a high fall risk because R1 had enough torso strength to lean forward while in her wheel chair. RN-A stated the wheelchair, in the upright position, would have contributed to her falling out of the wheelchair. RN-A stated the expectation was nursing assistants would carry and check group sheets prior to working with any residents. During an interview on [DATE], at 8:32 a.m. DON stated he had asked NA-A to assist R1 with her meal. DON stated he did not see NA-A look at group sheets that included R1 or ask staff about R1's conditions and treatment information. DON stated he had not told NA-A anything about R1 nor remind NA-A to check the group sheets, but he should have. DON stated the expectation was all staff looked at care sheets prior to working with residents. The DON stated if there were time constraints then staff pulled to other units should at least talk with other staff on the unit to find out about resident needs prior to providing care. Facility policy Comprehensive Assessments and Care planning last revised [DATE], indicated care plan interventions may be communicated through electronic health record, resident profile, assignment sheets, and/or verbal communication. The policy lacked any discussion about assignment/group sheets and how/when to utilize them.

Based on interview and document review, the facility failed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to ensure weekly skin assessments were conducted on R1, who repeatedly declined weekly full body bathing. Subsequently, R1 was hospitalized after R1 was assessed to have a new wound to his left lower leg (ankle to calf). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and he lacked rejection of care behaviors. In addition, the MDS indicated R1 did not participate in bathing during the seven day assessment period and he was independent with lower body dressing with setup. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 required surgical wound care with applications of wound dressings to his feet. A review of R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed to apply from toes to knees when up. R1's associated treatment administration record (TAR) directed staff to apply in the morning and remove at hour of sleep (HS). A review of R1's TAR dated 8/3/22 through 9/27/22, identified per staff documentation R1 utilized his tubi-grips during the day and they were off at HS on all days with the exception of 8/14/22 and 9/20/22. The Reasons/Comments section on 8/14/22 identified the tubi-grips were not administered at HS in which no reason was identified and the dedicated area for staff signature on 9/20/22 at HS remained blank. In addition, R1's TAR identified he was scheduled for weekly weights, vitals, and skin observations [on his bath day] every Tuesday and designated the following dates (Tuesdays): 8/9/22, 8/16/22, 8/23/22, 8/30/22, 9/6/22, 9/13/22, 9/20/22, and 9/27/22. The Reasons/Comments section on 9/6/22 indicated unable to complete and 9/20/22's date remained blank. In addition, 9/27/22 identified R1 was at the ER. A review of R1's medical records identified the following information: -On 8/9/22: the medical record lacked documentation R1 was provided or declined bathing or that R1's skin was assessed. -On 8/16/22: a progress note identified R1 declined bathing. The note lacked documentation to identify the declined reason or that R1's skin was assessed. -On 8/23/22: the medical record lacked documentation R1 was provided or declined bathing or that R1's skin was assessed. -On 9/6/22: the medical record lacked documentation which identified the reason R1 was unable to have bathing completed or that R1's skin was assessed. -On 9/13/22: the medical record lacked documentation R1 was provided or declined bathing; however, a progress note dated 9/14/22, identified R1 was assisted with bathing on 9/13/22 and no skin issues were reported. The note lacked documentation a skin assessment was completed on 9/14/22. -On 9/15/22: a progress note identified R1 was a rather independent, private man and [liked] to do most cares for himself. There was a concern R1 was unable to perform his daily cares adequately/thoroughly. In addition, R1 was resistive to cares not necessarily behaviorally but rather because he wanted to maintain his independence. R1 was very resistive to showering; however, he agreed to bathing that week with much encouragement. R1's wheelchair cushion presented with a strong odor and suggested his self-performed cares were not as thorough as [they] should be. An occupational therapy (OT) referral was initiated to determine R1's self-care abilities and to provide staff with suggestions for successful interventions to assist R1 with his cares. -On 9/20/22, at 12:35 p.m. a progress note identified R1 completed an evaluation with OT in which OT would work with R1 on self-cares starting 9/21/22. -On 9/20/22: a progress note identified R1 declined bathing and indicated he would be working with therapy the following day in relation to independent showers. The note lacked documentation R1's skin was assessed. R1's OT Evaluation and Plan of Treatment, dated 9/20/22, indicated R1 was independent with functional cognition, showed modified independence with decision making ability for routine activities and his safety awareness was intact; however, a section labeled Complexities identified R1 lacked capacity for chronic disease management and insight into conditions and risk factors. During the evaluation, R1 refused the shower/bathe assessment process. The evaluation identified R1 was independent with lower body dressing; however, lacked documentation specific to OT's assessment of R1's ability to manage/maintain tubi-grips or stockings or any observed status of these items. The section labeled Summary of Daily Skilled Services identified OT spoke to the nurse manager in which R1 was felt to be taking care of himself properly and that up until last week R1 refused to take a shower. In addition, R1's room still had an odor despite his mattress and wheelchair cushion being changed out and his room and equipment being sanitized/cleaned. R1's OT Treatment Encounter Note, dated 9/21/22, identified R1 was observed by OT to perform hygiene cares to his face, neck, underarms, and peri area while at sink-side. In addition, OT observed R1 doff his pajama pants and donned a clean pair of underwear and pair of pants. During the session, R1 was provided with a clean pair of grippy socks for R1 to change into as his grippy socks at that time were visibly dirty; however, the note lacked documentation R1 was observed for donning/doffing the grippy socks. In addition, the note lacked documentation R1 was assessed for showering. The note identified R1 was physically able to complete all cares and dressing without OT assistance and OT recommended the following: twice a week showering if R1 agreed with a potential bathing time change, daily foot soak/cleaning as R1 reported he wore the same grippy socks for some time, review R1's clothing to see if he had enough for him to change them more frequently, change bedding more frequently than once a week, change tubi-grip daily and wash alternate pairs, and if available alternate seating in room so R1 was not seated on the same surface all day. OT also questioned depression in her recommendation as R1 spoke of his long wait for insurance and his desire to more to an assisted living facility. The note lacked documentation the OT staff conversed with R1 or nursing staff related to her recommendations or to any potential reason as to why R1 declined weekly bathing. R1's Care Plan last reviewed/revised on 9/21/22, identified R1 participated in his care decisions; however, his sister assisted in making major medical .decisions and that R1 displayed a self-care deficit for activities of daily living in which R1 required assist of one staff for bathing and toileting needs and to help him remain free from skin breakdown. R1's care plan lacked information R1 repeatedly declined weekly bathing, interventions to decrease the risk of R1's bathing declines, R1's order for tubi-grips, and OT's 9/21/22 recommendations. R1's Woodland Way: Group 6 nursing assistant information group sheet directed R1's tubi-grips were to be on in the morning and off in the evening. In addition, the group sheet directed one staff to assist R1 with his ADLs. From 9/13/22 through 9/26/22, R1's medical record identified R1 went 13 days without evidence that R1 participated in full body bathing or that R1 received a full body skin observation after his 9/13/22 shower. In addition, R1's medical record lacked documentation R1's family (sister) was updated or involved with R1's weekly bathing concerns. From 9/21/22 through 9/26/22, R1's medical record lacked evidence OT's recommendations related to R1 were addressed or that staff followed-up to ensure R1 received a shower during his therapy session. On 9/27/22: a progress note identified R1 had a skin observation completed after staff observed drainage on R1's tubi-grip and smelt a strong odor. R1 was found to have a new wound on his left lower extremity (back calf) region and subsequently was sent to the emergency room for evaluation. In addition, the progress note identified R1 received a bath every Tuesday evening in which the last skin observation did not reveal this area was present and that R1 had chronic bilateral lower extremity [CONDITION(S)] (left greater then right) in which he wore tubi-grips and grippy socks. R1's Emergency Department (ED) Provider Note, dated 9/27/22, indicated R1 presented to the ED with a Wound: Foul smelling the left lower extremity with eschar (dead tissue) over it, discharge present, some slight [CONDITION(S)] (redness) in the periphery (outer edges). The note identified R1 reported the wound was present for the last two weeks, in which nursing staff had not looked at his left leg. R1 attributed the wound to his not eating for a couple weeks. R1 denied sensation to the area. An ED Addendum Note, dated 9/27/22 completed by a registered nurse, identified R1 present with significant 4+ (most severe type) swelling to his left lower extremity. R1's leg was wrapped in Kerlix (gauze dressing) upon his arrival which was removed without issues; however, once removed R1 was noted to have a compression stocking adhered (stuck) to the wound. R1 stated he noticed the wound approximately one to two weeks ago when it was a small red spot. A hospital Discharge Planning Assessment, dated 9/27/22, identified hospital staff contacted care center staff who reported R1 had self-decreased his outpatient wound care visits due to improvements of the left foot and right elbow wounds and presented with recent concerns R1 was not completing adequate ADLs independently. OT worked with him a couple times a week on this and recently R1 was noted to be malodorous. In addition, the assessment indicated R1 typically applied his own Tubi-grips and that his sister was a source of support for him. A Hospital Medicine Service progress note, dated 10/3/22, indicated R1 underwent wound debridement (procedure to remove infected/dead tissue) on 9/30/22 with findings of extensive necrotic (dying) tissue down to the fascia (tissue that encases the body and binds it together) and Achilles tendon (heel cord). Per the surgeon R1 did not appear to have enough of a posterior flap for a below-knee amputation and thus a decision was pending for either an above-knee amputation or extensive reconstruction. R1 initially required intravenous (IV) antibiotics for infection which were discontinued on 9/30/22 and oral antibiotics started as the majority of the infection was controlled with source control [debridement]. A Molnlycke Tubi-grip self-care guide, dated 2021, directed the tubi-grips should be work as instructed and replaced upon health care professional direction. A Skin and Wound Product Information Sheet for Tubi-grip (Lower Leg Application), adapted from Molnlycke product information, revised 9/22, directed the tubi-grips were to be removed daily to allow for skin checks and skin care in which the tubi-grip was to be hand washed daily in cold water and hung to dry. In addition, the sheet directed the tubi-grip was to be without wrinkles, creases, or pulled down/slouched around the ankles as improper placement may cause a tourniquet effect. Weekly bath sheets for R1 were requested. None were provided. When interviewed on 10/3/22, at 1:04 p.m. R1's family member (FM)-A stated he was unaware R1 often declined weekly bathing and he confirmed the facility had not talked to him related to R1's refusals. FM-A indicated R1 was very compliant and, If you tell him what to do he will do it .he does not like to push the envelope. During interview on 10/3/22, at 2:37 p.m. R1's FM-B stated she was unaware R1 declined or refused cares and she confirmed the facility had not talked with her related to R1's refusals. She indicated, [R1] would not do that. She stated R1 was a very private person and was not a person who would initiate communication with staff related to any concerns he may have. FM-B stated when she visited R1 approximately two weeks earlier, there was a very rank odor in R1's room. She questioned R1 on this to which R1 declined he smelt. FM-B denied she brought the smell concern to staff. FM- B explained she felt the facility dropped the ball and that the facility should have discovered R1's leg wound much sooner. When interviewed on 10/3/22, at 4:05 p.m. clinical manager licensed practical nurse (LPN)-A stated she expected any care refusals and any related follow-up were documented in the resident's progress notes, along with staff communicating to ensure a plan was formulated to decrease the risk of missed weekly bathing and skin checks. In addition, LPN-A stated she expected a weekly skin check to be completed, even if the resident declined bathing. LPN-A explained after bathing the skin check was written onto a bath sheet, which she kept for approximately a month, and a progress note was entered into the medical record. She denied an official skin check form was placed within the medical record. LPN-A stated tubi-grips were to be removed at HS and she expected staff to follow provider orders and the care plan (group sheets) in order to prevent adverse events from occurring, and if concerns were noted to update her. In addition, . LPN-A expressed R1 refused showers all the time and consistently for weeks at a time: R1 was a very private man who liked to do as much for himself as he could despite significant [physical] limitations. LPN-A acknowledged she was made fully aware of the degree R1 declined showers early/mid September and that on 9/13/22 staff were able to arrange for R1 to shower which was his first shower in weeks, and she initiated an OT referral. In addition, she stated she completed a head to toe skin check on R1 on 9/14/22 in which she removed the tubi-grips. No skin concerns were observed at that time. She acknowledged her documentation on 9/14/22 should have been more detailed. LPN-A stated she expected R1 would have received a skin check on 9/20/22 when he declined pending an OT session. Further, LPN-A stated she did not discuss R1 with OT after 9/20/22 and acknowledged she was made aware of the OT recommendations after R1 was admitted to the hospital. After reviewing R1's TAR, LPN-A verbalized R1's tubi-grips were signed off as removed at HS; however, commented, This did not appear as if it had been getting done. She explained when she was a floor nurse on 9/22/22, she signed off that R1's tubi-grips were off without visually observing they were removed. She made an assumption the aides did as the group sheet directed. She stated such an action was not acceptable and she acknowledged she and other staff failed to follow facility policy and procedures. LPN-A confirmed R1's medical record lacked documentation R1 received a shower and a full body skin check after his 9/13/22 shower. During interview on 10/3/22, at 4:29 p.m. LPN-B stated the facility expected residents to be bathed weekly in which a skin observation was completed, even if the resident declined the bathing. In addition, she was expected her documentation was accurate and if orders or tasks were not completed there should be a related progress note. She confirmed she worked on 9/13/22; however, was not present for R1's actual shower, but she was aware he agreed to shower after increased encouragement from staff and a plan to cover his feet with plastic bags. She explained she did not complete a skin check on 9/13/22 as she was informed OT would shower R1 the next day. In addition, she did not instruct staff to bathe R1 on 9/14/22 when she discovered OT did not shower him. LPN-B confirmed at times she observed R1's tubi-grips on when they were to be off; however, she was unsure if she reported this to LPN-A or that she followed-up with the nursing assistants to ensure they were following R1's plan of care. She explained if orders, the care plan, and procedures were not followed it could lead to problems: We could have sores .we could have [an incident like R1]. When interviewed on 10/3/22, at 4:50 p.m. OT-A stated she did not assist R1 with a shower on 9/21/22 nor did she remove R1's tubi-grip. She explained she understood nursing assisted R1 with the tubi-grips and felt that was not a concern OT needed to address. She stated the tubi-grips looked dirty and R1 declined to change them. OT-A indicated she left new tubi-grip with R1 at the end of the session and she was not concerned he would have issues putting on as he was able to demonstrate no concerns putting his pant on over his feet. She denied she followed up with R1 to ensure he applied the new tubi-grips. OT-A denied she worked with R1 after the 9/21/22 session; however, she indicated she emailed her recommendations for R1 to the group, which included LPN-A. She expected her recommendations to be followed, but she did not follow up to ensure her recommendations were addressed as the therapy director and nursing staff met weekly to discuss residents and she assumed recommendations were discussed at that meeting. On 10/4/22, at 9:26 a.m. R1 was interviewed at the hospital. He stated he had showered a few times in the past couple months; however, he bathed himself a couple times a week at the sink in his room. R1 verbalized staff had not communicated with him any concerns related to his bathing practices or his tubi-grip use and he could not remember him ever declining to remove the tubi-grips. R1 stated he used the tubi-grip to help his swelling, which was present on 9/27/22. He declined he noticed a change in the swelling. He explained a couple weeks ago he noticed a red spot on the side of his foot. He did not think anything of it and did not update staff. He thought it would just go away. He lacked any ideas of what caused the wound and he denied direct injury to the area. He remembered it the day staff found the wound there and he indicated he experienced a twinge once in a while but then disappeared; other than that, he lacked any other indication to remind him there was a wound under his tubi-grip. R1 stated the red spot was present when staff showered him a couple weeks ago and was present about half a week prior to that. He explained both his feet were covered with bags so no one really saw it. R1 stated staff did not remove his tubi-grips and the only skin check he remembered right after that shower was to his exposed skin, not his feet, and he felt the tubi-grip they removed at the hospital had been in place about two weeks prior to staff finding the wound. R1 stated what will be will be when asked how he felt about the possibility of a left leg amputation. During interview on 10/4/22, at 11:29 a.m. trained medication aide (TMA)-A stated if a resident declined/refused the weekly expected bathing then the bath sheet would indicate the refusal and the floor nurse and the nurse manager were to be updated. In addition, staff were expected to ensure a head to toe skin check was still completed if they declined bathing and staff were to follow up with the resident to determine the reason for them declining and if re-approach was ineffective, a progress note would be entered into the residents medical record indicating the declined event. TMA-A stated she was expected to follow provider orders and resident group sheets in order to decrease residents risks which included new skin issues. Further, she was expected to visually ensure tubi-grips were on or off if an order was present before she signed the order as complete. She stated depending on how tight the tubi-grip is it could cause swelling and discomfort. She acknowledged she had witnessed R1 go to bed at times with the tubi-grips on due to his refusal for them to be removed. She explained in those situations she would expect the event to be documented; however, declined she did this. She confirmed she worked with R1 on 9/24/22 and acknowledged she documented on R1's TAR his tubi-grips were off despite the fact she did not visually confirm. She explained she assumed the nursing assistant would remove them when R1 went to bed. She stated this was a concern and one which may be a reason R1 was found to have a wound. She stated if she would have ensured the tubi-grips were off she may have noticed his leg concerns that evening. On 10/4/22, at 1:58 p.m. a subsequent interview with LPN-A was conducted. She stated if a bathing event and associated skin condition were not documented in the progress notes they did not occur. LPN-A explained it was standard of practice for tubi-grips to be on during the day and off at night. Associated concerns if they were to remain on for an extended period of time [weeks] included [MEDICATION(S)] and decreased circulation as the natural process for circulation would be disrupted. During interview on 10/4/22, at 2:14 p.m. the wound care registered nurse (RN)-A stated he expected residents to be bathed weekly and a skin check completed in which, depending on the resident and their medical condition, risk factors associated with either of these being missed would fluctuate. In addition, RN-A expected provider orders and group sheets were followed in order to provide assessed resident needs and cares. If a resident were to decline tubi-grip removal, he expected staff to re-approach and educate the resident. If the resident were able to remove them independently, he expected staff to follow-up with the resident to ensure the order was followed. RN-A stated he lacked knowledge on manufacture standards for tubi-grip use and explained he followed the provider order and/or OT recommendations for use. RN-A stated any potential risks with tubi-grips that remained on for extended periods of time depended on a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A acknowledged he provided R1 with right foot wound care but he always noted gripper socks on R1's left leg so never observed the state of R1's tubi-grip on that side. In addition, he stated he had noted an odor during wound care; however, he attributed it to R1's right foot wound. When interviewed on 10/4/22, at 2:33 p.m. nursing assistant (NA)-A stated R1 for the most part declined weekly bathing but R1 agreed to a shower on 9/13/22 in which she placed plastic over his feet so the tubi-grip and his grippy socks remained dry. NA-A acknowledged she was expected to follow the group sheets and confirmed tubi-grip directions were placed on the group sheets. She confirmed she had assisted R1 with evening cares that night and prior; however, she identified she had never removed his tubi-grips. She stated she was unaware R1's group sheet directed staff to remove these. During interview on 10/4/22, at 2:49 p.m. TMA-B stated the facility expected residents to be bathed twice a week in which it was expected the nurse lays eyes on their skin and group sheets were to be followed. In addition, she confirmed she was expected to follow provider orders and perform accurate documentation. She identified not following tubi-grip orders could lead to constricted blood flow to the applicable limb as their purpose was to assist with compression. If she were to see them on at HS, she would remove them or direct the nursing assistants to. TMA-B stated R1 never declined bathing assist or tubi-grip removal from her. She acknowledged R1's 9/23/22 tubi-grip documentation which indicated the tubi-grips were removed that evening was her. TMA-B stated she charted that evening R1's tubi-grips were removed as she thought it would get done. She stated it was a facility policy to make sure they were taken off: I did not meet that expectation. When interviewed on 10/4/22, at 3:11 p.m. the director of nursing (DON) stated he expected provider orders to be followed, that staff were accountable for their documentation, resident care/treatment refusals were documented in the medical record, group sheets were followed, residents were bathed weekly and if they declined all avenues were to be pursed to encourage compliance, weekly skin checks were completed no matter if the resident declined the bathing or not, and therapy recommendations were reviewed and follow-ed up on. He explained risk associated with not following orders, approaches and/or care planned interventions, along with therapy recommendations, could lead all the way to resident death and R1 was an example of what could happen. The DON identified there was a lack of communication between therapy and nursing related to R1 and R1's therapy recommendations should have been care planed or interventions modified and/or placed on the group sheets. He acknowledged concerns with tubi-grips remaining on residents for extended periods of time as there could be concealment of a wound under them. The DON reviewed IDT notes from the month of September and confirmed the only conversation that occurred for R1 was on 9/29/22 when they discussed his hospitalization . The DON acknowledged the facility had processes in place; however, staff failed to follow them. A policy titled Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy directed a residents skin was to be observed daily with cares, and assessed weekly by a licensed nurse. In addition, those residents with increased risk for impaired skin integrity were provided preventative measures, care, and services to maintain skin integrity and prevent potential skin breakdown. A policy titled Charting and Documentation in the Medical Record, dated 2/19, identified the purpose to ensure a clinically complete medical record. The policy directed an event involving the resident was to be documented in the medical record, which included incidents where the resident refused procedures/treatments. Additionally, the policy directed staff were to document education regarding risk/benefits and the residents response when a refusal occurred. A policy titled Activities of Daily Living (ADL), dated 6/21, identified residents were to receive the services necessary to maintain .personal hygiene. The policy directed if a resident refused cares staff were to approach at a different time or have another staff member speak with the resident as needed. In addition, interventions to improved and/or minimize a resident's abilities was to be in accordance with their assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to the interventions was then to be documented, monitored, evaluated and revised as appropriate.

Based on interview and document review, the facility failed to ensure 1 of 1 residents (R1) was free from abuse when nursing assitant (NA)-A called R1 lazy and gestured his fists at R1 in a threatening manner. The IJ began on 5/26/22, at approximately 5:00 a.m. when indicated nursing assistant (NA)-A was assisting R1 to boost in bed. R1 was uncooperative and NA-A called R1 lazy. R1 responded loudly that he was not lazy, and shook his fist at NA-A. NA-A subsequently raised and shook his fist at R1 and yelled back at him. No actual physical contact was made other than appropriate boost in bed with NA-B assisting. The administrator and the director of nursing (DON) were informed of the IJ on 6/1/22, at 2:15 p.m. The facility had implemented corrective action to prevent recurrence by 5/26/22, therefore, F600 is being issued at past non-compliance. Findings include: R1's Face Sheet, undated and printed 6/1/22, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 3/9/22, indicated R1 was vulnerable to abuse from others and needed assistance to remain safe in the facility. R1's vulnerabilities included weakness, depression, mild cognitive impairment, intellectual disabilities and physical needs. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's was mildly cognitively impaired and needed the extensive assistance of two staff with bed mobility. A Nursing Home Incident Report to the State Agency (SA) indicated on 5/26/22, at 7:35 a.m. NA-A was assisting R1 to boost in bed. R1 was uncooperative and NA-A called R1 lazy. R1 responded loudly that he was not lazy and shook his fist at NA-A. NA-A subsequently raised and shook his fist at R1 and yelled back at R1. No actual physical contact was made other than appropriate boost in bed with NA-B assisting. On 5/31/22, at 12:35 p.m. R1 was interviewed. R1 stated he did not know NA-A's name but remembered the situation. R1 stated NA-A called him lazy and told R1 he could do it himself (boost himself up in bed). R1 stated he got upset and was getting ready to tell NA-A to get out of his room. R1 stated NA-A did not touch him. R1 stated NA-A did not help him boost up in bed, just left the room. R1 stated NA-B helped him move up in the bed. R1 stated NA-A had called him lazy other times before, and this makes him feel bad. R1 stated NA-A was disrespectful, and it made him feel like he was not wanted. R1 stated he has not seen NA-A since the incident. R1 stated he feels safe in the facility. On 5/31/22, at 1:26 p.m. NA-A was interviewed. NA-A stated the incident with R1 occurred 5/26/22, at approximately 4:45-5:00 a.m. NA-A stated NA-B was in with R1, and he went into the room to help. NA-A stated his voice was raised a little because R1 was falling off the bed. NA-A stated he had worked with R1 for a year and a half, and R1 pretends he cannot do things. NA-A stated he told R1 now was not the time to be lazy. NA-A stated he was not mocking R1. NA-A stated R1 made a fist, and so he also made a fist, and moved his hand to the side to block if R1 tried to hit him. NA-A stated he had been assaulted by residents before. NA-A stated R1 then lowered his fist. Registered nurse (RN)-A came into the room, and NA-A stated he left the room. NA-A stated he went on to complete last rounds. NA-A stated he raised his voice and RN-A saw him with his hand by his side. NA-A stated he would not have hit R1, he was ready to block any punches R1 might make towards him. At 3:00 p.m. NA-A stated after he left R1's room, he gave a resident a shower, and no other staff assisted him. NA-A stated he was done with work at 6:40 a.m. On 5/31/22, at 1:51 p.m. the director of nursing (DON) was interviewed. The DON stated R1 could be difficult and was often resistive to cares. The DON stated NA-A called R1 lazy in a derogatory fashion. The DON stated when R1 put his fists up, NA-A put his fists up in the same manner. The DON stated he suspended NA-A that same day due to NA-A's verbal abuse toward R1. The DON stated he interviewed other residents to see if they had abuse concerns with NA-A, and none of them had. The DON stated no other staff had concerns with NA-A. On 5/31/22, at 3:04 p.m. RN-A was interviewed. RN-A stated the day of the incident, she heard a sound of someone yelling out. RN-A stated she investigated and went into R1's room. RN-A stated NA-A and N-B were in R1's room, and R1 was quiet. RN-A stated she felt R1 was not the one yelling out, and when she walked in the room everything was calm and quiet. RN-A stated she did tell NA-B that she wanted to talk with her before she left for the day. RN-A stated she did talk with NA-B, who told her R1 yelled at NA-A, and NA-A yelled back. NA-B also told her R1 showed his fists to NA-A, who showed a fist back to R1. RN-A stated she did not question NA-A about what happened and did not follow him with cares the rest of the morning or have anyone follow him with cares. RN-A stated she did report the incident to RN-B at about 7:00 a.m. On 5/31/22, at 2:12 p.m. NA-B was interviewed. NA-B stated she was in helping R1 boost up in bed. NA-B stated NA-A came into the room, and NA-A was upset. NA-A told R1 there were only two staff working, and R1 can't be lazy. NA-B stated R1 muttered, and NA-A started mocking him. NA-B stated R1 raised his fists, NA-A bent down toward R1, pulled his own arm back and had his hand in a fist like he was going to punch [R1] in the face. NA-B stated R1 told NA-A to leave the room twice, and NA-A told him no. NA-B stated RN-A heard the yelling and came in the room. NA-B stated she told NA-A she would finish with R1, he could leave. NA-A stated she is new (one month) and others think she's slow so they will come in to try to hurry thing s along. NA-B stated R1 was very upset, told NA-A he wanted to sue him and never wanted to see him again. On 6/1/22, at 8:51 a.m. RN-A further stated she asked NA-B what had happened but NA-A was still in R1's room and RN-A could not understand NA-B. RN-A stated she needed to talk to NA-B when she was alone and out of R1's room. RN-A got busy doing cares, answering call lights of which were non-stop and helped another resident in the bathroom. RN-A stated it was just the three of them at the time. RN-A was not sure who was yelling and wanted to make sure everything was okay and wanted NA-B to tell her what was going on. There were no signs of abuse when RN-A entered R1's room and R1 would normally tell her if something was wrong. Felt the residents would be safe with NA-A. as they know him and he is a regular staff. On 6/1/22, at 9:00 a.m. NA-B further stated she viewed the incident as abuse. RN-A asked her about the incident right after it happened but NA-B did not want to talk it because NA-A was present. NA-B waited until after her shift ended and NA-A had gone home. NA-B's shift ended at 6:00 a.m. On 6/1/22, at approximately 11:00 a.m. RN-B provided the sequence of text messages with RN-A. The text messages consisted of the following: On 5/26/22, at 7:31 a.m. RN-A sent a text message stating, I just want to tell you that NA-A told R1 last night that he was lazy because he wouldn't move to help boost himself (which R1 normally does when he's behavioral), that made R1 upset and yelled out once and showed his fist to NA-A. NA-A yelled back to R1 and showed his fist to him too. R1 was calm after that. It was witnessed by the other aid NA-B because she was also there doing the care with NA-A. It was uneventful but I just wanted to let you know. RN-B read the text message at 8:24 a.m. and responded back to RN-A, thank you. At 9:54 a.m. RN-B sent a text to RN-A stating the DON would be calling her, probable report as verbal abuse. On 6/1/22, at 11:50 a.m. the DON stated the incident occurred on 5/26/22, around 5:00 a.m. The DON reported it as soon as he became aware. The DON further stated needed to know immediately when incidents occur so he can ensure the safety of all residents. The facility's Abuse Prevention Plan dated 8/14/20, indicated the definition of abuse included the willful infliction of unreasonable confinement, intimidation or punishment of which resulted in physical harm, pain or mental anguish. This included verbal abuse. The past noncompliance IJ began on 5/26/22. The IJ was removed and the deficient practice corrected on 5/26/22, when NA-A was suspended after his shift was done. The facility conducted an investigation (no further incidents of abuse were found), and re-training was completed at a later time with NA-A retuerning back to work at the facility with a performance improvement plan. This was verified through interviews and document review.

Based on interview and document review, the facility failed to ensure a resident's medical provider was notified in a timely manner of a change in condition for 1 of 1 resident (R1) related to a change in vital signs, poor appetitie, insulin refusals and deterioraring respiratory status. The facility's failure resulted in actual harm for R1 whose treatment was delayed despite requiring an increase in oxygen from 2 liters (L) to 6 L since hospital discharge and an elevated temperature of 100.5 degrees. R1 required hospitalization related to a low oxygen saturation level of 54% even with the use of 6 L of oxygen. Findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's nurse's notes revealed the following: -Admission Note dated 12/17/20, at 9:40 p.m. indicated R1 was admitted to the facility for rehabilitation from the hospital where he had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated R1 was alert and orientated, but had some memory loss/forgetfulness. The note also indicated R1's lung sounds were somewhat diminished in bilateral bases and some crackles were noted to right lower lobe. R1 had shortness of breath with minimal exertion, was unable to tolerate lying in bed, and had reported he felt too short of breath even with head of bed elevated at 90 degrees. Further the note indicated R1 reported he preferred to sit/sleep in his recliner at night and wore continuous oxygen at 2 liters (L) via nasal cannula. The resident's oxygen saturation was identified as 92%. -Progress Note dated 12/18/20, at 10:54 a.m. indicated R1 had a temperature of 99.3 this AM (morning) with resident also de-sating (blood oxygen levels dropping) to 76-77% on 2 L of oxygen, with respirations at 24 per minute. The note also indicated the resident complained of mild congestion that started about 2 days ago and was complaining of feeling light headed while at rest in wheelchair. Resident also stated he felt more fatigued and weaker in comparison to yesterday. Resident had some conflicting reports; told therapy he was experiencing shortness of breathe (SOB) at night and did not get any adequate sleep and told writer that he had a good night of sleep and denied SOB. Lung sounds diminished. Binex swab was negative for Covid. The note indicated St. Luke's Community Care (SLCC) was updated and orders were obtained to check labs which included complete blood count (CBC) with differential, comprehensive metabolic panel (CMP- is a test that measures 14 different substances in your blood), B-type natriuretic peptide (BNP- blood test measures the levels of the BNP hormone in your blood which can indicate heart failure), daily weights are to be obtained every morning, chest x-ray and oxygen orders changed to state maintain oxygen [02] between 88-92%, document liter flow. The note further indicated R1's oxygen had been increased from 2 LPM to 5 LPM to get the oxygen saturations up to 88-89% . There was no documentation/order for the oxygen liter flow being bumped above 4 liters according to the nurse practitioner. -Progress Note dated 12/18/20, at 1:52 p.m. indicated, Chest X-ray came back with the following impression: Peripheral airspace opacities in both lungs are concerning for atypical infectious process such as COVID-19 pneumonia. The heart size and pulmonary vascularity appear stable. The right hemidiaphragm remains elevated. The lateral view is nondiagnostic. Results faxed to SLCC. Lab results still pending. Infection nurse and nurse manager updated. Copy of results placed in resident's chart. -Progress Note dated 12/18/20, at 5:22 p.m. indicated labs had been drawn and the tests that were elevated (high) included: BNP 196.0 with normal levels (0.0-100.0 K/ul); carbon [MEDICATION(S)] (C02) 38 with normal level (23-32 mmol/L); glucose 112 (60-99 mg/dL); blood urea nitrogen 27 (a test that reveals how well one's kidneys are working with normal levels 8-23 mg/dL); WBC 12.3 (a blood test to measure the number of white blood cells in the blood. WBC's help fight infections with normal level 4.0-10.0 K/uL) and Neutrophils 8.95 (a type of white blood cell that act as the immune system's first line of defense. Having a high percentage of neutrophils in the blood is a sign that a person's body has an infection with normal levels 1.56-6.13 K/uL). The noted further indicated Family member (FM)-A was updated, a copy of results were placed in resident's chart, the rounding nurse practitioner (NP) was updated, and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During further review of R1's medical record it was revealed the medical record lacked who the rounding NP was who provided the orders to repeat the labs on 12/21/20. There was also no record of the order as a telephone order or verbal order written in R1's medical record for re-checking the labs. In addition, the medical record lacked documentation from the rounding physician/NP of why other treatments were not initiated despite R1 having elevated white blood cell count at 12.3 with normal levels (3.8-10.6) and Neutrophil's 8.95 with normal levels (1.8-7.8) despite this being abnormal compared to the last labs obtained prior to discharge from the hospital the day prior, 12/17/20, when results of 9.4 for WBC and 6.1 Neutrophil's (both normal lab values) were identified. -Progress Note dated 12/18/20, at 9:59 p.m. indicated Resident is alert and orientated, can use call light and verbalize needs. Resident had no complaints of pain. Resident had complaints of increased SOB when getting ready for bed, oxygen saturation was at 87% on 5 L, Resident was situated into his recliner and told to take deep breathes through his nose, oxygen was turned up to 6 L and nurse observed him taking deep breaths, resident is now sating at 92% on 6 L. Resident's blood sugars were 169 and 110. -Admission Note dated 12/19/20, at 1:50 a.m. indicated Resident is able to make needs known, uses call light appropriately. Resident complains of SOB, oxygen on at 6 L, oxygen saturation at 91%, sitting in recliner as it is easier to for resident to breath. Resident had temp of 100.3 this NOC [night] shift. Residents blood sugar was 110 at bedtime [HS], had HS snack. Resident had chest x-ray done today, still awaiting results. COVID swab done, still awaiting results. The progress note lacked evidence the physician/provider had been contacted about the elevated temperature as this was the first time following the abnormal x-ray and chest x-ray with pending labs on 12/21/20. -New Admit Note dated 12/19/20, at 3:04 p.m. indicated Resident ate poorly this day shift. Held insulin due to BS [blood suger] only 74 in am and poor appetite. Res refused noon insulin. Ate only about 1/3 of lunch. BS was 282 before lunch, res still did not want the insulin. Next nurse notified. Res sats were in the low 90's on 6 L high flow O2. Some SOB noted at times, especially when lying in bed to change. Res could not tolerate this, was put back in reclining chair, but sitting upright all shift. Staff able to calm res SOB down by talking him thru deep slow breathing exercises. Afebrile for day shift. Tolerated dressing change. Small yellowing drainage on removed dressing. Wrapped right lower extremity after dressing change and wrapped Kerlix on left lower extremity. Lung sounds [LS] are dim [diminished] with some wheezing noted in upper lobes. The note lacked evidence the physician/provider had been updated on staff holding the insulin as ordered, poor appetite and resident noted wheezing in upper lobes. -Admission/Medicare Note dated 12/19/20, at 11:35 p.m. indicated Resident's lung sounds remain diminished in bilateral bases. He has shortness of breath with minimal exertion and is unable to tolerate lying in bed, as he reports he feels too short of breath--even with head of bed elevated 90 degrees. He prefers to sit/sleep in recliner. Oxygen sats are 92% on 6 L via NC [nasal cannula]. No cough noted. Resident remains afebrile. Denied chest pain. Left shoulder/clavicle and left lower extremity/stump pain effectively managed with scheduled [MEDICATION(S)] and prn [as needed] Tylenol. Resident resting comfortably in recliner at this time. -Admission Note dated 12/20/20, at 3:10 a.m. indicated Resident able to make needs known, uses call light appropriately. Resident complains of SOB, on 6 L oxygen, sitting in recliner due to [d/t] easier to breath sitting up. Temp [temperature] 100.5. Resident wanted blood sugar [BS] checked d/t feeling low, blood sugars 112 at 0120 [1:20 a.m.] with snack given after checking, rechecked at 0245 [2:45 a.m.]with blood sugar of 234 [2:34 a.m.], feels a little better. No PRN [as needed] medication given. No scheduled medications given. Resident remains on enhanced precautions awaiting Covid testing results. The noted lacked evidence of the physician/provider being updated of the continued SOB and elevated temperature. In addition, the note did not indicate the oxygen saturation level R1 was at with the 6 liters of oxygen. -New Admit Note dated 12/20/20, at 1:56 p.m. indicated Res SOB [short of breath]at times. Sats in the 88-90% range on 6 L of O2 [oxygen]. Res appetite poor, insulin held. Granddaughter called for update and stated res has had some history [hx] of bowel obstructions. Res had 2 loose large stools this shift. Granddaughter insisted loose stool could mean an obstruction for him. Abd [abdomen] non-tender, hard. BS [bowel sounds]are active. Res was asked about pain/discomfort, res stated his shoulder was uncomfortable, but not that bad. Gave PRN Tylenol. Granddaughter stated res has a hard time telling people of how much pain he is in. Res does state at times he has a hard time breathing. Some anxiety noted with resident. Granddaughter would like res tested further for bacterial pneumonia and possible bowel obstruction. Res is stable, informed granddaughter we are waiting Covid test results. Will update RN case manager and pass on to St [NAME] Community Care for f/u [follow up]. The medical record lacked documentation of a physician/provider being updated of the loose stools, insulin being held and R1's responsible party requesting R1 to be tested further related to the issues R1 was experiencing. In addition, the medical record lacked evidence of the nurse manager and SLCC being updated to follow up on the concerns. -Admission/Medicare Note dated 12/20/20, at 11:40 p.m. indicated Resident is a diabetic and his blood sugars this shift were 265 prior to dinner. Resident ate less than 25% of dinner, stating he had no appetite. Writer held scheduled 45 units of [MEDICATION(S)] secondary to poor intake. At HS, resident's blood sugar was 456. He reported he did not eat anything since dinner. Writer administered the 45 units of [MEDICATION(S)] previously held, along with 80 units of scheduled [MEDICATION(S)]. At 2230 resident's blood sugar was 118. He was provided an HS snack of milk and [NAME] diabetic friendly cookies. Resident's lung sounds remain diminished in bilateral bases. He has shortness of breath with minimal exertion and is unable to tolerate lying in bed, as he reports he feels too short of breath--even with head of bed elevated 90 degrees. He prefers to sit/sleep in recliner. Oxygen sats are 93% on high flow oxygen of 6 L via NC. No cough noted. Resident remains afebrile. Denied chest pain. Left shoulder/clavicle and left lower extremity/stump pain effectively managed with scheduled [MEDICATION(S)] and PRN Tylenol. Resident resting comfortably in recliner at this time. The medical noted lacked evidence of the provider/physician being updated of staff holding the scheduled insulin at 4:30 p.m. then administering it at HS together with scheduled [MEDICATION(S)] (long acting insulin) and R1's continued report of feeling too short of breath plus the diminished lung sounds. -Shift Note dated 12/21/20, at 3:37 a.m. indicated Beginning midnight resident's O2 dropped between 88 to 54 on 6 L free airflow. O2 sat went back up to 90 with help of deep breathing. O2 sat continued going up and down through the night till 3 am. Unable to keep sat above 88, stayed 74. Writer called on-call St [NAME] Community Care physician who gave verbal order to send R1 to emergency room (ER). Nurse at ER was updated with resident's condition. Family member was notified, and resident consent to going to ER. The medical record lacked documentation of the provider/physician being notified timely when the oxygen saturation levels were dropping between 88% to 54% beginning at midnight so the physician could make the decision to continue monitoring R1 at the facility or send R1 to the hospital. The nurse waited until 3:00 a.m. which was 3 hours later and although R1's oxygen saturations went back to 90% with deep breathing, R1's oxygen level continued to go up and down through the night. In addition, the medical record lacked documentation of what the oxygen levels were through out the time frame from when the level stayed at 74% upon which the nurse called the on-call physician who gave order to send R1 to ER. The note also lacked R1's temperature at the time of the assessment prior to transferring R1 to the hospital. During review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -12/18/20, order for O2 to keep sats between 88-92%. Document liter flow every shift. -12/18/20, check temperature, blood pressure (BP), pulse, respirations and O2 sats once daily. Special Instructions: Report Temperature over 100 to registered nurse [RN]. During review of the hospital Internal Med Progress Note dated 12/23/20, the note indicated R1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated a CT scan of the chest had been completed with the following results Extensive ground glass [finding on CT (computerized tomography) scan that indicates a partial filling of air spaces in the lungs], interstitial and airspace opacities were seen throughout the bilateral hemithoraces likely representing pulmonary [CONDITION(S)] versus multifocal with associated small basilar effusions and compressive atelectasis. In addition, the note indicated R1 had blood gas showing acute respiratory acidosis with arterial blood gas (ABG- test measures the oxygen and carbon [MEDICATION(S)] levels in your blood) with carbon [MEDICATION(S)] level of 82 with normal levels (35-45 mmHg); WBC 13.5 K/ul with normal (4.0-10.0 K/ul) and due to R1 showing signs of respiratory distress R1 was started on [MEDICATION(S)] (water pill), [CONDITION(S)] (a type of ventilator machine used to treat chronic conditions that affect your breathing), Solumedrol (used to treat many different [CONDITION(S)] conditions including exacerbations) and two antibiotics [MEDICATION(S)] and [MEDICATION(S)]). During interview on 3/7/22, at 12:39 p.m. RN-A clinical coordinator stated she recalled R1 coming from the hospital and seemed medically complex and did not feel it was a safe discharge from the hospital. RN-A stated she had tried to work with the other nurse to make sure R1 got all the orders he needed to get good care. RN-A stated after going through her documentation, the chest x-ray was inconclusive and she had brought it up to the provider and had updated the responsible party. RN-A then stated without reviewing the medical record and from the little she could remember R1 had been tested for Covid-19 and the result ended up testing negative. RN-A stated after she had received the results for the x-ray and the labs she had documented them in the progress note and she had contacted the provider about R1 along the way as she wanted R1 to be managed. When asked where she would document which provider she had contacted she stated it would have been the resident notes. RN-A also stated she also would have communicated with the supervisor RN-B, nurse on the cart or would have documented in the 24 hour board. RN-A stated usually the process was if a resident oxygen level they were receiving needed to be bumped, or there was a change in condition, or a significant lab result typically the expectation was we contact the on-call so we know how to proceed moving forward. I know when I was working with him I was keeping close contact with the providers I don't recall who I spoke with. During interview on 3/7/22, at 1:34 p.m. licensed practical nurse (LPN)-A reviewed both her progress note for 12/19/20 at 3:04 p.m. and 12/20/20, at 1:56 p.m. and verified R1 had been on 6 liters of oxygen and had still continued to complain of being short of breath. LPN-A stated during both times she had worked with R1, she had found R1 was on 6 liters of oxygen and that was what R1 had for the shift. LPN-A stated from her recollection, R1 was very sick and had a lot of things wrong. When asked about the charting and who she had spoken to or updated regarding R1's responsible party concerns on 12/20/20, at 1:56 p.m. progress note, LPN-A stated after reading the note she had spoken to R1's responsible party because the responsible party was insisting about the loose stools and had questioned if R1 had a bowel obstruction. LPN-A also stated she had assessed R1, and had passed the responsible party concern to the RN manager and RN-B. When asked where she would have documented who she had communicated about R1's responsible party concerns, LPN-A stated she would have called the on-call, put a SBAR Situation, Background, Assessment and Recommendation note in the provider binder for the provider to review when in the building next or could have done both. LPN-A acknowledged the medical record lacked documentation of her following up with the responsible party concerns to review the course for treatment. LPN-A further acknowledged it was the weekend and since the nurse manager was not in the building she could have sent an e-mail. During interview on 3/7/22, at 4:49 p.m. primary facility nurse practitioner (NP) stated he had not seen R1 as the resident was admitted on [DATE], which was a Thursday and R1 was sent to the hospital 12/21/20, before he could do the first visit with R1. The NP reviewed the lab result for 12/18/20, and acknowledged R1 had an elevated WBC count. NP stated although the 12/18/20, results were elevated for WBC count and the Neutrophils, it was hard to draw a conclusion if R1 had an infection because someone had to look at the previous labs results to compare the trends. The NP stated going by the nursing note about the provider being updated of the lab results on 12/18/20, it appeared at 5:22 p.m. he would have been off work that time and the facility nurse would have called the on-call at those hours. The NP acknowledged he did not have any documentation of seeing R1 or regarding the nurse update of the lab results and the chest x-ray. The NP reviewed R1's hospital lab results dated 12/17/20, and acknowledged R1 had within normal WBC count and Neutrophils which was different from the labs on 12/18/20. The NP reviewed the staff nursing notes and stated according to the notes, R1 had appeared to have gotten worse as the night went on from 12/18/20, and was going a different direction compared to the hospital labs. When asked if the nurses were supposed to call the on-call about R1's elevated temperatures, SOB, loose stools, responsible party concerns about treatment, insulin being held and the lung sounds, the NP stated someone had to review the whole picture including the chest x-ray, code status if R1 had any specific measures and the lab results. The NP stated since R1 was on 2 liters of oxygen from the hospital and continued to need more, normally staff were to run the oxygen flow rate at 1-4 liters, the nurses should have known to call the on-call with a change of condition when they had increased the oxygen to over 4 liters. The question is the nursing judgement we are only as good as our notes. Someone's judgement must have felt he was not deteriorating. When did he tip when someone should have been notified. When asked about the chest x-ray indicating the result was: Peripheral airspace opacities in both lungs are concerning for atypical infectious process such as COVID-19 pneumonia the NP stated it was hard to answer the question about what atypical meant because this question would have to be asked of the person who read the x-ray. The NP stated atypical infectious process in simple terms would be like walking pneumonia, they did not say consolidation it's like more of a fog like look mycoplasma. It's hard to know with atypical because it was not showing fluid lines so I think that's the challenge. It will be difficult to be able to tell from the x-ray if it's [CONDITION(S)] pneumonia. It's hard to put judgement into this. During interview on 3/7/20, at 3:37 p.m. the interim director of nursing (DON) stated the chest x-ray results from 12/18/20, were faxed to the NP and the rounding NP had also been updated of the lab results and had given orders to re-check CBC and BMP on Monday 12/21/20, which were both seen by RN-A. The interim DON stated R1 was very sick when he was admitted to the facility. The interim DON acknowledged the medical record lacked documentation of the nurses notifying the provider/physician through the weekend when R1 had elevated temperatures, insulin was held, when the responsible party had concerns with R1's condition and the decreased oxygen saturation levels leading up to being sent to the hospital. The interim DON stated, I see there was no documentation of the nurses doing a follow up during the day. Myself, I have gone over the notes and looked at them. He was not eating and they were not giving him his insulin and this is in the notes. The interim DON acknowledged the nurses had opportunities to notify the physician between the course of the 3 days when the resident required the increased oxygen level, as the standing house was 1-4 liters, when R1 had a temperature and stated that was the reason why RN-C was no longer working at the facility. During interview on 3/7/22, at 5:28 p.m. when asked about her documentation regarding R1's diminished lung sounds, RN-B stated she had reviewed the chest x-ray and the lab results which had been faxed to SLCC and in her opinion nothing had changed with R1's lung sounds from admission. RN-B stated R1 continued to have the intolerance to lying in bed from admit. RN-B stated to her R1 looked like he had improved compared to when he had admitted to the facility because at admission time he was compensated and I felt we needed to keep a close eye on him we had been keeping the primary informed I felt with the labs and x-ray being done. I was not there during the night shift when he was sent in to judge what he was like. RN-B stated, During my shift, when we notice people are not at their baseline we follow the care plan and the treatment orders and if we feel a resident has had a change in condition we would notify the doctor. RN-B also stated, If family came back and was questioning the treatment plan, basically I would do an assessment and update the RN coordinator, she is right there able to be in contact with the provider and would update them. We would e-mail the care coordinator and update St Luke's Community Care on the weekends on-call and tell them what is going on and would find out what they want us to do. RN-B then stated, I train the nurses to do a SBAR [Situation- Background -Assessment - Recommendation] and tell them if something is urgent they need to call the on-call or you can fax a SBAR to the provider during the business hours. When asked where the SBARs completed for residents were kept, RN-B stated some of the providers will sign off on the SBARs as orders and others will write it in the orders as there is no regulation of where really they can document the orders. RN-B further stated, The nurses are supposed to write notes of what is going on with the residents during their shifts. RN-B reviewed R1's notes leading up to being sent to the hospital and acknowledged there was no documentation of what the resident condition was before the nurse notified the physician who ordered R1 to be sent to the hospital. During interview with the medical director (MD) on 3/8/22, 8:18 a.m. when asked about the chest X-ray results, Peripheral airspace opacities in both lungs are concerning for atypical infectious process such as COVID-19 pneumonia. The facility MD stated atypical mycoplasma pneumonia like Covid could be either bacterial or [CONDITION(S)] however, in R1's chest x-ray, it would have been bacterial pneumonia but the result did not come out and say that. The MD stated he was aware of R1's incident however, acknowledged he had not reviewed R1's medical record. The MD stated the issue was R1 had tests completed and the staff were aware of the x-ray results and the labs and the rounding nurse practitioner had ordered the labs to be repeated in 3 days adding, I would say someone should have had a nurse practitioner or someone on call to have weighed in on it given the fact he was continuing to have the sats going down even with the increased oxygen and the other things including the temperature. The nurses are to notify the provider on call to see if there was need to alter the course of treatment. The MD further stated there was just a lot of things which made the issue complex including the medical history and being the weekend which should not be an excuse. They should have called the on-call. The facility undated Change in Condition policy directed the following: Purpose: To provide care and services based upon the current needs of the resident under the direction of the attending provider. To inform resident/resident representative and attending provider when a significant change in resident condition occurs. Policy: When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative Procedure Licensed nursing associate: 1. Assess significant change in the resident's condition noted through direct observation, interview or report for other staff. 2. Obtain a set of vital signs and repeat as needed or ordered. 3. Open Matrix Event and conduct a symptom review and assessment, as condition warrants. 4. Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed. If unable to contact the physician, contact the Medical Director, as appropriate. 5. Notify the appropriate members of the IDT (interdisciplinary) team. 6. Notify the resident/resident representative. 7. Document symptom(s), assessment, observations, resident/resident representative, and medical provider notification. 8. Monitor and provide treatment as ordered by the attending provider. 9. Update the care plan as appropriate .

Based on interview and document review, the facility failed to ensure a system to identify a resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) situation placing the resident at risk for death in the event his heart stopped beating, and his breathing ceased. The IJ began on [DATE], when R45 requested a change from a Do Not Resuscitate (DNR status, if a person's heart stopped beating a natural death would be allowed to occur) code status to a full code status (full code status, if a person's heart stopped beating CPR would be initiated). A POLST was filled out on [DATE], and given to the health unit coordinator (HUC)-C. HUC-C made a copy and gave it to the nurse manager, registered nurse (RN)-D. Neither the HUC-C nor RN-D transcribed the order into R45's electronic medical record (EMR). The administrator was informed of the IJ on [DATE], at 11:40 a.m. The IJ was removed on [DATE], at 10:51 a.m. but noncompliance remained at a lower severity of a D, no actual harm, with potential for more than minimal harm. Findings include: The facility policy Initiation of CPR/Automated external defibrillator (AED) and Basic Life Support (BLS) Associate Training Expectations dated 2017, directed CPR would be initiated on a resident who is found unresponsive, except when: 1) a Provider medical order states a code status of DNR; 2) a resident Declination of CPR Form is present; or 3) there are signs of obvious long standing death of the resident present. The policy lacked direction on where staff would obtain code status information. R45's Face Sheet printed [DATE], identified R45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's annual Minimum Data Set (MDS) dated [DATE], indicated R45 had moderately intact cognition, and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. On [DATE], at 1:39 p.m. R45's POLST dated [DATE], indicated R45's wishes were to attempt CPR, full treatment. On [DATE], at 1:53 p.m. R45's EMR indicated his code status was DNR, and his MD orders also indicated DNR status. On [DATE], at 1:55 p.m. R45 was interviewed. R45 stated the day before, he signed a paper to indicate he wanted CPR if his heart stopped. On [DATE], at 2:16 p.m. trained medication aide (TMA)-A was interviewed. TMA-A stated she would check a resident's code status in the physical chart or the EMR, then stated the physical chart would be the most accurate. On [DATE], at 2:19 p.m. TMA-B was interviewed. TMA-B stated she would look in the computer for a resident's code status. On [DATE], at 2:22 p.m. registered nurse (RN)-B was interviewed. RN-B stated he would look for a resident's code status depending on which was closer the physical chart, or the EMR. On [DATE], at 2:26 p.m. RN-C was interviewed. RN-C stated she would look in the computer for a resident's code status. On [DATE], at 2:30 p.m. HUC-C was interviewed. HUC-C stated the RN's transcribe the POLST orders and they update the EMR. On [DATE], at 3:38 p.m. licensed practical nurse (LPN)-C was interviewed. LPN-C stated she would look in the resident's physical chart for code status. On [DATE], at 3:40 p.m. RN-G was interviewed. RN-G stated the process for changing code status is for the HUC to update the order in the EMR and change the banner in the EMR to reflect the change. The HUC would put the new POLST in the chart, and bring the chart to the clinical manager to verify the order. After hours, the order would be verified by the supervisor or the medication nurse. On [DATE], at 3:44 p.m. RN-E was interviewed. RN-E stated she would look in the computer if she was in a resident room, if she was at the nurse's station she would look in the physical chart for a resident's code status. On [DATE], at 3:50 p.m. the director of nursing (DON) was interviewed. The DON stated a POLST was handled the same way any other order was processed. The DON went on to state the RN nurse managers were responsible to update the resident's code status in the EMR. The DON stated the failure to transcribe the code status order could have resulted in death for R45 if his heart would have stopped between the time the order was written on [DATE], and the time the discrepancy in the physical chart and the EMR was discovered on [DATE]. The immediate jeopardy that began on [DATE], was removed on [DATE], at 10:51 a.m. when the facility completed an audit of all resident records to ensure the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These actions were verified through interview and record review.

Based on observation, interview, and document review, the facility failed to ensure care planned interventions were timely implemented for 1 of 1 residents (R193) with worsening of current pressure ulcer and development of new pressure ulcers. This resulted in actual harm when R193's right hip Stage 2 pressure ulcer worsened to unstageable, and he developed an unstageable pressure ulcer to the right heel, an unstageable pressure ulcer to the left heel, a Stage 2 pressure ulcer to the right lower coccyx, a Stage 2 pressure ulcer to the left lower coccyx, an unstageable pressure ulcer to the sacrum, and a deep tissue injury on the left great toe. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) and eschar (black, dry, and leathery dead tissue and may form a thick covering) are not present. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. R193's Face Sheet printed 6/21/21, indicated R193 was admitted to the facility on [DATE]. R193's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R193's admission Minimum Data Set (MDS) dated [DATE], indicated R193 had severe cognitive impairment, required assistance with bed mobility, extensive assist with transfers, was occasionally incontinent of urine, and frequently incontinent of bowel. R193's MDS further indicated R193 was at risk for pressure ulcers, and had one Stage 2 pressure ulcer upon admission. R193's MDS also indicated R193 had a pressure reducing device in chair and bed, and pressure ulcer care interventions in place. R193's care plan initiated 5/57/21, indicated R193 was at risk for alteration of skin, required extensive assist of one for bed mobility, and extensive assist of two for transfers. R193's goal was not to develop any skin alterations. The care plan also included interventions for an alternating pressure mattress. R193's care plan further indicated R193 required special attention when positioning related to right hip pressure ulcer and red blanchable heels. R193's care plan was revised 6/21/21, to include Prevalon boots (pressure relieving boots) while in bed, and if R193 refused Prevalon boots to float heels with a pillow. In addition, if R193 refused care, staff were to explain risk vs benefits of the refusal, re-approach in 15 minutes, try a different care giver, and report refusal to licensed nurse (LN). R193's care plan further directed if R193 continued to refuse, the LN was to document the refusal and notify social services, family, and provider. R193's care guide updated 6/14/21, indicated R193's bath was on Monday during the day, R193 was to be up in his wheelchair at mealtimes, required toileting and reposition every two hours, and directed staff to float heels with pillows and report noncompliance to the nurse. R193's Admission Skin Risk assessment dated [DATE], inaccurately identified R193 was not at risk for the development of pressure ulcers, had advanced age and cardiac diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment further indicated R193 was admitted with a small Stage 2 pressure ulcer to right hip with surrounding skin a Stage 1 area of pressure-non blanchable 2.0 centimeters (cm) x 3.0 cm. R193's heels were red and blanching, nursing were to float heels and encourage every two hours repositioning, and offload right hip from pressure. R193's Medical Administration Record (MAR) dated 6/1/21, through 6/29/21, indicated orders for Prevalon boots on when R193 was in bed, and to float heels. From 6/1/21, through 6/22/21, R193's MAR lacked indication staff were monitoring and ensuring R193's Prevalon boots were put on, and heels were floated while in bed. The MAR further lacked frequency of monitoring. On 6/4/21, a progress note indicated R193 had developed new skin issues on both sides of the coccyx (tailbone). A larger area noted on left side with lighter spots of purplish color with a non-blanching wound bed. No drainage was noted. A large foam border dressing was applied after cleansing and applying skin prep. The note further indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/5/21, a progress note indicated R193's right heel had skin breakdown with a dark area approximately the size of a quarter. R193's feet were placed in soft boots on pillows to take pressure off heels, and he was to be repositioned often due to skin breakdown on coccyx and right hip. The note further indicated R193 was noncompliant and required much encouragement. On 6/6/21, a progress note indicated R193 refused to turn to the side to relieve pressured areas. R193 was educated, and R193 continued decline to offload the coccyx area. On 6/18/21, a progress note indicated R193 had a new deep tissue injury to left great toe measuring 1.2 cm x 2.0 cm. The area was purplish red in color, on the tip of toe, and was related to his shoes. R193's Wound Management Detail Report indicated documentation on the following six pressure ulcers: R193's right heel pressure ulcer: On 6/7/21, measured 1.5 cm x 3.0 (unstageable) On 6/15/21, measured 1.8 cm x 2 cm (unstageable) R193's left heel pressure ulcer: On 6/7/21, measured 4.0 cm x 3.5 cm (unstageable) note indicated area not present on 6/6/21 On 6/15/21, measured 4.0 cm x 2.5 cm (unstageable) R193's coccyx (right lower) pressure ulcer: On 6/7/21, measured 3.0 cm x 2.5 Stage II with 70% dark purplish/red appearance and 30% epithelial with sanguineous (bright red) drainage On 6/15/21, measured 1.2 cm x 0.5 cm Stage II with 100% epithelial tissue R193's coccyx (left lower) pressure ulcer On 6/7/21, measured 1.0 cm x 2.2 Stage 2 On 6/15/21, measured 1.2 cm x 1.2 cm R193's sacrum (right upper coccyx) pressure ulcer: On 6/7/21, measured 2.2 cm x 1.5 cm of 60% of wound unstageable deep tissue, and 40% unstageable yellow slough, with light amount of sanguineous drainage On 6/15/21, measured 2.0 cm x 1.7 cm covered 100% yellow slough R193's right hip pressure ulcer: On 5/27/21 measured 2.0 cm x 3.0 stage I and stage II with non blanching peri-wound On 6/7/21 measured 2.6 cm x 0.5 cm deep tissue injury On 6/15/21 measured 2.1 cm x 0.5 cm (unstageable) R193's Wound Management Detail Report dated 6/18/21, indicated a new deep tissue injury on left great toe measured 1.2 cm x 2.0 cm and was suspected from wearing shoes. Foot cradle was ordered (to keep bedding off of foot), R193 was to avoid wearing shoes, and a request for a wound clinic referral due to multiple areas of skin break down since admission. On 6/15/21, at 2:43 p.m. R193 was observed in bed with his Prevalon boots on both feet. R193 stated he had to wear the heel boots while he was in bed because he had sores on his heels that were acquired during his stay at the facility. On 6/17/21, at 1:12 p.m. R193 was not in his room and his Prevalon boots where on his bed. On 6/18/21, at 7:58 p.m. R193 was up in bed eating breakfast, his Prevalon boots were not on, and R193's heels were lying directly on the mattress. On 6/18/21, at 8:26 a.m. R193 was observed in bed and Prevalon boots remained off, and heels were lying directly on the mattress. On 6/18/21, at 9:00 a.m. NA-K and NA-L exited R193's room. NA-L verified R198 continued to not wear his Prevalon boots presently and did not have them on that morning when NA-L started the shift. NA-L stated during morning shift change, there was no report R198 refused to wear his Prevalon boots from the previous shift. NA-L stated R193 was supposed to wear the Prevalon boots while in bed. On 6/18/21, at 9:03 a.m. NA-K stated NA-K and NA-L had repositioned R193 and verified R193 did not have his Prevalon boots nor were his heels floated off the bed. NA-K stated R193 was to be turned, repositioned, and offered toileting every 2 hours. NA-K stated R193 preferred to be in bed and sometimes would refuse to wear his Prevalon boots or change position. NA-K stated if R193 refused to wear his Prevalon boots or refused to be repositioned staff we report to the nurse. NA-K stated NA-K was not aware if R193 refused to have his Prevalon boots on. On 6/18/21, at 9:25 a.m. R193 was escorted to therapy in his wheelchair. R193 did not have his Prevalon boots on, and both feet and heels were observed resting directly on the wheelchair pedals. On 6/18/21, at 11:25 a.m. licensed practical nurse (LPN)-H stated R193 was admitted with a pressure area to his right hip, which had healed. LPN-H stated R193 had developed new pressure ulcers to his coccyx and heels, and LPN-H was about to complete R193's wound care. R198's dressing changes to his four pressure ulcers on his coccyx, and [MEDICATION(S)] treatments to blackened areas on the out outside of both heels were observed. During these treatments, LPN-H noted a new pressure ulcer to the top of R198's left great toe. LPN-H summoned registered nurse (RN)-F, who measured the new pressure ulcer at 2.1 cm x 2 cm. RN-F stated R193 mostly likely developed the new pressure area from wearing shoes, even though he had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/21/21, at 8:26 a.m. R193 was observed sitting up in bed eating breakfast, R193's heels were observed resting directly on the bed. Two Prevalon boots were observed in R193's chair in his room. When asked if he was supposed to have his Prevalon boots on while in bed R193 stated, I have no idea, sometimes they are put on and other times they are not. On 6/21/21, at 8:42 a.m. RN-I was unsure when R193 was supposed to wear his Prevalon boots. RN-I checked R193's EMAR and stated she did not see the Prevalon Boots on the MAR or TAR. RN-I further stated the Prevalon boots would be an order and should be on the TAR for the nurse to sign off. RN-I stated if R193 refused to wear his Prevalon boots or reposition, staff were to reproach, notify the nurse and document the refusal. RN-I stated since the start of her shift, there had been no reports R193 refused to wear his Prevalon boots or declined to change position. On, 6/21/21, at 9:10 a.m. RN-I exited 193's room and verified R193 did not have his Prevalon boots on and his heels were not floated off the bed. RN-I stated R193 allowed RN-I to put on his Prevalon boots without any hesitation. On 6/21/21, at 9:12 a.m. NA-M stated she started her shift at 6:00 a.m. that morning. NA-M stated she assisted R193 that morning and verified R193 did not have his Prevalon boots on. NA-M stated R193 would ask to have his boots taken off or refuse to wear them. NA-M stated when R193 first was admitted to the facility, R193 refused a lot and overtime R193 became more accepting and was more compliant and refused less. NA-M stated she did not put R193's Prevalon boots on because R193 was scheduled for shower that morning. NA-M stated R193 refused to get up for breakfast that morning and agreed to get up and take his shower after breakfast. NA-M stated if a resident refused, NA-M would reproach and if continued to refuse, notify the nurse. On 6/21/21, at 12:23 p.m. the director of nursing (DON) stated if a resident refused any treatments or services, she would expect staff to reproach, try a different caregiver, offer a different time of the day if appropriate, and notify the nurse. The DON stated she would expect the nurse to provided education on the risk vs benefits, update the physician and document. The DON stated it was important to follow the interventions on the care plan to promote wound healing and prevent skin concerns. The facility policy Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Evaluate current pressure reductions interventions and revise resident centered care plan. -Educate resident/resident representative on skin impairment and care plan interventions. -Notify the attending provider, resident/resident representative and supervisor if the skin injury has not shown progress in two weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate.

Based on interview and document review, the facility failed to provide ongoing comprehensive discharge planning to ensure all discharge needs of the resident were identified in order to avoid the development or worsening pressure ulcers, and to avoid readmission for 1 of 3 residents (R1) reviewed for discharge planning. This resulted in actual harm to R1, who had developed a pressure ulcer that worsened, and had an unsuccessful discharge that resulted in readmission to the facility. Findings include: R1's Face Sheet printed 10/26/20, indicated R1 was admitted to the facility on [DATE], and [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 was cognitively intact, required assistance of two for bed mobility, and assist of one for ambulation, dressing, eating, toileting, and personal hygiene. R1 had an indwelling urinary catheter, and had bowel incontinence. R1 was at risk for pressure ulcers (PU), and had no unhealed PU. R1's care plan dated 9/24/20, indicated R2 had impaired mobility, required limited assistance with ambulation and transfers, and supervision with bed mobility. R1's care plan indicated R1 had a cognitive loss, and required assistance with activities of daily living (ADLs), medication management, and supervision for safety. R1's care plan indicated R1 was at risk for skin breakdown, and required assistance of two for turning and repositioning every two hours. The care plan further indicated R1's goal was to return to home with necessary referrals and supportive services. R1's physical therapy (PT) plan of care dated 9/23/20, indicated R1 was referred to PT post hospitalization due to a fall resulting in multiple rib fractures, and required PT services for improving activity intolerance, transfers, gait, balance, and safety with functional mobility. R1's goal was to return home. PT treatment plan included PT visits six times a week for five weeks. R1's occupational therapy (OT) plan of care note dated 9/23/20, indicated R1 presented with decreased activity intolerance, impaired balance and mobility, impaired cognition affecting ability to safely complete ADL/IADL tasks. R1's goal was to return home. OT treatment plan included OT visits six times a week for five weeks. On 9/22/20, a progress note indicated R1 was admitted to the facility for short term rehab after a hospitalization from a fall that occurred at home, which resulted in rib and compression fractures. R1's goal was to return to own home when therapies were completed. R1's Weekly Skin Documentation dated 9/22/20, and 9/27/20, indicated R1 had mushy, blanchable heels, and three abdominal surgical incisions with steri-strips. R1's chart lacked further Weekly Skin Documentation from 9/27/20, to R1's discharge on 10/13/20. R1's Admission Skin Observation note dated 9/23/20, indicated R1 was at risk for skin breakdown, and was without pressure ulcers. R1's eight day skin assessment dated [DATE], indicated R1 had no areas of pressure. R1's care conference note dated 9/29/20, indicated R1, social services, therapy, nursing, and family member (FM)-D attended R1's care conference. R1's care conference note indicated R1 required contact guard assistance (CGA) for transfers with four wheeled walker (FWW), required stand by assistance (SBA) with bed mobility, required assistance with dressing, and extensive assist with toileting. R1's Allen Cognitive Level Screen (ACLS, a test that evaluates the ability of someone to make decisions, function independently, safely perform basic skills, and learn new abilities) score was 4.5 which recommended R1 receive daily checks while at home, and required assistance. The care conference note further indicated R1 and FM-D were adamant on R1's return to home, and FM-D indicated she lived near R1, and could be at R1's home at any time. The care conference note indicated therapy questioned if R1 would benefit from an assisted living facility (ALF) if FM-D was unable to provide the level of care R1 needed. On 10/6/20, R1's physical therapy (PT) daily treatment note indicated FM-D spoke with PT-A, and was informed R1 would not be able to fit her walker in the bedroom next to R1's bed. PT-A worked with R1 on ambulating from the end of the bed towards the head of bed while supporting herself on the bed using upper extremities with CGA (requiring one or two hands on the body for assist). R1 was able to complete the task after multiple cues from therapy, and multiple attempts by R1. R1's physician signed discharge orders dated 10/7/20, included orders for in home PT, OT, and Home Health Nurse for vital sign checks, medication education, medication set up, and disease education. Discharge medication and treatment orders lacked orders for wound care treatment. On 10/5/20, R1's OT progress note indicated OT recommended R1's discharge plan include 24 hr care/assistance. The note further indicated FM-D was adamant R1 would do better at home, and FM-D would check on R1 daily. On 10/6/20, R1's OT daily treatment note indicated R1 required SBA from sit to stand, and CGA with ambulation with FWW. The note further indicted OT-A and PT-A spoke with FM-D to discuss discharge planned to be 10/12/13. Therapy recommended 24 hour care, which FM-D stated she could not provide, but she would check on R1 during the day. The note indicated FM-D was concerned with R1 being alone at night, and R1's ability to empty her urinary drainage bag. FM-D inquired about home health aide for overnight care, and therapy referred FM-D to social services for information. On 10/9/20, a progress note indicated R1 had a 1 centimeter (cm) x 0.5 cm area on R1's right buttock, surrounding skin was blanchable but unable to determine center. The area was cleansed, and a foam dressing was applied. R1's medical records lacked further monitoring of the area, or the condition of R1's skin at time of discharge. On 10/12/20 (day of discharge), R1's OT daily treatment note indicated R1 struggled to sit up on the edge of bed, and required assistance to put her pants over her feet, and thread the catheter bag through the leg of her pants. R1 required SBA to CGA to stand and pull up her pants. The note further indicated during the morning meeting it was discussed family would be staying with R1 for a couple of weeks. OT-A expressed concerns regarding R1 living alone with [MEDICAL CONDITION] diagnoses, and social services reported family was aware of R1's situation. On 10/12/20, a PT note indicated R1 required SBA to transfer to the toilet, and required assistance of one to remove her lower extremity clothing. The PT note further indicated R1 reported buttock pain, and she had a small dressing over the right of her sacrum area. PT-A notified nursing, and nursing applied a new dressing to R1's sacrum. R1's medical records lacked documentation of an assessment of R1's sacrum, and lacked discharge orders for at home treatment. On 10/12/20, a progress note indicated R1 transferred and ambulated with limited assist of one with FWW. R1 required assistance with bathing, dressing, and was independent with eating. On 10/13/20, a progress note indicated R1 was discharged to home with family providing transportation, and a referral was made to a home care agency (HCA) for in-home nursing, OT, and PT. The HCA home care visit note dated 10/14/20, indicted home care nurse arrived at R1's home on 10/14/20, to complete R1's initial assessment, and initiate home care services. The note indicated FM-A and FM-C were present during the visit, and expressed concern R1 was discharged from the facility unable to care for herself or manage her Foley (urinary) catheter. The note indicated R1 had three unstageable pressure ulcers (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed) on her buttocks that were not noted in R1's discharge paperwork from the facility. The note further indicated R1 required one to two assist to transfer, and was unable to change position on her own when she was in bed. The note indicated R1 required a higher level of care than the agency could provide, and R1 would need to either go to the emergency department (ED) or back to the facility. FM-A and FM-C agreed to stay with R1 until R1 was able to be readmitted back to the facility. The home care nurse called R1's primary care provider (PCP), and agreed to re-admit R1 back to the facility. R1's physician orders [REDACTED]. On 10/15/20, R1's Wound Management sheet indicated R1 was readmitted to the facility with a Stage 1 pressure ulcer (Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury), which measured 0.7 cm in length by 0.5 cm in width to R1's right buttock near rectum. Opened area had a small amount of serous (clear, thin, watery) drainage. Skin surrounding open area was excoriated. On 10/16/20, R1's OT progress note indicated R1's discharge to home was unsuccessful, and R1 returned to the facility. The note further indicated therapy made recommendations for an assisted living facility or 24 hour supervision if R1 stayed at home. On 10/15/20, R1's PT daily treatment note indicated R1 required CGA with FWW with ambulation, required cues for proper walker use, and R1 had some unsteadiness when rising. On 10/22/20, at 10:03 a.m. family member (FM)-A was interviewed and stated he was informed R1 was being discharged from the facility a few days before R1's scheduled discharge date of [DATE]. FM-A stated he lived out of town, had planned to stay with R1 for a few days, and FM-B planned to stay with R1 for about 12 days. FM-A stated when R1 got home from the facility, FM-A was unaware how much assistance R1 required. FM-A stated R1 could not get up on her own, needed assistance with incontinent cares, and could not care for her urinary catheter. FM-A stated R1 had a urinary catheter for about eight years, and used to be able to empty the urinary drainage bag on her own, but could not longer manage. FM-A stated he didn't know how to empty R1's urinary drainage bag, and the facility did not offer FM-A education. FM-A stated R1 was sent home with some medications, and two different medication lists. FM-A called the facility and spoke with registered nurse (RN)-A to clarify R1's medication list. FM-A stated he expressed concern with R1 needing more assistance than FM-A felt comfortable in providing. FM-A stated nursing and therapy did not recommend R1 to return home, and R1 needed 24 hour supervision for safety. FM-A stated he called FM-B and informed FM-B of R1's condition, and explained R1 was unable to do anything on her own except feed herself. FM-A stated FM-B called FM-C, and FM-C planned to arrive at R1's home the next day to be present when the home care nurse arrived. FM-A stated FM-D was not a close family member, and should not have been listed as R1's primary contact and caregiver. FM-A stated because of that, the facility never included FM-A or FM-B in R1's discharge planning. FM-A stated after the facility was aware of FM-A and FM-B's involvement on 10/7/20, and FM-D was no longer involved in R1's care, the facility did not offer a discharge care conference before R1's was discharged home. FM-A stated R1's family never spoke with any staff from the therapy department to discuss R1's care needs, and felt family was not prepared. FM-A stated he thought he was just going to be helping with R1's meals, cleaning, and being around for a few days to make sure R1 got settled in. FM-A stated if he was properly informed of R1's care level needs, he never would have allowed R1 to return home. FM-A stated on 10/14/20, the home care nurse arrived and told him R1 should have never been discharged from the facility and required 24 hr care. FM-A stated the home care nurse and FM-C discovered three pressure ulcers on R1's buttocks that he was not informed of. FM-A stated the home care agency could not provide care for R1 due to her high level care needs, and R1 required 24 hour supervision. FM-A stated the HCA nurse told him R1 needed to return to the facility, or go to the ED. FM-A stated family stayed with R1 until after her oncology appointment 10/15/20, and brought R1 back to the facility to be readmitted . FM-A stated when R1 was brought back to the facility on [DATE], family talked to RN-A and expressed their frustration of the facility's lack of communication to the family of R1's high care level needs, and pressure ulcers on R1's buttocks that were not addressed at discharge. FM-A stated family had not been involved in R1's care conferences and discharge planning. On 10/22/20, at 1:18 p.m. FM-B was interviewed and stated R1 had FM-D listed as R1's primary contact and caregiver so the facility communicated with FM-D about R1's care and discharge. FM-B stated she received a call from FM-A the day R1 was discharged home. FM-A was informed R1 was weak, needed help to stand, could barely walk with her walker, and could not empty her urinary drainage bag. FM-B stated on 10/7/20, she found out R1 was being discharged to home, she had planned to spend 12 days with R1 to help with cleaning, meals, and shopping since FM-D was no longer involved in R1's care. FM-B stated the first interactions with the facility was via email with the social worker (SW)-A on 10/7/20. FM-B stated SW-A was informed FM-D was no longer involved in R1's care, and SW-A sent a return email with information on medical assistance application for R1 and links for resources for R1's diet. FM-B stated the facility did not offer a care conference after the facility was informed FM-D was no longer going to be providing care for R1. On 10/22/20, at 2:13 p.m. the HCA RN-K stated she arrived at R1's home on 10/14/20, to initiate home care services for nursing, OT, and PT. RN-K stated when she arrived at R1's home, FM-A and FM-C were present and R1 was in bed. RN-K stated R1's condition was poor, she had 3 unstageable PU to her buttocks, and there was a transparent dressing on R1's buttocks that did not cover R1's PU. RN-K was unable to admit R1 to home care due to R1's high skill level needs, cognitive deficit, and inabilty to make safe decisions. RN-K stated R1 needed 24 hr care/supervision, and family was unable to meet R1's care needs. RN-K recommended R1 be taken to the ED or readmitted to the facility. RN-K called R1's primary physician to update, the PCP agreed R1 should not be home, and to readmit R1 to facility. On 10/22/20, at 2:33 p.m. the HCA manager (HCA)-M stated they received R1's referral from SW-A on 10/6/20, with planned discharge for 10/13/20. HCA-M stated R1's referral requested nursing services for vital signs, medication set up and education, disease education, PT, and OT services. HCA-M stated R1's referral paperwork from SW-A included physician orders, physician visit, and therapy notes. HCA-M stated based on the information in R1's referral, R1 would be an acceptable client for admission. HCA-M stated therapy notes indicated R1 required assistance with footwear, and SBA with ambulation. HCA-M stated R1's referral did not indicate R1 had any skin concerns or wound care orders in place. HCA-M stated based on the home cares nurse observations and assessment, R1 was not admitted to home care due to R1's high skill level needs which the agency was not able to provide. On 10/22/20, at 2:50 p.m. RN-A stated she was a part of R1's discharge planning. R1 stated at the time of discharge, R1 required assistance of one with transferring, dressing, grooming, toileting, and ambulation. RN-A stated nursing and therapy did not recommend R1's discharge to home and recommended 24 hr care in the home or an assisted living facility. RN-A stated R1 and FM-D were determined to get R1 home. RN-A stated, People had the right to make bad decisions. RN-A stated R1's discharge plan included FM-D to assist R1 in the home during the day, and home care services for nursing, OT, and PT were to be initiated. RN-A stated FM-D attended R1's care conferences via phone, and had spoken with OT and PT, was aware of R1's care level needs, and therapy's recommendations for 24 hour care. RN-A stated R1 was readmitted to the facility two days after being home, because family was unable to care for R1 at home. RN-A stated she spoke with R1's family when R1 was brought back to the facility. RN-A stated R1's family expressed they were not aware R1 had pressure ulcers, and they were not informed of R1's high care level needs. RN-A stated skin observations were not completed at the time of discharge, and RN-A was unaware R1 had any skin concerns or had a transparent dressing to her buttocks at the time of discharge. RN-A verified R1 did not have treatment orders at the time of discharge for pressure ulcer care. On 10/22/20, at 3:32 p.m. FM-C stated she arrived at R1's home around 10:00 a.m. on 10/14/20. FMC stated R1 was lying in bed, and her urinary catheter leg bag was full of dark colored urine. FM-C stated R1 was weak, unable to care for her catheter, required assistance to turn in bed, and one to two assist to transfer. FM-C stated R1 had pressures ulcers on the right side of her coccyx, and had a transparent dressing to her buttocks that was undated and scrunched up. FM-C stated the home care nurse cleaned R1's pressure ulcers and applied a new dressing. FM-C stated she was a home care nurse, and was surprised the facility discharged R1 home with the skilled level of care she required, and expected untrained family to be able to provide appropriate care for R1. On 10/22/20, at 4:05 p.m. SW-A stated she was involved in R1's discharge planning, and made a referral to the HCA for R1 to receive nursing, OT, and PT in-home services. SW-A stated the home care services were temporary, and did not include evening or overnight care, and FM-D was going to help R1 at home. SW-A stated FM-D was listed on R1's contact information from the hospital as R1's caregiver, and R1 confirmed FM-D lived close to her and helped R1 in her home. SW-A stated FM-A and FM-B did not live in town and were unable to assist R1 in her home, and were not initially involved in R1 care planning. SW-A stated FM-D attended R1's initial care conference via phone and agreed to provide daily checks, and assist with meals when R1 returned home. SW-A stated FM-D expressed concern of R1 being alone at night, and SW-A referred FM-D to Senior Linkage. SW-A stated she was contacted by FM-B via email, and FM-B requested FM-D not be involved in R1's care plan moving forward due to concern of FM-D taking financial advantage of R1. SW-A stated she emailed FM-B a link for resources for R1's diet, an application for medical assitance, and contact number to report concerns or financial abuse. SW-A stated FM-A and FM-B did not request a discharge meeting for R1. SW-A verified FM-A and FM-B were not offered a discharge care conference for R1. On 10/23/20, at 12:07 a.m. an interview was conducted with physical therapist (PT)-B and occupational therapist (OT)-A. PT-A stated R1 required supervision with ambulation with FWW for safety and cues. OT-A stated R1's ability to dress herself varied on a day to day basis. OT-A stated R1 was unable to manage her urinary drainage bag or manage medication on own. OT-A stated she and PT-A talked with FM-D via phone and discussed R1's discharge recommendations of 24 hour in-home care, and that R1 required CG with transfers. OT-A stated it was her impression R1's family that lived out of town was going to stay with R1 for a couple of weeks. OT-A stated R1 did not have a discharge care conference because FM-D declined. PT-B and OT-A stated FM-A and FM-B were not offered a discharge care conference, and both were unaware FM-D was no longer involved in R1's care. On 10/23/20, at 2:55 p.m. social services director (SSD)-A stated she was not involved with R1's original discharge on 10/13/20. SSD-A stated SW-A forwarded an email received from FM-B on 10/7/20, indicating family had concerns with FM-D taking financial advantage of R1, and requested the removal of FM-D from R1's plan of care. SSD-A stated she was unaware there were any concerns with R1's discharge to home. On 10/23/20, at 3:31 p.m. a follow up phone interview was conducted with RN-A. RN-A stated the morning of R1's discharge, RN-A called FM-D to review R1's medications, was informed by FM-D she was no longer involved in R1's care, and was directed to call FM-A. RN-A called FM-A and reviewed R1's medications, and informed him of R1's scheduled oncology appointment. RN-A stated she informed SW-A that FM-D was no longer R1's caregiver. RN-A stated she was informed by SW-A that R1's family was coming from out of town to stay with R1 for a while. RN-A stated she did not review R1's care needs with FM-A once she found out R1's original caregiver, FM-D was no longer involved in R1's care. RN-A stated a change in discharge planning should be discussed as a team to make sure all disciplines involved were aware of the changes to ensure the discharge plan remained a safe plan. RN-A stated there were no adjustments made to R1's discharge plan. On 10/26/20, at 1:33 p.m. a follow up phone interview was conducted with SW-A. SW-A stated no one officially informed her FM-D was no longer involved in R1's care. SW-A stated she heard second hand by staff FM-D was no longer R1's caregiver the day R1 was to be discharged . SW-A stated it was her understanding, out of town family would be staying with R1 for a short time, and assumed FM-D was going to be involved in R1's care, but unsure to what extent. SW-A stated if FM-D was not going to be involved in R1's care at all, SW-A would have put R1's discharge on hold until R1, family, nursing, and therapy met to make sure everyone had an understanding of R1's needs when home, and R1 had a safe plan for discharge. SW-A stated she did not contact FM-A, FM-B or therapy to ensure all involved parties had an understanding of the changes in R1's discharge plan. On 10/26/20, at 3:27 p.m. an interview with RN-B and SSD-A was conducted. RN-B stated the discharge planning process started upon admission, and went until the day the resident was discharged . RN-B stated the facility had two Nurse Transition Coordinators that were involved in the day-to-day discharge planning, along with nursing, social services, and therapy who met daily. RN-B and SSD-A both agreed that with any significant changes in R1's caregivers after discharge, they would have expected a meeting to have occurred with the new caregivers, nursing, social services, and R1 to discuss the changes, and to ensue R1 had a safe discharge plan. SSD stated R1's new caregivers would be offered any education if needed, including hands on training by therapy, or by nursing for any education on R1's catheter care. SSD-A verified no discharge care conference occurred with R1's new caregivers. SSD-A stated she was unaware therapy made recommendations for an ALF for R1, or 24/7 care in R1's home. SSD-A further stated if family was unable to provide 24/7 care, R1 should not have been discharged home. SSD-A was unsure if therapy was aware FM-D was no longer involved in R1's care, or if they had communicated therapy recommendations to FM-A or FM-B. RN-B stated she would expect any skin concerns to be addressed in R1's discharge paperwork, and verified R1's discharge orders did not include any dressing treatment to R1's buttocks. RN-B stated it was best practice to date and initial all dressings when applied. RN-B stated skin checks were not completed before the patient was discharged . RN-B stated if a skin check had been completed for R1 at time of discharge, R1's skin concern and dressing to her coccyx would have been discovered, and treatment orders would have been obtained. SSD-A stated it appeared there was a lack of communication between departments with R1's discharge plan. The facility policy Discharge Planning dated 2017, directed the Social Worker/Licensed Nurse will evaluate and identify resources available and potential health issues that may interfere with the residents ability to return home. The policy directed in collaboration with the resident and family caregivers, a patient-driven education plan with related goals implemented. Prior to discharge, the patient or family caregivers demonstrate achievement of education goals for a safe transition. The policy indicated the Social Worker/Licensed Nurse collaborate with all disciplines, to evaluate the reality of the resident's plans and to approximate the time period for moving toward discharge. If discharge to the community is determined not feasible, the facility will document who mad the determination and why. Discharge plans are reviewed at least quarterly by the interdisciplinary team and revisions made as the needs arise. The policy further directs prior to discharge, the Social Worker/Licensed Nurse or nursing staff reviews and provides a written discharge instructions through the Discharge Plan of Care Observation in the electronic health record. The facility policy Prevention and treatment of [REDACTED]. Weekly skin audits are performed by a licensed nurse. The policy indicated if a resident was admitted with impaired skin integrity or new pressure injury or a lower extremity ulcer develops, the licensed nurse implements the following items: -Documentation of the skin impairment is completed in the medical record. Staging is completed as necessary by trained licensed nursing associates. -Standing orders/protocol for skin impairment are indicated. -Notify the attending provider, resident and resident representative. Attending provider determines wound type and may provide additional orders. -Notify the Supervisor/designee -Evaluate current pressure reduction interventions and revise resident centered care plan. -Notify dietician for nutritional interventions -Educate resident/resident representative on skin impairment and care plan interventions. -When pressure injury is present, the dressing and/or wound as appropriate are monitored daily. -The Licensed nurse will stage, measure, and examine the wound bed and surrounding skin weekly. -Notify the attending provider, resident/resident representative and supervisor if the skin injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate.

Based on observation, interview, and document review, the facility failed to implement appropriate COVID-19 infection control practices related to the appropriate utilization of personal protective equipment (PPE) when providing personal care and treatment to residents in order to minimize or contain the spread of COVID-19. These practices resulted in an immediate jeopardy (IJ) due the potential risk for widespread outbreak of COVID-19 with the potential to affect 77 of 84 residents residing in the facility. The immediate jeopardy began on 9/18/20, when it was determined the facility had begun reusing washable infection control gowns in resident rooms for staff entering a resident room, regardless if contaminated during the provision of cares, and failed to implement a system to identify which gown had been used by which staff even though the facility currently had an outbreak of COVID-19 within the facility. The administrator, director of nursing (DON) and the infection preventionist (IP)-A were notified of the IJ at 3:44 p.m. on 10/15/20. The IJ was removed on 10/16/20, but noncompliance remained at the lower scope and severity level of E, pattern which indicated no actual harm with potential for more than minimal harm that is not IJ. The Center for Disease Control (CDC) update on prioritizing the use of gowns dated 3/17/20, indicated gowns should be used during high contact patient care activities that provide opportunities for pathogen transfers such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use, and wound care. For the care of patients with suspected or confirmed COVID-19, health care providers risk from re-use of cloth isolation gowns without laundering among (1) single health care provider caring for multiple patients using one gown or (2) among multiple health care providers sharing one gown is unclear. The Center for Medicare and Medicaid Services (CMS) memo COVID-19 Long Term Care Facility Guidance dated 4/2/20, directed nursing homes to immediately ensure they were complying with all CMS and CDC guidance related to infection control, which included the use of standard, contact, and droplet precautions. On 10/14/20, at 9:22 a.m. nursing assistant (NA)-C was observed. NA-C approached a resident room on the Transitional Care Unit (TCU). A sign on the outside of the door indicated the resident was on isolation precautions until 10/21/20. NA-C removed a clean gown from a bin outside the door, tied the neck of the gown, and pulled it over her head prior to entering the room. At 9:31 a.m. NA-C left the room without the gown on. At 9:40 a.m. NA-C approached another resident room, removed a clean gown from a bin outside the door and tied the neck of the gown before pulling it over her head. At 9:44 a.m. NA-C pulled the gown over her head while it was still tied at the neck and hung it on a hook on the back of the door before leaving the room. R1's Face Sheet indicated he returned to the facility on [DATE], following a hospital stay. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated he required extensive assistance with all activities of daily living (ADLs) and was always incontinent of bowel and bladder. R1's care plan dated 8/25/20, identified cognitive loss, and indicated he was dependent on staff for toileting, transfers and repositioning. On 10/15/20, at 7:12 a.m. NA-D and NA-E were observed to enter R1's room. NA-C removed a soiled pillow case from a pillow on a chair in R1's room. At 7:18 a.m. NA-C stated she was going to leave the room to obtain supplies. NA-C removed her gown by pulling it over her head while still tied at the neck, then hung the gown on a hook on the back of the door along side another gown that was hanging on the back of the door. At 7:23 a.m. NA-C re-entered the room, removed a gown from the hook on the door, and pulled it over her head while still tied at the neck. NA-D and NA-C assisted R1 to shave his face, both NAs leaned over the bed with their gowns touching the linens. R1's gown was noted to be soiled with a dark yellow substance. At 7:30 a.m. NA-C removed the soiled gown while NA-D washed R1's upper body. NA-D then rolled R1 to his side while touching her gown to the bed linens and R1's skin. At 7:43 a.m. NA-C again removed her gown by pulling it over head head with the neck still tied. Both NA-C and NA-D hung their gowns on hooks on the back of R1's door prior to leaving the room. At that time there were three gowns observed hanging on the back of the door. At approximately 8:00 a.m. random room observations were completed and the following was observed: room [ROOM NUMBER], three gowns were hanging on hooks on the back of the door. Two of the gowns were tied at the neck. room [ROOM NUMBER], four gowns were hanging on the back of the door, two on one hook and two on another hook. On 10/15/20, at 8:10 a.m. NA-C was interviewed and stated if a resident was on isolation precautions, staff were supposed to use a new gown each time they entered the room. NA-C stated if a resident was not on precautions, staff hung the gown on the back of the door for re-use prior to leaving the room. NA-C stated the hooks on the doors were numbered, and stated she always used number one. In regard to R1, NA-C stated he was on precautions, and a new gown should have been used. NA-C stated if there were multiple gowns hanging on the back of the doors, staff would not necessarily know which one was theirs. At 8:33 a.m. IP-A and the DON were interviewed. IP-A stated the use of disposable or washable reusable gowns was based on the facility supply. IP-A stated the facility had received a huge shipment of gowns, so they had been given the option to use either disposable or washable reusable gowns. IP-A stated they had been letting staff know shift to shift what gown to use, and staff knew they could use either type of gown. IP-A stated if staff were using the washable reusable gowns, there were hooks on the back of the doors labeled with the numbers one, two, and three. IP-A stated the hooks were designated to staff: one for the nurse, two for the NAs and three for therapy staff. When asked how staff were educated on the system, IP-A stated they talked to staff shift to shift. IP-A stated staff had received multiple trainings on the use of PPE, and the proper way to don and doff the gowns. IP-A stated pulling the gown on or off while still tied at the neck was not the proper way to don or doff the gown. On 10/15/20, at 12:41 p.m. IP-A stated staff had not received any formal education on the use of the hooks for the reusable gowns, and said it was done verbally shift to shift. IP-A stated it was possible staff may not have been aware of which hook to use. At 1:22 p.m. random observations indicated room [ROOM NUMBER] had four gowns hanging on the back of the door. Hooks one and two each had one gown hanging on them,. Hook three had two gowns hanging on the same hook. In room [ROOM NUMBER], hook three also had two gowns hanging on the one hook. At 1:25 p.m. NA-D stated she always used hook number one to hang her reusable gown. NA-D stated the staff talked to each at the start of the shift to determine which hook they would use. NA-D stated there was no designated numbers that she had been made aware of. At 1:36 p.m. registered nurse (RN)-B entered a resident room, and removed a gown from a hook on the back of the door. There were two hooks on the back of the door, and one hook on the wall. Hook one was on the wall and was empty. Hooks two and three both had gowns hanging on them after RN-B had put on a gown. At 1:51 p.m. prior to leaving the room, RN-B removed her gown and placed it in a bag. RN-B stated when she entered the room she had put on the gown that was on hook number three, even though it already had a used gown hanging on it. RN-B stated she knew it was hers because she had hung it there. On 10/14/20, at 3:31 p.m. trained medication aide (TMA)-A was interviewed and stated reusable gowns were reused, and hung on a hook on the back of the door, upon exiting a quarantine room. TMA-A stated he was uncertain how to distinguish between whose reusable gowns was whose, but thought it would be by putting the gown in a spot where he knew he left it. On 10/15/20, at 7:41 a.m. NA-A stated staff wore the blue disposable gowns if the resident was negative for COVID-19, and wore a reusable, washable gown if the resident was positive for COVID-19. NA-A stated there were currently no positive COVID-19 cases on the long term care unit. NA-A further stated staff were told when a resident was off their 14 day precautions. -at 7:20 a.m. NA-B was working on the TCU unit. NA-B stated new admissions and residents returning from the hospital were placed on isolation precautions for two weeks. NA-B stated staff used one gown per shift, per room. NA-B stated there were three hooks on the back of each door, and staff discussed at the beginning of the shift who would use which hook. NA-B stated staff removed the gowns at the end of the shift, and the reuseable, washable gowns were placed in laundry. If the gowns were disposable, they would be thrown in the garbage after every use. -at 8:33 a.m. IP-A stated the facility used reusable, washable gowns based on supply. IP-A stated ideally staff would use reusable, washable gowns for residents on 14-day quarantine, and if they were running low on reusable, washable gowns, they would use the disposable gowns. IP-A stated the second floor staff had been using reusable, washable gowns since the last COVID-19 outbreak in June. IP-A stated if staff were using a reusable, washable gown and not hanging it on the door, the gown should be placed in a bag, and immediately brought to the utility room. IP-A stated reusable, washable gowns should be removed after every shift, and placed in dirty utility room. IP-A further stated competency training had been completed for donning/doffing PPE for all staff on multiple shifts and times. -at 1:12 p.m. room [ROOM NUMBER] had three reusable, washable gowns behind the door, one gown on each hook. The hooks labeled 1, 2 and 3. -at 1:13 p.m. physical therapist (PT)-A was observed to don a clean reusable, washable gown, and enter an unidentified resident room on the TCU unit. PT-A stated the nursing staff used the gowns hanging on the back of residents doors. PT-A stated there were three reusable, washable gowns on back of residents door, one on each hook which were numbered 1, 2 and 3. PT-A stated nurses pick a hook number, and use that same numbered hook to hang their gown on during their shift. PT-A stated the number system had been in place for a while, but changed depending on gown supply. PT-A also stated he always wears new reusable gown into room, does not reuse gowns or take one off the back of the door. -at 1:24 p.m. NA-B stated she had previously worked on the COVID-19 unit. NA-B stated she thought the numbered hooks on the back of the doors had been there for a while. Four reusable, washable gowns were observed on the back of the door to room [ROOM NUMBER]. NA-B verified this, and stated there were more gowns hanging on the hooks than usual, because there were nursing students in the facility. NA-B stated the students each had a specific hook to hang their gowns on, she always used hook 1 and the nurse also had a specific hook, but the nurse usually wore a disposable gown. -at 1:30 p.m. RN-A stated staff tried to use the disposable gowns for the quarantined residents. RN-A stated the reusable, washable gowns were used if there was a staff member that was going to be on the unit for the entire shift. RN-A stated that staff member would hang their reusable, washable gown on the designated hook on the back of the door. RN-A stated she'd only used reusable, washable gowns if they were out of the disposable gowns. RN-A stated staff communicated at the beginning of the shift which hook they would use for that shift. The immediate jeopardy that began on 9/18/20, was removed on 10/16/20, when the facility implemented an infection control plan to minimize the spread of COVID-19 which included procedures for the appropriate use and reuse of PPE by facility staff, and these interventions were verified through observations and interviews.

Based on interview and document review, the facility failed to ensure medications were administered as prescribed for 1 of 5 residents (R89) reviewed for medications. This failure resulted in actual harm to R89, who required transfer to the emergency department (ED) for medical treatment due to unsafe insulin administration practices. Findings include: R89's Face Sheet printed 6/13/19, indicated R89's [DIAGNOSES REDACTED]. R89's Physician order [REDACTED]. -Tresiba (long acting insulin) 27 units to be administered at 8:00 a.m. -[MEDICATION NAME] (rapid acting insulin) 17 units to be administered with meals at times 8:00 a.m., 12:00 p.m. and 6:00 p.m. Blood glucose checks were ordered 4 times a day at 7:00 a.m., 12:00 p.m., 5:00 p.m., and 8:00 p.m. R89's physician order [REDACTED]. On 4/9/19, at 8:47 p.m. a progress note indicated R89 was alert and orientated to person, and vital signs were stable. R89's appetite was reported good and blood glucose taken at 5:00 p.m. was 235; and blood glucose taken at 8:00 p.m. was 309. R89's nutritional intake report was poor 4/10/19. Intake results from 4/9 and 4/10/19 indicated: 4/9/19 at 7:53 p.m. ate 76-100 percent of supper and no bedtime snack 4/10/19 at 11:36 a.m. R89 ate 1-25 percent of breakfast 4/10/19 at 1:30 p.m. ate 1-25 percent of lunch R89's Medication Administration Record [REDACTED] R89's MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED]. On 4/10/19, at 2:58 p.m. a progress noted indicated R89 was sent to the ER (emergency room ) by ambulance after oxygen saturation dropped to 74% on 2 liters of oxygen. R89 was described to be snoring, and lungs sounds noted to have crackles and congestion. R89 was not responding to verbal cues. On 4/10/19, at 10:24 p.m. nurse practitioner (NP) note indicated R89 had received 17 units of [MEDICATION NAME]before breakfast and lunch, even though he had not eaten, and was then transported to the ER. On 6/13/19, at 2:24 p.m., an interview was conducted with a family member (FM)-D by phone. FM-D stated R89 was admitted to the facility on [DATE], from the hospital. FM-D further stated on 4/10/19, R89's daughter had been at the facility and noticed a significant change in R89's condition, and requested R89 to be sent to the hospital. FM-D stated when the paramedics arrived, R89's blood glucose level was in the 20's. FM-D stated after the paramedics gave R89 medications to elevate his blood glucose, R89 was taken to the ER, admitted to the hospital, and did not return to the facility. On 6/13/19 at 5:28 p.m., an interview was conducted with both the director of nursing (DON) and registered nurse (RN)-B. The DON stated giving R89 insulin when he had not eaten was a medication error, she was aware of the medication error, and stated a report had been filed. RN-B stated it was a significant medication error,and the DON agreed. RN-B stated R89's intake had been poor and staff tried to get R89 to eat. The DON stated administering insulin 2 hours late, not rechecking the blood glucose or monitoring food intake was not common practice. The DON and RN-B both agreed they would expect insulin to be held for R89 if his food intake was poor. The facility policy Administering Medication dated (YEAR), directed medications will be safely administered to residents as ordered by the physician. The undated facility Medication Administration Guidelines directed rapid acting insulin to be administered within 15 minutes before eating or immediately after a meal, and for long acting insulin to be administered evening with meals or at HS (hour of sleep).

Based on observation, interview, and document review, the facility did not administer adequate pain medication prior to repositioning and dressing change for 1 of 2 residents (R11) in the sample reviewed for pain. This resulted in actual harm to R11. R11 had physician orders [REDACTED]. R11 was not provided [MEDICATION NAME] for pain prior to the dressing change observed at R11's [DIAGNOSES REDACTED]. The annual minimum data set (MDS), dated [DATE], indicated R11 had severe cognitive impairment, received scheduled pain medications ([MEDICATION NAME] (narcotic [MEDICATION NAME]) 10 mg 4 times daily, and Naproxin (non-steroidal anti-inflamatory medication) 220 mg daily), but no PRN (as needed) pain medications. The MDS further identified R11 was unable to answer interview questions regarding pain, and did not display any non-verbal sounds of pain (crying, whining, gasping, moaning or groaning). The care plan, edited 5/16/12, indicated R11 offered no answers to pain assessment interview questions due to severe cognitive impairment. The care plan further indicated R11 would whimper/cry at times due to anxiety as it did not always occur with movement, and staff denied any verbal/non-verbal indicators of pain. The care plan identified risk factors for pain that included a stage 4 (a full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone) sacral pressure ulcer. Physician's notes dated 6/6/12, indicated R11 had ongoing chronic pain and the current [MEDICATION NAME] would continue. Per interview with the registered nurse manager (RNM-A) on 6/11/12, at 4:18 p.m., R11 had 3 stage 4 pressure ulcers on the sacrum with the following measurements: right lateral side: 5.2 centimeters (cm) x 1.7 cm x 0.1 cm; skin bridge of sacrum: 2.8 cm x 0.7 cm x 0.1 cm: area at 2 o'clock: 0.3 cm x 0.3 cm x 0.1 cm. RNM-A indicated physical therapy (PT) did the dressing change every 3 days, and the order was for normal saline to cleanse, skin prep around the wound, alevyn foam dressing (a [MEDICATION NAME] dressing that absorbs exudate), and [MEDICATION NAME] (a transparent dressing used to cover and protect wounds). On 6/11/12, at 4:01 p.m., a PT progress note indicated R11's 3 pressure ulcers had declined, becoming one pressure ulcer measuring 8.0 cm x 5.1 cm, and the depth was unable to be determined due to an increase in necrotic (dead) tissue. The pressure ulcer was further described as having copious (large) amounts of serosanguenous drainage with a very foul odor. On 6/11/12, at 5:35 p.m., a progress note recorded by the registered nurse manager (RNM)-C indicated R11's pressure ulcer had declined and suggested the dressing be changed to calcium alginate (a highly absorbable dressing) and foam dressing. On 6/13/12, at 11:37 a.m., R11's pressure ulcer and dressing change were observed with RNM-A, RNM-C, and licensed practical nurse (LPN)-C. R11 cried and said "Ow! Ow! Ow!" when staff repositioned her onto the right side. R11's cries intensified, becoming louder and more frequent "Please! Please! Please!" and "Ow! Ow! Ow!" as LPN-C removed the soiled dressing, RNM-C measured and assessed the pressure ulcer, and LPN-C cleansed the pressure ulcer and applied the clean dressing. RN-C verified the pressure ulcer had increased in size and severity since 6/11/12. The ulcer was now unstageable and measured 10.5 centimeters (cm) x 5.5 cm. R11 continued to cry out "Ow! Ow! Ow!" and "Please! Please! Please!" as staff finished the dressing change and repositioned R11 onto her side. RNM-A stated R11 normally cried out with cares, and R11 had not had pain medication prior to the dressing change. On 6/13/12, at 12:45 p.m., a progress note indicated "there is pain associated with the wound. Will fax MD to possible get a pain medication to be given 30 mins (minutes) prior to dressing change. On 6/13/12, at 12:36 p.m., nursing assistant (NA)-E was interviewed and stated R11 moans and cries out with cares about 90% of the time. On 6/13/12, at 1:30 p.m., R11 was observed being transferred back into bed with a mechanical lift by NAs G and E. R11 cried out "Ow! Ow! Ow!" and "Please! Please! Please!" during the transfer. When asked if she was in pain, R11 replied "Please! Please! Please!" and "Ow! Ow! Ow!" On 6/14/12, at 10:08 a.m. R11's pressure ulcer and dressing change were observed with RNM-C, LPN-E, and nursing assistant (NA)-F. R11 cried out "Ow! Ow! Ow! " and "Please! Please! Please!" during repositioning onto the right side, and the cries intensified during the measurement of the pressure ulcer and the dressing change. RNM-C measured the pressure ulcer as 10.4 cm x 5.5 cm x 0.4 cm of depth. RNM-C verified a new area of dark redness approximately 4 cm to the right of the sacral area (at 3:00 o'clock), measuring 3 cm x 2.5 cm. RNM-C stated the new area was a deep tissue injury. LPN-E verified R11 had not received any pain medication prior to the dressing change. On 6/14/12, at approximately 3:00 p.m., RNM-A stated the physician ordered PRN [MEDICATION NAME] (opiod pain reliever) 5/500 milligrams (mg), 1 tablet 30 minutes prior to dressing changes; however, [MEDICATION NAME] was not administered prior to the dressing change because the order had not been transcribed. RNM-A also stated a pain assessment had not been completed with the decline in R11's pressure ulcer. The director of physical therapy services (DPT), interviewed on 6/14/12, at 1:08 p.m., stated PT had been providing treatment and dressing changes for R11's sacral pressure ulcer since March 2012. DPT stated that R11 previously made crying noises during repositioning but was quiet while the treatment was completed. On 6/15/12, at 10:32 a.m., the director of nursing (DON) stated he expected a new pain assessment be completed whenever a pressure ulcer worsened or a new treatment was ordered by the physician.

Based on documentation and interviews the facility failed to ensure residents remained free of accident hazards and received adequate supervision and assistance devices for 1 of 2 Residents reviewed. When Resident (#1) did not receive adequate supervision and interventions in accordance with her plan of care she fell and sustained a left hip fracture. Findings include: Review of the medical record for Resident #1 revealed she has [DIAGNOSES REDACTED]. Her care plan dated 12/16/2010 notes she has severe cognitive impairment, impaired balance and mobility and requires hands on staff assistance with all of her cares. Resident #1's fall assessment dated [DATE] notes Resident #1 had diminished safety awareness, was a high risk for falls due to severe cognitive impairment and was to be monitored for restlessness. It also indicates that on the early morning of 6/18/2011 she was to have an alarm on her wheelchair for fall prevention. Nursing progress notes dated 6/18/2011 indicated Resident #1 had been restless and was transferred up into her wheelchair during the night. Nursing progress documentation dated 6/18/2011 revealed later that early morning staff heard a crash and Resident #1 was found on the floor at the dining room complaining of much pain. Her hip was noted to be externally rotated and she was transferred to the hospital where she was found to have sustained a left hip fracture. Documentation in the unusual occurrence report of 6/18/2011 revealed Resident #1 was found to not have her wheelchair alarm on her wheelchair at the time of the fall. The care guide and plan of care noted Resident #1 was to have a wheelchair alarm on her wheelchair. Hospital medical records reviewed notes she had a surgical repair of her left hip at the hospital and later returned to the facility. An interview was conducted with Employee F /Nursing Assistant (NA) on 8/23/2011, at 9:16 a.m. She stated she assisted Resident #1 up into her wheelchair since she was restless that night to early morning hours of 6/18/2011. Resident #1 had a bed alarm. Employee F said she read the care guide but had difficulty reading it making her unsure about the use of a chair alarm versus the bed alarm and asked Employee E/Nurse Supervisor for guidance on how to proceed with Resident #1's care. She also stated she went to assist her coworker with other residents and asked the nurse in the area if he could supervise Resident #1 due to her restlessness and no alarm on her chair. She said he stated he would be in the area. Approximately an hour later the nurse called to the nursing assistants as Resident #1 had fallen and was found on the floor in front of her wheelchair in the dining room. An interview was conducted with Employee G /NA on 9/26/2011 at 12:38 p.m. She stated she witnessed Employee F trying to clarify Resident #1's care need with Employee E and was told he would check into it. She also stated Resident #1 was restless and was left near the nurses on the unit to supervise while the nursing assistants went to assist other residents with cares. Approximately 30-60 minutes later the nursing assistants were called and notified Resident #1 was lying on the floor in front of her wheelchair near the dining room. An interview with Employee M/Licensed Practical Nurse (LPN) revealed he was in orientation training the night of 6/18/2011 but did not remember a nursing assistant asking for the nurses to supervise Resident #1. He acknowledged Resident #1 was up in her wheelchair during the night due to her being restless. While she was up that night she propelled her wheelchair around the area of the nursing desk and hallway near the dining room. An interview with Employee E/Nurse Supervisor revealed Resident #1 was up in her wheelchair during the night of 6/18/11 due to restlessness. He did not remember the nursing assistant asking him to supervise Resident #1 while she provided resident cares. Resident #1 was in his line of vision but then he walked away while providing training to a nurse in orientation. He heard a noise and found Resident #1 lying on the floor in front of her wheelchair at the entrance into the unit dining room. She complained of much pain in her hip. Employee E said Resident #1 did not have an alarm on her wheelchair to alert staff when she got up as she should have according to her care plan and nursing assistant care guide. Resident #1 was transferred to the hospital where she was found to have a hip fracture.