Every finding on record at Benedictine Living Community of St. Peter

Based on observation and interview, the facility failed to ensure a process for residents and resident representatives to file grievances anonymously, when R22, R23, R35, R45, R46, and R63 voiced they were not aware of how to submit a grievance or an anonymous process to submit a grievance. This had the potential to affect all 67 residents in the facility. Findings include:R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 was cognitively intact.R23's quarterly MDS dated [DATE], indicated R23 had moderately impaired cognition, R35's quarterly MDS dated [DATE], indicated R35 was cognitively intact.R45's quarterly MDS dated [DATE], indicated R45 was cognitively intact.R46's annual MDS dated [DATE], indicated R46 was cognitively intact.R63's annual MDS dated [DATE], indicated R63 was cognitively intact.On 1/13/26 at 11:32 p.m., during a facility tour with social services (SS)-B director concern forms were observed on each unit, however no confidential collection box was present. SS-B confirmed there were grievance forms in the designated areas accessible to all residents and stated grievance forms could be turned in to staff or placed under my door. SS-B confirmed there was no confidential grievance box and confirmed he did not know of anywhere forms could be placed securely for anonymous submission.On 1/13/26 at 12:08 p.m., the administrator stated residents could complete concern forms located on the units and may give them to any staff member. The administrator stated they thought there was a box to place the concerns forms on each wing and after a tour of the facility the administrator confirmed there was no confidential receptacle available for grievance submission. The administrator stated they expected one to be present so residents could voice concerns.On 1/13/26 at 1:05 p.m., during the resident council meeting, residents R22, R23, R35, R45, R46, and R63 stated they were not aware of any method to submit concerns anonymously. All residents reported they would talk to someone if they wanted to file a grievance. None of residents stated they were aware of a process to file a grievance anonymously. Residents reported they were unsure whether forms existed and, if so, how they should be turned in.Facility Concerns, Grievances Policy dated 9/17/19, indicated: Purpose: To create an environment where resident and customer concerns are solicited and readily resolved.Policy: A resident/customer/resident representative has the right to voice grievances and concerns without discrimination or reprisal and without fear of discrimination or reprisal. The term voice concerns is not limited to a formal, written grievance process, but may include a resident's verbalized concerns to staff. Concerns and grievances can be made anonymously.The community views customer concerns as a primary method to learn of and meet customer expectations. In keeping with this belief, staff is trained to obtain and respond to resident/resident representative customer concerns.The social worker/grievance officer /designee checks the confidential container daily; removes the completed forms, logs the concern, and routes the copy to the staff responsible to acknowledge, investigate, and resolve the concern.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) guidelines for appropriately implementing measures to prevent the spread of infection when the facility failed to ensure signage was posted for visitors and staff regarding visiting when ill, hand hygiene and respiratory management, and failed to follow infection control practices while washing resident personal laundry. This practice had the potential to affect all residents residing in the facility.Findings include:INFECTION CONTROL SIGNAGEDuring observation on 1/12/26 at 9:45 a.m., no signs were posted at facility entrance doors to encourage visitors and staff to follow respiratory hygiene, cover their cough, stay home while sick, or sanitize hands prior to visiting. In addition, no facemasks or hand sanitizer were available at the main entrance.Review of current CDC guidelines from the CDC website on 1/13/26, indicated for prevention of transmission of viral respiratory infections in long term care, facilities should provide instructions and post visual alerts at the entrances to healthcare facilities reminding patients, visitors, and staff to tell healthcare personnel about any symptoms of respiratory infection, visitors should be encouraged to defer non-urgent routine visits until they have recovered, wear a mask in the facility if they have any respiratory symptoms, clean their hands after having contact with respiratory secretions, practice respiratory hygiene and cough etiquette. Healthcare facilities should ensure the availability of materials for adhering to respiratory hygiene and cough etiquette at facility entrances, including facemasks and alcohol-based hand sanitizer.LAUNDRYDuring observation and interview on 1/13/26 at 10:39 a.m., laundry assistant (H-A) placed soiled laundry into facility washing machine. H-A was not wearing a gown while touching resident laundry. Resident personal laundry was in contact with H-A's clothing. H-A stated she washed all resident personal laundry for the facility. H-A stated she sometimes wore a gown but did not wear one today. H-A stated her gown was being washed and she did not have any disposable gowns available in the laundry room.During observation and interview on 1/13/26 at 2:11 p.m., H-A was observed carrying resident clean laundry to resident's room while holding the laundry against her shirt. H-A was wearing the same shirt she wore while handling resident soiled laundry without a gown. H-A stated she did not normally carry clean resident clothing up against her own clothing. H-A stated that could cause the clean laundry to become contaminated and could be an infection control issue.During interview on 1/13/26 at 2:41 p.m., registered nurse (RN)-E also known as infection preventionist stated the facility should have signs, masks, and hand sanitizer at the entrance to the facility to prevent infection in the facility and promote proper infection control practices and was not sure why they were not there. RN-E further stated she could understand why a gown should be worn when handling soiled laundry and asked if it should be a cloth or disposable gown. RN-E stated handling soiled laundry without a gown and then handling clean laundry could be a cause for spread of infection. RN-E stated she would work with H-A to get her some gowns.During interview on 1/13/26 at 3:35 p.m. director of nursing (DON) stated she was made aware of the lack of signage, masks, and hand sanitizer and had already made sure they were put by the entrance. DON further stated she was not aware H-A had not been wearing a gown when handling soiled laundry and would have expected her to be wearing a gown for infection control purposes.Facility Infection Prevention and Control Program policy dated 8/30/23, indicated the infection prevention and control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection. In addition, personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

Based on interview and document review the facility failed to ensure follow-up of ordered diagnostic testing, review by the provider, or notification to the resident and/or family regarding results of an x-ray for 1 of 1 resident (R23) reviewed for pain. Findings Include:R23's quarterly Minimum Data Set (MDS) dated [DATE], indicated R23 had moderately impaired cognition, required partial/moderate assist for chair to bed transfer, sit to stand transfer, and toilet transfer; required substantial assistance with lower body dressing and toileting hygiene and diagnoses included Non-Alzheimer's Dementia and depression.R23's care plan dated 11/27/25, indicated experience pain/discomfort related to osteoarthritis; monitor for nonverbal indicators of discomfort such as restlessness, anxiety, change in ADL (activity of living) ability, guarding, or impaired cognition.R23's order history dated 1/6/26, indicated on 1/6/26 radiology right ankle, right foot. R23's progress note dated 1/7/26 at 2:04 p.m., indicated called on status of x-ray, x-ray company stated that they don't have coverage today for this area and tech will be out tomorrow to do.R23's x-ray result dated 1/8/26 at 11:18 p.m., indicated no acute bone abnormality. On 1/12/26 at 12:17 p.m., R23 was observed seated in her wheelchair in her room and stated she had an x-ray last week on Thursday for right leg pain and had not heard back regarding the results.On 1/12/26 at 6:00 p.m., R23 stated she still had not received x-ray results, did not know who to ask, and had not been followed up with. R23 verbalized ongoing right foot pain and uncertainty about her walking ability due to the pain.On 1/13/26 at 8:06 a.m., nurse practitioner (NP)-E stated R23 reported right foot pain the prior week and an x-ray had been ordered. NP-E confirmed she had not been contacted by the facility regarding x-ray results.On 01/13/2026 at 8:40 a.m., licensed practical nurse (LPN)-A stated R23 had an x-ray last week, and they thought R23's x-ray results came back showing a bone spur and did not know if the resident or family had been informed. LPN-A reviewed the electronic medical record and confirmed there was no documentation of receipt of results or notification to the provider or family.On 1/13/26 at 8:43 a.m., registered nurse (RN)-A, known as the nurse manager, stated she was not sure if R23's x-ray results had been received. RN-A confirmed progress notes did not show results or notifications and stated they would need to find out more information.On 1/13/26 at 11:27 a.m., RN-A stated the x-ray results were located that morning after calling the x-ray company. RN-A acknowledged this was not the first time x-ray results had not been received or had been misplaced. RN-A confirmed no documentation existed showing staff reviewed or communicated the results. RN-A stated she expected the resident and family to be notified and confirmed this was not reflected in the record. RN-A stated a delayed receipt could be a problem if something serious. RN-A described the facility's usual process: the physician orders the x-ray, the facility calls the x-ray vendor, and results are faxed to the facility to be reviewed, with nursing responsible for notifying the resident, family, and provider.On 1/13/26 at 11:50 a.m., during a follow-up interview, LPN-A stated during shift report she was told that R23 had completed an x-ray last week and that a bone spur was identified. LPN-A confirmed there was no documentation showing the x-ray results were communicated or acted upon. LPN-A stated she expected a progress note documenting review and notification. LPN-A described routine practice: reports print on the fax machine, nursing staff check the fax tray, and either provide the results to RN-A and notify the resident, family, and provider. LPN-A stated results are then placed in the provider folder for review unless urgent, in which case staff should call immediately.On 1/13/26 at 12:57 p.m., the director of nursing (DON) stated that when x-ray results are received by fax, nursing staff are expected to review them and notify the provider immediately if urgent, and if non-acute, notify the provider on the next business day. The DON stated she would expect staff to have addressed R23's x-ray results prior to today (1/13/26) and confirmed there should have been documentation reflecting review, follow-up, and notification. The DON stated the facility received x-ray reports both via the physical fax and email and nursing is responsible to ensure results are routed and acted upon.Facility Change in Condition, Resident Examination and Evaluation Facility Policy dated 11/10/25, indicated document symptom(s), assessment, observations, resident/resident representative, and medical provider notification.

Based on observation, interview and document review, the facility failed to ensure a gradual dose reduction (GDR) or a clinical justification of psychotropic medications was documented for 1 of 5 residents (R8) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 was sometimes understood and sometimes understands. R8 had severe cognitive impairment, and no mood or behavioral issues. R8 required maximal/substantial assistance with activities of daily living and is dependent on staff with transfers. R8 does not walk. R8's medication used included antipsychotic, antidepressant, antianxiety, anticonvulsant, anticoagulant and diuretic. R8's care plan dated 1/6/26, indicated use of psychotropic drug including antidepressant, antipsychotic, benzodiazepine (used to treat anxiety). Medications managed by psychiatry. Interventions included attempt a gradual dose reduction as indicated. R8's Physician Order Report dated 1/12/26, included the following psychotropic medications: aripiprazole (antipsychotic) 15 milligram (mg), 1/2 tablet orally once a morning for major depressive disorder, single episodedesvenlafaxine succinate (antidepressant) extended release 100 mg oral once a morning for major depressive disorder, single episodealprazolam (antianxiety) 0.25 mg orally twice a day for anxiety. Consultant Pharmacist Recommendation to Physician dated 7/2025, indicated R8 had been taking aripiprazole 7.5 mg every day since 9/23 without a GDR. Could we attempt a dose reduction to perhaps 5 mg every day to verify this resident is on the lower possible dose. The response was left blank. R8's provider note dated 8/12/25, by nurse practitioner (NP)-G indicated most recent PHQ-9 score was 0 indicating no depression. The progress note did not include a pharmacy request for gradual dose reduction (GDR), deferral to psychiatry to address the request or rationale to continue current psychotropic medications. R8's medical record review indicated R8's last documented behavioral issue was 6/1/25, when R8 was upset with nursing assistant (NA) yelling get out, get out and don't come back. R8's progress note dated 10/7/25 at 3:53 p.m., by social services (SS)-A indicated observations completed with no delirium noted and no changes. R8's psychiatry note dated 10/9/25, included last AIMS score (abnormal involuntary movement scale used to evaluate movements for patients taking neuroleptic medications {antipsychotic} was 4 (indicates severe abnormal movements), up one point from previous. Consultant Pharmacist recommendation to physician dated 11/2025, indicated R8 had been taking desvenlafaxine 100 mg every day since 9/23 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose. The resident has been taking alprazolam 0.25 mg twice a day since 4/24 without a GDR. Could we attempt a dose reduction to perhaps 0.25 mg at bedtime to verify this resident is on the lower possible dose. R8's progress note dated 12/12/25, by nurse practitioner (NP)-D included R8 has severe cognitive impairment without depression as recent PHQ-9 (depression scale) score was 0. Orders and plan included depression screening was reviewed. The progress note did not include pharmacy request for gradual dose reduction (GDR), deferral to psychiatry to address the request or rationale to continue current psychotropic medications. R8's AIMS observation report indicated on 12/29/25 at 2:41 p.m. registered nurse (RN)-F completed the observation with a score of 4, which was unchanged. R8's progress note dated 1/5/26 at 1:50 p.m., by social services (SS)-A indicated R8 was intermittently dozing off, requiring gentle physical redirection to maintain engagement. R8 reported no mood concerns. During observation and interview on 1/12/26 at 4:09 p.m., R8 was sitting in chair in her room with the television on. R8 answered yes and no questions. R8 denied any side effects from her medications and denied any anxiety or depression at this time. On 1/13/26 at 12:53 p.m., pharmacist (P)-F indicated that GDR's are important, they aren't urgent needing to be done immediately but they do need to be addressed by a provider at the next visit to ensure resident is on the lowest possible dosage of medication. On 1/13/26 at 2:10 p.m., RN-E, also identified as case manager, stated the local provider wants these requests sent to the psychiatry office but she never receives an answer back from them. RN-E stated in 10/2024, psychiatry, family and medical provider agreed to continue the medications and not attempt a GDR but confirmed a GDR has not been discussed since that time. RN-E stated she had not attempted to reach psychiatry with 7/25 and 11/25 requests. RN-E stated the local provider should have seen the GDR request at the 12/25 visit but the medical record lacked evidence the provider saw the request or deferred to psychiatry. On 1/13/26 at 3:40 p.m., the director of nursing (DON) stated she would expect pharmacy recommendations to be addressed within the next month of the recommendation but sometimes it can take longer if it is deferred to psychiatry. The DON stated if psychiatry isn't responding to facility requests, she should be notified so it can be addressed and a note should be present in the medical record indicating attempts to reach psychiatry. Attempt made to reach NP-D and psychiatry without success. Facility Psychotropic Medication Use policy dated 9/7/23, included: Psychotropic medications are given upon a medical provider order. The nursing associates collaborate with the medical provider to ensure the lowest possible dosage is given for the shortest period of time and are subject to gradual dose reductions and re-reviewPsychotropic medications are ordered by the medical provider to treat a specific condition as diagnosed and documented in the medical record.Gradual Dose Reduction (GDR) begins within the first year in which a resident is admitted with or is newly prescribed a scheduled psychotropic medication. GDR is attempted in two separate quarters (with at least one month between the attempts), unless clinically contraindicated and documented by the medical provider. Contraindications may include:The continued use is in accordance with relevant current standards of practice and the medical provider has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; orThe resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the medical provider has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.The IDT team monitors the resident condition and target behaviors for efficacy of the medications and any clinically significant adverse consequences. Documentation will reflect implementation of the above.

Based on observation, interview, and document review, the facility failed to ensure a new intervention was followed to prevent further falls for 1 of 2 resident (R51) reviewed for fall with major injury.Findings include:R51's face sheet printed 1/13/26, indicated diagnoses of femur fracture, dementia, muscle weakness, and unsteadiness on feet.R51's annual Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, no upper or lower extremity impairment, use of walker, partial/moderate assistance with upper and lower body dressing, supervision with personal hygiene, independent with transfers, independent with walking 150 feet.R11's care plan dated 12/8/25, indicated at risk for falls due to diagnoses, impaired mobility, weakness, impulsivity, poor safety awareness, history of fall with left hip fracture-tripped over equipment in the hallway while ambulating independently. Provide with an environment free of clutter. Due to constant ambulating around the unit and history of sticking to pattern when walking fall was unavoidable. Since event resident ambulating per usual.Facility progress note documented by registered nurse (RN)-B dated 12/5/25, indicated R51 found on the floor in the hallway lying of left side. R51 stated he had been on the way to the bathroom and got caught up on something. Note further indicated R51's walker became caught on vitals machine, had been against the wall in the hallway. R51 attempted to back up after the walker became caught and subsequently fell. R51 had left hip and upper leg pain with left knee appearing externally rotated. R51 transferred to emergency department and diagnosed with left femur fracture.Facility progress note documented by RN-C dated 12/8/25, indicated R51 returned from hospital following left hip repair.Facility event note documented by RN-B dated 12/5/25, indicated R51 fell in hallway, landed on left side. Following the event, the fall was determined to be related to an environmental hazard combined with R51's cognitive impairment. A vitals machine had been positioned along the hallway wall in R51's usually walking path, causing his walker to become caught and resulting in loss of balance. Resident is highly ritualistic and the presence of a new object in his customary route disrupted his established routine and contributed to the incident. Environmental hazard removed and to be kept in alternate location.During observation on 1/12/26 at 4:15 p.m., R51 was on his bed in his room. A vitals machine on wheels was plugged in along the wall in the hallway directly outside his room.During observation on 1/13/26 at 8:23 a.m., R51 was seated in dining room. Vitals machine was plugged into the wall in the direct path to his room.During interview on 1/13/26 at 8:57 a.m., RN-D stated she was unaware the vitals machine was not supposed to be plugged in near R51's room. RN-D stated she worked five days per pay period and may have missed the message about that intervention. RN-D further stated fall interventions were normally place in a binder at the nurses' station or told in report.During interview on 1/13/26 at 9:02 a.m., nursing assistant (NA)-A stated she was aware of fall interventions for R51 and that the vitals machine should not be in the hallway. NA-A stated she did not know where to find new fall interventions but knew to ask the nurse if anything changed after a fall. NA-A stated communication was poor at the facility.During interview on 1/13/26 at 9:04 a.m., NA-B stated she was unaware of specific interventions for R51 but knew that new fall interventions were put in a binder at the nurses' station and staff had to initial to indicate they had read them.During interview on 1/13/26 at 9:08 a.m., RN-E also known as case manager stated the vitals machine should not have been in the hallway because that was determined to be the cause of his fall and could cause more falls for R51 or other residents. RN-E further stated R51 was not walking as much as he used to after his fall but could improve and be at risk again for falls. R51 stated fall interventions were put in a binder at the nurses' station for staff to review and sign off on. R51 showed the binder and that the fall intervention for removing the vitals machine from the hallway had not been put in the binder. RN-E could not find a sign off sheet to show staff had been made aware of the new intervention after the fall.During interview on 1/13/26 at 3:35 p.m., director of nursing (DON) stated she expected fall interventions to be followed and staff to be made aware of new fall interventions to prevent additional falls.Facility Integrated Fall Management policy dated 9/23, indicated residents are assessed for their risk of falls upon admission, significant change, and quarterly. Residents with risk for falling will have interventions implemented through the resident centered care plan. Post fall the environment of the fall is evaluated for possible contributing factors and addressed. The interdisciplinary team reviews the fall and may implement additional interventions. Documentation of the above is completed.

Based on observation, interview and document review, the facility failed to ensure required nursing staffing information, specifically registered nurse (RN) hours, were posted for residents, staff and visitors. This had the potential to affect all 67 residents residing in the facility and their visitors.Findings include:During an interview on 1/13/26 at 11:13 a.m., nursing staffing was reviewed with the director of nursing (DON) who stated there was a licensed nurse on duty 24/7 and at least one registered nurse (RN) on duty for eight consecutive hours each day. During an observation on 1/13/26 at 11:35 a.m., the daily staffing posting, located on the wall next to the entrance to the administrative offices was reviewed. It was not clear by the information posted there had been an RN on duty. Information listed on the posting included the various nursing position, hours worked and number of staff. For 1/13/26, the daily staffing posting indicated: DAY SHIFT: 6:00 a.m. to 6:30 p.m.LN/RN - 1RN - 0RN/LPN/TMA - 3TMA - 0TMA - 0NAR - 6NAR - 2EVENING SHIFT: 2:00 p.m. to 10:30 p.m. RN - 0LPN/RN - 3TMA -1NAR - 4NAR/TMA - 2NAR - 0NIGHT SHIFT: 6:00 p.m. to 6:30 a.m.RN - 0LPN/RN/TMA - 1LPN/RN - 2TMA - 0NAR - 2NAR - 2Each shift listed RN several times, either singularly, or along with LN, LPN, TMA. Each time RN was listed singularly, the number of staff indicated was zero. During an interview on 1/13/26, at 11:38 a.m., together with the DON, the staffing coordinator (SC)-B and the health information coordinator (HIC)-C looked at the posting. They agreed, one could not tell if there had been an RN scheduled to work that day. HIC-C stated she was responsible for the form and for filling it out and would make the necessary changes to reflect individual RN hours. In addition, SC-B admitted she did not adjust the form for staff absences due to call outs or illness.Nursing staffing posting forms were reviewed for the prior months of November and December 2025, and for January 2026, verifying an RN was not identified as working nor were staffing adjustments noted. Nursing staff schedules were reviewed for October, November, December 2025, and January 2026, which indicated there had been at least one RN scheduled to work each day. Facility Posting of Nursing Hours policy with review date of 9/20/22, indicated the purpose was to provide the number of direct care associates available during any given shift. At the beginning of each shift, the number of licensed nurses, including registered nurses (RN), licensed practical nurses (LPN) and licensed vocational nurse (LVN) and the number of unlicensed nursing associates - certified nursing assistants (CNA), directly responsible for resident care would be posted in a prominent location that was accessible to residents and visitors and in a clear and readable format. Schedule would be amended as schedule changed. Shift staffing information would be recorded for each shift. The information included the facility name, the date for which the information was posted, the resident census at the beginning of the shift for which the information was posted, twenty-four hour shift schedule, the shift for which the information is posted, the type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift, the actual time worked during that shift for each category and type of nursing staff, total number of licensed and non-licensed nursing staff working for the posted shift.

Based on document review and interview, the facility failed to identify diagnoses/indication for use of medications for 5 of 5 residents (R37, R48, R59, R67, R42) reviewed for unnecessary medications. Findings include: R37's admission MDS dated [DATE], indicated moderately impaired cognition, required substantial/maximal assistance with personal hygiene, and had behaviors including significantly disrupting the environment, wandering, verbal and physical behaviors. R37's care plan dated 9/26/24, indicated a potential to experience pain/discomfort but currently denies pain. An alteration in mood/behavior/symptoms related to new admission, dementia, anxiety, depression psychotic disturbance, aphasia, delirium, accusatory statements, pushing/pulling;throwing environmental objects at peers and staff, refusal of care. An additional plan of care indicated R37 receives psychotropic medications, antixolytic, antidepressant and antipsychotic medication. R37's Physician Order Report dated 9/25/24 - 11/25/24, included the following medications but lacked indication for use or diagnosis: - acetaminophen [OTC] tablet, 500 mg twice a day - aspirin tablet delayed release 81 mg oral once a morning - atorvastatin 40 mg at bedtime - magnesium oxide 250 mg at bedtime - metoprolol tartrate 25 mg twice a day R37's Medication Administration Record (MAR) also lacked indication for use and administration of above medications. 50764 R48's admission MDS assessment dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with dressing and toileting, partial/moderate assistance with bathing and personal hygiene, and diagnoses of renal failure, diabetes, arthritis, and dementia. R48's care plan dated 10/29/24, indicated psychotropic medications which placed R42 at risk for adverse reactions with interventions of attempting gradual dose reductions, non-pharmacological interventions, and monitoring for side effects. R48's Physician Order Report printed 10/30/24, included the following medications that lacked indication for use or diagnosis: -acetaminophen tablet, 500 mg four times per day -aspirin tablet, 81 mg daily -atorvastatin tablet, 20 mg daily -dapagliflozin propanediol tablet, 5 mg daily -donepezil tablet, 5 mg daily at bedtime -famotidine tablet, 40 mg daily at bedtime -ferrous sulfate tablet, 65 mg daily -finasteride tablet, 5 mg daily -Humalog KwikPen, 8 units three times per day -Lantus Insulin, 50 units at bedtime -meclizine tablet, 25 mg as needed -metformin tablet, 1000 mg twice per day -metoprolol tartrate tablet, 12.5 mg twice per day -Miralax, 17 gram daily -multivitamin tablet, daily R48's Medication Administration Record (MAR) also lacked indications for use and diagnoses for above medications. R59's quarterly MDS assessment dated [DATE], indicated no cognitive impairment, impairment of upper and lower extremities, use of wheelchair, substantial/maximal assistance with toileting, bathing, dressing, transfers, and diagnoses of dementia and Parkinson's disease. R59's care plan printed 10/30/24, indicated high risk medications placing R59 at risk for adverse reactions. Interventions included administering medications per physician order, observing for side effects of medications, and reporting indications of intolerance. R59's Physician Order Report printed 10/30/24, included the following medications that lacked indication for use or diagnosis: -acetaminophen tablet, 1000 mg three times per day -bisacodyl suppository, 10 mg as needed -carbidopa-levodopa tablet, 25-100 mg three times per day -ketoconazole 2% shampoo, one time per week -Miralax, 17 gram daily -morphine solution, 5 mg every four hours as needed -Senna Plus tablet, 8.6-50 mg daily at bedtime R59's Medication Administration Record (MAR) also lacked indications for use and diagnoses for above medications. R67's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, use of wheelchair, partial/moderate assistance with bathing, toileting, dressing, and diagnoses of hypertension (high blood pressure), renal failure, and dementia. R67's care plan printed 10/30/24, indicated psychotropic medications which placed R67 at risk for adverse reactions. Interventions included administering medication per physician's orders, monitoring for antipsychotic side effects, attempting gradual dose reductions, and attempting non-pharmacological interventions. R67's Physician's Order Report printed 10/30/24, included the following medications that lacked indication for use or diagnosis: -acetaminophen tablet, 500 mg three times per day and 1000 mg at bedtime -amlodipine tablet, 2.5 mg daily -aspirin tablet, 81 mg daily -carvedilol tablet, 3.125 mg twice per day -Senna-S tablet, 8.6-50 mg daily R67's Medication Administration Record (MAR) also lacked indications for use and diagnoses for above medications. 44630 R42's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with personal hygiene, and diagnoses of Alzheimer's disease and atrial fibrillation (heart arrhythmia). R42's care plan dated 10/29/24, indicated high risk medications which place R42 at a high risk for adverse reactions: anticoagulant (blood thinner); administer anticoagulant as ordered by MD/NP (medical doctor/nurse practitioner) R42's Physician Order Report dated 9/30/24-10/30/24, indicated warfarin (blood thinning medication) tablet; 2.5 mg (milligram), once an evening and lacked diagnosis or indication for use. R42's Medication Administration Record (MAR) dated 10/1/24-10/30/24, indicated warfarin tablet 2.5 mg once an evening, and lacked diagnosis or indication for use. On 10/30/24 at 10:05 a.m., director of nursing (DON) stated resident's medications were expected to have a indication or diagnosis on the MAR and provider orders to ensure staff knew the indication for the medication. The DON confirmed R42's MAR and physician orders lacked diagnosis or indication for the warfarin. On 10/30/24 at 11:04 a.m., the consulting pharmacist (CP)-C stated the provider was responsible to attach a diagnosis to the medication order, and stated if a medication order did not have a diagnosis the facility should contact the provider. CP-C stated an indication for each medication was expected in the electronic medical record (EMR) for each medication order. The facility Administering Medications policy dated 8/31/23, indicated To ensure safe administration of resident's medication as indicated and ordered by the provider. Policy: To administer resident medications in a safe and accurate manner that will ensure the 6 rights of patient indication for administration.

Based on observation, interview, and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 8 residents (R15) reviewed for medication administration. Finding include: R15's Face Sheet printed 10/30/24, indicated diagnoses of unspecified dementia, muscle weakness, anxiety disorder, and essential primary hypertension (high blood pressure). R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, use of a wheelchair, and substantial assistance required for dressing, bathing, and hygiene. R15's care plan printed 10/30/24, indicated self-care deficit related to dementia with goal of maintaining current abilities and safety. R15's physician's orders dated 10/29/24, indicated an order for metoprolol succinate tablet extended release 25 mg tablet (blood pressure medication) daily for high blood pressure. During observation on 10/29/24 at 8:02 a.m., trained medication aide (TMA)-A prepared medications for administration to R15. TMA-A crushed acetaminophen 500 mg tablets, escitalopram 15 mg tablet, magnesium 400 mg tablet, senna-docusate 50-8.6 mg tablet, and metoprolol succinate extended release 325mg tablet for ease of swallowing for R15. During interview on 10/29/24 at 8:05 a.m., prior to administration of medication to R15, TMA-A verified she had been crushing R15's metoprolol succinate extended release tablet for quite some time due to R15's difficulty swallowing multiple pills and intended to administer metoprolol succinate tablet crushed. TMA-A further verified there was no order to crush metoprolol succinate extended release tablet. TMA-A verified with registered nurse (RN)-A that metoprolol succinate extended release tablet could not be crushed and disposed of crushed medication mixture. During interview on 10/29/24 at 8:54 a.m., RN-A stated there should be an order for crushing medications. RN-A stated sometimes staff will start crushing medications without an order due to residents not being able to take them whole. RN-A further stated R15 did not have an order to crush medications and metoprolol succinate extended release tablets should not have been crushed due to medication being extended release. During interview on 10/30/24 at 10:34 a.m., director of nursing (DON) stated metoprolol succinate extended release tablet should not have been crushed and would expect an order to crush medications for R15 if her medications were being crushed. During interview on 10/30/24 at 11:04 a.m., consulting pharmacist (CP)-A stated metoprolol succinate extended release was not expected crushed, and stated crushing of the extended release tablet interferes with the disbursement of the medication and disrupts the medication's intended use. The facility Administering Medications policy reviewed 8/31/23, included the following: Medications are administered in accordance with the orders. .

Based on observation, interview, and document review the facility failed to provide treatment/services to maintain optimal visual abilities for 1 of 1 resident (R2) reviewed for vision. Findings include: R2's diagnoses included dizziness and giddiness, anemia, and type 2 diabetes. R2's admission minimum data set (MDS) dated [DATE], indicated adequate vision with glasses or other visual appliances and R2 has corrective lenses (contacts, glasses, or magnifying glass). R2's care plan dated 9/12/24, indicated R2 will be provided adaptive equipment/materials as needed for effective communication. On 10/28/24 at 11:31 a.m., during observation R2 was not wearing eyeglasses. On 10/29/24 at 9:14 a.m., during observation R2 was not wearing eyeglasses. On 10/28/24 at 11:32 a.m., during interview R2 stated eyeglasses need to be adjusted since they keep sliding down R2's nose. R2 stated staff were notified at the end of September and the eyeglasses have not been adjusted. On 10/29/24 at 9:15 a.m., during interview NA-A stated R2 does wear glasses and R2 asked for them to be adjusted. NA-A stated R2's concern was discussed with the unit manager a while ago and unsure if R2's glasses were ever adjusted. On 10/29/24 at 9:24 a.m., during interview licensed practical nurse (LPN)-B stated she is not sure if R2 wears glasses but did mention last week that R2 would like the eyeglasses fixed. R2 mentioned to LPN-B that R2 wanted to have eyeglasses adjusted and LPN-B told R2 she would inquire how to get the glasses adjusted. LPN-B stated eyeglasses need to be adjusted outside the facility. LPN-B stated she informed R2 that he needs an outside appointment, and the RN case managers helps with coordinating appointments. On 10/29/24 11:01 a.m., during interview registered nurse (RN)-A stated she was made aware that R2's eyeglasses need to be adjusted and stated, I might have just forgot about it. RN-A stated she will help coordinate an appointment and transportation to have R2's eyeglasses adjusted. A facility policy addressing vision/eye glasses needs was requested but not received.

Based on document review and interview, the facility failed to identify diagnoses/indication for use of medications for 2 of 5 residents (R37, R59, R67) reviewed for unnecessary medications. Findings include: R37's admission MDS dated [DATE], indicated moderately impaired cognition, required substantial/maximal assistance with personal hygiene, and had behaviors including significantly disrupting the environment, wandering, verbal and physical behaviors. R37's care plan dated 9/26/24, indicated a potential to experience pain/discomfort but currently denies pain. An alteration in mood/behavior/symptoms related to new admission, dementia, anxiety, depression psychotic disturbance, aphasia, delirium, accusatory statements, pushing/pulling;throwing environmental objects at peers and staff, refusal of care. An additional plan of care indicated R37 receives psychotropic medications, antixolytic, antidepressant and antipsychotic medication. R37's Physician Order Report dated 9/25/24 - 11/25/24, included the following psychotropic medications but lacked indication for use or diagnosis except quetiapine: - buspirone 5 mg tablet twice a day - quetiapine 50 mg once a morning for delusional disorder R37's Medication Administration Record (MAR) also lacked indication for use and administration of above medications 50764 R59's quarterly MDS assessment dated [DATE], indicated no cognitive impairment, impairment of upper and lower extremities, use of wheelchair, substantial/maximal assistance with toileting, bathing, dressing, transfers, and diagnoses of dementia and Parkinson's disease. R59's care plan printed 10/30/24, indicated high risk medications placing R59 at risk for adverse reactions. Interventions included administering medications per physician order, observing for side effects of medications, and reporting indications of intolerance. R59's Physician Order Report printed 10/30/24, included the following medications that lacked indication for use or diagnosis: -sertraline tablet, 125 mg daily at bedtime R59's Medication Administration Record (MAR) also lacked indications for use and diagnoses for above medications. R67's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, use of wheelchair, partial/moderate assistance with bathing, toileting, dressing, and diagnoses of hypertension (high blood pressure), renal failure, and dementia. R67's care plan printed 10/30/24, indicated psychotropic medications which placed R67 at risk for adverse reactions. Interventions included administering medication per physician's orders, monitoring for antipsychotic side effects, attempting gradual dose reductions, and attempting non-pharmacological interventions. R67's Physician's Order Report printed 10/30/24, included the following medications that lacked indication for use or diagnosis: -buspirone tablet, 5 mg twice per day -Lexapro tablet, 20 mg daily R67's Medication Administration Record (MAR) also lacked indications for use and diagnoses for above medications. On 10/30/24 at 10:05 a.m., director of nursing (DON) stated resident's medications were expected to have a indication or diagnosis on the MAR and provider orders to ensure staff knew the indication for the medication. On 10/30/24 at 11:04 a.m., the consulting pharmacist (CP)-C stated the provider was responsible to attach a diagnosis to the medication order, and stated if a medication order did not have a diagnosis the facility should contact the provider. CP-C stated an indication for each medication was expected in the electronic medical record (EMR) for each medication order. The facility Administering Medications policy dated 8/31/23, indicated To ensure safe administration of resident's medication as indicated and ordered by the provider. Policy: To administer resident medications in a safe and accurate manner that will ensure the 6 rights of patient indication for administration.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was completed for 2 of 8 residents (R23 and R127) observed for medication administration. Finding include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, required supervision with personal hygiene. R23's care plan dated 9/4/24, indicated staff to apply gloves and gowns prior to facility-identified high-contact care activities, discard PPE in designated location following activities, and sanitize hands after PPE removal. R127's face sheet dated 10/30/24, indicated R127 was admitted [DATE], with diagnoses including left femur (hip) fracture and fracture of shoulder. On 10/28/24 at 7:03 p.m., licensed practical nurse (LPN)-D entered R23's room with eye drops, lidocaine (prevent and to treat pain) bottle, medication cup with apple sauce, and medication cup with a pill. LPN-D placed gloves on both hands and administered R23's eye drops to both eyes, used the lidocaine bottle and rolled on the lidocaine on R23's right shoulder, then placed a pill on the spoon and used apple sauce and administered R23's pill. LPN-D exited the room and walked to the medication storage area, removed gloves, used keys to unlock the medication storage drawers, and returned the eye drops and lidocaine to the medication drawer. LPN-D was further observed to place the medication cup with applesauce and spoon uncovered in the medication drawer. LPN-D stated the applesauce was placed in the drawer to use later for R23's administration of Tylenol. LPN-D was not observed to complete hand hygiene or disinfect hands during or after R23's medication administration. At 7:12 p.m., LPN-D entered the other side of Eagle wing medication area and was observed to prepare R127's medications, and then entered R127's room and failed to complete hand hygiene prior to entering R127's room. LPN-D was observed to hand R127 a medication cup with pills. R127 asked for more water in her water insulated uncovered mug and LPN-D with bare hands grabbed the mug and exited R127's room, entered the dining area and used the water dispenser to place water in the insulated mug, LPN-D reentered R127's room used bare hands and touched the top of the lid to push down the lid and attached the lid to the mug. LPN-D exited the room and walked to the medication storage cabinets and used a sink and washed her hands. LPN-D did not sanitize her hands during the entire medication pass. On 10/28/2424 at 7:27 p.m., LPN-D confirmed hand hygiene was not completed during the medication pass with R23 and R127. LPN-C stated it was not her normal process to perform hand hygiene when gloves were used. LPN-A confirmed hand hygiene was expected prior to R127's lid placed on the water mug. On 10/29/24 at 11:58 a.m., registered nurse (RN)-B, known as the nurse manger, stated staff were expected to complete hand hygiene after glove removed and prior to entering or exiting resident's room, and prior to the next medication administration. On 10/29/24 at 2:39 p.m., RN-A, known as infection preventionist nurse, and director of nursing (DON) stated staff were expected to perform hand hygiene before and after medication pass, between resident contact, and entering in and out of resident rooms. The facility Hand Hygiene policy dated 9/23, indicated: Infection Prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the residents. Times to Perform Hand Hygiene are, but not limited to: Before and after direct resident contact. The facility Administering Medications dated 8/31/23, indicated: Staff follows established infection control procedures for the administration or medications.

Based on observation, interview and document review, the facility failed to ensure 1 of 2 residents (R65) reviewed who was observed to have medications at the bedside, had been appropriately assessed and deemed appropriate to self-administer medications. Findings include: R65's Admission Record printed 10/30/24, identified diagnoses including cerebral infarction (stroke), muscle weakness, chronic kidney disease, and vascular dementia. R65's admission Minimum Data Set (MDS) assessment dated [DATE], identified admitted [DATE], moderately impaired cognition, impairment to both upper and lower extremities, dependent on staff for personal hygiene and transfers. R65's care plan dated 9/22/24, included goals of maintaining general orientation to person, place, and time, receiving appropriate assistance with business matters and decisions, and no adverse reactions to medications. R65's Physician's Order Report printed 10/30/24, identified an order for Artificial Tears 0.1%-0.3% (eye lubricant), one drop to both eyes twice per day. During observations on 10/28/24 at 2:33 p.m., and 7:09 p.m., 10/29/24 at 9:10 a.m., 1:05 p.m., and 3:43 p.m., an individual bottle of Systane eye drops (eye lubricant) was on top of R65's bedside table and within reach of R65, who was present in his bed. During interview on 10/29/24 at 3:45 p.m., registered nurse (RN)-D stated R65 did not have an order for self-administration of medications listed in his chart and should not have had Systane eye drops in his room without a physician's order for self-administration. During interview on 10/29/24 at 4:02 p.m., registered nurse (RN)-A, also known as nurse manager, stated she expected Systane eye drops to be in the medication cart, and they should not have been in R65's room without an assessment and order for self-administration of medications. RN-A further stated R65 did not have an assessment completed or a physician's order for self-administration of medications and the Systane eye drop should have been removed from the room. During interview on 10/30/24 at 12:24 p.m., director of nursing (DON) stated she would expect an assessment completed for self-administration of medication and a physician's order for self-administration prior to medications being left in R65's room. DON further stated an assessment should have been completed to ensure R65 was safe to have medications at bedside. Facility Self-Administration of Medications policy and procedure undated, included: Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe. The nurses will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Assessment is documented in the electronic medical record (EMR).

Based on interview and document review the facility failed to provide and evaluate the effectiveness of physician ordered respiratory cough stimulator treatment (machine used to simulate a cough to help person clear mucus from lungs) for 1 out of 1 resident (R1) reviewed who required respiratory care. Findings include: R1's Admission Record identified R1 had diagnoses of amyotrophic lateral sclerosis (ALS)-(a disease that affects nerve cells in the brain and spinal cord. Symptoms can begin in the muscles that control speech & swallowing or in the extremities) and dyspnea (difficulty breathing). R1's department of Neurology order dated 8/16/22, identified R1 had an order for durable medical equipment (DME) cough stimulating device, alternating positive and negative pressure. Order included: Synclara Device to be set for effectiveness and comfort with suggested pressure setting of 35 inspiratory and 2 inspiratory time with same setting and time for expiratory pressures and time delivered by mask. If well, perform treatment two times a day 10 cycles and if ill, perform treatment four times a day and as needed for as many cycles as needed to clear mucus. Other forms of airway clearance are not an option because of the decreased expiratory flow and patient intolerance. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, was dependent on staff for all ADL's but was independent with wheeling self once seated in wheelchair/scooter. MDS indicated R1 had 1 to 3 days of verbal behaviors directed towards others during the assessment period. R1's care plan dated 12/29/23, indicated R1 was at risk for ineffective airway clearance and significant respiratory distress related to ALS and overall functional decline need of cough assist machine, Bipap, oxygen, oral cares to remove excess secretion from mouth. Resident has specific preferences with positioning during use of cough assist, and bed mobility. Resident has a history of refusing interventions to promote good respiratory health. Approach dated 12/29/23 monitor for signs of hypoxia. 12/29/23 monitor for signs of respiratory distress. 12/29/23 use cough assist as per provider order. R1's physician orders dated 11/10/23 and 12/6/24, included: cough assist machine, special instructions: Please watch video prior to first administration. Https://youtu.be/-zls-Y9ParY. Hold mask to face and hold back of head firmly. After 8 cycles the machine will stop, then clean my mouth out with the toothettes and a cloth/tissue. (Diagnosis: amyotrophic lateral sclerosis) Twice a day Mornings 5:00 a.m. -7:00 a.m. Bedtime 9:00 p.m.-11:30 p.m. R1's care plan nor physician orders identified the settings for the cough assist machine. R1's medication administration record (MAR) dated 11/15/23-11/30/23, included the aforementioned order. The documentation indicated R1 was not administered the treatment on the morning of 11/22/23; R1's record did not include why the treatment was not administered. R1's December 2023 indicated R1 was not administered the breathing treatment seven (7) times during the month; the missed treatments did not include the occurrences that R1 refused. -On 12/1/23, a.m.) not administered as R1 was away getting a bath. Documentation did not identify if the treatment was later offered. -On 12/6/23, p.m. documented resident refused, however did not identify why R1 refused or if a subsequent attempt was made. -On 12/7/23, a.m. no documentation of administration or reason for omission. -On 12/10/23, a.m. no documentation of administration or reason for omission. -On 12/12/23, a.m. documentation of refusal, however, did not identify why R1 refused or if a subsequent attempt was made. -On 12/13/23, a.m. no documentation of administration or reason for omission. -On 12/14 /24 a.m., no documentation of administration or reason for omission. -On 12/18/23, the a.m. treatment indicated R1 declined. Evening (p.m.) documentation indicated R1 attempted to do cough assist machine but when machine was started, he became upset. The record did not identify how much of the treatment was completed. -On 12/19/23, a.m. not administered reproached before lunch and apologized for not getting back to him earlier to complete and he refused. -On 12/22/23, a.m. no documentation of administration or reason for omission. -On 12/27/23, a.m. no documentation of administration or reason for omission. -On 12/28/23, a.m. no documentation of administration or reason for omission. -On 12/29/23, a.m. not administered R1 refused offered times 4 and refused times 3. R1's January 2024 MAR R1 was not administered the breathing treatment seven (7) times during the month, not including the occurrences when R1 refused. -On 1/8/24, a.m. documented resident refused. Corresponding progress note dated 1/18/24 at 6:48 a.m. included, cough assist stopped mid cycle, resident wanted a different position. Second attempt also stopped by resident verbalizing it was the same and resident refused to try again. -On 1/11/24, a.m. no documentation of administration or reason for omission. -On 1/12, /24 a.m. R1 refused. -On 1/15/24, a.m. no documentation of administration or reason for omission -On 1/18/24, p.m. documented as not needed. -On 1/18/24, a.m. documented as not needed. -On 1/23/24, a.m. documented as completed by other staff not writer. -On 1/24/24, a.m. no documentation of administration or reason for omission. -On 1/25/24, a.m. no documentation of administration or reason for omission. R1's nursing notes reviewed in conjunction with the MAR between 1/6/24 and 2/3/24, identified inconsistent documentation of assessment/evaluation of the effectiveness and tolerance of the cough assist treatment for both scheduled administrations. Examples included but were not limited to: -On 1/5/24, 1/6/24, and 1/7/24 no indication of a completed evaluation for effectiveness and tolerance. -On 1/8/24, at 5:31 p.m. progress note indicated cough assist was not done in the morning because R1 did not need it or request throughout the shift, even though the physician order directed twice a day treatment. -On 1/9/24 and 1/10/24, there was no indication of completed evaluation for effectiveness or treatment. -On 1/11/24 at 6:38 p.m. the progress note indicated cough assist was not done in the morning because the nurse not asking if R1 needed it and R1 did not request the treatment. -On 1/12/24, progress notes indicated R1 refused the morning treatment; notes did not identify if the treatment was later offered. There was no documentation for the evening administration. -On 1/13/24, 1/14/24, and 1/15/24, no indication of completed evaluation for effectiveness and tolerance. -On 1/16/24 at 1:42 a.m. note indicated cough assist done, has clear-whitish secretions, note at 7:37 p.m. indicated R1 was short of breath today and reported he was short of breath all the time. No indication cough assist was attempted, or respiratory assessment completed. -On 1/18/24, at 6:48 a.m. indicated the cough assist stopped in mid cycle, R1 wanted it in a different position. Second attempt was also stopped by R1 verbalizing it was still the same. R1 refused to try again. -On 1/19/24 at 3:33 p.m. Covid test was positive. Progress notes did not identify the use of cough assist. -On 1/20/24, no indication of a completed evaluation for effectiveness and tolerance. -On 1/23/24 at 8:18 a.m. resident became irritated while nurse was placing mask for cough assist. The treatment was not administered. -On 1/24/24 and evening shift 1/25/24, no indication of a completed evaluation for effectiveness and tolerance. -On 1/26/24, progress notes indicated R1 had rubs in his right middle lob and crackles in bilateral bases. He doesn't feel like he has any more sputum production. Difficult to clear secretions. Color is white/yellow. R1 has occasional shortness of breath. Notes did not indicate cough was used. -On 1/27/24 and 1/28/24, there was no indication of completed evaluation for effectiveness or treatment. During an interview on 2/6/24, at 10:40 a.m., R1 stated staff who would get him ready in the morning often forgot to do the cough assist unless he reminds them. During on interview on 2/7/24, at 11:56 a.m. family member (FM)-A stated she had concerned that cough assist was not being completed at the facility. FM-A stated R1 had covid positive test and she had asked to facility to provide extra cough assist during that time and was informed by R1 that it had not been getting done as well as she had a c.m. in the room and was observing that it had not been done. FM-A stated on 1/28/24 they had called the facility around 7:00 p.m. and asked for a nurse to go and help provide R1 with cough assist and to bed. FM-A stated no one went and assisted him until around 11:00 p.m. During an interview on 2/6/24 at 12:27 p.m. NA-A stated she has administered R1's cough assist and has been asked by nurses to complete it because the nurse didn't know how. NA-A stated about a week ago she provided cough assist to R1 because he was up and needed it, so she just did it. NA-A explained she could tell if the treatment was effective if there was secretions in the mask and R1 would tell her it was effective. During an interview on 2/8/24, at 9:33 a.m. nursing assist (NA)-C stated he was the one who has provided R1 with cough assist when he was working. He stated if he was not at the facility, he knew that it usually was not getting done. NA-C stated R1 informed him that only 4 people knew how to do the cough assist correctly and he was one of the few. During an interview on 2/8/24 at 9:33 a.m. NA-C stated he has worked with R1 for a little over two months and was trained to use the cough assist by a previous NA who had worked with R1. NA-C stated he has provided the cough assist to R1 at least 20 times since he has started working with him and knows of only one nurse who has provided R1 with the cough assist while he was working. NA-C stated he would not know how to complete a respiratory assessment and did not know what all was involved as he was not a nurse and did not go to school for that. He stated he would inform the nurses he had completed the cough assist and figured the nurses knew what to do. NA-C did not know what settings the machine should be on, or if the settings were correct as he would just turn the machine on and R1 would let him know if it was working correctly or not. During an interview on 2/6/24 at 2:29 p.m. registered (RN)-A stated R1 was particular on who he lets do his cares. RN-A stated NA-C did the cough assist this morning. RN-A indicated she did not go in and evaluate the effectiveness of the breathing treatment. RN-A indicated when she has been assigned to R1, she has never completed the breathing treatment even thought she had experience working with the device in another care setting. RN-A also reported had never completed a respiratory assessment on R1. During an interview on 2/6/24 at 11:29 a.m. with hospice registered nurse (HRN) stated R1's disease was progressing, and he needed cough assist. R1 could aspirate on his own secretions so a nurse should be present when cough assist was being completed. HRA stated she sent forms how to use cough assist in email to the facility along with a link with a video describing how to use the cough assist machine. She stated she was not sure how the staff are being educated at the facility because they didn't have access to email. HRN stated R1 complains at 90% of her visits that the staff do not know how to use cough assist. HRN stated she did feel that all nurses who work with R1 should be trained on how to use the cough assist machine. During an interview on 2/6/24, at 2:46 p.m. director of nursing (DON) stated she was not aware R1 was not getting his cough assist and also was not aware NA's were the ones providing it. DON stated she was working on the investigation and had informed all nurses that only they were supposed to be providing the cough assist. DON stated the nurses should be following the providers orders as written in the MAR. During an interview on 2/8/24, at 9:06 a.m. representative of the manufacturer and licensed respiratory therapist stated R1's cough machine has been FDA approved for 3 years to help clear the lungs of secretions and maintain the airways of people who are too weak to produce a natural productive cough. If a person was to retain secretions in the lungs these secretions could serve as a source of infection and or aspiration. The representative also stated they train all durable medical equipment suppliers of their machine, and this training is to be passed down to the front-line person to make sure the front line clinical staff are trained on how to use the cough assist machine properly. A specific cough assistant policy or protocol and or a treatment policy was requested however none received. BiWaze cough user manual Issue date: February 2023, indicated, The BiWaze(R) Cough device helps to clear bronchopulmonary secretions from the respiratory system by providing a therapy which mimics a cough. The therapy consists of three phases which mimic a cough; inhale, exhale, and pause phase. The inhale phase is positive airway pressure to expand the lungs. Then exhale phase is a sudden shift to negative pressure to pull the air out of lungs. Finally, the pause phase provides a rest before the next inhale phase. BiWaze allows for positive pressure to be delivered during the pause phase to keep the airways open in between the inhale and exhale phases. Use BiWaze Cough only as directed by a physician or healthcare provider. Use BiWaze Cough only for the intended use as described in this manual. Advice contained in this manual does not supersede instructions given by the prescribing physician. Read the entire manual before using BiWaze Cough. The operator should read and understand this entire manual before using the device. BiWaze Cough is a restricted medical device intended for use by qualified, trained personnel under the direction of a physician. BiWaze Cough is not intended to be operated by persons (including children) with reduced physical, sensory or mental capabilities without adequate supervision by a person responsible for the patient's safety. Therapy shall not be performed on a patient without a Bacterial/Viral (B/V) filter along the Breathing Circuit. Always use a new bacterial filter when using the device on a new patient. Confirm all settings before each treatment. Soreness and/or pain in the chest from a pulled muscle may occur in patients using BiWaze Cough for the first time if the positive pressure used exceeds pressures which the patient normally receives during Positive Pressure Therapy. Such patients should start at a lower positive pressure during treatment, and gradually increase the positive pressure used based on patient tolerance and comfort. Facility Policy titled, Oxygen Therapy, stated residents are assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy have interventions/equipment implemented in accordance with the resident-centered care plan

Based on interview, and document review, the facility failed to ensure licensed nursing staff demonstrated competency skills related to use of BiWaze cough system (machine used to simulate a cough to help person clear mucus from lungs) for 1 of 1 resident (R1), reviewed for respiratory care. Findings include: SEE F695: Based on interview and document review the facility failed to provide and evaluate the effectiveness of physician ordered respiratory cough stimulator treatment (machine used to simulate a cough to help person clear mucus from lungs) for 1 out of 1 resident (R1) reviewed who required respiratory care. R1's Admission Record identified R1 had diagnoses of amyotrophic lateral sclerosis (ALS)-(a disease that affects nerve cells in the brain and spinal cord. Symptoms can begin in the muscles that control speech & swallowing or in the extremities) and dyspnea (difficulty breathing). R1's department of Neurology order dated 8/16/22 indicated R1 had an order for durable medical equipment (DME) cough stimulating device, alternating positive and negative pressure. Order indicated Synclara Device to be set for effectiveness and comfort with suggest pressure of 35 inspiratory pressure and 2 inspiratory pressures delivered by mask. If well to be done, two times a day 10 cycles and if ill to be done four times a day and as needed as many cycles to clear mucus. Other forms of airway clearance are not an option because of the decreased expiratory flow and patient intolerance. R1's physician order dated 11/10/23 and 12/6/23, included cough assist machine, special instructions: Please watch video prior to first administration. Https://youtu.be/-zls-Y9ParY Hold mask to face and hold back of head firmly. After 8 cycles the machine will stop, then clean my mouth out with the toothettes and a cloth/tissue. (Diagnosis: Amyotrophic lateral sclerosis- (a disease that affects nerve cells in the brain and spinal cord. Symptoms can begin in the muscles that control speech & swallowing or in the extremities.)) Twice a day Mornings 5:00 a.m. -7:00 a.m. Bedtime 9:00 p.m.-11:30 p.m. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, was dependent on staff for most ADL's. R1's care plan dated 12/29/23 indicated at risk for ineffective airway clearance and significant respiratory distress related to ALS and overall functional decline need of cough assist machine, Bipap, oxygen, oral cares to remove excess secretion from mouth. The facility did not have evidence staff were trained and competent to use the cough assist machine. Further when asked for the manual for the cough assist machine, one was not located and provided during the survey. The video identified in the physician orders was reviewed in conjunction with the manufacturer's instruction manual; the video was approximately 2 minutes and demonstrated how to apply the machine, however, did not address all of the safety information and care of the machine outlined in the manual. During an interview on 2/6/24 at 9:39 a.m., R1 stated the facility has a lot of newer staff and did not feel they had been trained very well. R1 indicated that he was worried about his safety and injury from incompetent staff. R1 stated he has been educating staff since his arrival. During an interview on 2/6/24 at 12:27 p.m. NA-A stated R1 was particular on who he allowed to complete his cares. NA-A stated she has administered R1's cough assist and has been asked by nurses to complete it because the nurse did not know how. NA-A stated about a week ago she provided cough assist to R1 because he was up and needed it, so she just did it. NA-A stated she did not know if the new nurses got any training on R1's treatments. R1 has told her only some staff knew how to use it correctly and others did not know how to hold the mask so that it did not leak. NA-A stated she felt all nurses should get trained by somebody not just watch the video. NA-A indicated the hospice nurse showed her how to do use the equipment, however, could not remember the training date, and the training was not documented. Additionally, R1 would also instruct how to use the device. NA-A explained she could tell if the treatment was effective if there were secretions in the mask and R1 would tell her it was effective. During an interview on 2/8/24 at 9:33 a.m. NA-C stated he has worked with R1 for a little over two months and was trained to use the cough assist by a previous NA who had worked with R1. NA-C stated he has provided the cough assist to R1 at least 20 times since he has started working with him and knows of only one nurse who has provided R1 with the cough assist while he was working. NA-C stated he would not know how to complete a respiratory assessment and did not know what all was involved as he was not a nurse and did not go to school for that. He stated he would inform the nurses he had completed the cough assist and figured the nurses knew what to do. NA-C did not know what settings the machine should be on, or if the settings were correct as he would just turn the machine on and R1 would let him know if it was working correctly or not. During an interview on 2/6/24 at 2:29 p.m. registered nurse (RN)-A stated R1 was particular on who provided his cares. RN-A stated NA-C did the cough assist this morning. RN-A indicated she did not go in and evaluate the effectiveness of the breathing treatment. RN-A indicated when she has been assigned to R1, she has never completed the breathing treatment even thought she had experience working with the device in another care setting. RN-A also reported had never completed a respiratory assessment on R1. During an interview on 2/6/24 at 11:29 a.m. with hospice registered nurse (HRN) stated R1's disease was progressing, and he needed cough assist. R1 could aspirate on his own secretions so a nurse should be present when cough assist was being completed. HRN stated she sent forms how to use cough assist in email to the facility along with a link with a video describing how to use the cough assist machine. She stated she was not sure how the staff were being educated at the facility because they didn't have access to email. HRN stated R1 complains at 90% of her visits that the staff do not know how to use cough assist. HRN stated she did feel that all nurses who work with R1 should be trained on how to use the cough assist machine. During an interview on 2/8/24 at 9:06 a.m. representative BiWaze and licensed respiratory therapist stated R1's cough machine has been FDA approved for 3 years to help clear the lungs of secretions and maintain the airways of people who were too weak to produce a natural productive cough. If a person was to retain secretions in the lungs these secretions could serve as a source of infection and or aspiration. The representative also stated they train all durable medical equipment suppliers of their machine, and this training was to be passed down to the front-line person to make sure the front line clinical staff are trained on how to use the cough assist machine properly. During an interview on 2/6/24 at 2:46 p.m. director of nursing (DON) stated nurses should be the only staff providing cough assist to R1. She confirmed the risk associated to using the cough assist machine and stated this treatment should not be delegated and only completed by a nurse. DON stated she was aware that some nurses were uncomfortable with administering the cough assist. DON admitted she had limited experience with it. DON stated staff had been asked to copy and paste the link out of the MAR and watch the video before administering the cough assist for the first time. DON denied any other training offered or auditing to make sure this had been completed. BiWaze cough user manual Issue date: February 2023, indicated, The BiWaze(R) Cough device helps to clear bronchopulmonary secretions from the respiratory system by providing a therapy which mimics a cough. The therapy consists of three phases which mimic a cough; inhale, exhale, and pause phase. The inhale phase is positive airway pressure to expand the lungs. Then exhale phase is a sudden shift to negative pressure to pull the air out of lungs. Finally, the pause phase provides a rest before the next inhale phase. BiWaze allows for positive pressure to be delivered during the pause phase to keep the airways open in between the inhale and exhale phases. Use BiWaze Cough only as directed by a physician or healthcare provider. Use BiWaze Cough only for the intended use as described in this manual. Advice contained in this manual does not supersede instructions given by the prescribing physician. Read the entire manual before using BiWaze Cough. The operator should read and understand this entire manual before using the device. BiWaze Cough is a restricted medical device intended for use by qualified, trained personnel under the direction of a physician. BiWaze Cough is not intended to be operated by persons (including children) with reduced physical, sensory or mental capabilities without adequate supervision by a person responsible for the patient's safety. Therapy shall not be performed on a patient without a Bacterial/Viral (B/V) filter along the Breathing Circuit. Always use a new bacterial filter when using the device on a new patient. Confirm all settings before each treatment. Soreness and/or pain in the chest from a pulled muscle may occur in patients using BiWaze Cough for the first time if the positive pressure used exceeds pressures which the patient normally receives during Positive Pressure Therapy. Such patients should start at a lower positive pressure during treatment, and gradually increase the positive pressure used based on patient tolerance and comfort. Facility Policy titled, Oxygen Therapy, stated residents are assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy have interventions/equipment implemented in accordance with the resident-centered care plan.

Based on observation, interview and document review, the facility failed to ensure all residents were consistently offered and provided a nutrient and/or calorie substantive snack after the dinner meal and before bedtime for 4 of 4 residents (R29, R43, R45, R51) who voiced a concern. Findings include: During an interview on 12/18/23 at 6:49 p.m., culinary aide (CA)-A who was working on the Angel Unit stated the evening dietary staff did not prepare snacks for residents and stated he had never seen snacks offered to residents in the evening. During observation on 12/18/23 from 6:30 p.m. to 7:25 p.m., no snacks were offered to residents on the Angel Unit. During interview on 12/18/23 at 7:25 p.m., nursing assistant (NA)-D stated no snacks were offered to residents after the evening meal and before bedtime and pointed to small bags of snacks on a tray in the kitchenette in the Angel Unit. NA-D stated if a resident asked for something, they could have those snacks or if they wanted something more substantial like a sandwich, staff could make a peanut butter sandwich. During an observation on 12/19/23 at 9:31 a.m., on the Angel Unit, snacks available for residents were located on a tray on a counter in the kitchenette and included: Goldfish crackers, Rice Krisipies treats, club crackers with cheese, strawberry Chex mix, fudge round cookies and ice cream in the freezer. During an interview on 12/19/23 at 11:29 a.m., culinary services director (CSD)-B stated dietary was not involved with delivering snacks to residents, but provided snacks that were always available in the kitchenettes. CSD-B described the prepackaged snacks noted on the tray in the Angel Unit. During an interview on 12/19/23 at 1:08 p.m., the director of nursing (DON) acknowledged staff did not offer snacks to residents after the dinner meal and before bedtime, but snacks were available to residents who asked. During an interview on 12/19/23 at 1:14 p.m., the administrator was informed residents were not offered a nutrient and/or calorie substantive snack after the dinner meal and before bedtime. The administrator stated she knew some residents received snacks and there was peanut butter and bread on the units for staff to make residents a sandwich. During an interview on 12/20/23 at 10:32 a.m., during a resident council meeting, the following residents stated they were not offered a nutrient and/or calorie substantive snack after the dinner meal and before bedtime. --R29, who resided on the Dove Unit and who's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, stated she was not offered a snack after the dinner meal and before bedtime. R29 stated she would like to be offered something to eat but kept snacks in her room in case she was hungry. --R43, who resided on the Butterfly Unit and who's quarterly MDS assessment dated [DATE], indicated intact cognition, stated he was not offered a snack after the dinner meal and before bedtime. R43 acknowledged he would probably take a snack if it were offered. --R45, who resided on the Butterfly Unit and who's quarterly MDS assessment dated [DATE], indicated intact cognition, stated he was not offered a snack after the dinner meal and before bedtime. R45 stated when staff came around with his evening pills, they asked if there was anything else he wanted and believed if he asked, could get a snack. R45 stated he would take a snack if it were offered. --R51, who resided on the Dove Unit and who's quarterly MDS assessment dated [DATE], indicated intact cognition, stated he was not offered a snack after the dinner meal and before bedtime. R52 stated he had not been asked if he wanted a snack but would take something if it were offered. The facility Between Meal Nourishment/Bedtime Snacks policy dated 7/2019, indicated a nourishing snack was defined as an item from the basic food groups, either singly or in combination with each other. The bedtime snack would normally consist of juice or milk with crackers or cookies, sandwich, fruit, pudding or ice cream. Bulk between meal and bedtime snacks would be prepared by culinary for distribution to all residents not receiving individualized nourishments/snacks. Nursing staff would offer and provide a nourishing snack at bedtime.

Based on observation and interview, the facility failed to ensure staff followed appropriate infection control practices, including proper handling of drinking cups and performing hand hygiene during meal service. This had potential to affect all 20 residents who resided on the Angel Unit. Findings include: During an observation and interview on 12/18/23 from 4:47 p.m. to 4:53 p.m., observed culinary aide (CA)-A wearing gloves to fill and deliver beverages to dining tables on the Angel Wing. CA-A held two cups in one hand, palm side down over the tops/rims of the two cups, one containing water and one containing juice. When approached to introduce self and ask his name, CA-A rubbed his gloved hands on his clothing. Without changing gloves, CA-A continued to fill cups of juice from the beverage dispenser in the kitchenette and while doing so, handled a laminated sheet with resident beverage preferences printed on it. CA-A dispensed more juice, holding the cups by rim, and took them to dining tables. CA-A was observed touching and rubbing a lower cabinet door below the beverage dispenser while talking to a co-worker. CA-A continued to work around the kitchenette with the same pair of gloves on, opening the refrigerator and removing items, pouring and delivering beverages. At 4:58 p.m., CA-A again held two cups in one hand, palm side down over the tops/rims of the two cups, one containing milk and one containing juice and set them on a table. At 5:01 p.m., CA-A started temping food, wearing the same pair of gloves. At 5:10 p.m., when informed of observations, CA-A stated he did not recall what he had learned about glove use and hand hygiene. At that point, CA-A removed his gloves, washed his hands, re-gloved and started plating food. CA-A stated he had been working fast and trying to remember to do everything as he did not normally work on this unit. At 5:41 p.m., CA-A was informed of observations of him handling cups by the rims where residents would put their mouth. CA-A stated no one had taught him how to properly handle drinking cups. During an interview on 12/19/23 at 11:29 a.m., culinary services director (CSD)-B stated she had been made aware of concerns from the previous evening meal regarding CA-A's improper handling of drinking cups and lack of hand hygiene. CSD-B stated she expected culinary staff to follow policy on hand hygiene and handling resident drinking cups. CSD-B stated CA-A would have had culinary aide training when he started which would have been done by another culinary aide. CSD-B admitted she had performance concerns about CA-A, and admitted the younger dietary aides on the evening shift should have supervision, but did not; adding, They're kids. During an interview on 12/19/23 at 12:57 p.m., the administrator was informed of observations of CA-A. The administrator stated CA-A had talked to her that night, 12/18/23, and told her what had happened and could verbalize to her what he should have done in terms of handling drinking cups and hand hygiene. The administrator acknowledged CA-A had performance issues and stated he generally did not work serving food on the unit kitchenettes; he usually dished up food for the attached assisted living facility. Review of CA-A's culinary aide training included a hand-hygiene competency dated 7/5/22, which included a section on glove use which indicated: contaminated gloved hands do no touch inanimate objects, and fresh gloves were utilized between soiled care delivery and clean care procedures. In addition, CA-A completed an online learning module on Infection Prevention and Control on 11/7/23. The facility Handwashing Procedure with review date of 8/2019, indicated the hands of those who prepare and serve food must be clean at all times to safeguard the health of those who were dependent on this service. Hands must be washed frequently, thoroughly and according to proper procedures. The facility Standard Precautions policy undated, indicated during delivery of healthcare, to avoid unnecessary touching of surfaces to prevent both contamination of cleans hands from surfaces and transmission of pathogens from contaminated hands to surfaces. Remove gloves after contact with the surrounding environment using proper technique to prevent hand contamination.

Based on observation, interview and document review, the facility failed to comprehensively assess and provide ongoing treatment for edema for 1 of 1 resident (R48), who required leg wraps to prevent and treat edema. Findings include: R48's face sheet printed 12/20/23, included diagnoses of Parkinson's disease (degenerative disorder of nervous system that affects motor and non-motor systems), neurocognitive disorder with Lewy bodies (progressive dementia that results from protein deposit in in nerve cells of the brain), and type two diabetes mellitus. R48's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R48 understands and is understood, and had a BIMS (Brief Interview for Mental Status) score of 14, indicating R48 is cognitively intact. In addition, R48 requires substantial to maximal assist with activities of daily living R48's provider orders dated 9/25/23, included apply ACE wraps to bilateral lower extremities for edema from foot to below knee. On in morning, off at bedtime. R48's plan of care dated 1/25/23, did not include edema (swelling) or use of ace wraps. A nursing assistant care sheet included R48 but did not include application or removal of ace wraps. During observation and interview on 12/18/23 at 1:02 p.m., R48 was sitting in wheelchair with legs dependent, and dressed with ace wraps on both lower legs. Left leg with swelling present. R48 indicated the wraps do help the swelling in his lower legs but sometimes they forget to wrap them. During observation on 12/19/23 at 8:05 a.m., R48 was in his wheelchair in the dining room. Feet dependent on foot rests of wheelchair with no ace wraps on lower legs. Two ace wraps were present in R48's room on his dresser/TV stand. During observation on 12/19/23 at 2:33 p.m., R48 was in the dining room having coffee. R48 was in his wheelchair, with feet dependent and no ace wraps on lower legs. Left lower leg with swelling present. During interview on 12/19/23 at 2:48 p.m., nursing assistants (NA)-A and B indicated they aren't allowed to put wraps on lower legs. NA-A and NA-B were not sure if R48 had ace wraps to be applied or not. NA-A and NA-B both indicated it is the responsibility of the nurse to put ace wraps on and monitor them. During observation on 12/19/23 at 3:46 p.m., R48 remained in his wheelchair with no ace wraps on lower legs. During observation and interview 12/20/23 at 7:32 a.m., R48 was dressed for the day. No ace wraps present on lower legs with ace wraps on his dresser/TV stand. R48 indicated he didn't refuse to wear them today or yesterday. R48 stated they just forgot to put them on. Denied any discomfort with swelling in his lower legs. During interview on 12/20/23 at 7:45 a.m., licensed practical nurse (LPN)-A indicated R48 has ace wraps ordered daily and to be removed at night. LPN-A indicated they were applied this morning with left leg having a trace of edema present. LPN-A indicated the ace wraps should be applied before R48 gets out of bed in the morning. During interview on 12/20/23 at 9:46 a.m., NA-C indicated nursing assistants are allowed to put ace wraps on lower legs and then the nurse will document it as done. NA-C indicated there are a few on the unit that require them on in the morning and R48 is one of them. During observation at 10:58 a.m., R38 was sitting in his room in his wheelchair with no ace wraps present on his lower legs. Edema is present in his left lower leg. The ace wraps remain on his dresser/TV stand. During interview on 12/20/23 at 11:08 a.m., registered nurse (RN)-A, identified as clinical manager, indicated ace wraps are generally placed on in the morning, ideally before the resident gets out of bed and off in the evening. RN-A indicated R48 is cognitively intact and would remember if he refused them or not. RN-A indicated NA's are allowed to put on ace wraps but ultimately it is the responsibility of the nurse to ensure they are put on. RN-A indicated she would expect them to be on by this time in the morning and applied daily per order. During interview on 12/20/23 at 12:54 p.m., the director of nursing (DON) indicated she was unsure if the staffing agency NA's were allowed to place ace wraps on lower legs, but stated it is ultimately the nurse who is responsible to ensure the ace wraps are on. The DON confirmed if ace wraps are ordered, they should be applied as ordered. During interview on 12/20/23 at 1:20 p.m., LPN-A indicated she reassessed R48's lower legs for edema with 1+ edema present in left lower leg and minimal to the right lower leg. During observation on 12/20/23 at 1:38 p.m., ace wraps present on R48's lower legs. The facility policy and procedure for edema, ace wraps was requested and none received. A policy for Activities of Daily Living, dated 6/21, included: - If a resident refuses care, associates will approach at a different time, or having another associate speak with the resident as needed. -Interventions to improve and/or minimize resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. -The resident's response to interventions will be documented, monitored, evaluated and revised as appropriate.

Based on observation, interview, and document review, the facility failed to ensure grooming cares were provided for 2 of 2 residents (R37, R55) reviewed for activities of daily living (ADLs), who were dependent upon staff for care. Findings include: R37's diagnoses located on the diagnosis sheet dated 5/10/23, included; muscle weakness, polyneuropathy (malfunction of peripheral nerves), quadriplegia (paralysis of all four limbs) and dysphasia (difficulty swallowing foods or liquids). R37's quarterly minimum data set (MDS) dated [DATE], identified R37 as having no impairment in cognition. R37 was dependent on staff with oral cares. R37's current care plan dated 12/6/23, identified R37 as being alert and oriented with adequate memory recall. The care plan identified R37 as having a self care deficit with ADL's that included oral cares. Interventions included: assist with oral cares twice daily and as needed. R37's current physicians orders dated 12/23, included an order to provide oral cares after each meal and at bedtime with toothettes. Interview on 12/18/23 at 1:30 p.m., R37 indicated staff had not been providing his oral cares after meals. R37 stated he has been reporting this concern to management staff for the past month, but it still is not getting done. R37 further stated oral cares after each meal with the use of toothettes, was included in his plan of care. During observation on 12/19/23, after breakfast and dinner and again on 12/20/23 after breakfast, staff did not implement oral cares after each meal, according to the plan of care. Interview on 12/19/23 at 2:15 p.m., registered nurse (RN)-B indicated she had been aware of R37's concerns related to oral cares not being done, for the past couple of months. RN-B indicated she had posted notes at the nurses station to remind staff to provide oral cares as well as re-educating staff. RN-B confirmed the care plan had not been updated to reflect the current physician orders, to provide oral cares with toothettes after every meal and at bedtime. Interview on 12/20/23 at 1:15 p.m., R37 confirmed staff had not provided oral cares on 12/19/23 for breakfast, dinner, supper or bedtime and again on 12/20/23 after breakfast and dinner. Interview on 12/20/23 at 1:30 p.m., nursing assistant (NA)-I confirmed she had not provided oral cares to R37 on 12/29/23 after breakfast or dinner. NA-I indicted she was unaware R37 needed assist with oral cares. R55's diagnoses located on the face sheet dated 8/11/23, included; Parkinson disease (a disorder of the central nervous system affecting movement), muscle weakness, diabetes mellitus ( a condition that happens when your blood sugar is too high) and osteoporosis (a condition in which bones become weak and brittle). R55's quarterly MDS dated [DATE], identified R55 as having minimal impairment in cognition. R55 requires substantial assistance with bathing, and hands on assist with personal hygiene. R55's current care plan dated 8/11/23, included a self care deficit of ADL's that included bathing and grooming. Interventions included: staff to assist with bathing,dressing and grooming. During observation and interview on 12/19/23 at 10:00 a.m., R55 was noted to have long, rigged and dirty fingernails on the right hand. When asked R55 if he liked nails long, he stated No. R55 further stated staff had not trimmed or cleaned his fingernails for a long time, but unable to recall exactly how long. Interview on 12/19/23 at 10:30 a.m., trained medication assistant (TMA)-B confirmed R55's nails were long and dirty. TMA-B further indicated the licensed nurse was responsible to trim R55's nails, because he was diabetic. TMA-B was unsure when R55's fingernails were last trimmed or cleaned. Observation on 12/20/23 at 11:30 a.m., R55's fingernails remained long, rigged and dirty on the right hand. R55 again, stated he did not like like his fingernails long, and indicated he was unable to trim per self. R55 indicated staff have trimmed his nails weekly on bath day in the past, but had not with the last 2 baths. Interview on 12/20/23 at 12:00 p.m., NA-J stated she had given R55 a bath that morning, but had forgotten to clean R55's fingernails or report to the charge nurse for trimming. A policy was requested, but not provided. .

Based on observation and interview, the facility failed to sanitize and/or replace resident water mugs on a daily basis to ensure a safe and sanitary vessel from which residents consumed water. This had the potential to affect all 55 residents residing in the facility. Findings include: During observations on 1/23, 1/24, 1/25, and 1/26/23, on the Angel wing, staff were not observed replacing resident thermal water mugs with clean mugs. During an interview on 1/26/23, 9:13 a.m., culinary services director (CSD) stated resident water mugs were not washed in the kitchen, adding they might be washed in dishmachines on unit kitchenettes. During an interview on 1/26/23, at 10:12 a.m., nursing assistant (NA)-A stated resident water mugs were supposed to be washed once a day in the dishmachine on the units but admitted it was not being done, adding the facility was planning to order more mugs to be able to change out mugs daily. During an interview on 1/26/23, at 10:40 a.m., culinary services aide (CSA)-B in Angel wing kitchenette stated resident water mugs were not washed in the dishmachine on a regular basis, only if there was one left in the sink would she put it in the dishmachine. During an interview on 1/26/23, at 2:16 p.m., the administrator and director of nursing (DON) acknowledged resident water mugs should be replaced daily with a clean mug to ensure residents received sanitized water mugs. During an interview on 1/26/23, at 2:46 p.m., registered nurse (RN)-D, stated a clean water mug should be provided to residents each day in order to prevent bacterial build up/contamination of the mugs, and had not been aware residents did not receive a clean water mug daily. Facility policy titled Resident Bedside Water Containers, dated 8/2019, indicated resident in-room water containers and cups would be washed and sanitized, or replaced with clean containers daily. Culinary department personnel would wash and sanitize or replace resident bedside water containers and cups at least once in a 24-hour period. Plastic bedside water containers would be collected by nursing personnel and delivered to culinary for washing and sanitizing in the dishmachine. It was recommended two sets of plastic water containers be available so that the washing of containers did not conflict with water container availability.

Based on observation, interview, and document review, the facility failed to ensure an interdisciplinary team assessment for safety was completed prior to self administration of medication for 1 of 1 resident (R37) reviewed for medication administration. Findings include: R37's Face Sheet printed 1/26/23, indicated diagnosis including heart failure, chronic kidney disease, polyneuropathy (damage to multiple nerves), anxiety, glaucoma, pain and atrial flutter (type of heart rhythm disorder caused by problems in heart's electrical system). R37's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R37 was cognitively intact, had moderate hearing impairment and wears hearing aide and adequate vision and was independent with eating, walking and toileting, and one person assist with personal hygiene. R37 received 7 days of anticoagulant, diuretic and opioid. R37's physician orders included: -morphine concentrate 100mg/5 milliliters, give 5 mg (0.25 ml) as needed for shortness of breath or pain 7-10 every 4 hours -Voltaren Arthritis pain gel 1%; amount 2 gms apply topically. Special instructions included ok to leave at bedside and resident to apply per self for pain in left knee three times a day. -dorzolamide-timolol drops; 22.3-6.8mg/ml; amt: one drop twice daily to left eye with am med pass and evening med pass. -latanoprost drops; 0.005%; amt: 1 drop to both eyes at bedtime -Systane Complete one drop to each eye four times a day. Ok to leave at bedside and self administer -furosemide 80 mg twice a day at 8 a.m., and 12 p.m. -gabapentin 100 mg three times a day Review of R37's plan of care dated 12/27/22, did not include self-administration of medications. Review of R37's electronic medical record revealed no assessment for self-administration of medication was completed and no interdisciplinary team evaluation. During interview and observation on 1/24/23, at 12:10 p.m., licensed practical nurse (LPN)-A set up R37's medications into a medication cup, which included Lasix 80 mg, gabapentine 100 mg, then prepared morphine 100 mg/5ml, 0.25 ml drew up in a syringe. LPN-A also had indicated Systane eye drops and Volatren Arthritis pain rub were scheduled but R37 can do those herself and are kept at the bedside. LPN-A administered the morphine via syringe and set R37's pills next to her plate on the dining room table and returned to the work station. LPN-A indicated R37 can self-administer all her own medications. During interview and observation on 1/26/23, at 12:05 p.m., registered nurse (RN)-B placed gabapentin 100 mg tablet, and Lasix 80 mg tablet into a medication cup. RN-B drew up morphine 100mg/5ml 0.25 ml into a syringe. RN-B indicated R37 keeps all her eye drops and Voltaren gel at bedside and does them by herself. RN-B set pill cup down on dining room table next to R37's plate. RN-A administered the morphine to R37 and then returned to her work station. RN-B indicated R37 can self administer her own medication after staff set them up for her. During interview on 1/25/23, at 3:20 p.m., RN-C indicated no self-administration assessment was completed for R37. RN-C indicated R37 does have an order from the ophthalmologist to self-administer her own eye drops. During interview on 1/26/23, at 12:48 p.m., the director of nursing (DON) indicated an observation or some type of an assessment is required to self-administer medications. The DON confirmed leaving medications with the resident and not observing them taking medication is considered self-administration and requires an assessment to do so. Facility policy and procedure titled Self-Administration of Medications, dated 2/2019, included: - Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe. - The nursing associates will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Assessment is documented in the electronic medical record (EMR). -The resident has the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate: -The medications appropriate and safe for administration -The resident's physical capacity to swallow without difficulty and to open the medication bottles -The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for -The resident's capability to follow directions and tell time to know when medications are needed. -The resident's ability to understand what refusal of medication is, and appropriate steps taken to associate to educate when this occurs. -The resident ability to ensure medication is stored safely and securely. -Reevaluation of the ability to self-administer will be done according to the interdisciplinary observation guide. Any changes noted in ability will be made known to the resident and the provider for further review.

Based on interview and document review, the facility failed to comprehensively assess, analyze and implement interventions, and failed to provide adequate supervision, to prevent resident to resident incidents on the Angel Wing, a memory care unit within the facility, which resulted in physical altercations between R12 and multiple cognitively impaired residents (R115, R9, R42, R20, R52, R47 & R56) who also resided on the unit. R56 sustained actual harm when she sustained a corneal abrasion to the left eye, requiring multiple physician visits and an emergency room (ER) visit. This resulted in immediate jeopardy (IJ) for all 20 residents residing on the Angel Wing due to the risk of serious physical harm or injury. The IJ began on 8/31/18, when R56's was grabbed by R12 sustaining a left eye corneal abraision injury, and the IJ was identified 9/27/18. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 1:30 p.m. on 9/27/18. The IJ was removed on 9/28/18 however, noncompliance remained at the lower scope and severity of G, isolated, which indicated actual harm with potential for more than minimal harm that is not I[NAME] In addition, the facility failed to ensure a safe environment to decrease the risk of wandering to an unsafe location for 1 of 1 resident (R114) reviewed for elopements. Findings include: R12's current face sheet included [DIAGNOSES REDACTED]. R12's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no [MEDICAL CONDITION], mild depression and indicated physical and verbal behaviors in addition to wandering behaviors. R12's Care Area Assessment (CAA), completed on 4/11/18, indicated R12 had cognitive loss/dementia and contributing factors included: [MEDICAL CONDITION] and [MEDICAL CONDITION] (difficulty finding words when communicating), behavioral symptoms of wandering on the unit, and impaired safety awareness. The CAAs also indicated R12 used antipsychotic medications and would be monitored for adverse reactions and changes in mood/behavior. R12's See Me, Know Me, care plan intervention sheet (used to communicate behavioral strategies to the nursing assistant staff), last revised on 9/20/18 included a problem for potential alteration in mood/behavior due to [MEDICAL CONDITION]. Behaviors that may be exhibited included: wandering in and out of other resident rooms, lashing out at care givers when I feel scared or unsafe, and a recent occurrence of physical aggression towards care giver and of grasping care giver arm tightly. Additional recent occurrence of physical contact using back of hand to female resident's face and grabbing female resident's face and neck. Approaches for staff to utilize included monitoring signs and symptoms of depression and behaviors, reassurance and TLC (tender loving care) PRN (as needed), 1:1 visits, encourage to verbalize feelings, involve in activities, divert or distract with conversations about cars, and providing a fidget spinner. The care plan sheet also included that staff were to have personal awareness when visibly upset, yelling, snapping fingers, swearing or close to and upset with other residents. Provide laminated picture of resident, wife and daughter and tell him he is a good person, offering of food, try to take unsafe objects out of his hands and give him something safe as well as calming music with headphones. Ask resident why he is mad and tell him he is scaring you. A provider's progress note dated 5/18/18, documented by nurse practitioner (NP)-A indicated R12 had been admitted to the facilty from home, due to family being unable to care for him. The note R12 had experienced difficulty sleeping at night prior to admission while still at home, and further indicated R12 had been experiencing behaviors nearly every day including yelling, wandering, swearing and grabbing at staffs' arms. In addition, the note indicated R12 had utilizing [MEDICATION NAME] (an antipsychotic medication) 300 milligrams (mg) daily while still at home, which had been reduced to 250 mg on 4/21/18, and then again to 200 mg. The note indicated further dose reduction of the [MEDICATION NAME] was contraindicated due to R12's increased behaviors however, NP-A did not want to increase the [MEDICATION NAME] back to the previous dose rather, wanted staff to work with R12 to find effective non-pharmacologic interventions to manage the behaviors at his present dose. A provider progress note, documented by R12's primary physician (MD)-A on 6/4/18, indicated R12 had not been sleeping well in the facility, had slapped another resident across the face, would yell, throw objects, and refuse cares. The note indicated that R12 had been started on [MEDICATION NAME] (an antidepressant, also known as [MEDICATION NAME]) in an effort to help the resident sleep better and control behaviors however, MD-A documented the [MEDICATION NAME] had not been effective. In addition, the note indicated R12's behaviors would arise suddenly without a clear precipitating factor. MD-A documented a plan to further increase the [MEDICATION NAME] to a higher dosage. A provider progress note completed by MD-A on 7/2/18, indicated R12 had not been sleeping well since admission, and the physician had been titrating the resident's [MEDICATION NAME] from 300 mg to 250 mg at bedtime, then down to 200 mg at bedtime. The note indicated the decrease has not had any effect on R12's sleep, however R12's behaviors had escalated somewhat. R12 was yelling, hitting walls, throwing things and refusing cares. The note also indicated [MEDICATION NAME] had been added to R12's medication regime 6/4/18, but it hadn't seemed to change the intermittent behaviors so it was increased as of this note's dictation. A scheduled dosing of [MEDICATION NAME] (generic for Tylenol) was added on 6/22/18 in the evening to determine whether pain was contributing to R12's behaviors. A provider progress note dated 9/7/18, documented by NP-A indicated R12 would grab and twist the staff's wrists and had yelled at other residents. A plan/summary at the bottom indicated to continue the current plan of care. Review of R12's nursing progress notes indicated frequent physically aggressive behaviors: -During the month of 4/18, R12 was noted to be wandering around the Angel Wing unit. The notes indicated the dosage of [MEDICATION NAME] (antipsychotic used for sleep) was decreased from 300 milligrams (mg) every bedtime to 250 mg every bedtime. -During the month of 5/18, nursing notes indicated R12 had made attempts at swinging at other residents on the Angel Wing unit, several occasions of grabbing staff members' arms and not letting go, yelling, swearing and snapping fingers. In addition, R12's [MEDICATION NAME] was decreased from 250 mg to 200 mg on 5/4/18. On 5/6/18, at breakfast time, R12 became agitated with another resident (R20) and grabbed his head and shook it, yelling at R20. No injuries identified. Notifications were made to the administrator, director of nursing, nurse manager and social worker related to the incident. On 5/13/18, R12 grabbed a nursing assistant's (NA) arm and twisted it behind her back, as well as trying to grab the NA by the neck. R12 had a computer in his hands that he was attempting to throw and the NA had been trying to get the computer away from R12 at the time. R12's family was called to assist to calm R12. On 5/16/18, R12 obtained a gait belt and ran after an NA staff member. The NA was able to get away from the immediate vicinity. Staff interventions tried during these events included talking with R12 in a calm manner, redirection, and food. During the month of 6/18, nursing progress note documentation revealed behaviors of wandering, escalating agitation and aggression evidenced by tipping over dining room tables, tipping over chairs, throwing items, threatening behavior and physical aggression towards other residents on the unit. On 6/20/18, staff had to step in between R12 and another resident to prevent contact when R12 became aggressive and had a balled up fist inches from the other resident's face. R12 then grabbed a staff member's forearm hard, with both hands, causing the staff member to fear it would be broken. Family was called later in the day (3:20 p.m.), in an effort to help de-escalate R12 as agitation and aggression continued after the incident. During the evening shift on this same date, R42 sustained a skin tear due to R12 grabbing R42's arm. The notes further indicated that on 6/5/18, R12 was started on [MEDICATION NAME] (an antidepressant) 50 mg 1/2 tablet daily for 6 days, then a full tablet daily for psychomotor agitation per the physician. During the month of 7/18, nursing progress notes indicated continued behaviors of physical aggression towards staff when intervening to protect other residents, grabbing computers and throwing speakers on floor and yelling. On 7/9/18, the notes indicated R12 had entered two different resident rooms and yelled at the occupants. Staff were able to re-direct R12 out of the rooms. R12's [MEDICATION NAME] was increased from 50 mg to 75 mg on 7/3/18 and increased again to 100 mg on 7/18/18. R12's [MEDICATION NAME] remained at 200 mg at bedtime. During the month of 8/18, documentation revealed R12's behaviors had significantly escalated with respect to physical aggression and abuse directed towards residents and staff. On 8/2/18, R12 gave R47 two bruises on the arms after becoming agitated in the dining room, flipping over a table. On 8/3/18, R12 tried to twist and bend the arm/hand back of a nursing assistant (NA). On 8/11/18, R12 tried to grab a nurse around the neck. Aggressive behaviors placed other staff and residents at risk in the dining room when R12 threatened to throw a baseball. The notes indicated staff had to remove other residents from the dining room due to R12's agitation. On 8/12/18, R12 walked fast up to R52 and grabbed R52's head and shook it. R12 continued to be agitated despite frequent and multiple interventions by staff. R12 grabbed a blood monitoring unit and threw it across the nurses station hitting another resident (unidentified). R12 grabbed R20 by the arm and hit R20. On 8/14/18, R12 and R20 had another altercation. Neither were harmed and walked away from each other. The DON, Administrator, social services and R12's nurse manager was notified. R12's physician also gave an order on 8/14/18 increasing R12's [MEDICATION NAME] due to the behaviors. On 8/31/18, a note documented at 4:54 p.m. indicated that at breakfast, R12 was attempting to make physical contact with an NA staff member, who stepped out of the way and R12 grabbed R56 in the face, causing a corneal abrasion. R56 was seen by a nurse practitioner and prescription eye drops were ordered to treat an eye injury, however, R56's eye failed to improve and R56 was subsequently seen in the emergency department at the local hospital --refer to F600. During the month of 9/18, nursing progress note documentation indicated R12 continued to exhibit physical aggression towards others. On 9/11/18, at 8:15 p.m., R12 grabbed R115 about the neck, staff were able to intervene before injury occurred. Less than an hour later, at 9:02 p.m., staff heard screaming and found R12 with his left hand around R9's throat and the other hand firmly grasping R9's upper right arm. While staff attempted to separate the residents, R12 struck R9 in the forehead---refer to F600. On 9/12/18, R12 was transferred to the Grace Unit, a geriatric psychiatric treatment unit. During interview on 9/26/18, at 7:34 a.m. registered nurse (RN)-H stated she was familiar with R12 and had worked with R12 since he had been admitted earlier in (YEAR). RN-H stated initially R12 was calm however, in 6/18 his behaviors began to escalate and he became more physically combative. RN-H stated it was hard to determine what caused R12's behaviors. RN-H stated at times it seemed to be the stimuli of having other residents wandering around him, but R12 could suddenly and without provocation walk by someone and hit or grab them. RN-H stated in 6/18, R12 grabbed her right arm so hard she had to file a workman's compensation claim and had sustained bruising from the incident. On several occasions, RN-H stated she'd voiced concern to the director of nursing (DON) about the safety of other residents due to R12's physical aggression however the DON had responded: He has rights like everyone else and they (staff) should approach him differently. RN-H stated there were approaches in a book at the nursing station (See Me, Know Me) but stated the approaches did not work, or lasted for only a couple of minutes. RN-H stated she did not know what to do anymore to keep other residents safe, and was herself fearful of R12. RN-H stated there was no specific supervision schedule for R12 rather, staff just tried to keep an eye on his whereabouts as able between other residents' care. During interview on 9/26/18, at 7:46 a.m. NA-C stated there was a book with interventions for R12 at the nursing station that staff could use if he exhibited physically abusive behaviors. NA-C stated the interventions sometimes helped, but only for a short time. NA-C referred to R12 as touchy, and stated he could easily become aggressive towards other residents and added, out of the blue, he may grab a resident walking by for no specific reason. NA-C stated she was fearful of R12. During interview on 9/26/18, at 9:06 a.m. NA-F stated she worked with R12. NA-F stated she utilized the interventions on R12's care plan to help calm him down, but stated R12 would get upset with other residents for no apparent reason and click his fingers at them. During interview on 9/26/18, at 9:47 a.m. housekeeper (H)-A stated she had witnessed the incident between R12 and R56 when he poked R56 in the eye (the incident which caused a corneal abrasion). H-A stated for no apparent reason, R12 had become angry with the NA that was wheeling R56 by and began to chase the NA trying to hit her, before proceeding to poke R56 in the eye when the NA had stepped away from the immediate area. During interview on 9/26/18, at 9:49 a.m. licensed practical nurse (LPN)-D stated she was not able to remember much of the incident between R12 and R56 from 8/31/18. LPN-D stated the immediate intervention was to separate the residents. During interview on 9/26/18, at 1:00 p.m. the social service assistant (SSA) and the licensed social worker (LSW) were interviewed. The LSW stated, We have had nursing meetings with regards to behaviors. At the end of (MONTH) we started the behavior sheets (for R12). The DON would meet with us and we would get the information documented on them. The LSW stated they were providing ongoing education for staff, but further stated R12's family member did not want to be called into the facility in the evenings to help staff de-escalate R12 as she felt this was the responsibility of the nursing home staff. The LSW stated they'd been unable to identify patterns or specific times of day related to R12's behaviors. The LSW and SSA both stated R12 was currently at the Grace Unit for evaluation of his behaviors. They stated the plan was for R12 to return to the Angel Wing after medication adjustments could be completed however, also acknowledged the Grace Unit had not been able to send R12 back this week due to his continued behaviors and angry outbursts. The LSW and SSA further verified reports that R12 hadn't slept well at home, which had also been an issue for his wife. During interview on 9/26/18, at 3:00 p.m. R12's primary physician (MD)-A stated, They (the facility) made me aware of the most recent episode of behavior so I facilitated an admission to the Grace Unit. They had not made me aware of the prior violent episodes involving other residents. I would expect to be involved in the planning of his (R12's) care when he returns. They are good about figuring out triggers---really good about that.They avoid over medicating, and are very proactive for the residents. During interview on 9/27/18, at 9:21 a.m. the DON stated the facility had implemented medication changes for R12, involved the ombudsman, involved the physican for support, as well as having completed staff education in an effort to control R12's behaviors and develop an effective plan to manage his behaviors. The DON further stated they did not want to drug the resident and felt that they were doing what they could. She said she felt the resident should be transferred to a group home which could provide more appropriate care for him however, verified she had not reached out to any resources for alternate placement as of yet, and confirmed there was no documentation of any such discharge efforts. The DON also said she felt the facility staff had done all they could to manage R12's behaviors, and did not feel R12's [MEDICATION NAME] was effective so the facility had been dose reducing it. The DON further stated she did not believe there was funding for a resident on medical assistance to be able to find a smaller, group home type setting for R12 in the local community. During interview on 9/27/18, at 11:30 a.m. NA-B stated she had been working with R12 on 8/31/18, when R12 had injured R56's eye. NA-B stated she had been provided education by the facility education director a couple of days after the incident related to how to respond differently to R12 in order to protect other residents. However, NA-B said she did not believe any other new interventions had been put into place to protect the other residents following that incident. Review of R12's behavioral incidents revealed R9, R20, R42, R47, R52, R56 and R115 had all been targets of R12's aggression. Each of these residents also resided in the facility's memory care unit and were vulnerable to abuse. According to review of the facility's undated Assessing Behavior Policy, the following staff directions were provided: 1. When a resident exhibits behaviors that may have the potential to cause harm to another person staff will intervene immediately. 2. Nursing staff will identify, document and inform the resident's provider about their mental status, exhibited behavior and cognition. This will include details about any problematic behavior such as onset, frequency, and precipitating factors which will be part of the root cause analysis. 3. Nursing staff will document the nature, duration and associated features of behavior changes over time. 4. Nursing will consult with the provider to review whether the current medication regimen is appropriate as well as current interventions being used and their effectiveness and any changes that need to be made. 5. IDT (interdisciplinary team) will meet Monday through Friday to review problematic/dangerous behaviors that have occurred. 6. IDT will try to determine the root cause of the behavior through documentation and conversations with staff and develop a plan with interventions to decrease the behavior. 7. The plan of care will be updated to reflect changes in behaviors and interventions. 8. Once aggressive behaviors are identified IDT will monitor documentation and effectiveness of of non-pharmacological interventions as well as medications given on a routine basis along with RN usage daily Monday through Friday. 9. As IDT reviews these behaviors and it is noted that there is an increase in behaviors or that behaviors have become more dangerous the provider will be updated and more discussion will take place regarding appropriate interventions including but not limited to: Referrals to psych and neurology Possible transfer to a geripsych facility for further evaluation and medication management Possible discharge planning from our facility - involving the Ombudsman The immediate jeopardy that began on 8/31/18, was removed on 9/28/18, when the facility initiated review of all resident behavioral incidents on a daily basis, updated resident care plans with interventions to reduce behaviors, and established more frequent meetings of the Gradual Dose Reduction committee (weekly to begin with) to review behavioral incidents for trends, and to evaluate outcomes of current interventions. In addition, the facility initiated staff education to look for signs/symptoms precipitating resident behaviors such as agitation- such as pacing, facial expressions of anger, verbal expressions of anger, etc.and initiated a daily review of behavioral incidents to determine root cause analysis of the behaviors. R114 was admitted to the facility on [DATE], with diagnosis (identified on the face sheet of the medical record) that included: dementia, anxiety disorder, delusional disorder and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R114 as having a [DIAGNOSES REDACTED]. R114 requires extensive assistance of 1 staff and use of a walker with mobility. Review of R114's current plan of care identified the resident as being independent with ambulation with supervision. R114 may need staff assistance and a wheeled walker as needed (PRN) when weak, related to muscle weakness. R114 requires assistance with activities of daily living (ADL's) related to muscle weakness and confusion. R114 is at risk for elopement evidenced by having a history of elopement, increased episodes of wandering and going into other residents rooms and increased anxiety. Interventions: wanderguard on left ankle to alert staff when making attempts to leave unit, provide comfort measures for basic needs when the resident begins to wander, observe for behavioral symptoms and provide redirection. Review of an elopement risk assessment dated [DATE], indicated R114 was found outside the facility near the front lobby door of the east wing. The staff heard the door close and found the resident walking down the sidewalk along the building The resdient has a [DIAGNOSES REDACTED]. Interventions: 30 minute safety checks and wanderguard placed on wrist. Review of a progress note dated 7/9/18, indicated R114's wanderguard was reassessed. The resdient has not made any further attempts to leave the building since the initial occurrence on 5/24/18, and has been cognitively clearer since that time and is more familiar with surroundings and staff. The wanderguard was removed. Review of a progress note dated 7/30/18, at 1:30 p.m. upon return from a hospital stay indicated R114 had increased confusion and anxiety while in the hospital. A wanderguard was placed on the residents left ankle for being at risk for possible elopement. Review of a progress note dated 8/6/18, at 5:30 p.m. indicated R114 was restless and wanted to go home. The resident started walking off of the unit and stated she was going to leave. R114 was reassured and redirected by the nursing assistant (NA) and social worker (SW)-[NAME] Review of the progress notes dated 9/4/18 through 9/23/18, indicated R114 had daily episodes of pacing the halls, wandering into other residents rooms, wandering off of the unit and verbalizing to staff that she wanted to leave the facility. These behaviors were noted to be throughout the day at times and to escalate. Review of a progress note dated 9/9/18, at 8:54 p.m. indicated R114 had been confused all shift wandering in and out of other residents rooms. R114 informed the staff she wanted to leave the building several times. The resident was difficult to redirect during this time. R114 was observed to eventually leave the building through the courtyard door on the east unit (the unit this resident resides on). R114 was observed by staff to have gotten just right outside the door. After attempting to redirect the resident for 10 minutes, the resident returned back into the building with staff assistance. Review of a progress note dated 9/23/18, at 10:24 a.m indicated R114 was observed to be pushing the door open that leads to the outside patio. The staff assisted the resident with opening the door as well as the gate to the outside premesis of the patio. R114 then grabbed the staff's arm and proceeded to walk down the sidewalk stating she was leaving. R114 was difficult to redirect and called for assist to redirect the resident back into the facility. After returning to the facility R114 proceeded to pace up and down the halls as well as into another unit. Review of a progress note dated 9/23/18, at 7:15 p.m. indicated R114 was found by the city police walking outside on the sidewalk down sunrise drive (a city road near the facility). The staff were unaware the resdient was missing until the police returned her to the facility. R114's wanderguard did not alarm so the staff were unsure which door the resident eloped from. The resident continued to be restless and walk up and down the halls after the elopement, but made no further attempts to leave the building. Review of a progress note dated 9/24/18, at 11:50 a.m. by the facility licensed social worker ( LSW), indicated after investigating R114 elopement on 9/23/18, it was determined R114 eloped out the patio door on the east unit. R114 was able to release the button on the gate that leads to the outside premesis. The note further indicated R114 had been wandering in and out of other residents rooms and had been upsetting other residents prior to the elopement. After discussion with the facility interdisciplinary team (IDT) it was determined to move R114 to a more secured unit in the building. The note indicated a vulnerable adult (VA) report had not been reported to the state agency (SA) at the time of the elopement and would be filed at this time. Interview on 9/7/18, at 9:48 a.m. with east unit registered nurse (RN)-E, indicated he was aware of the unsecured/unalarmed patio door. RN-E included there was also a gate that exited the patio to the outside premises The gate had a push button that would open the gate door. Although R114 had a wanderguard on due to the potential for elopement, RN-E did not think the resident would leave the building. RN-E confirmed R114 exhibited behaviors of increased anxiety that included: wandering in the halls, into other residents rooms, off the unit as well as attempting to leave the building. Interview on 9/27/18, at 3:04 p.m. with RN-F indicated she was the east unit charge nurse when R114 eloped on 9/23/18. RN-F indicated R114 had been wandering in and out of other residents rooms prior to the elopement as well as days leading up to the incident. RN-F confirmed she was aware of the unsecured/unalarmed patio door/gate that exited the patio to the outside premises. RN-F stated she did not report the elopement to the (SA) because she did not consider R114's elopement as a (VA). Review of the facility's policy titled, Missing Person Policy and Procedure (undated), indicated the purpose of the policy and procedure is to ensure that all necessary steps are taken in the event that a resident wanders away from the facility. An elopement event shall be created and completed in the Matrix software by the charge nurse providing detailed accounting of the incident in its entirety. A VA report shall be filed with the designated S[NAME]

Based on observation, interview and document review, the facility failed to ensure residents were free from abuse for 2 of 2 residents (R56 & R9) who obtained injuries after being physically hit/grabbed by another resident (R12) in the facility. R56 experienced actual harm resulting in an abrasion to the left cornea. Findings include: R56 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R56's cognition as being severely impaired. R56 required extensive assistance with all activities of daily living (ADL's). Review of R56's current plan of care identified the resident as receiving hospice/end of life services. R56 had alterations in physical and cognitive limitations requiring extensive assistance in ADL's, as well as alteration in understanding others, making self understood and making needs known. The care plan included a vulnerability /abuse prevention plan related to a [DIAGNOSES REDACTED]. Interventions listed: ensure safety and remove resident if in a unsafe situation. Review of a progress note dated 8/31/18, at 4:54 p.m. indicated nursing assistant (NA)-B was pushing R56 to the breakfast table at 8:00 a.m. when R12 was walking towards them. R12 became upset and started to charge after NA-B. As this occurred, NA-B moved out of R12's way and R12 grabbed R56 in the face squeezing with both hands causing his finger to poke her in the left eye. Housekeeper (H)-A intervened and seperated R12 from R56 and NA-B moved R56 to the other side of the neighborhood. The note further indicated nurse practitioner (NP)-C had examined R56's left eye following the incident. Review of a Vulnerable Adult (VA) Report dated 8/31/18, indicated an incident of resident to resident abuse occurred, but was not immediately reported. The incident occurred at 8:00 a.m., but was not reported to the State Agency (SA) until 6:30 p.m. that day. The investigation summary describing the details of the resident to resident abuse incident included: NA-B was wheeling R56 to the breakfast table at 8:00 a.m., when R12 started to walk towards NA-B. NA-B smiled at R12, and he suddenly started to charge towards NA-B and attempted to push her. NA-B moved out of R12's way while letting go of R56's wheelchair (W/C). R12 then moved towards R56 and grabbed her face with both hands and squeezed. H-A intervened and removed R56 from R12, and NA-B moved R56 to the other side of the neighborhood to prevent further incident. The report further indicated R56 had sustained a left corneal abrasion from R12's aggression. Review of a faxed note dated 8/31/18, to NP-C described the above incident and verified R56's left sclera appeared reddened. NP-C ordered [MEDICATION NAME] (steroid/antibiotic) to the left eye and instructed the staff to report to the physician if the eye worsened. Review of a physician visit progress note from 5 p.m. on 8/31/18, also verified R56 had been seen by NP-C due to her left eye being watery and sclera being red following an injury from being poked in the eye by R12. The note indicated an exam determined R56's left eye has a clear watery discharge and the sclera was red, and there was a scratch noted on the lower inner conjunctiva. Additionally, the physician's note indicated R56 had sustained a corneal abrasion based on the symptoms. Treatment was identified on [MEDICATION NAME] (antibiotic) ophthalmic solution to the left eye and to monitor for changes as well as potential infection. Review of a progress note dated 9/1/18, indicated R56's left sclera continued to be red with a small amount of red tinged drainage, and the resident flinches when instilling eye drops. Review of a progress note dated 9/2/18, indicated R56's left sclera remained red and looked irritated, with a small amount of red tinged drainage. The resident flinched when instilling eye drops. R56's son requested resident to be seen by a physician at this time, and transported the resident to the emergency department (ED) for examination of the left eye. Review of a ED visit note dated 9/2/18, indicated R56 was seen by a physician in the ED for an eye injury. The exam indicated the left eye has [DIAGNOSES REDACTED] and bloody serous discharge from the conjunctiva membrane. There is a subconjunctival hemorrhage. Intra-ocular lens implant in place. The conjunctiva is inflamed and appears to have an abrasion. Treatment included: stop the steroid eye medication and [MEDICATION NAME] ointment. [MEDICATION NAME] (anti-[MEDICAL CONDITION]) eye drops ordered to the left eye Review of a follow-up ER visit note dated 9/4/18, indicated R56 was seen by NP-C. NP-C's note indicated R56 continued to have bloody serous drainage that seemed to be worse in the morning. R56 has been rubbing her left eye off and on, but difficult to determine if the resident has eye pain due to impaired cognition and inability to communicate. The left eye is blood shot in appearance and injected throughout with increased [DIAGNOSES REDACTED] and subconjunctival hemorrhage. Bloody serous drainage and watery eyes. treatment of [REDACTED]. Further, the note indicated NP-C would contact the on-call ophthalmologist for further input regarding R56's continuous serous bloody drainage and pain management. Review of a progress note and exam by NP-C dated 9/7/18, indicated R56's left eye continues to have purulent drainage with a scant amount of blood. Orders: Muro (reduce swelling) and [MEDICATION NAME] (antibiotic) eye drops to the left eye and evaluate in one month. NP-C will discuss hospice care with family and evaluate in 1 month if R56's family would like the resident to be seen by an ophthalmologist. Review of a progress note dated 9/14/18, noted R56's left eyelid to be slightly swollen, closes eyes tight and pulls head back when instilling eye drops. Small amount of red drainage noted from the left eye. Review of a progress note dated 9/25/18, indicated the interdisciplinary team (IDT) met and reviewed the above incident related to R12 causing an abrasion to R56's left eye on 8/31/18. R56 has since been admitted to hospice and has been on various eye drops for the treatment of [REDACTED]. This has been a source of pain for the resident and difficult for staff to administer eye drops effectively. All drops were discontinued and the resident will be seen by In-House Vision on 10/1/08 for comfort. On 9/26/18 at 9:04 a.m., R56's left eye on 9/26/18, at 9:04 a.m. note the left sclera to be slightly pink and eyelid slightly swollen around. The resident is in a broda chair and dependent on staff with all ADL's. The resident was non-interviewable due to severe cognitive impairment. During interview with H-A on 9/26/18, at 9:47 a.m. H-A stated she'd observed R12 grab R56's face with both hands. H-A said R12 grabbed R56 harshly and poked her in the left eye causing an injury. H-A further stated R12 had become angry for no apparent reason and had started charging at NA-B. When NA-B stepped away from R56, R12 proceeded to grab R56 in the face. H-A stated she immediately intervened to protect R56, and added that R12 had been aggressive and anxious throughout the day prior to the incident, but is often physically aggressive on a daily basis. Interview with licensed practical nurse (LPN)-A on 9/26/18, at 9:49 a.m. confirmed she was the unit charge nurse when the above incident occurred. LPN-A stated she was summoned to check on R56 by a NA after the resident had been poked in the left eye. LPN-A stated she'd examined R56's left eye and noted the sclera to be reddened and the eyelid to be slightly swollen so she'd contacted NP-C for further treatment orders. LPN-A also stated she had filed a VA report, but had not submitted it to the State Agency until 6:30 p.m. even though the incident had occurred at 8:00 a.m. During a phone interview with the director of nursing (DON) on 9/27/18, at 9:21 a.m. the DON confirmed R56 sustained a left corneal abrasion during the incident on 8/31/18, when R12 aggressed towards her. Interview with the facility licensed social worker (LSW) on 9/27/18, at 11:00 a.m. confirmed LPN-A should have reported the above incident to the SA immediately after the incident occured. During interview on 9/27/18, at 11:30 a.m. NA-B stated she had been working with R12 on 8/31/18, when R12 had injured R56's eye. NA-B stated she'd been wheeling R56 to the breakfast table on 8/31/18, when R12 became angry and started to charge at her. NA-B stated she stepped away from R56 to avoid confrontation. R12 then proceeded to grab and squeeze R56 in the face with both hands causing his finger to poke R56 in the left eye. NA-B was unsure what triggered R12 to become upset, but that he would just snap like that on a daily basis for no reason. NA-B indicated after the incident she wheeled R56 to the other side of the unit away from R12. NA-B confirmed R56 obtained an injury to her left eye causing the sclera to be very reddened and the lid to be slightly swollen. NA-B stated she had been provided education by the facility education director a couple of days after the incident related to how to respond differently to R12 in order to protect other residents. However, NA-B said she did not believe any other new interventions had been put into place to protect the other residents following that incident. R9's [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], indicated R9 had severe cognitive impairment, and there were no behaviors identified. R9's care plan, revised 9/25/17, indicated R9 was dependent on staff for activities of daily living and required the assistance of two with a mechanical lift for transfers and repositioning, and included an abuse prevention plan related to dementia, and major [MEDICAL CONDITION], with a goal of, The resident will not be harmed. A notation on the care plan dated 9/21/18, indicated that R9 had been offered a room off of the memory care unit for R9, due to incident involving another resident with dementia and family concerns for R9's safety. Review of a facility incident report, dated 9/11/18 at 10:30 p.m., and submitted to the state agency at 10:53 p.m., indicated, Writer heard screaming from R9's room and ran to investigate. Found R12 with right hand around R9's neck and left hand firmly grabbing R9's right arm. Writer and NA-A, intervened, and pulled R12 away from R9. As NA-A and RN-H were pulling R12 away, R12 reached out and slapped R9's forehead. The incident report was completed by RN-H. The follow up investigation report submitted on 9/14/18 at 5:08 p.m., documented that the mood and behavior plan for R12 was reviewed, and confirmed that staff were following the policy. The investigation summary indicated, Resident has dementia with behavioral disturbance. He wanders within boundaries of unit he resides on. Care plan reviewed and was being followed. Resident behavior escalated .cause for escalation in behavior was verbal outburst from another male resident in the vicinity that took place prior to resident to resident occurrence. R12 provider was informed and provided order for R12 to be sent to Grace Unit in Hastings, Minnesota where he will be evaluated for dementia with behavioral disturbance. Resident transported there on 9/12/18. Length of stay undetermined at this time. A section on the report entitled description of harm indicated that R9 sustained a red mark on the right side of her neck, and the area was being monitored for changes, and pain in that area. R9's progress notes revealed the following documentation: -9/11/18 at 9:21 p.m., R9 heard screaming from her bedroom at 2030 (8:30 p.m.) this evening. Writer and other staff ran to investigate. R12 found to be standing at her bedside with hand around (R9's) throat and upper right arm. Staff intervened and led R12 away. Resident assessed and skin is found to be reddened but does not appear to be bruising yet. Stated to writer I'm just terrified! I was sleeping and then I woke up to him choking me! I need to go home. Resident reassured that we would keep a close eye on wandering residents and check on her frequently. Neuros initiated as resident was hit in the head; are negative. Resident continues to be fearful, found sitting on side of bed wanting to leave. (Family) called to update but have not answered. Message left on (family member's) phone to call back for update. -9/12/18 at 5:33 a.m., Resident sleeping soundly since writer here at 0300 (3:00 a.m.). Staff report resident has not been incontinent of urine, she did have a small soft incontinent bowel movement. Resistive with pupil checks, tries to squeeze her eyes shut. Had been lying on her right side, after repositioning to the left side she was noted to have some redness to right side of neck with a very small scratch and some redness to right cheek that did lessen. No complaints, discomfort with repositioning. Writer tried to offer her some pudding to eat, she wouldn't open her mouth, turned her head away. Blood pressure readings lower in left arm than right arm, 90/59 on left arm at 4:20 a.m.,109/69 on right arm at 5:15 a.m. -9/12/18, at 7:08 a.m., In bed awake, acknowledged writer with good morning when writer initiated conversation. Stated she was ready to get up anytime. Note reddened area to right side of neck with small skin abrasion approximate. 0.1 cm within reddened area. No bruising apparent. On attempt to complete pupil checks, closed eyes tightly, unable to complete pupil check. Movement to all body limbs at baseline state. VS:96.1-63-20 109/72 93% sat. -9/12/18, at 11:05 a.m., Content in wheelchair/ through the a.m., dozing per normal in chair in lounge area. Responsive when spoken to indicated to writer she was just tired when asking how she was. Note redness to right side of neck diminishing in color. Vital signs: temperature 97.2, pulse 62, respirations 18, 98/64, 94% oxygen saturation, body movement remains at baseline, again closing eyes tight with attempt to complete pupil check, replied don't to writer. Following assessment contacted family member (FM)-A per request from social services as FM-A had called earlier and writer unavailable. FM-A inquired how (R9) was doing and if she voiced any fear to writer, assured her none stated. -9/12/18, at 1:18 p.m., Meeting this morning with (FM-A) and (FM-B). Meeting requested by family to discuss occurrence last p.m. that involved a male resident. Resident family very involved in resident care. Facility Administrator present as well. Family expressed concerns about resident's safety. Assured family that care plans for involved residents were being followed. Further discussed dementia and the many ways it presents and that how one resident may act or what may trigger certain actions/behaviors will be different than another. Also, discussed others venturing into other's rooms, that this is going to happen, etc. They expressed understanding. Assured family that both resident providers were informed of the event and appropriate interventions were taking place and proper reporting to Minnesota Department of Health was done. Assured them that R9 will be monitored for adverse affects of occurrence of last evening, monitoring for pain, bruising, emotional changes, etc. Offered to them, that when they are here to visit that if they see/hear adverse events they should alert nursing staff verbally or use call light. Also, suggested that if they felt more comfortable they were welcome to visit behind closed room door. -9/14/18, at 12:54 p.m. Resident seen today by nurse practitioner (NP-C) today in regards to incident on 9/11 with R12. No new orders or changes in plan of care. Nursing staff to continue to monitor area for worsening/healing/resident's complaints of pain. -9/16/18, at 6:30 a.m. (Recorded as Late Entry on 9/17/18, at 9:32 AM), Resident not sleeping well the past two nights, have tried as needed Tylenol ES with little effectiveness. Resident talking about seeing 3 men in here and talks about people stealing things. Given reassurance, but continues awake, talking. In later night, she was still awake, looking at ceiling and then finally did fall asleep. -9/20/18, at 1:43 p.m. (Recorded as Late Entry on 9/21/18, at 8:56 AM) Resident's daughter and Ombudsman came to facility to discuss daughter's concerns with incident that occurred with other resident. FM-A is upset and does not feel some residents belong here in this facility. Encouraged her to discuss further with Ombudsman and restrictions on facilities to involuntarily discharge someone. Ombudsman did explain some to daughter. Ombudsman requested the VA report that was submitted and the Abuse Prevention Plan for (R9 & R12) be sent to him. Discussed overall needing a plan in place prior to the other resident returning. Explained that will take guidance from the hospital the other resident is in re: his needs, how he is doing, etc to help guide that plan. Requested information will be sent to Ombudsman. The facility's undated Abuse Prevention Plan Policy included: to prevent abuse/neglect the facility should identify, correct and intervene in situations where abuse/neglect occur, ensure sufficient staff and appropriate supervisory staff on each shift to meet the needs of the residents, assess the residents needs and behaviors that might lead to conflict or neglect through team meetings, provide specific measures to be taken to minimize the risk of abuse/neglect of resident and other vulnerable adults, provide training to employees related to protection of residents involved in incidents of abuse/neglect, resident incident/accident reports and medical records shall be routinely monitored for indicators of possible abuse/neglect, all incidents and accidents and allegations of abuse shall be investigated by the DSS (director of social services), DON, or appropriate designees, measures will be taken to identify the source of the alleged abuse and prevent future incidents, implement safety measures of the VA and other residents. Report suspected abuse/neglect in accordance with legal requirements: staff will notify the charge nurse immediately of any possible reports of abuse/neglect, the charge nurse will immediately notify the administrator, DON and DSS, report suspected abuse/neglect immediatley upon receiving a report to the Minnesota Department of Health (MDH), staff will notify the physcian and family as appropriate, within 5 working days the designee will electronically submit an investigative report to the appropriate state agency.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure relieving interventions for 1 of 1 resident (R36) with current facility acquired pressure ulcers. This deficient practice resulted in actual harm for R36 when a stage 2 pressure ulcer deteriorated to a stage 3 pressure ulcer, and 2 new stage 1 pressure ulcers developed. Findings include: R36 was admitted to the facility with diagnosis (identified on the face sheet of the medical record) that included: [MEDICAL CONDITION], incontinence, type 2 diabetes mellitus and [MEDICAL CONDITION]. Review of R36's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R36 had severe cognitive impairment, required extensive assistance with bed mobility, transfers and toileting. Always incontinent of bladder and frequently of bowel. The MDS further indicated R36 was at risk for pressure ulcers and had a stage 3 pressure ulcer that measured 0.7 centimeters (cm) in length by 0.5 cm in width with granulation tissue. No depth measurements. R36 utilized a pressure reducing device in the chair/bed and pressure ulcer care. No positioning program. R36's quarterly MDS assessment dated [DATE], indicated R36 had severe cognitive impairment, required extensive assistance with bed mobility, transfers and toileting. Always incontinent of bladder and frequently of bowel The MDS further indicated R36 was at risk for pressure ulcers and utilized a pressure reducing device in the chair/bed. No positioning program. Review of R36's Braden Scale for Predicting Pressure Sore Risk dated 9/9/18, was scored as 13, indicating R36 was at moderate risk for skin breakdown. Interventions listed: pressure reducing device on wheelchair (W/C)/bed, repositioning program, pressure ulcer care that included a treatment dressing and a nutritional intervention. Review of R36's current plan of care identified the resident as receiving hospice care related to terminal vascular disease on 8/17/18, having a self care deficit related to muscle weakness and dementia, alteration in mobility due to scoliosis and muscle weakness and frequently incontinent of bowel and bladder requiring extensive assistance with all ADL's. R36 is at risk for alteration in skin integrity and has a history of pressure ulcers as well as a current open area on the coccyx on 7/29/18. Interventions: reposition every 2 hours, wound dressing changes as ordered, balance diet, avoid shearing with positioning, skin inspection weekly on bath days and as needed, encourage fluids, provide peri cares with incontinence as needed, pressure relieving mattress, heel protectors with off loading in bed, pressure relieving cushion in W/C, keep skin clean and dry, report any signs of skin breakdown, nutritional supplements as ordered Review of R36's current physicians orders included: Ensure Plus 120 milliliters (ml) three times a day (TID) and as needed (PRN) ordered on 7/1718, and [MEDICATION NAME] dressing to pressure sores on bottom once every 3 days (Q3D) ordered on [DATE]. Review of the nursing assistance (NA) care sheets for R36, directed staff to turn and reposition R36 every 2 hours. Review of a skin integrity event/pressure sore ulcer assessment dated [DATE], identified 2 new stage 2 pressure ulcers to R36's coccyx. A pressure ulcer located in the center of the coccyx measured 0.6 cm in length by 0.6 cm in width and to the right side of the coccyx a pressure ulcer that measured 0.3 cm in length by 0.3 cm in width. No depth measurements. The pressure ulcers were identified to have granulation tissue in the center with no drainage/odor. Interventions: pressure reducing device in W/C/bed, turning and repositioning program and nutritional intervention. Reported the new identified pressure ulcers to the certified nurse practitioner (NP)-C and orders received to apply [MEDICATION NAME] dressing to pressure sores on bottom Q3D until healed. Weekly measurements of the pressure ulcers listed below: 7/30/18-Coccyx center (0.5 cm length by 0.5 cm width). Granulation tissue with no drainage/odor. Right side of coccyx (0.6 cm length by 0.6 cm width). Granulation tissue and no drainage/odor. Stage 2. 8/6/18- Coccyx center( 0.5 cm length by 0.5 cm width). Granulation tissue with no drainage/odor. Pressure ulcer to right side of coccyx was not identified. Stage 2. 8/13/18- Coccyx center (0.7 cm length by 0.5 cm width) Granulation tissue with no drainage. Stage 2. 8/20/18 -Coccyx center (1.0 cm length by 0.4 cm width by 0.1 cm depth). Granulation tissue with serosanguineous drainage. Stage 2. 8/27/18-Coccyx center (1.0 cm length by 0.3 cm width).Granulation tissue with no drainage/odor. Stage 2. 9/6/18- Coccyx center (1.0 cm length by 0.5 cm width) Granulation tissue with no drainage/odor. Stage 2. 9/10/18-Coccyx center (1.5 length by 1.0 cm width) Granulation with [MEDICAL CONDITION] drainage. The assessment indicated the pressure ulcer was declining. No new interventions implemented. Stage 2. 9/17/18-Coccyx center (1.2 cm length by 1.5 cm width). Granulation tissue with [MEDICAL CONDITION] drainage. Identified as a stage 3 pressure ulcer. No new interventions implemented when the pressure ulcer worsened from a stage 2 to a stage 3. 9/25/18 Coccyx center (0.5 cm length by 0.3 cm width). Granulation with [MEDICAL CONDITION] drainage. Stage 3. Review of the NP visit and exam dated 9/14/18, did not address or include R36's pressure ulcer on the coccyx. Although the pressure ulcer was identified as worsening and becoming larger in size on 9/10/18, and had increased from a stage 2 to a stage 3 pressure ulcer on 9/17/18, this decline was not reported to the medical provider (MP). Observation on 9/24/18, from 4:15 p.m. to 6:45 p.m. R36 was observed to be sitting up in a regular W/C in the lobby. The resident was not observed to be repositioned at this time nor was there a pressure relieving decide in the W/C. During interview on 9/25/18, at 2:30 p.m. nursing assistant (NA)-D confirmed R36 is turned and repositioned every 2 hours according to the plan of care. NA-D further stated if R36 does not lay down in bed she should be reclined in the Broda chair to change her position after being up after 2 hours. NA-D further include on 9/24/18, R36 was in a regular W/C because she had her hair done and she was not positioned back in the Broda chair when done. Observation on 9/26/18, from 7:00 a.m. to 9:20 a.m. R36 was observed to be sitting straight up in a Broda chair while eating breakfast at the dining room table and in the lobby. No repositioning was observed. Observation on 9/27/18, from 8:00 a.m. to 12:19 p.m. R36 was observed sitting in a Broda chair only slightly reclined, R36 remained sitting on her coccyx. No repositioning was observed. Interview with nursing assistant (NA)-C at this time confirmed R36 had not been repositioned since 8:00 a.m. NA-C further revealed she was so busy she did not have time to reposition the resident other than slightly recline her in the Broda chair at 8:30 a.m. after breakfast. Interview on 9/27/18, at 8:37 a.m. with registered nurse (RN)-D supervisor, confirmed there were no new interventions implemented when R36's pressure ulcer deteriorated on 9/10/18, and was identified as a stage 3 pressure ulcer on 9/17/18. RN-D stated R36's skin tolerance was not re-assessed as well after the decline in the pressure ulcer. Observation on 9/27/18, at 12:56 p.m. R36's pressure ulcer was observed with Observation of the pressure ulcer with hospice registered nurse (RN)-I. R36 was observed to have an open area on the center of her coccyx as well as an open area on the right side of the coccyx and the left side of the coccyx. RN-I measured the stage 3 pressure ulcer on the center of the coccyx which measured 1.1 cm length by 0.4 cm width. There was a new stage 1 pressure ulcer located on the right side of the coccyx that measured 0.7 cm in length by 0.1 cm in width. There was a new stage 1 pressure ulcer located on the left side of the coccyx that measured 0.2 cm in length by 0.6 cm in width. [MEDICATION NAME] treatment applied to area of coccyx. The skin around the pressure ulcers is reddened with no drainage noted. Interview with RN-I at this time indicated she was unsure if the pressure ulcers on the right and left side of the coccyx were identified or being treated. When interviewed on 9/28/18, at 11:50 a.m. RN-D stated she was not aware of the stage 1 pressure ulcers on R36's right and left side of the coccyx that were identified on 9/27/18, by hospice RN-I. RN-D further included RN-I documented the pressure ulcers in the progress notes, but failed to communicate the new pressure ulcers to the facility staff when they were identified on 9/27/18. The facility's undated policy Prevention and treatment of [REDACTED]. Care and service are delivered to maintain skin integrity and promote healing if skin breakdown should occur. Residents at risk for impaired skin integrity are provided preventive measures to reducing the potential for skin breakdown. Residents who experience a break in skin integrity are provided care and service to heal skin according to professional standards of care. Interventions: skin integrity is monitored and abnormal findings are documented, skin is observed daily and reported to the licensed nurse with any concerns identified, weekly skin assessments are done by the licensed nurse including measurements and the condition/description of the pressure ulcer/wound, if a wound has deteriorated or not shown progress in 2 weeks, report to the attending provider and re-evaluate the plan of care as appropriate.

Based on observation, staff interview, and record review, the facility failed to provide care and services in a timely manner to promote healing, and prevent further development of pressure ulcers, for 1 of 3 residents (R34) in the sample reviewed with pressure ulcers. This deficient practice caused harm, development of a new pressure ulcer for R34. Findings include: R34, who the facility had identified as having pressure ulcers, was not repositioned in a timely manner. The resident was observed during the survey to have developed another pressure ulcer. During interview with Registered Nurse (RN)-A on 8/20/12 at 2:45 p.m., it was learned that R34 had a Stage 4 pressure ulcer on the right ischial tuberosity and a Stage 2 pressure ulcer to the right heel. R34's record was reviewed. The resident had most recently been admitted to the facility on [DATE]. The resident has [DIAGNOSES REDACTED]. A quarterly minimum data set (MDS) assessment from 1/20/12 did not identify the resident as at risk for pressure ulcers, and indicated the resident had no pressure ulcers at that time. However, quarterly MDS' dated 4/1/12 and 6/24/12, identified the resident as being at risk for pressure ulcers, and as having Stage 2 unhealed pressure ulcers. The 6/24/12 quarterly MDS also indicated the resident had a Stage 3 pressure ulcer. A progress note from 2/2/12 indicated the resident had an open area on the buttocks, and on 2/24/12 the notes indicated the resident had a newly discovered dark red area on the posterior right heel. R34's care plan revised 7/2/12, identified a problem area of "self care deficit related to mental [MEDICAL CONDITION] and [MEDICAL CONDITIONS] evidenced by the inability to complete tasks per self at risk for skin breakdown" Goal included: "...open areas on buttocks and heel will resolve without complications." Interventions included for staff to "check skin integrity BID (twice a day) with AM (morning) and PM (evening) cares and report...change and repo (reposition) every 1-2 hours." The Nursing Assistant (NA) Group Sheet (a portion of the plan of care specific to aide NAs with providing appropriate care) dated 8/15/12, identified R34 was to be off- loaded every hour and chart. Although the care plan indicated R34 was at risk for pressure ulcers, and was dependent on staff for care, the resident was not repositioned in accordance with his individualized plan of care. During continuous observations of R34 on 8/23/12, from 7:15 a.m. until 9:45 a.m., the resident remained in the same position in bed without any assistance with position change by the facility staff. The resident was observed to be laying on his left hip, with his right foot in heel protectors resting directly on the bed. NA-D, who had been working all night, was interviewed at 7:15 a.m. on 8/23/12. NA-D stated she had not repositioned R34 that morning because they were supposed to let residents sleep as late as they wish in the morning. NA-B and NA-C verified during interview at 10:15 a.m. on 8/23/12, that R34 had not been repositioned by either of them since their shifts had started at 6 a.m. that morning. They both verified their awareness that R34 was supposed to be repositioned every hour. The licensed practical nurse (LPN)-A verified during interview at 9:45 a.m. on 8/23/12, that R34 should be allowed to sleep. She verified staff would wait to provide repositioning and pressure ulcer care until R34 awoke on his own. She stated that residents are allowed to sleep in as long as they desire in the morning, and that she would wait to provide pressure ulcer care for R34 until he awakened on his own. When the surveyor asked about the care plan intervention indicating R34 needed to be repositioned every 1-2 hours, LPN-A immediately went into R34's room and repositioned him. R34's pressure ulcer care, provided by LPN-A, was observed at 10:00 a.m. on 8/23/12. R34 was observed to have a stage 4 pressure ulcer on his right buttock, a stage 1 pressure ulcer on his left buttocks, an unstageable pressure ulcer on his right heel, and another unstageable pressure area observed on the inner aspect of his right foot. The nurse stated, "oh this is new" in reference to the area on the inner aspect of his right foot. This new area was observed to be blackish in color and oval in shape. LPN-A measured the area to be 2 centimeters (cm) x 3.7 cm.