Every finding on record at Boundary Waters Care Center

Based on interview and document review, the facility failed to ensure a nutrient and/or calorie substantive snack was offered and provided after the evening meal and before bedtime. This had the ability to affect all 32 residents who reside within the facility. Findings include: During interview on 10/14/24 at 10:30 a.m., cook (C) stated mealtimes are 8 a.m., noon, and 5 p.m. and the facility does not prepare or distribute a bedtime snack cart. During interview on 10/14/24 at 11:06 a.m., licensed practical nurse (LPN)-A stated a bedtime snack pass does not occur. Snacks such a pudding, chips, cookies, and sandwiches are always available, but not offered. If a resident wants a snack, they need to ask for one. During interview on 10/14/24 2:08 p.m. nursing assistant (NA)-A stated a bedtime snack pass does not occur and if a resident wants a bedtime snack, they need to ask for one. Not all residents ask for a bedtime snack. During interview on 10/15/24 8:55 a.m., culinary director (CD) confirmed mealtimes are 8 a.m., noon, & 5 p.m. and snacks are available, but not offered at bedtime. CD stated it was important to offer a bedtime snack to maintain resident nutrition and caloric needs. During resident council interview on 10/15/24 at 1:25 p.m., residents stated a bedtime snack was not offered and they were unaware snacks were available in the evening. During interview on 10/16/24 at 11:20 a.m., administrator confirmed there was greater than 14 hours between meals and a nourishing snack was not served at bedtime. It was important to offer a bedtime snack to the residents to maintain their nutrition. Facility policy, Meal Frequency dated 11/2002, identified there will be no more than 14 hours between a substantial evening meal and breakfast the following day, expect when a nourishing snack is served at bedtime. A snack is to be offered to all residents at bedtime.

Based on observation, interview and record review, the facility failed to provide physical therapy and occupational therapy as ordered for 1 of 1 resident (R30) reviewed for therapy services. Findings include: R30's Admission Record undated, identified R30 was admitted from another long-term care (LTC) facility on 5/7/24, Diagnoses included acute infarction of spinal cord and paraplegia. R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had intact cognition and did not exhibit behavioral symptoms. The MDS identified R30 had impairments to both lower extremities, could not ambulate, and needed maximal assistance for transfers. R30's discharge instructions and summary from R30's former LTC facility, dated and signed 5/6/24, identified R30 was discharged to Boundary Waters Care Center. Instructions included under section F-Activity/Therapy/Current Mood/Behavior part B indicated orders for therapy for transfers to another facility included PT to OT. The orders lacked documentation orders were only for a decline or change in condition. The Active Order Summary Report from R30's former LTC facility, dated and signed 5/6/24, was included in the discharge/admission instructions and included PT/OT to evaluate and treat. Those orders also lacked documentation to do only if there was a change of condition or decline. During interview on 10/13/24 at 7:12 p.m., R30 stated the facility had never evaluated for either occupational or physical therapy. During interview on 10/14/24 at 11:08 a.m., certified occupational therapy assistant (COTA)-A stated when any resident was admitted or transferred into the facility, orders were reviewed to see if they had therapy orders or qualified for therapy orders. If there were therapy orders the physical therapist and/or occupational therapist would do an evaluation. If no order, then the ID would do a screening to see if they qualified for therapy. The ID stated she had reviewed R30's admission paperwork and was aware of therapy orders from 5/6/24. COTA-A stated the inter-departmental team discussed the referrals and felt it was not appropriate since the resident had been evaluated for hospice and was thinking about it. If R30 had decided against hospice the nursing was to notify therapy department so the evaluations could be done. The therapy department never requested orders to cancel or postpone the PT/OT evaluate and treat orders that arrived on admission. COTA-A did acknowledge R30 was at increased risk of contractures and other declines due to not following orders and having PT/OT evaluate and treat. R30's discharge instructions and summary and active order summary report dated and signed 5/6/24, were reviewed and lacked any orders for hospice or hospice consult. R30's referral forms dated 4/25/24, sent to the facility to review to accept transfer lacked any documentation related to hospice referral or orders. The facility's C-Fast Form-Clinical Fast Approval Screening Tool, last reviewed 2/26/24, included R30's medical information. The form lacked any indication there was a hospice referral. During an interview on 10/16/24 at 10:53 a.m., registered nurse (RN)-A stated the IDT team had been aware of R30's admission orders upon arrival but thought he was going on hospice, so they had not been followed through on. A few days following admission, R30 decided not to seek hospice. The therapy department was not made aware of R30's decision and order to cancel the PT and OT orders were not completed. During interview on 10/16/24, at 11:48 p.m., the director of nursing (DON) stated if a resident is admitted with therapy orders, the expectation was to evaluate and address with the provider. If the resident did not come in with orders, therapy should screen for orders. The facility policy Rehabilitation Services Orders dated 4/1/08, identified the facility provided physical, occupational or speech therapy to attain or maintain function and/or prevent decline with a physician-ordered treatment plan.

Based on observation, interview, and document review the facility failed to notify the provider of a resident presenting with mentation and respiratory changes for 1 of 1 residents (R6) reviewed for change in condition. Findings included, R6's Quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had moderate cognitive impairment. Diagnoses included coronary artery disease, cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD) and respiratory failure. The MDS indicated R6 was not comatose. R6 could also hear adequately without hearing aides, speak clearly, and usually understood others. R6's care plan, last revised [DATE], identified respiratory concerns but lacked notification to provider for intervention changes. R6's provider signed Minnesota Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE] indicated under section A- Cardiopulmonary Resuscitation (CPR) R6 was a do not attempt resuscitation (DNR). It also indicated under section A when not in cardiopulmonary arrest (the heart and or lungs have stopped working), follow orders in section B. Section B -Medical Treatments R6 had Selective Treatments chosen. Selective Treatments included use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. Also may consider less invasive airway support and transfer to hospital if indicated, but to avoid intensive care units. On [DATE] at 3:18 p.m., R6 was observed laying in bed with the head of bed at a 90 degree angle. Respirations were deep and labored and moisture could be heard in her airway as she took breaths and when she coughed. R6 was observed staring forward and not responding to verbal questions, requests, and was not tracking where the voices were coming from. R6's medical record was reviewed and identified the following: - On [DATE], R6 was discharged from hospice since her condition had been very stable and steady. R6 responded to commands, cooperative and follows directions. Assessment indicated lungs were clear but diminished in the bases. Hospice staff had interviewed staff and documented R6 had no cough and had been alert. - On [DATE] at 1:13 p.m., MDS interview completed with R6 and staff and R6 answered questions appropriately and understood directions with cares when given. There was shortness of breath when laid flat but not with transfers. - On [DATE] at 9:09 a.m., family called to advise of change in R6's breathing and increased lethargy. - On [DATE] at 11:24 a.m., daughter called to speak with R6. Held phone up to ear because R6 was unable to communicate. Family in route as soon as able. During interview on [DATE] at 6:30 p.m., licensed practical nurse (LPN)-A stated anytime a resident had a change of condition the family, director of nursing (DON) and the provider would be notified of a change of condition. If the person was on hospice, then hospice would be notified along with the provider. LPN-A stated that at 9:00 a.m. R6 became more lethargic and had changes in her respiratory system. Breathing was labored, deep, and there was audible moisture heard when she was breathing. R6 did eventually lose ability to communicate. She called R6's family members and the DON and reported the change of condition to them. She stated she did not notify the provider of the change of condition and had not been advised to call the provider. LPN-A stated family had asked if R6 should be sent to the emergency room and was told it was not needed. LPN-A did acknowledge there was a significant change in R6's condition. During interview on [DATE] at 10:50 a.m., registered nurse (RN)-A stated that changes in mentation and respiratory system issues would be considered a change in condition, especially if the patient had been stable prior to the incident. Any change of condition would result in the family, provider, and DON being notified so a plan of care could be made to address the changes. RN-A stated code status would not affect the decision to notify the provider. During interview on [DATE] at 11:48 a.m., the DON stated that a change of condition was based on each individual case. If a change of condition did occur the expectation would be the nurse notify the family, provider, and myself [DON] of the change. The DON stated that even if the resident was DNR the provider would still be notified of the change. Facility policy Notification of Change, last reviewed ,d+[DATE], indicated the staff would consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there was an acute illness or a significant change in the resident's physical, mental or psychosocial status. Examples were deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. Life-threatening conditions would include but were not limited to such things as heart attack or stroke.

Based on interview and record review the facility failed to assess, monitor, and implement interventions to prevent decreased range of motion (ROM) for 1 of 4 residents (R5) reviewed for positioning, mobility, and ROM. Finding include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact and had functional range of motion (ROM) impairment of the right and left upper extremities (shoulder, wrist, and/or hand). R5 requires partial to moderate assistance for upper body dressing and was dependent on staff to for personal hygiene. During the assessment period (9/10/24 to 9/17/24) R5 did not receive physical therapy (PT), occupational therapy (OT), or restorative nursing services. R5's OT evaluation and plan of treatment dated 4/11/23, identified R5 did not have functional limitations due to a contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity, rigidity of joints, and reduced ROM). During interview on 10/13/24 at 3:25 p.m., R5 stated she has had ROM impairment in her left hand for at least 3 years. R5's fingers on her left hand were curled into, and touching her palm. R5 stated she was unable to extend/open her fingers and would be willing to work with PT, OT, and/or restorative nursing to improve/maintain the ROM in her left hand if it was offered. During interview on 10/14/24 at 3:14 p.m., COTA-A confirmed R5's last OT evaluation was on 4/11/2023. At that time, R5 was referred for weakness and the goal of therapy was to improve transfer ability. R5 was discharged from OT on 5/4/23 and has not received PT/OT services since. During interview on 10/15/24 at 12:26 p.m., occupational therapist registered (OTR)-A confirmed she had completed R5's OT evaluation on 4/11/23 and the evaluation identified R5 did not have a contracture. OTR-A stated at the time of the evaluation, R5 had tightness in her left hand and then used her hand to demonstrate that R5's fingers were curled in an opened C shape. OTR stated she re-evaluated R5 today (10/15/24), noted R5's left hand fingers were now folded into her palm, and determined R5's left hand was contracted. OTR-A explained rehabilitation therapy services do not routinely screen for changes in ROM or the development of contractures. The facility process was for nurses to monitor for changes in ROM and the development of contractures and to report these changes. Reported changes would result in a PT/OT evaluation. OTR-A states since discharge on 5/4/23 and up until today (10/15/24) she was not notified of any changes in R5's ROM or contracture development. During interview on 10/15/24 at 1:56 p.m., registered nurse (RN)-A stated it was the responsibility of nursing staff to monitor and report any change in resident condition which included the development of a contracture. During interview on 10/16/24 at 10:28 a.m., RN-B stated all nurses are trained and expected to monitor and report any change in ROM which included the development of a contracture. When a change in ROM was reported, a PT/OT referral would be made, and a PT/OT evaluation would be completed. During interview on 10/16/24 at 11:23 a.m., the administrator stated it was important to report contractures so steps can be taken to prevent further decline or impairment. Facility policy Restorative Program last revised 5/20, indicated while in this facility, all residents are supported to maintain or attain their highest level of functioning. Further, all residents are assessed upon admission and at each care plan meeting for possible inclusion in restorative programs.

Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to facility policy as well as failed to ensure nebulizer tubing/canisters were cleaned and allowed to air dry after each use for 1 of 1 resident (R21) reviewed for oxygen therapy. Findings include: R21's annual Minimum Data Set (MDS) dated [DATE], identified R21 was cognitively intact and had continuous oxygen therapy. Diagnoses included chronic obstructive pulmonary disease (COPD). R21's provider order dated 12/28/23, identified orders to change oxygen tubing and nebulizer tubing weekly on Saturday night. Provider orders dated 6/20/23, identified Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligram(mg)/3 Milliliters (ml) (a respiratory medication utilized to treat COPD). 3ml inhale orally every 4hr for COPD while awake. Provider orders dated 8/29/24 indicated oxygen 2-4 liters(L) continuous. R21's care plan undated, identified R21 needed continuous oxygen therapy and to administer oxygen and respiratory medications as per orders. The care plan lacked documentation when to change oxygen tubing and when/how to clean nebulizer tubing/canister. R21's treatment administration record for 10/24, indicated oxygen tubing and nebulizer tubing had been changed on 10/5/24, but not 10/13/24. On 10/13/24 at 3:42 p.m., R21 was observed wearing continuous oxygen via nasal cannula. The date on the green extension tubing and the nasal cannula could not be located. An undated nebulizer canister and tubing were observed sitting on the chest. The canister was noted to be closed and had visible liquid in the canister along with condensation along the inner walls of the canister. The mask was covered with dried items and moisture stained. During interview on 10/13/24 at 3:44 p.m., R21 stated the staff occasionally change the oxygen tubing, nebulizer tubing, and canister the way they were supposed to and R21 could not remember when it was last changed. The staff will never clean out the nebulizer canister after my treatment. They bring me the medication and I give myself the treatments and staff is supposed to clean the nebulizers. I give myself my first nebulizer treatment around 7:00 a.m. and they are every 4 hours after that. On 10/15/24 at 10:17 a.m., the oxygen tubing and nasal cannula were observed, and a date could not be found. The tubing on the nebulizer was noted to have date 10/14/24, taped on it. The nebulizer canister was noted to have visible liquid inside the closed canister, as welll as condensation. During interview on 10/15/24 at 10:50 a.m., registered nurse (RN)-A stated all oxygen tubing and nebulizer tubing/canisters would be changed every 7 days on Saturday night. Documentation of the change would be done in the TAR and the tubing would be labeled with tape and the current date on the tape. RN-A stated nebulizer canisters needed to be cleaned after each use and allowed to air dry in separate pieces before the next treatment was given. Cleaning should occur immediately after the medication in the nebulizer was administered. RN-A entered R21's room and looked at the nebulizer tubing and confirmed a date of 10/14/24 was written on tape and placed on the nebulizer tubing. RN-A then looked at the green extension tubing and nebulizer tubing and found a faded date written directly on both tubing of 9/14. RN-A also confirmed 9/14 was a Saturday in 2024 and the writing style was different than the nasal cannula and nebulizer tubing. RN-A also confirmed the nebulizer had not been cleaned out since the last treatment had been taken. During interview on 10/16/24 at 10:38 a.m., RN-B stated all oxygen tubing and nebulizer tubing/canisters should be changed every 7 days, on Saturday night. RN-B stated nebulizer canisters should be cleaned immediately after each use to prevent bacteria growth that can occur with left over moisture in the canister. During interview on 10/16/24 at 11:48 a.m. the director of nursing (DON) stated staff were expected to change the nebulizer tubing weekly and clean nebulizer canisters after each use. Facility policy Nebulizer Treatment last revised 4/09, indicated after each use staff should disconnect nebulizer tubing, shake out excess liquid, allow the nebulizer cup to air dry and then place the dry nebulizer in a clean plastic bag. Nebulizer and tubing should be replaced every 7 days. Facility policy Oxygen Administration last revised 2/23, indicated the oxygen tubing needed to be replaced weekly and as needed.

Based on observation, interview, and record review the facility failed to ensure the electronic medical record (EMR) was secured in a manner that prevented unauthorized individuals from viewing and or accessing confidential resident information contained within the EMR. This had the potential to affect all 31 residents residing at the facility. Findings include: During an observation on 1/24/24 at 8:33 a.m., trained medication aide (TMA)-A walked away from the medication cart located in the hallway. The EMR was open and displayed resident information. TMA-A assisted another staff access a storage room around the corner and then returned to the medication cart. During a continuous observation on 1/25/24 at 8:22 a.m., the medication cart in the hallway was unattended and the EMR was open and displayed a resident's medication list. - 8:25 a.m., the cart was unattended and the EMR continued to display resident information. - 08:29 a.m., no change, multiple staff walked by the medication cart and did not notice the open EMR. - 8:31 a.m., TMA-A exited a resident room, stopped at cart, looked at screen, left EMR open, left cart unattended, and entered another resident room. -8:34 a.m., TMA-A returned to the medication cart. During an interview on 1/25/24 at 8:34 a.m., TMA-A acknowledged that they had left the EMR open and unattended. TMA stated it was easy to lock the screen and demonstrated how to lock and unlock the EMR with a few clicks. TMA-A stated the EMR needed to be locked for resident privacy and confidentiality and confirmed they should have locked the EMR when they stepped away from the medication cart. The EMR should be locked every time we step away from the medication cart. During an observation on 1/25/24 at 9:57 a.m., the EMR on the medication cart in the hallway was noted to be unattended and displayed a resident's name and medication administration information. TMA-A exited a resident room from down the hallway and returned to the medication cart. During an interview on 1/25/24 at 10:52 a.m., the director of nursing (DON) stated to be in compliance with HIPAA [Health Insurance Portability and Accountability Act (a federal law that restricts access to individuals' private medical information)], resident information needed to be protected and secured. The DON explained that their EMR had a built-in lock feature designed to secure their EMR and prevent unauthorized access or viewing of confidential resident information. The DON stated they expected staff to lock or close the EMR every time they stepped away from the EMR, no exceptions. This had the The facility policy Privacy and Confidentiality dated 11/2016, identified residents had the right to have privacy and confidentiality of their personal and medical rights and their information would be safeguarded at all [NAME] to ensure confidentiality.

Based on observation, interview and document review the facility failed to ensure residents were offered proper hand sanitization prior to meals. This had the potential to impact all residents that consumed meals in the dining room. Findings include: During a continuous observation of the dining room on 1/24/24 from 8:26 a.m., to 9:26 a.m., residents were seated at three tables. Each resident was offered a clothing protector and assistance with meal setup and or consumption as needed. However, there were no observations of staff offering or of resident's hands being sanitized prior to meal consumption. The main entrance to the dining room had a sign on the door that read be a germ buster wash your hands. Staff observed to be assisting residents during this time included nursing assistant (NA)-A, NA-B, NA-C, NA-D, and activities aide (AA)-A and AA-B. During a continuous observation on 1/24/24 12:05 p.m., to 12:51 p.m., residents were seated at four tables. There were no observations of residents already seated in the dining room or being brought into the dining room being offered to have their hands sanitized. Staff observed to be assisting residents during this included nursing assistant (NA)-A, NA-B, NA-C, NA-D, (AA)-A and AA-B and kitchen staff that assisted with passing beverages and food to residents. During a continuous observation on 1/25/24 from 8:19 a.m. to 8:40 a.m., there was a large pump bottle of hand sanitizer located by the sink staff used to wash their hands. Staff offered residents clothing protectors but did not offer residents the opportunity to sanitize their hands prior to eating their meal. Staff observed to be assisting residents during this time included (NA)-A, NA-B, NA-C, NA-D, (AA)-A, and the physical therapist assistant (PTA)-D. During an interview on 1/25/24 at 10:13 a.m., NA-D-stated they did not help residents sanitize their hands before meals because they were never taught to do that before meals during their orientation. NA-D indicated it would be important for residents to have their hands sanitized before eating to prevent the spread of germs and for good hygiene. During an interview on 1/25/24 at 10:32 a.m., NA-B confirmed they had not been helping residents sanitize their hands before meals during meals, but indicated normally staff did offer hand sanitizer to residents before meals. It was important for residents to sanitize their hands before they ate for infection control. During an interview on 1/25/24 at 10:41 a.m., the director of nursing (DON) stated residents should be offered an opportunity to have their hands sanitized before they eat meals. The sanitization of hands is important for infection prevention and control. The facility policy Handwashing dated 11/2022, did not address resident hand sanitization. The facility policy Dining and Food Service dated 10/2022, instructed staff Prior to eating, assess resident's appearance at meals for hygiene issues as needed, but did not include instruction for resident hand sanitization prior to meals.

Based on observation, interview and document review, facility failed to ensure staff properly utilized a total body mechanical lift for 1 of 2 residents (R15) reviewed for accidents. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was severely cognitively impaired, required substantial assistance with activities of daily living (ADLs), and was dependent on staff for transfers. R15's diagnoses included Parkinson's disease (progressive disease of the nervous system), heart disease, and dementia (progressive or persistent loss of intellectual functioning). R15's care plan dated 1/8/24, identified R15 required use of a total body mechanical lift for transfers with assist of two staff. R15's care guide dated 1/24/24, identified R15 required use of Hoyer lift (manufacturer of mechanical lifts) with an assist of two staff. On 1/24/24 at 9:01 a.m., nursing assistant (NA)-A was observed pushing R15 in wheelchair to resident's room. NA-A left R15 in room and brought a total body mechanical lift into R15's room. NA-A closed R15's door. No other staff were observed to enter or exit room. On 1/24/23 at 9:20 a.m., NA-A was observed to bring mechanical lift out of R15's room. NA-A pushed R15 in wheelchair out of resident's room and brought resident to the lounge. No other staff were observed to enter or exit room during this time. During interview on 1/24/24 at 9:21 a.m., NA-A stated he brought R15 to their room to complete ADLs. NA-A confirmed he used the total body mechanical lift to transfer R15 to bed and back to wheelchair. NA-A volunteered he should have had another staff to help with lift. During interview on 1/24/24 at 12:07 p.m., NA-A stated he was not sure on the policy for safely transferring residents with total body mechanical lifts. NA-A further stated he felt confident in his abilities to safely transfer residents without the help of other staff. During interview on 1/24/24 at 2:30 p.m., NA-B confirmed two staff were needed to use the total body mechanical lift with residents. During interview on 1/25/24 at 9:13 a.m., director of nursing (DON) stated the training for use of total body mechanical lifts included videos of proper technique and demonstration of safe use. DON stated staff were expected to use two staff when using a total body mechanical lift to transfer a resident. Mechanical Lifts (Total Body & Sit-to-Stand) policy dated 11/2022, indicated a minimum of two staff will be used to operate all mechanical lifts at all times.

Based on observation, interview and document review, the facility failed to follow provider interventions for wound care for 1 of 2 residents (R8) reviewed for pressure ulcers. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 as moderately cognitively impaired, was dependent on staff for transfers and repositioning, and had lower extremity impairment. R8's diagnoses included multiple sclerosis (autoimmune disease in which the insulating covers of nerve cells are damaged), functional quadriplegia (weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk and pelvis), nondisplaced transverse fracture of shaft of right tibia (bone fracture of the tibia in right leg), heart disease, diabetes mellitus, and an unstageable pressure injury on the right foot. R8's care plan dated 1/2/24, identified R8 was at risk for impaired skin integrity including skin tears, bruising, and/or pressure injury. Intervention instructed staff to float R8's heel with boots or pillows on all sides of heels. Further, it instructed staff to check R8 for boots or pillow use on rounds and when needed. R8's care plan further identified R8 to have heel protectors on while in bed. Care guide dated 1/24/24, identified R8's heels must be floated at all times when in bed and heel boots worn for pressure reduction when in bed. Physician order dated 5/4/23, instructed staff to turn and reposition R8 twice on day and evening shifts and once during night shift. Order also stated any refusals by R8 should be documented in the chart. Physician order dated 11/21/23, ordered nursing staff to apply green protective boots on R8 whenever in bed. Orders further instructed nursing staff to document when boots are on or off R8. Physician order dated 12/15/23, medical doctor (MD) placed cast on R8's lower right leg and foot. Physician order dated 1/2/24, instructed nursing staff to check R8's right heel cutout spot for drainage. Provider progress note dated 1/2/24, MD identified blanchable red spot 7 centimeters (cm) in diameter on R8's right knee and ulceration 2 cm in diameter on resident's right heel. MD identified R8's cast to have cutouts over areas of concern on resident's right knee and right heel. MD instructed nursing staff to float R8's heel to take pressure off the heel. Progress note dated 1/16/24 at 3:16 p.m., identified interdisciplinary team (IDT) discussed R8's pressure injury on right heel. IDT identified cutouts on cast as appropriate treatment and that R8's heels should be floated when lying in bed and continue to use pressure relief boot on R8's left foot. On 1/23/24 at 11:19 a.m., R8 observed to be lying in bed. R8's right foot in a splint, on a pillow and not floated. Heel protector observed to be on chair in R8's room. On 1/24/24 at 7:17 a.m., continuous observation began with the following observed: -At 7:17 a.m., R8 was lying in bed with the door open and lights off. No staff observed to go into R8's room. -At 7:31 a.m., R8 was lying in bed with the door open and lights off. No staff observed to go into R8's room. -At 7:59 a.m., R8 was lying in bed with the door open and lights off. No staff observed to go into R8's room. -At 8:30 a.m., R8 was lying in bed with the door open and lights off. No staff observed to go into R8's room. -At 8:43 a.m., activities assistant (AA)-A brought in breakfast tray to R8. AA-A placed breakfast tray on bedside table, and moved table closer to R8. AA-A did not offer to reposition R8. Heel protectors observed to be on chair in R8's room. An unidentified nurse entered the room and was observed moving R8 up towards head of bed. Unidentified nurse did not remove blanket from R8's legs, and did not check to see if R8 had heels floated or if wearing heel protectors. Heel protectors continued to be on chair in R8's room. On 1/24/24 at 9:04 a.m., AA-A entered R8's room to give menu to resident. AA-A turned on television at R8's request. AA-A did not offer to reposition R8. Heel protectors continued to be on chair in R8's room. On 1/24/24 at 9:24 a.m., AA-A and registered nurse (RN)-A entered R8's room. RN-A uncovered R8's legs and saw their heels were not floated. RN-A administered heel protectors and a pillow to float R8's heels. During interview on 1/24/24 at 9:30 a.m., RN-A confirmed R8's legs were flat on the bed when she went into R8's room. RN-A stated R8's heels should always be floated and checked during every interaction with R8. RN-A further stated the expectation was R8's heels should be floated when in bed, and it was important to do so to promote healing of pressure injury. During interview on 1/24/24 at 9:45 a.m., nursing assistant (NA)-C confirmed R8's heels should be floated at all times when in bed. NA-C also confirmed R8's legs were flat on the bed that morning. During interview on 1/24/24 at 10:05 a.m., director of nursing (DON) expected staff to float R8's heels to promote healing and prevent further damage. DON also expected staff to reposition R8 every 2-3 hours. DON stated staff should notify nurse when R8 refuses cares and refusal should be documented in R8's chart. During interview on 1/24/24 at 10:46 a.m., physician stated they expected nursing staff would follow orders for R8 and float heels when in bed. Pressure Ulcer/Skin Integrity policy dated 4/2022, identified facility will ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from forming.

Based on interview and document review, the facility failed to ensure provider orders to monitor blood pressure were followed for 1 of 5 residents (R3) reviewed for unnecessary medications. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of essential hypertension, history of cerebral vascular attack (CVA), and schizoaffective disorder. R3's care plan dated 3/22/18, identified the potential for medication side effects including hypotension (low blood pressure) with an intervention to monitor for orthostatic hypotension (low blood pressure upon standing). R3's provider orders dated 4/8/21, identified an order for orthostatic blood pressure readings (one reading taken while seated and one minute later a reading taken after standing) to be taken on R3's shower day every 28 days and to make a progress note if not obtained. R3's electronic health record did not reflect orthostatic blood pressure readings or notes regarding why it was not obtained. During an interview on 1/24/24 at 1:47 p.m., the director of nursing (DON) stated she would expect the orthostatic blood pressure to be done if as ordered, and it was important because R3 took medication which may cause hypotension and they needed to track this because it (orthostatic hypotension) put R3 at risk for falls. A facility policy, Physician's Order - Recording dated May 2020, did not address expectations with following a provider order.

Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 2 of 3 residents (R17, R137) reviewed whose Medicare Part A coverage ended while in the facility. Findings included: R17's Notice of Medicare Non-Coverage (CMS-10123), dated 11/15/23, indicated R17's last day of skilled services was on 11/17/23. The form was signed by resident representative (RR) and dated 11/15/23. In addition, R17's Advance Beneficiary Notice of Non-Coverage (ABN; CMS-R-131) had been provided which indicated a potential cost of over $329.48 / day to R17 if paying privately for care and services at the facility. However, R17's medical record lacked evidence the required CMS-10055 had been reviewed and/or provided to R17 prior to their Medicare Part A coverage ending. R137's Notice of Medicare Non-Coverage (CMS-10123), dated 1/10/24, identified R137's last day of skilled services was on 1/12/24. The form identified R137 signed on 1/10/24. In addition, R137's Advance Beneficiary Notice of Non-Coverage (ABN; CMS-R-131) had been provided which identified a potential cost of $418.65 / day to R137 if paying privately for care and services at the facility. However, R137's medical record lacked evidence the required CMS-10055 had been reviewed and/or provided to R137 prior to their Medicare Part A coverage ending. During an interview on 1/23/24 at 3:53 p.m., social services designee (SSD) stated she was responsible to ensure the CMS-10123 and subsequent appeal notices, including the CMS-10055, were provided to residents. SSD reviewed R17's and R137's census reports and stated each resident had been covered with only Medicare Part A coverage and transitioned to a different payer source when their coverage was ended when the SNF determined they would no longer qualify for coverage. The SSD verified the CMS-10055 was not provided to R17 and R137. The SSD stated CMS-10055 was used up till 6 months ago when corporate staff told the facility to change to the CMS-R-131. The facility's policy titled Notice of Medicare Non-Coverage, was requested but not provided.

Based on observation, interview, and document review the facility failed to provide range of motion (ROM) services to prevent a decline in ROM for 1 of 1 resident (R17) reviewed for ROM. This resulted in actual harm to R17 who had functional decline in ROM to the left hand. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had severe cognitive impairment and required extensive assist with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. R17 had functional limitations in ROM in upper and lower extremities on both sides; however, R12 had not received PROM (Passive range of motion (PROM) is the ROM that is achieved when an outside force (such as a therapist or a CPM machine) exclusively causes movement of a joint) services during the assessment period. Diagnoses included Parkinson's disease, dementia, diabetes mellitus type 2, contracture to hand, major depressive disorder, and chronic pain. R17's care plan dated 7/28/20, indicated R17 had a contracture to his left hand/wrist, with an intervention indicating to refer resident to therapy for range of motion. R17's Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 4/18/22, indicated R17 needed encouragement to participate and follow all occupational therapy recommendations for improved performance. R17's occupational therapy discharge summary dated 6/13/22, indicated discharge recommendations to continue with range of motion exercises. R17's left hand finger to palm measurements being completed on 5/25/22, indicated third digit finger to palm 3.75 centimeters (cm), 4th digit finger to palm 2.5 cm, and 5th digit finger to palm 5 cm. During an observation on 4/17/23 at 6:58 p.m., R17 had a brace on his left hand with his pointer finger straight and all other fingers curled into his palm. During an interview on 4/19/23 at 7:49 a.m., nursing assistant (NA)- A stated therapy does the hand exercises for the resident, and that he wouldn't be the one to complete any exercises with resident's hands. On 4/19/23 at 10:37 a.m., the director of nursing (DON) stated R17 didn't have range of motion exercises on his care sheet or care plan, but she was going to update them to reflect the need for range of motion. On 4/19/23 at 11:10 a.m., NA-B stated the floor staff did not complete PROM with R17's left hand. On 4/19/23 at 1:28 p.m., the therapy director stated R17 had not been in therapy since June of 2022. She stated there were discharge instructions and she trained the nursing staff on what to do with R17's left hand. On 4/19/23 at 2:16 p.m., the DON stated her expectation was that the staff were to complete range of motion on R17. She stated she does not think it was communicated clearly and there is no documentation of any range of motion being done on R17's left hand. R17's therapy evaluation completed on 4/19/23 at 3:04 p.m. resulted in R17's left hand finger to palm measurements third digit finger to palm 3 cm, 4th digit finger to palm 2 cm, and 5th digit finger to palm 4 cm. During an interview on 4/19/23 at 3:41 p.m., the therapy director stated the measurements taken have indicated the contracture has gotten worse and she was requesting therapy orders. On 4/20/23 at 10:06 a.m., the therapy director stated if the facility would have done range of motion to R17's left hand he would have maintained the function he had in his left hand and wouldn't have lost function to his left hand. On 4/20/23 at 10:10 a.m., the medical provider stated there would be a decrease in range of motion if the facility didn't follow therapies recommendations to provide range of motion to R17's left hand. Facility policy titled Restorative Program revised 5/2020, indicated all residents are supported to maintain or attain their highest level of function. Resident are assessed upon admission and at every care plan meeting for possible inclusion in restorative programs. Documentation on R17's range of motion to left hand was requested while on survey and not provided.

Based on observation, interview and document review, the facility failed to store food in accordance with professional standards for food service safety, monitoring of refrigerator temperatures. This had the potential to affect all residents who stored or consumed food and beverages from this refrigerator. Findings include: During observation on 4/20/23 at 8:11 a.m., a refrigerator near the nurse's station labeled for resident use only, had a brown, dry, and raised substance covering nearly the entire bottom of the refrigerator. There were two areas, each about one-and-a-half inches in size, of a dry, cream-colored, and bumpy substance on the bottom shelves. There is a thermometer on the door of the refrigerator reading 49 degrees. Pudding cups, Ensure beverages, and juice are all dated. During an interview on 4/20/23 at 8:15 a.m., Culinary director and director of nursing (DON) are interviewed. DON confirmed she did not know she was responsible for making sure this fridge was cleaned and temperature monitored. Culinary director stated he did not know it wasn't being cleaned or monitored. Policy and procedure for refrigerator cleaning and temperature monitoring was requested but not received.

Based on observation, interview, and document review, the facility failed to provide timely repositioning to prevent worsening pressure ulcers and the development of pressure ulcers for 4 of 4 residents (R25, R30, R6, R17) reviewed for pressure ulcers. Findings include: R25's significant change Minimum Data Set (MDS) assessment, dated [DATE], indicated R25 had diagnoses which included diabetes mellitus, arthritis, Alzheimer's disease, and obstructive uropathy (when urine doesn't flow due to an obstruction). R25's MDS indicated he was moderately cognitively intact, required extensive assistance with bed mobility, toilet use, and personal hygiene. R25's MDS further indicated he was non-ambulatory, frequently incontinent of bowel and had an indwelling urinary catheter. R25's MDS indicated he was at risk for pressure ulcers but did not currently have one. R25's care plan, dated [DATE], indicated R25 required an assist of one person for bed mobility, assist or encourage pressure relief as needed or accepted, to follow community skin protocol, to encourage repositioning in bed, and to get up for meals, activities, and therapy. Facility document, titled Care Guide dated [DATE], indicated R25 should be side to side as much as possible when in bed and to encourage R25 to get out of bed. A facility form entitled Weekly Skin Check Tool, dated [DATE], noted no new skin issues. R25's provider orders indicated: - [DATE] calazime cream (a cream containing zinc oxide to form a temporary barrier against external irritants) to denuded skin on coccyx twice a day, notify MD with changes - [DATE] circulating air mattress for resident's bed - [DATE] turn resident side to side every two hours - [DATE] right coccyx wound 2 cm x 1 cm, cleanse with normal saline and apply Mepilex (an absorbent polyurethane foam dressing). Change every three days and as needed. R25's wound assessments for April indicated the following: -[DATE] Indicated a new pressure wound with ten percent granulation tissue (new vascular tissue). Minimal amount of drainage. Skin surrounding wound with erythema (superficial reddening of the skin). Current treatment is 3x3 Mepilex. Resident rates the wound pain at a level 4. Positioning plan indicates staff to keep side to side as much as will allow in bed. Was given a cut-out cushion from OT for wheelchair. -[DATE] Wound number two: right side spot 0.5 cm MASD (Moisture Assoiciated Skin Damage). Blanchable. 100% granulation, surrounding skin intact. notes date of onset is [DATE]. current treatment is Z-Guard Resident rates it as tender. -[DATE] Wound number one: MASD on coccyx, onset [DATE], blanchable, 100% granulation. no drainage. 1.5 cm by 1 cm surrounding skin intact. Current treatment apply Z-Guard (a petroleum and zinc oxide paste). on coccyx after every toileting. Check and change every two hours. Encourage daily to get out of bed into chair. Resident rates it as tender when touched. -[DATE] Documented as: spot on buttock as a pressure wound measures 2 centimeters (cm) by 1 cm wound with no drainage or odor. Some white moisture associated skin damage (MASD) around pink wound bed. Around the wound is purple blanchable tissue measuring 6 cm by 6 cm. R25's progress note dated [DATE] indicated the interdisciplinary team (IDT) had met and determined the alteration in R25's skin was MASD. Interventions implemented included a cut-out cushion for R25's wheelchair, to cleanse wound and apply a foam dressing to be changed daily and as needed. Furthermore, R25 was to avoid lying on that area and staff were to get him up as much as he would allow. During interview on [DATE], at 6:51 p.m., R25 stated he had a painful sore on his bottom; he thought it developed about five months ago. On [DATE], R25 was continuously observed from 7:01 a.m. to 9:55 a.m. -7:01 a.m. R25 was lying on his back with the covers on, lights off, and curtains closed. -8:29 a.m. culinary director went into room with breakfast tray and left it on tray table. R25 lying flat in bed with blankets on. -8:43 a.m. Activity-A brought in a new calendar for resident and visited with him briefly. -8:54 a.m. RN-A brought R25 his medications. No repositioning was offered. -9:19 a.m. NA-B answered R25's call light. NA-B assisted resident to clean off his shirt and chest which had breakfast food on them. Handed R25 his harmonica and cell phone. NA-B tidied the room, put gloves on, checked catheter bag, collected dirty linen, and left the room. R25 was on his back and was not offered to be repositioned. -9:27 a.m. RN-A brought R25 a TUMS tablet. No repositioning was offered. -9:28 a.m. NA-B went into the room, checked the garbage, and left again. -9:55 a.m. NA-B and RN-A entered R25's room to assist with toileting and repositioning. R25 stated he had kind of an ulcer in his rectal area, and it stings from time to time. Mepilex on R25's coccyx is dated [DATE]. RN-A demonstrated the peri-wound was blanchable, though discolored a dusky, purple color. R25 stated it stung when the wound was cleansed with normal saline. RN-A measured the purple area at 6 cm by 6 cm., and the open area at 1 cm by 2 cm. RN-A further stated it looked like a pressure sore to her and noted no drainage or odor from wound. R25 requested to be on his back, RN-A encouraged off-loading and placed a pillow as a wedge under his left side. During an interview on [DATE], at 9:50 a.m., NA-B stated a resident should be repositioned after two hours. During an interview on [DATE], at 9:53 a.m., RN-A stated residents should be repositioned every two hours, and R25 should have been turned because he had a sore bottom. RN-A verified R25 had not been repositioned that morning. R30 R30's significant change MDS assessment, dated [DATE], listed diagnoses of diabetes mellitus, rhabdomyolysis (when damaged muscle tissue releases proteins into the blood), polymyalgia rheumatica (an inflammatory disorder that causes muscle pain and stiffness), unspecified open wound of lower back and pelvis, and generalized muscle weakness. R30's MDS indicated severely impaired cognition, a stage 3 pressure ulcer, was at risk for pressure ulcers, needed extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. R30's care plan indicated risk of skin impairment, with a goal to be free of serious complications, and for staff to assist/encourage pressure relief as needed/accepted, observe skin with AM/PM cares, pressure reducing cushion in wheelchair, and to follow wound treatment protocol. R30's provider order, dated [DATE], indicated left buttock/coccyx wound treatment as: Remove old dressings. Clean areas well using saline and gauze applying light pressure to wipe tissue clean and gently flush coccyx wound using saline flushes. Wash surrounding skin with soap and water. Cut linear strip of Exufiber Ag (a sterile non-woven gelling fiber antimicrobial) ,d+[DATE] cm in length and using cotton tipped applicator gently advance to wound base leaving external wicking. Secure in place with bordered Mepilex. Change every three days or if excessive drainage, increase frequency of dressing changes to every other day. R30's wound progress notes indicated improvement in wound measurements, with [DATE] being 1 cm by 0.5 cm by 1.5 cm and [DATE] being 0.4 cm by 0.2 cm by 0.3 cm. On [DATE] R30 was continuously observed from 7:03 a.m. to 10:29 a.m. -7:03 a.m. NA-A in room with R30. R30 was seated in wheelchair neatly dressed, hair was combed, socks and shoes were on. NA-A wheeled R30 to the dining room. -7:09 a.m. R30 remained in the dining room seated alone at a table alone with a beverage. -8:33 p.m. R30 seated at a table with other residents who were eating their breakfast. -9:10 a.m. moved to another table in the dining room that had paper and colored pencils. -10:06 a.m. remained at the craft table in the dining room. -10:28 a.m. NA-A brought R30 from the dining room to her room. -10:29 a.m. NA-A and RN-A went into R30s room and closed the door. During an interview on [DATE] at 10:26 a.m. NA-A stated any resident who needed to be checked and changed is repositioned every two hours. If a resident refused, he would try reapproaching, and if not successful NA-A would chart the refusal and let the nurse know. NA-A stated R30 refused to be repositioned after breakfast as she wanted to color in the dining room and verified he hadn't told RN-A about R30's refusal yet. During an interview on [DATE] at 10:56 a.m. RN-A verified she placed a new dressing on R30's coccyx wound as the old one was not in place. RN-A stated there was no redness to R30's buttocks or back of thighs after this period of static sitting. Furthermore, RN-A stated there was no way for NAs to track resident repositioning times. Facility document, referred to as a care guide and dated [DATE], indicated R30 had intact skin, was incontinent of bowel and bladder, and to offer toilet and incontinent care upon rising in the morning, before meals and activities, and every two hours at night. R6 R6's quarterly MDS, dated [DATE], indicated diagnoses of non-Alzheimer's type dementia, depression, and a body mass index (BMI) of 19.9 percent or less. R6's MDS indicated moderately impaired cognition, had a non-ambulatory status and required extensive assistance for bed mobility, transfers, toilet use, and hygiene. R6 was incontinent of bowel and bladder and at risk for pressure ulcers. R6's care plan, dated [DATE], included a problem for potential of impaired skin integrity with a goal of having clean, dry, and intact skin through next review date and an intervention for incontinence care with brief changes. R6's provider orders indicated: [DATE] regular diet, regular texture, and thin liquids [DATE] give 120 mL fluid with med pass [DATE] nutritional supplement four ounces, two times per day On [DATE], R6 was continuously observed from 7:02 a.m. until 10:51 a.m. -7:02 a.m. door to room open, lights off, R6 lying in bed -7:11 a.m. staff looked in her room, did not wake her, left the room, and walked down the hall -7:16 a.m. NA-B entered R6's room to wake her and help with dressing, grooming, perineal hygiene, and transferring from the bed to the wheelchair -7:33 a.m. NA-B wheeled R6 to breakfast in the dining room -8:33 a.m. eating her breakfast in the dining room -8:45 a.m. remained in the dining room at the table -9:06 a.m. wheeled to the TV area near the nurse's station -9:46 a.m. wheeled back to the dining room for trivia -10:26 a.m. remains in the trivia activity seated in wheelchair -10:51 a.m. NA-B brought R6 to her room and assisted her to a standing position with the EZ stand. NA-B verified R6's buttocks and backs of thighs are red from just below her buttocks to just above the backs of the knees. During an interview on [DATE], at 10:49 a.m., NA-B stated he didn't know if NA-A had already repositioned R6. NA-B verified it had been over three hours since he last repositioned R6. Facility document, referred to as a care guide and dated [DATE], indicated R6 was to be offered toileting and incontinent care upon rising in the morning, before meals and activities, and every two hours at night. During an interview on [DATE] at 2:45 p.m., the Director of Nursing (DON) stated staff should know when to turn residents and it was in their care guides. During the day she would expect about every two to three hours based on a routine of bringing residents to the bathroom upon waking, after meals, before activities, before bed, and every two hours at night. The DON confirmed there was not a system for employees to track turning and repositioning times for residents. Further stated tissue tolerance testing is not done, if a resident is at risk, they watch their weight and care plan for turning and repositioning. 47790 R17 R17's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment needs extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. R17 is incontinent of bowel and bladder and at risk for pressure ulcer but none present, has pressure reducing device for chair and bed. Diagnoses include Parkinson's disease, dementia, contractures to left hand, diabetes mellitus type 2, and chronic pain. R17's care plan dated [DATE], indicated staff to provide incontinence cares as able upon rising, before meals, before activities, at bedtime, and every 2 hours at night as resident allows. On [DATE], R17 was continuously observed from 7:39 a.m. to 10:41 a.m. -7:39 a.m. nursing assistant (NA)- A and NA-B got R17 into wheelchair. -7:42 a.m. NA-A left R17's room with R17 in wheelchair and brought him to the dining room. -8:26 a.m. NA-B was assisting R17 with breakfast. -8:51 a.m. R17 was wheeled to the commons area in his wheelchair and placed in front of the television. -9:36 a.m. registered nurse (RN)-A took R17 into a private area to give eye drops. No repositioning offered or occurred. -9:40 a.m. R17 was wheeled back to common area by RN-A. -9:45 a.m. R17 was moved into dining area for activity. - from 9:51 a.m. to 10:35 a.m. R17 was noted to be sleeping on and off during activity. - 10:41 a.m. NA-A and RN-A removed R17 from his wheelchair and onto the toilet. RN-A assessed R17's buttocks and noted area was blanchable, no redness, and no open areas to the skin. During interview on [DATE] at 10:43 a.m., RN-A stated the facility tries to make sure that residents are repositioned every 2 hours. On [DATE] at 10:43 a.m. NA-A stated the last time R17 was repositioned was when he got out of bed. R17 should have been repositioned every 2 hours. On [DATE] at 1:10 p.m. director of nursing (DON) stated R17 should be repositioned every 2 hours. Facility policy entitled Pressure Ulcer/Skin Integrity, dated [DATE], indicated a resident will receive care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Interventions will be implemented to mitigate the risk for skin breakdown based on individual risk factors which may include the implementation of individualized turning or repositioning schedules.

Based on observation, interview and document review, the facility failed to ensure appropriate infection control measures were maintained for 1 of 1 (R25) resident reviewed for infection control. Findings include: R25's significant change Minimum Data Set (MDS) assessment, dated 3/19/23, indicated he was moderately cognitively intact, required extensive assistance with bed mobility, toilet use, and personal hygiene. R25's MDS further indicated he was non-ambulatory, frequently incontinent of bowel and had an indwelling urinary catheter. R25's Diagnosis Report dated 4/20/23 indicated enterocolitis (infection of the small intestine) due to c-diff (clostridium difficile is an infection of the large intestine), not specified as recurrent. R25's care plan, dated 6/26/22, indicated R25 required an assist of one person for bed mobility, assist or encourage pressure relief as needed or accepted, to follow community skin protocol, to encourage repositioning in bed, and to get up for meals, activities, and therapy. During an observation on 4/17/23 at 6:22 p.m., nursing assistant (NA)-B was providing evening care to R25 without a gown or gloves on. NA-B transferred R25 with a sit-to-stand mechanical lift, assisted to brush his teeth, and wash his hands and face. During an observation on 4/19/23 at 9:19 a.m. NA-B assisted resident with cleaning off his chest and shirt, which were soiled from breakfast. Gave R25 his harmonica and cell phone. Straightened up the room and put on gloves to check catheter bag. Collected dirty linen and left the room. During an observation on 4/19/23 at 9:55 a.m. NA-B came in to assist resident. NA-B put on two pairs of gloves, but no gown, and emptied catheter bag into a graduate cylinder. Registered nurse (RN)-A came into R25's room and donned gown and gloves. NA-B removed gloves, cleaned hands, and left the room after RN-A whispered something to him. At 10:03 a.m. NA-B returned with isolation gowns, put one on and put the rest into a drawer. NA-B again left the room, with gown and gloves on, and came back with a box of gloves and donned three pairs. Assisted RN-A to provide incontinent care as R25 had been incontinent of loose, dark brown stool. NA-B doffed the gown first and the gloves second and cleaned his hands with alcohol-based hand rub (ABHR). During an interview on 4/20/23 at 3:38 p.m., licensed practical nurse (LPN)-A stated R25 was colonized with c-diff and had outbreaks periodically. Furthermore, staff would be made aware of personal protective equipment (PPE) needs by the signs on R25's room door. Any direct care staff were to have gloves, gown, and mask on for providing care. LPN-A claimed responsibility for putting an isolation cart in place and would expect staff to wear all PPE to transfer or provide care to R25. During an interview on 4/19/23 at 9:29 a.m., NA-B stated the signs were on R25's door initially because he had c-diff, but he knew it was over because there was no longer an isolation cart outside the door. A facility document, referred to as a care guide and dated 4/13/23, indicated R25 had enhanced barrier precautions and a gown and gloves were needed for resident care and room cleaning. A document located on R25's door was titled, Contact Precautions from 2007 Guideline for Isolation Precautions, indicated the following for preventing transmission of infectious agents in health care settings: -Indicated contact precautions were in place. -Use of PPE (yellow highlighted areas): wear gloves whenever touching intact skin or surfaces and articles near the patient. Wear gowns whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment near the patient. Don gown upon entry into the room. Remove gown and observe hand hygiene before leaving the patient care area. -In long term care (LTC) settings, use disposable non-critical patient care equipment or implement patient-dedicated use of such equipment. Clean and disinfect equipment if not possible to have dedicated equipment. -Discontinue contact precautions after signs and symptoms of the infection have resolved or according to pathogen-specific recommendations. An undated document located on R25's door indicated enhanced barrier precautions consisted of: -clean hands with ABHR. -Providers and staff must also wear gloves and gown for high-contact resident care activities such as: dressing, bathing, transferring, changing linens, providing hygiene, changing brief or wound care. A policy entitled Enhanced Barrier Precautions (EBP), dated 10/4/22, described the use of EBP as an infection control intervention designed to reduce the transmission of resistant organisms by using targeted gown and glove use during high-contact resident care activities. To be employed when wounds or indwelling medical devises are used regardless of multi-drug resistant organisms (MDRO) status and/or if there is an infection or colonization with an MDRO. Signage will clearly indicate what type of PPE to use, during what activities to use it, and shall be posted outside the resident room. Make PPE available immediately outside the resident room, including masks for care that may generate a splash or spray (e.g., emptying a catheter bag).

Based on interview and documentation review, the facility failed to ensure labs were drawn according to physician orders to determine therapeutic dosing for 1 of 5 (R7) residents reviewed for unnecessary medications. R7's quarterly minimum data set (MDS) assessment indicated she was cognitively intact and had diagnoses of diabetes mellitus, diabetic kidney complication, seizure disorder, hypothyroidism, and long-term use of insulin. R7's provider orders indicated: 9/1/17 - check vitamin D level, and fasting lipids every 12 months. Last lipid panel and vitamin D level done on 1/19/21. 2/27/19 - check hemoglobin A1C (a blood test indicating blood sugar levels over the past two to three months) every three months. Last hemoglobin AIC done 12/1/22. 2/27/19 - check thyroid stimulating hormone (TSH) every six months. Last TSH done on 9/14/22. During an interview on 4/19/23 at 2:45 p.m., the director of nursing (DON) verified it was important for labs to be checked for medication monitoring. Further stated they don't have a process for tracking labs due. During an interview on 4/20/23 at 5:00 p.m., pharmacy consultant (PC)-A verified labs were important to be done timely for on-going medication therapy. Further, if there is a doctor order to do labs, then they should be done per the order. Facility policy entitled, Laboratory Results and Reporting, dated November 2022 indicated lab results were to be communicated with the ordering provider promptly. The policy didn't include procedures for tracking and obtaining labs.

Based on observation, interview and document review, the facility failed to comprehensively assess to assure safety with smoking for 1 of 2 residents (R8) who was smoking outside the facility. Findings include: R8's significant change Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact and was a current tobacco user. R8 needed extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease, muscle weakness, and nicotine dependent. During the facility entrance conference on 4/17/23 at 2:51 p.m. the director of nursing (DON) stated the facility had one resident who smoked off campus. R8's care plan dated 2/14/23, indicated R8 smoked, and the facility would remind/educate on facility smoking policy and R8 had to agree to follow policy. During observation on 4/18/23 at 12:20 p.m., R8 was noted to have a clear container on bedside tray table with cigarettes in it. During interview on 4/18/23 at 12:20 p.m., R8 stated she was told by staff last night that she is not able to go outside and smoke alone anymore. On 4/19/23 at 7:49 a.m., nursing assistant (NA)- A said they helped R8 to go out and smoke sometimes, but she also took herself sometimes and would ring the bell when she was ready to come back inside. On 4/19/23 at 9:51 a.m. registered nurse (RN)-A stated R8 had to go off property to smoke with family. On 4/19/23 at 11:10 a.m. NA-B stated R8 must be able to smoke on her own. The facility staff would not be able to help her smoke. On 4/20/23 at 8:48 a.m., NA-C stated R8 smoked, and staff would open the door for R8, but she would have to be able to do the rest on her own. On 4/20/23 at 9:39 a.m., administrator stated R8 was notified when she admitted that is was a non-smoking facility and she couldn't smoke on grounds. R8 then asked if she could go out with her family to smoke. Administrator told R8 that she would have to sign out and go off grounds. Staff are not to assist R8 to smoke. On 4/20/23 at 9:39 a.m., DON stated the facility does not have a smoking assessment on R8 as the facility is a non-smoking facility. During observation on 4/20/23 at 11:22 a.m., R8 was outside with an unknown visitor on facility property. The administrator went out to R8 with smoking policy in hand. R8 and unknown visitor moved off facility property. Administrator stated R8 had not started smoking at the time of the encounter. The facility Smoking policy revised 11/1/20, indicated the facility does not allow smoking on the premises. Prior or on admission the resident is made aware of the facility smoking policy. During orientation, all new employees are made aware of the facility's smoking policy. Residents that choose to admit as smokers are offered cessation programs.

Based on observation, interview and document review, the facility failed to ensure communication devices were available to maintain hearing and communication needs for 1 of 1 resident (R10) reviewed for hearing. R10's quarterly MDS, dated [DATE], indicated resident was severely cognitively impaired and had diagnoses of Alzheimer's dementia and major depressive disorder. Section B indicated R10 had minimal difficulty hearing, had hearing aids and the ability to understand others. A care area assessment (CAA), dated 11/29/22, indicated R10 had impairment with receptive communication and hearing, and used a hearing aid as a communication device. R10's care plan, dated 1/4/23, indicated a problem statement for hearing impairment. Interventions included staff placing hearing aids in resident's ears, ensure availability and functioning of adaptive communication equipment, message board, telephone amplifier, computer, or pocket talker. Furthermore, refer to audiology for hearing consult as needed. R10's provider order, dated 9/9/21, indicated resident was to have her hearing aid placed every morning, removed in the evening, and placed in the medication cart. During an observation on 4/18/23 at 3:24 p.m., R10 was awake and there were no hearing aids in her ears. During an interview on 4/17/23 at 3:29 p.m., R10 was unable to participate in conversation as she could not hear what was being said to her. R10 shook her head and stated she does not have her hearing aids, stated they disappeared. During an interview on 4/19/23 at 1:35 p.m., R10 stated she didn't have any hearing aids yet. R10 further stated she was upset because they should be in her ears, but they hadn't come back yet. During an interview on 4/19/23 at 1:45 p.m., registered nurse (RN)-A stated she didn't believe R10 had any hearing aids but thought the facility may have pocket talkers (a personal sound amplifying device). During an interview on 4/19/23 at 1:49 p.m., trained medication aid (TMA)-A stated R10's hearing aids used to be in her room but knew her family had been taking them home with them after they visited her because R10 would lose them. During an interview on 4/19/23 at 2:45 p.m., the director of nursing (DON) stated R10 had refused to wear hearing aids and the DON was not sure where they were. During an interview on 4/20/23 at 8:19 a.m., social service designee (SD)-A stated R10 only had one hearing aid, and she had been using it for a while, but it would get lost, and her daughter was tired of dealing with it. SS-A further stated R10 didn't like wearing the hearing aid. A policy titled, Vision and Hearing, dated September 2022 indicated residents would receive proper treatment and assistive devices to maintain vision and hearing abilities; the facility would assist the resident by making appointments and arranging transportation.

Based on observation, interview and document review, the facility failed to ensure care plan timing and revision was completed for 2 of 2 (R10 and R11) residents reviewed for care planning. R11 was admitted on [DATE]. R11's diagnoses included: Alzheimer's disease, glaucoma, and macular degeneration. R11's quarterly Minimum Date Set (MDS) assessment dated [DATE], indicated R11 was cognitively intact. R11 requires extensive assistance from one person for bed mobility, dressing, toilet use and personal hygiene. During an interview on 4/17/23 at 6:40 p.m., R11 stated she wanted to get up for the day after breakfast, and if she was sleeping, she wanted staff to wake her. R11 indicated she had told staff, multiple times to wake her after breakfast, but it doesn't happen. R11 said she is often left to sleep until lunch. R11 care conference documentation dated 1/17/23, included a care conference for R11. R11 's daughter, the director of nursing (DON) and SW were in attendance. R11's daughter requested that R11 not be left in bed in the morning and said R11 needs to be up in the morning. R11's care plan as off 4/20/23, included: Activities of daily living: limited assistance for upper body dressing and total assist for lower body. R11's care plan lacked the preferences discussed in care conference. During an interview on 4/20/23 at 8:37 a.m., social worker (SW) stated members of the interdisciplinary team update the care plan. A preference for when a resident gets up in the morning would be something nursing would update or revise on the care plan. On 4/20/23 at 11:20 a.m., The director of nursing (DON) verified she was aware of R11 request to up after breakfast and not be left in bed. DON confirmed a resident/family personal preference including when they prefer to get up should go on the care plan and the care sheet. 48109 R10's quarterly MDS, dated [DATE], indicated resident was severely cognitively impaired and had diagnoses of Alzheimer's dementia and major depressive disorder. Section B indicated R10 had minimal difficulty hearing, had hearing aids and the ability to understand others. A care area assessment (CAA), dated 11/29/22, indicated impairment with receptive communication and hearing, and used a hearing aid as a communication device. R10's care plan, dated 1/4/23, indicated a problem statement for hearing impairment. Interventions included staff placing hearing aids in resident's ears, ensure availability and functioning of adaptive communication equipment, message board, telephone amplifier, computer, or pocket talker. Furthermore, refer to audiology for hearing consult as needed. R10's provider order, dated 9/9/21, indicated resident was to have her hearing aid placed every morning, removed in the evening, and placed in the medication cart. During an observation on 4/18/23 at 3:24 p.m., R10 was awake and there were no hearing aids in her ears. During an interview on 4/17/23 at 3:29 p.m., R10 was unable to participate in conversation as she could not hear what was being said to her. R10 shook her head and stated she does not have her hearing aids, stated they disappeared. During an interview on 4/19/23 at 1:35 p.m., R10 stated she didn't have any hearing aids yet. R10 further stated she was upset because they should be in her ears, but they hadn't come back yet. During an interview on 4/19/23 at 1:45 p.m., registered nurse (RN)-A stated she didn't believe R10 had any hearing aids but thought the facility may have pocket talkers (a personal sound amplifying device). During an interview on 4/19/23 at 1:49 p.m., trained medication aid (TMA)-A stated R10's hearing aids used to be in her room but knew her family had been taking them home with them after they visited her because R10 would lose them. During an interview on 4/19/23 at 2:45 p.m., the director of nursing (DON) stated R10 had refused to wear hearing aids and the DON was not sure where they were. During an interview on 4/20/23 at 8:19 a.m., social service designee (SD)-A stated R10 only had one hearing aid, and she had been using it for a while, but it would get lost, and her daughter was tired of dealing with it. SS-A further stated R10 didn't like wearing the hearing aid. The facility policy Care Plan Reviews/Conferences dated 10/22 read The community will conduct a care plan review/conference at least quarterly, and as needed, that is interdisciplinary, provides in-depth review of the resident's plan of care, and provides an opportunity for resident and resident representative/or family discussion/input. The care plan policy included directive: Care plans may be written prior to the care plan meeting, knowing that input from resident or family may require it to be revised.

Based on observation, interview and document review the facility failed to ensure their Minimum Data Set (MDS) assessment was accurately coded for 3 of 14 residents (R10, R25, R30) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Resident Facility Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, OBRA-required comprehensive assessments include the completion of both the MDS and the CAA process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. Section B: hearing, speech, and vision. The intent of items in this section is to document the resident's ability to hear (with assistive hearing devices, if they are used), understand, and communicate with others and whether the resident experiences visual limitations or difficulties related to diseases common in aged persons. R10's quarterly MDS, dated [DATE], indicated resident was severely cognitively impaired and had diagnoses of Alzheimer's dementia and major depressive disorder. Section B indicated R10 had minimal difficulty hearing, had hearing aids and the ability to understand others. R10's care plan, dated 1/4/23, indicated a problem statement for hearing impairment. Interventions included staff placing hearing aids in resident's ears, ensure availability and functioning of adaptive communication equipment, message board, telephone amplifier, computer, or pocket talker. Furthermore, refer to audiology for hearing consult as needed. R10's provider order, dated 9/9/21, indicated resident was to have her hearing aid placed every morning, removed in the evening, and placed in the medication cart. During an interview on 4/17/23 at 3:29 p.m., R10 was unable to participate in conversation as she could not hear what was being said to her. R10 shook her head and stated she does not have her hearing aids, stated they disappeared. During an observation on 4/18/23 at 3:24 p.m., R10 was awake and there were no hearing aids in her ears. R25 Section M: Skin Conditions intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. R25's significant change MDS assessment, dated 3/19/23, indicated R25 was moderately cognitively intact with diagnoses of diabetes mellitus, arthritis, and Alzheimer's disease. R25's MDS further indicated he required extensive assistance with bed mobility, toilet use, personal hygiene and was non-ambulatory, frequently incontinent of bowel and had an indwelling urinary catheter. R25's MDS further indicated he was at risk for pressure ulcers but did not currently have one. R25's care plan, dated 6/26/22, indicated R25 required an assist of one person for bed mobility, assist or encourage pressure relief as needed or accepted, to follow community skin protocol, to encourage repositioning in bed, and to get up for meals, activities, and therapy. During an observation on 4/19/23 at 9:55 a.m., NA-B and RN-A entered R25's room to assist with toileting and repositioning. R25 stated he had kind of an ulcer in his rectal area, and it stings from time to time. Mepilex on R25's coccyx is dated 4/17/23. RN-A demonstrated the peri-wound was blanchable, though discolored a dusky, purple color. R25 stated it stung when the wound was cleansed with normal saline. RN-A measured the purple area at 6 cm by 6 cm., and the open area at 1 cm by 2 cm. RN-A further stated it looked like a pressure sore to her and noted no drainage or odor from wound. R25 requested to be on his back, RN-A encouraged off-loading and placed a pillow as a wedge under his left side. R30 Section L: Oral/Dental Status intent: This item is intended to record any dental problems present in the 7-day look-back period. R30's significant change MDS assessment, dated 1/20/23, indicated severely impaired cognition, and need for extensive assistance with personal hygiene. Section L indicated no dental problems (e.g., broken, or missing teeth). Care Area Assessment (CAA) for dental care was not triggered on the 1/20/23 MDS. R30's care plan indicated a problem statement for personal hygiene but lacked direction for providing personal hygiene. A progress note, dated 4/18/23, reported no observed difficulty chewing or swallowing. During an observation on 4/17/23 at 6:20 p.m., R30 was noted to have missing, broken with tooth fragments and discolored teeth on the upper jaw as observed during conversation while sitting lower than R30. During an interview on 4/19/23 at 11:00 a.m., RN-B identified responsibility for coordinating the MDS assessments. RN-B stated she did all the pain interviews and would ask about shortness of breath, eating, dentures, broken or missing teeth or dentures, glasses and hearing aids. RN-B recalled doing a significant change assessment, on 1/20/23, for R30 and there were no complaints about her teeth though RN-B had observed there were dark colored teeth. During an interview, on 4/20/23 at 5:17 pm, the DON verified she would expect the MDS to be accurate regarding things like broken teeth, cavities, or hearing loss because it was important for the care planning. A policy and procedure regarding MDS and assessments was requested but not received.

Based on interview and document review, the facility failed to ensure staff who had symptoms of COVID-19 and had negative antigen test(s) were not allowed to work, and tested with a confirmatory real-time reverse transcription polymerase chain reaction (RT-PCR) test, according to CDC guidance. This deficient practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all 32 residents residing in the facility, along with staff and visitors. The IJ began on 1/10/22, when licensed practical nurse (LPN)-A reported COVID-19 symptoms and was allowed to work four shifts. The facility only conducted antigen testing, no NAAT or PCR testing to follow up, as is indicated in CDC guidance. On 1/18/22, her fifth shift, LPN-A tested positive with an antigen test. The administrator, director of nursing (DON), and assistant director of nursing/infection preventionist (ADON) were notified of the IJ on 3/8/22, at 3:48 p.m. The immediate jeopardy was removed on 3/9/22, at 12:29 p.m. when the facility implemented interventions to ensure all staff would be tested according to CDC guidelines; however, noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance People with Certain Medical Conditions dated 5/13/21, identified older adults were more likely to get seriously ill from COVID-19. More than 80 percent of COVID-19 deaths have occurred in people over the age of 65, and more than 95 percent of COVID-19 deaths have occurred in people older than 45. Further, among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. STAFF TESTING: The Centers for Disease Control and Prevention (CDC) guidance [CONDITION(S)] CoV-2 Antigen Testing in Long Term Care Facilities dated 1/7/21, identified symptomatic people who test antigen negative should have a confirmatory test performed. Confirmatory test should be performed with nucleic acid amplifications tests (NAAT) such as reverse transcriptase polymerase chain reaction (RT-PCR). As the sensitivity of antigen tests is generally lower than RT-PCR, negative POC antigen tests should be considered presumptive. Testing of symptomatic residents or healthcare personnel (HCP). -If an antigen test is presumptive negative, perform NAAT immediately (e.g., within 2 days). -Symptomatic residents should be kept on transmission-based precautions until NAAT results return. -If a confirmatory NAAT is performed within 2 days, people should be assumed to be infectious until the confirmatory test results are completed. For instance, in general, if a symptomatic resident tests presumptive negative by antigen test and a NAAT is performed, the resident should remain in Transmission-Based Precautions until the NAAT result is available. The facility's Employee Tracking Tool 2022, indicated licensed practical nurse (LPN)-A reported symptoms of cough, myalgia, and body aches on 1/10/22. The employee tracking tool indicated LPN-A repeatedly tested negative for COVID-19 each day of the four days she worked using an antigen test for COVID-19. However, the facility failed to test with a confirmatory RT-PCR test. LPN-A tested positive for COVID-19 with a facility antigen test on 1/18/22, the fifth day she was to work. LPN-A was then removed from the schedule. No confirmatory RT-PCR was done. The facility's updated employee schedule for January 3, 2022, through January 30, 2022, identified LPN-A worked 1/10/22, 1/11/22, 1/12/22, and 1/17/22, and before being removed from the schedule on 1/18/22, when she tested positive for COVID-19 with the facility's antigen test prior to starting her shift. LPN-A was removed from the schedule for a period of 10 day quarantine. No confirmatory RT-PCR test was done. During interview on 3/7/22, at 4:34 p.m. the facility infection preventionist (IP) stated the county COVID-19 transmission rate was high. The facility tested their employees with antigen testing and if it was negative, the employees were allowed to work their shift. When an employee tested because of symptoms, the facility evaluated them on a case by case basis and if the antigen test was negative, they were allowed to work their shift. Employees with COVID-19 symptoms with a negative antigen tests were required to wear an N95 mask while working, however, employees, included LPN-A, were not fit tested for N95 masks until February 2022. The IP verified LPN-A had worked with symptoms of cough and nasal congestion for four days before she tested positive with an antigen test on 1/18/22. The IP stated she was not sure why the facility was not using RT-PCR tests for their testing, but did indicate the antigen tests were quick and easy. They were able to send employees to the clinic for a PCR test if it was needed. If employee symptoms were mild such as a runny nose or cough and the employee tested negative with an antigen test, the facility required them to wear an N95 mask and they were allowed to work. The IP stated she did not send the employees to the clinic for a confirmatory PCR test. If an employee tested positive and had symptoms of COVID-19 they were sent home. The IP stated the facility had always used the antigen tests long before she started in August 2021. When interviewed on 3/8/22, at 8:46 a.m. the administrator stated the facility tested their employees and residents with antigen testing only. The facility did not confirm negative or positive tests with RT-PCR tests, however, they did encourage their staff to obtain an RT-PCR test when/if they were symptomatic for COVID-19. When employees reported symptoms of illness, the facility would test them with an antigen test and if negative and symptoms appeared mild, they would allow the employee to work. If symptoms were more severe, they would send the employee home. The facility did not perform confirmatory RT-PCR tests to confirm a negative antigen test, even if the employee was reporting symptoms of illness. In an interview on 3/8/22 at 1:30 p.m. the IP stated they had outbreak testing beginning on 1/8/22. Review of the facility's outbreak testing spreadsheets confirmed the first COVID-19 positive staff (contract) and another facility staff on 1/8/22. This was only 2 days before LPN-A reported her COVID-19 symptoms and continued to work. No residents were positive for COVID-19 at the time LPN-A had symptoms. Two residents had symptoms in January (onset 1/10/22 [not tested for COVID-19], and onset 1/24/22 [negative antigen test]). Three other residents tested positive for COVID-19 on 2/5/22. The facility policy Infection Prevention and Control: COVID-19 Testing, with revision date February 4, 2022, indicated staff with symptoms or signs of COVID-19, regardless of vaccination status, would be tested immediately and were expected to be restricted from the facility pending the results of COVID-19 testing. If COVID-19 was confirmed or not, staff who had symptoms of COVID-19 should follow the facility policy for return to work. The policy lacked identification of what test the facility was to use for testing of staff and residents. The IJ which began on 1/10/22, was removed on 3/9/22, at 12:29 p.m., when it could be verified through interview and document review the facility immediately implemented COVID-19 testing in accordance with CDC guidance including confirmatory testing for asymptomatic antigen positive residents and staff and performing confirmatory testing on symptomatic antigen negative residents and staff. In addition, the facility would follow recommended infection prevention and control precautions for residents and staff with symptoms of COVID-19 illness. The facility reviewed policies and revised to reflect protocols for testing of to ensure all staff and residents were tested for COVID-19 in a manner consistent with current standards of practice for testing for COVID-1. Education was provided to all employees on current and updated COVID-19 protocols for testing.

Based on interview and document review, the facility failed to reassess and provide appropriate interventions following attempted elopements for 1 of 3 residents (R1) reviewed for elopements, who subsequently eloped from the facility. The survey resulted in an immediate jeopardy (IJ) to resident health and safety. The facility failed to ensure a wander guard (alarm system to alert staff if a resident attempts to leave a facility) was in place for R1 who was identified as a wandering risk. R1 was last seen by staff in the facility on 2/17/20, at 4:30 p.m. At 4:55 p.m. R1 was seen by an off-duty staff nursing assistant (NA)-A, and was approximately ½ mile away from the facility. R1 was not wearing any outdoor clothing (no jacket or gloves). The temperature outside was approximately 25 degrees F. R1 was returned to the facility at 5:15 p.m. by the local police department. The IJ began on 2/17/20. The administrator and director of nursing (DON) were notified of the IJ on 3/2/20, at 3:52 p.m. The facility corrected the IJ on 3/2/20, but non-compliance remained at the lower scope and severity of a D, no actual harm, with potential for more than minimal harm. Findings include: R1's Admission Record printed 3/2/20, included [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment, was independent with ambulation, and required minimal assistance with all activities of daily living (ADLs). R1's care plan initiated 8/18/17, identified R1 as an elopement risk/wanderer related to loss of cognition. R1's care plan goals included R1's safety will be maintained, and R1 will not leave facility unattended. R1's interventions included placement of wander guard, and the care plan indicated R1 had a history of [REDACTED]. R1's care plan directed nursing staff to check for placement of the wander guard every shift and as needed; and staff to check functionality of wander guard weekly, and as needed. Additional interventions included a current photo and resident identifier information to be placed in the facility binder titled Elopement Book, distract from wandering by offering pleasant diversions, and staff were to refer to recreation department care plan for resident specific activities. R1's quarterly Elopement Risk assessment dated [DATE], indicated R1 had a history of [REDACTED]. The assessment indicated staff were to check for placement every shift, and R1's information and picture was to be in the facility binder titled Elopement Book. A progress note dated 4/17/17, indicted R1 required a wander guard, and it was to be placed on his left ankle. A facility document Resident Accidents/Fall/Skin Form dated 2/17/20, indicated R1 was last seen by staff on 2/17/20, at 4:30 p.m. The report indicated at 4:55 p.m, R1 was seen by an off-duty staff member NA-A, and was approximately ½ mile away from the facility. R1 was returned to the facility at 5:15 p.m. by the local police department. The report further indicated R1's care plan was not being followed, and R1 did not have a wander guard on at the time of elopement. A facility fax form sent to R1's primary physician dated 2/18/20, indicated R1 had eloped from the facility on 2/17/20. The fax indicated R1 had removed his wander guard, and left the facility through the front entrance. The fax also indicated R1 was found a few blocks away, and was returned by the police without incident. The fax indicated R1 had no apparent injuries, family was notified, and the facility implemented 15 minute checks and 1:1 staff supervision was provided for R1 while awake and out of his room. On 2/18/20, a progress note indicated a second head to toe assessment was completed on R1, no signs or symptoms of frostbite or any other injury were noted. The progress note indicated R1 received 1:1 supervision from staff until 11:00 p.m., and 15 minute checks were to be ongoing. On 2/20/20, a progress note indicated R1 was to be discharged to a secure memory care facility on 2/21/20. Family was notified and in agreement with placement to secure memory unit. On 3/2/20, at 10:27 a.m. NA-A was interviewed and stated on 2/17/20, at approximately 5:00 p.m. she was off-duty, and observed R1 walking alone outside of the facility. NA-A stated R1 was not wearing a winter jacket or gloves. NA-A stated she immediately called 911, and stayed with R1 until the police arrived. NA-A stated she called the facility, and notified them R1 had eloped, and she had found him. On 3/2/20, at 11:21 a.m. the DON stated R1 was to have a wander guard on his person, however, R1 was known for removing the wander guards. The DON stated R1 had several occurrences where he would try to go outside of the facility doors, but the wander guard system did work, and an alarm would notify staff. The DON stated the facility did not provide any new interventions when R1 would remove his wander guard, or when R1 would attempt to leave the facility. The DON stated that on 2/17/20, R1 had eloped from the facility at approximately 4:30 p.m. The DON stated upon return to the facility, R1 did not have a wander guard on, and one was placed on him when he was returned to facility by the police at approximately 5:15 p.m. The DON confirmed the facility did not check placement of R1's wander guard each shift, nor was the facility documenting weekly checks to ensure the alarm was functioning properly. The DON stated there would be no way of knowing when R1 removed the wander guard, which led to his ability to elope undetected. The DON stated upon R1's return to the facility, they initiated to check each shift for wander guard placement. The DON stated all residents who required wander guards were to be checked and documented on the individual's medication administration records (MAR) each shift for proper placement, and weekly checks. The DON stated the importance of checking the wander guard each shift and weekly function testing was to keep the residents safe and prevent elopement. On 3/2//20, at 1:53 p.m. the administrator stated R1 removed his wander guard several times, and had also attempted to elope from the facility several times, and no new interventions were put into place. The administrator stated the facility would have no way of knowing when R1 had removed his wander guard since they did not document when or if they checked placement of the wander guard. The administrator stated R1 returned to the facility on [DATE], at approximately 5:15 p.m. with no wander guard on. The administrator stated they found a wander guard they suspected R1 had removed, in the laundry the following day 2/18/20. The administrator stated 1:1 with staff was initiated upon R1's return, and a new wander guard was placed on R1. The administrator stated the facility also started looking for alternative placement for R1 to ensure his safety, and R1 was transferred to a secure memory care unit on 2/21/20. The administrator stated the facility should have been monitoring R1 to prevent elopement. On 3/3/20, at 7:09 a.m. registered nurse (RN)-A stated she was working the evening shift on 2/17/20, when R1 had eloped from the facility. RN-A stated she had last seen R1 around 4:30 p.m. when she was charting at the nurse's desk near the front doors. RN-A stated she was made aware of R1's elopement when the police called the facility and asked if there was a missing resident. RN-A stated she immediately thought of R1, and went to look for him in his room. RN-A stated R1 was returned to the facility and was immediately checked for injuries, and he had none. RN-A stated R1 did not have a winter jacket or gloves on at the time of elopement. RN-A stated R1 was put on 1:1 until 11:00 p.m., and after that, was put on 15 minute safety checks until he was discharged on [DATE]. RN-A stated we should have been completing and documenting wander guard placement checks for R1, but we did not. The facility implemented corrective action to prevent recurrence by 3/3/20. All facility doors with a wander guard system were checked to ensure proper functioning. Facility will continue to check functioning. All residents who required wander guards were reassessed and determined risk for elopement and care plans updated. All residents who required wander guards MAR indicated [REDACTED]. Facility policy updated to when a resident removed wander guard nursing staff will replace twice and notify DON/Adm if attempts to remove. Facility will then begin a search for more secure facility placement. During this time period of looking for more appropriate placement, the facility will provide 1:1 supervision to the resident. The corrective actions were verified by staff interview and document review. The facility policy Elopement /Missing Resident dated 4/09, lacked direction for staff on what to do in the event a resident would remove a wander guard.

Based on observation, interview and document review, the facility failed to implement care planned interventions to promote healing and comfort, and prevent the worsening of pressure ulcers, for 1 of 3 residents (R6) reviewed who had current facility acquired pressure ulcers. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP) included: Unstageable pressure ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury R6's Face Sheet printed 6/27/19, indicated R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R6's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had severely impaired cognition, and was independent with bed mobility. The MDS also indicated R6 was not at risk for the development of pressure ulcers, did not currently have a pressure ulcer, and did not have any pressure ulcer prevention interventions in place. R6's progress note dated 6/6/19, indicated multiple pressure and diabetic wounds found on both feet; the heel pressure ulcers were identified as facility acquired. R6's care plan revised 6/11/19, identified R6 as at risk for skin breakdown due to dementia and deconditioning. The interventions directed to administer Juven (a nutritional supplement) twice daily, measure the pressure ulcer and document weekly, perform dressing changes per physician order, and to reposition and float heels on a pillow while in bed. R6's significant change MDS dated [DATE], indicated R6 required extensive assistance with bed mobility, was at risk for pressure ulcer development, and had 2 DTPI. The MDS indicated R6 received pressure ulcer care, and interventions included a pressure relieving device for her wheelchair, nutritional interventions, and dressings to her feet. R6's Wound Assessment Flow Sheets, completed weekly from 6/6-6/25/19 were reviewed. The 6/6/19, evaluation identified acquired right and left heel DTPI. The assessments included characteristics and measurements of the pressure ulcer, current treatments, and new interventions, whether there were improvements or worsening of the pressure ulcer, and notifications to the physician. The positioning plan directed to float both of R6's heels, and treatment was listed as application of [MEDICATION NAME] (absorbent foam dressing) every 3 days and as needed. R6's nursing assistant care guide dated 6/26/19, indicated R6 had pressure ulcers to bilateral heels, and diabetic ulcers on her toes. The care guide directed staff to turn and reposition R6 every two hours, not put on shoes and, in red font: Float heels on pillows. Documented assessments of the right heel pressure ulcer indicated: 6/6/19: 3.8 centimeters (cm) by 3.3 cm with no depth, no drainage, intact, no undermining or tunneling and no odor. The progress note indicated 3.8 cm x 3.3 cm dark purple fluid filled blister, peri wound intact. 6/11/19: 3.1 x 2.9 cm with no depth, no drainage, intact, no undermining or tunneling and no odor. The progress note indicated the wound was an intact maroon fluid filled blister with red border, no signs or symptoms of infection. Nursing were to provide Juven by mouth twice daily. The wound was described as unstageable. 6/18/19: 3.2 cm x 3.0 cm with no depth, no drainage, intact, no undermining or tunneling and no odor. The progress note indicated the wound was an intact maroon fluid filled blister with maroon border, there were no signs or symptoms of infection. 6/25/19: 3.2 cm x 3.2 cm with no depth, no drainage, intact, no undermining or tunneling and no odor. The progress note identified an unstageable pressure wound present as an intact maroon fluid filled blister which was showing signs of re-absorbing. The superior aspect of the wound was boggy. Well defined edges. treatment of [REDACTED]. Staff were to continue to monitor. Documentation on the left heel ulcer indicated: 6/6/19: 2.1 cm by 1.9 cm with no depth, no drainage, skin intact, no undermining or tunneling, and no odor. The progress note described the wound as a deep tissue injury with pink/purple and was non-blanching. 6/11/19: 2.0 cm x 1.4 cm with no depth, no drainage, skin intact, no undermining or tunneling and no odor. The progress note described the wound as maroon in color with red borders and was non-blanching. The wound was intact with well defined edges. 6/18/19: 1.8 cm x 1.4 cm with no depth, no drainage, skin intact, no undermining or tunneling and no odor. The progress note described the wound as unstagable pressure wound presented as an intact, dark maroon wound with well defined edges; and was non-blanchable. 6/25/19: 1.6 cm by 1.1 cm with no depth, no drainage, skin intact, no undermining or tunneling and no odor. The progress note indicated an unstageable pressure wound to R6's left heel presented as a dark pink and maroon intact area, showing signs of healing and re-absorbing with intact skin and well-defined edges. On 6/27/19, at 12:33 p.m. during continuous observations from 12:33 p.m. until 1:10 p.m., R6 was observed to be in bed, laying on her back asleep, with her heels directly on the mattress. The blankets were spread smooth and evenly over R6, she had grippy socks on, and there were no pillows near or around her feet, nor on the floor nearby, on the dresser in her room, or in the closet. R6 had a pillow under her head, but there were no other pillows in the room. On 6/27/19, at 12:46 p.m. nursing assistant (NA)-A stepped into the room briefly then left, she did not put a pillow under R6's feet, nor did she reposition R6. At 1:02 p.m. NA-B entered R6's room and checked on her but did not put pillows under R6's heels, nor did she reposition R6. At 1:10 p.m., NA-B and NA-C confirmed there was no pillow under R6's heels. When asked whether having a pillow under the heels was part of R6's care, NA-C stated, We put one there sometimes. On 6/27/19, at 1:16 p.m. NA-A stated she had laid R6 down for her nap, and had put a blanket under her heels. On 6/27/19, at 2:50 p.m. registered nurse (RN)-A stated R6's bilateral heel pressure ulcers were acquired at the facility. RN-A stated she had done the weekly wound assessments, and the pressure ulcers remained unstageable, but were improving. On 6/27/19, at 3:00 p.m. R6's bilateral heel pressure ulcers and pressure ulcer cares were observed with RN-[NAME] The pressure ulcers had no changes from the 6/25/19, measurements and descriptions. RN-A stated R6's right heel pressure ulcer was not open, was intact, but could open up. On 6/27/19, at 4:31 p.m, the director of nursing (DON) stated R6's heels were to be floated on a pillow when R6 was in bed. The DON stated they do not record repositioning times or audit pressure ulcer interventions for implementation. The DON also stated that both she and RN-A update nursing assistant care guides, which are reviewed during report. The DON stated the NAs should know what was on the nursing assistant care guide for each resident. The facility's 11/16 Pressure Injury/Skin Integrity/Wound Management policy indicated a system was in place for the prevention .of pressure injuries and non-pressure wounds. The policy also indicated avoidable pressure injuries develop when the facility does not do one or more of the following: *Evaluate the resident's clinical condition and pressure injury risk factors; *Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; *Monitor and evaluate the impact of the interventions; and /or *Revise the interventions as appropriate. In addition, the policy also directed residents with risk for, or who had a loss of skin integrity, were to receive the appropriate treatment/services which may include reposition or off-loading as per resident assessment and care plan. The policy directed all interventions and treatments would be evaluated for efficacy and modified/changed as needed. Finally, the policy directed if a resident refused or resisted staff interventions, the care plan should reflect efforts to seek alternatives.

Based on observation, interview and document review, the facility failed to prevent the development of a pressure ulcer when staff failed to place a palm protector for 1 of 1 resident (R2) who was reviewed for pressure ulcer. This practice resulted in a new open area in the palm of R2's left hand. Findings include: R2's medical record was reviewed. The admission record dated 7/2/2008 indicated R2 had [DIAGNOSES REDACTED]. The Nurse Practioner's (NP) progress note dated 3/3/2012 indicated R2 was severely cognitively impaired for daily decision making. The NP note also noted R2's skin was normal without rashes, moles or suspicious [MEDICAL CONDITION]. R2's care plan dated 3/5/2012, directed staff to cleanse hands in a.m. and p.m., and place a rolled up washcloth in her hand if she allows. The care plan also directed staff to apply a palm protector. The palm protector was to be removed in the a.m. and p.m. for hand washing then reapplied. The nurses notes dated 1/15/2012, indicated R2 was screaming "ow" during hand hygiene. R2 would not allow staff to do proper hand hygiene without screaming. The staff had a difficult time placing palm protectors without R2 becoming angry and physically abusive. The nursing notes dated 1/23/2012, indicated R2 refused palm protectors on right and left hands and expressed extreme pain when touched. Warm packs applied to hands prior to initiating finger manipulation. R2 stated "ow- that hurts." R2 was able to move index finger and thumb on both hands but not the others without pain. R2 appeared to have more behavioral symptoms of paranoia when approached by staff. Licensed practical nurse (LPN)-B was interviewed on 4/25/2012 at 9:45 a.m. and stated R2's hands are very contracted and the palm protectors don't get placed because of pain. LPN-(B) stated she had attempted to cut R2's finger nails because they appeared to be growing into her right hand causing an open sore. LPN-(B) said R2's contracted hands were crusted over with debris and were odorous because staff can't wash her hands or place a pressure relieving device like a washcloth or the palm protectors without causing pain. R2 was observed on 4/25/2012 at 11:15 a.m. sitting in a reclined position in a geri chair in her room. The interim director of nursing and nurse manager (NM-A) attempted to open R2's contracted right hand. R2 cried out in pain and had a fearful expression on her face. The DON confirmed there was an open sore on R2's right palm however, the DON could not measure the open wound based on the level of pain and limited range of motion (ROM) in R2's hand. R2's finger nails were quite long and the sore on the palm of her hand appeared to be from the long nails. The DON confirmed she was unaware the palm protector or a wash cloth was not being used to prevent pressure and stated the open sore was new. The Nursing assistant (NA-B) that was responsible for completing range of motion and applying the palm protectors was interviewed on 4/27/2012 at 10:15 a.m. and stated the ROM and placement of palm protectors doesn't get done because it hurts R2 too much. NA-(B) said there is supposed to be a warm pack applied to R2's hands prior to placing the palm protectors but it doesn't help. NA-(B) stated this has been reported this to the nurse several times.

Based on observation, interview and document review, the facility failed to provide care and services to alleviate pain for 1 of 1 residents (R2) in the sample who was reviewed for pain. The failure to manage the pain caused extreme pain when staff attempted to place palm protectors in R2's hands. Findings include: R2's medical record was reviewed. The admission record dated 7/2/2008, indicated R2 had [DIAGNOSES REDACTED]. The Nurse Practioner's (NP) progress note dated 3/3/2012, indicated R2 was severely cognitively impaired for daily decision making. R2's care plan dated 3/5/2012, directed staff to cleanse hand a.m. and p.m. and place a rolled up washcloth in her hand if she allows. The care plan also directed staff to apply a palm protector. The palm protector was to be removed in the a.m. and p.m. for hand washing then reapplied. The nursing progress notes, Nurse Practioner notes and orders were reviewed as follows: The Nurse Practioner (NP) orders dated 12/22/2011, indicated the orders for the pain medications Roxinol and Tylenol, each to be given as needed; were discontinued for non-use. The nurses notes dated 1/15/2012, indicated R2 was screaming "ow" during hand hygiene. R2 would not allow staff to do proper hand hygiene without screaming. The staff had a difficult time placing palm protectors without R2 becoming angry and physically resistive. The note indicated Tylenol had been given prior however, had given no relief. On 1/17/2012, the NP ordered [MEDICATION NAME] 400 (milligrams) three times a day for one week and monitor pain. Place a warm pack on R2's hands 20 minutes prior to doing range of motion (ROM). The pain flow sheet dated 1/18/2012, indicated R2 refused palm protectors, screaming "ow" and hitting at staff. The same pain flow sheet dated 1/19/2012, indicated R2 refused palm protectors, yelling "ow" at the mention of wearing them. R2's hands were wrapped in warm packs prior to manipulation of the fingers and R2 was yelling "ow" when the palm protectors were placed. The nursing notes dated 1/23/2012, indicated R2 refused palm protectors on right and left hands. R2 expressed extreme pain when touched. Warm packs applied to hands prior to initiating finger manipulation. R2 stated "ow- that hurts." The note indicated R2 was receiving [MEDICATION NAME] 400 mg three times a day for hand pain with no significant relief noted. R2 continued to clench fists and was unable to relax her fingers. R2 was able to move index finger and thumb on both hands but not the others without pain. R2 appeared to have more behavioral symptoms of "paranoia" when approached by staff. Staff would continue to monitor. The NP was not notified R2 continued to have pain. The pain flow sheet dated 1/24/2012, (am shift) indicated R2 complained of hand pain during manipulation and placement of palm protectors. R2 was unable to move her fingers on command without becoming agitated and "paranoid". R2 stated the [MEDICATION NAME] helped some. The NP orders dated 1/24/2012, were; continue with [MEDICATION NAME] 400 mg three times a day (helpful). However, R2 had been and continued to yell out in pain during ROM or placement of palm protectors. No other orders for pain intervention was noted. The nurses notes dated 1/24/2012, (p.m. shift) indicated R2 refused ROM on her hands. R2 said it hurts too much. Warm towels were placed on her hands and she was told to move her fingers the best she could on her own. Staff would continue to monitor. The [MEDICATION NAME] was not alleviating R2's pain and the NP was not updated. The nurse's notes dated 1/25/2012, (a.m. shift) indicated R2 expressed pain by yelling ow when palm protectors were placed on both hands. The note indicated R2 became very "paranoid" and "agitated" when her hands were touched. R2 clenched her fists and would not move her fingers. The note identified staff were continuing with [MEDICATION NAME] 400 mg three times a day per NP order and staff would continue to follow up on pain level to hands while on medication. The nurses note dated 1/26/2012, (p.m. shift) indicated no complaints of pain however, R2 hollered out in pain when staff removed the palm protectors. The NP order dated 1/30/2012, ordered staff to hold the [MEDICATION NAME]. The order to hold was related to a [DIAGNOSES REDACTED]. The active medication order sheet for February indicted R2 was receiving [MEDICATION NAME] HCL (a pain medication) 5 mg every 12 hours for pain. Despite receiving this medication R2 continued to have pain. The nurses note dated 2/1/2012, indicated R2 continued to yell "ow" during placement of palm protectors on right and left hands. On 2/6/2012, the NP discontinued the [MEDICATION NAME]. No other pain medication or other intervention was ordered and R2's pain was not reassessed by the NP for 22 more days. The NP progress note dated 2/28/2012, indicated the NP assessed R2 and noted R2 was having increased signs and symptoms of pain with attempts at ROM. The Assessment/plan part of the note indicated it was difficult to do ROM due to pain and the plan was to increase the [MEDICATION NAME] dose and work on treatment for [REDACTED]. However, the order to increase the [MEDICATION NAME] was not written in R2's medical record until 3/29/2012. The next NP progress note dated 3/12/2012, indicated R2 had transitioned from [MEDICATION NAME] (a narcotic used to treat moderate to severe pain) to [MEDICATION NAME]. R2 was noted to have an increase in complaints of pain, increased stiffness of her legs, more so on the left; and still had pain with attempts to extend digits 3,4,5 on both hands. The NP indicated she would address the pain issues and monitor the outcome. There was no documentation addressing pain in R2's medical record after the NP visited R2 on 3/12/2012. Then on 3/29/12, the NP order indicated to discontinue the [MEDICATION NAME] 5 mg twice daily and start [MEDICATION NAME] 5 mg every a.m. and p.m. with [MEDICATION NAME] 2.5 mg daily mid day for one week then assess for pain control. The [MEDICATION NAME] dosing was increased 30 days after the NP assessment done 2/28/2012. The nurses note dated 4/6/2012, indicated staff had been called to R2's room due to R2 yelling out in pain. When staff asked R2 if she was in pain R2 yelled "yes." The note indicated where ever staff touched R2 she would yell "ow." Indicating R2 had pain all over. Tylenol was administered however there was no documentation indicating the effectiveness of the Tylenol. The NP order dated 4/6/2012, indicated the [MEDICATION NAME] was increased to 5 mg three times a day. However, three days after the increase R2 continued to have pain. The nurses notes dated 4/9/2012, indicated no significant change noted in R2's level of pain during cares since starting extra dose of [MEDICATION NAME] 2.5 mg with increase to 5 mg and receiving 5 mg three times a day. R2 continues to yell "ow" during cares when arms and legs are manipulated in any way. The nurse wrote; R2's arms and legs are rigid and she holds her hands in a fist formation. Her arms are held tight and close to her torso. Her legs are held tight together and outstretched. The nurses notes dated 4/11/2012, indicated R2 had complaints of left arm pain during cares in bed. R2 would yell "ow." [MEDICATION NAME] 5 mg had been given three times a day for pain. R2 had very rigid legs and arms held in tight close to the body with contractured hands in fist formation. Staff unable to manipulate without pain; will review with NP. However, eight days later the nurses continued to document R2 was in pain and there was no indication the NP had been notified. On 4/19/2012, the nurses notes indicate R2 had verbalized pain on palpation of all extremities by yelling "ow" with every touch. The notes indicated R2 had cognitive deficits and was unable to assess level of pain and the location. R2 would yell "ow" when not being touched. R2 was receiving [MEDICATION NAME] 5 mg three times a day with no sign of any relief of pain. R2's arms and legs were very stiff and rigid and unable to manipulate or range any areas without R2 verbalizing pain. Staff will follow up with NP for further instruction. However, R2 continued to be in pain for another five days and it was not clear the NP had been notified. On 4/20/2012, the nurses note indicated R2 stated she had a lot of pain that day. Gave Tylenol which gave no relief. She also stated that her hands hurt as well. They are very contracted, attempted to get a washcloth in her hands and she was yelling at staff. When staff tried to turn her side to side she was yelling. R2 is on 5 mg [MEDICATION NAME] three times a day. She refuses to get out of bed for dinner. Will continue to monitor. The NP or R2's physician was still not notified and then on 4/21/2012 at 2:43 p.m. the nurse charted that R2 yelled out in pain during repositioning in bed that afternoon. Appeared to be having pain in left arm when turned. Had no complaints of pain while up in the wheelchair. Continuing with [MEDICATION NAME] 5 mg three times a day with not much relief for pain noted. Will continue to monitor. On 4/21/2012 at 11:00 p.m. the nurses notes again indicated R2 continued to have pain and was yelling out throughout the shift due to pain. When staff asked her where her pain was, she said mostly in her left hand but stated "everywhere hurts." The nurse gave Tylenol but charted R2 had no relief and staff would continue to monitor. There was no documentation that the NP or R2's primary physician had been notified of the on going pain until 4/24/2012, when the NP ordered to discontinue the [MEDICATION NAME] 5 mg three times a day and change to [MEDICATION NAME] 10 mg twice a day. Licensed practical nurse (LPN)-B was interviewed on 4/25/2012 at 9:45 a.m. and stated R2's hands are very contracted and the palm protectors don't get placed because of pain. She stated R2 will scream in pain when ROM is attempted. LPN-B stated she had attempted to cut R2's finger nails because they appeared to be growing into her right hand causing an open sore. LPN-B said R2's contracted hands were crusted over with debris and were odorous because staff can't wash her hands without causing pain. LPN-B stated she had informed nurse manager- (A) (who at the time was the director of nursing) however, she felt not enough was being done to alleviate R2's pain. R2 was observed by this investigator on 4/25/2012 at 11:15 a.m. with the director of nursing and nurse manager-(A) present. Both of R2's hands were contracted and she voiced pain with manipulation of her hands. There were no palm protectors in place and the right hand was noted to have a stage 2 open area with macerated edges in the palm of her hand. R2 had one long finger nail that appeared to have caused the open area. R2 voiced pain loudly during this assessment. NM-A was interviewed on 4/25/2012 at 11:55 a.m. and stated staff had never told her R2 was having increased pain and were unable to do ROM. She stated R2 had been contracted since admission and had always had pain. NM-A said you can't touch her without her yelling. The Nursing assistant (NA-B) that was responsible for completing range of motion and applying the palm protectors was interviewed on 4/27/2012 at 10:15 a.m. and stated the ROM and placement of palm protectors doesn't get done because it hurts R2 too much. NA-(B) said there is supposed to be a warm pack applied to R2's hands prior to placing the palm protectors but it doesn't help. NA-(B) stated this has been reported this to the nurse several times. R2 was observed again on 4/27/2012 at 11:55 a.m. being transferred into a geri chair with the use of a mechanical lift by one staff. R2 was exhibiting facial grimacing and had a look of fear on her face. When asked if she was in pain she very forcibly stated yes. R2 would flinch if someone tried to touch her hands. The nursing assistant (NA-D ) stated she does not do range of motion or place the hand protectors because it is too painful for R2. The nurse Practioner was interviewed at 9:20 a.m. on 5/21/2012, and stated R2's pain was controlled at the time the [MEDICATION NAME] was discontinued for non-use. The NP stated she completed assessments every 60 days for R2 and would address issues more frequently if the nurses told her about resident issues. The communication process consisted of a book the nurses could write resident issues in and the NP would follow up, however, she stated the nurses did not always keep her apprised of R2's pain. The nurses did inform her of the urinary tract infection [MEDICAL CONDITION] and had asked for a gradual dose reduction of another medication in March however, she referred to pain control as being the primary goal. The NP indicated it seemed the nursing staff had determined the UTI was at the forefront of her medical issues. The NP verified no other interventions were ordered when the [MEDICATION NAME] was held and then discontinued on 2/6/2012 however, R2 had been receiving [MEDICATION NAME] 5 mg every 12 hours. The NP indicated she did not routinely read the nurses notes in the computer and would usually get a brief report from the nurse on duty when she made rounds. The NP stated she is in the facility and available a few days every week. The NP also verified the [MEDICATION NAME] was not increased after her assessment on 2/28/2012 until 3/29/2012 however, couldn't say for sure if the nursing staff had alerted her to R2's pain in the interim.