Every finding on record at Capital View Transitional Care Center

Based on observation, interview and record review the facility failed to ensure a skin tear had continued monitoring and treatment for 1 of 1 resident (R17) reviewed for non-pressure skin injuries. Findings include: R17's face sheet dated 11/12/25, indicated R17 was recently admitted to the facility and had diagnoses of pathological compression fractures of the cervical spine and squamous cell cancer involving the bone.R17's Wound Care Alert dated 11/12/25, indicated R17 had a skin tear on the right forearm that was covered with a mepelix (foam protective dressing). The document lacked indication of an assessment or description of the skin tear. R17's daily skin assessments dated 11/12/25- 1/17/25, indicated R17 had a skin tear, however lacked where it was located or if further monitoring or treatments were provided.R17's provider and nursing orders as of 11/17/25, lacked indication of treatment orders for R17's skin tear.A facility document titled Standing Orders dated 2/2025, directed staff to cleanse minor skin tears, and cover with non-adherent dressing. Furthermore, the standing orders directed staff to change all dressings every three days and as needed. R17's temporary care plan dated 11/12/25, lacked indication R17 had a current skin tear or was at risk for skin injury. During observation and interview on 11/17/25 at 1:00 p.m., R17 was sitting in their wheelchair in her room. R17 had a mepelix (foam dressing used to protect the skin) on her right forearm, dressing was undated. R17 was not sure what was underneath the mepelix and couldn't remember when it was placed. R17 further stated she gets bruises and bumps all the time. An observation on 11/18/25 at 8:35 a.m., nursing assistant (NA)-A was assisting R17 to the bathroom. An undated mepelix was still in place on R17's forearm. When interviewed on 11/18/25 at 2:11 p.m., registered nurse (RN)-A stated when a skin alteration was found on a resident, an assessment of it would be completed. The assessment included what the skin altercation was, measurements and what was done. The skin alteration would then be placed on the body avatar in the residents electronic medical record (EMR). RN-A verified the undated mepelix on R17's forearm and believed it was a skin tear that happened prior to admission and had not provided any cares or looked under the mepelex dressing. RN-A verified R17's body audit did not indicate there was a skin alteration on R17's forearm and a Lines, Drains, Airway (LDA) (specific flowsheet documentation where skin alterations and wounds documented) had not been created for R17's arm. Furthermore, RN-A was not able to find a progress note to indicate when the mepelix was placed or if it had been changed.A follow up interview at on 11/18/25 at 2:24 p.m., RN-A stated they had removed R17's mepelix dressing and it appeared to be a skin tear. RN-A stated the skin tear was almost completely healed and now believed the dressing was placed at the facility and not prior to admission. When interviewed on 11/18/25 at 2:43 p.m., the Director of Nursing (DON) stated upon admission, any skin altercation would be expected to be documented on the body audit. If the staff find a new wound or skin injury, the nurse will add to the body audit and add an LDA to complete the assessment. If there was a need for a dressing, the nurse would obtain one. DON further stated nurses are trained to peel back a mepelix to determine what the skin injury is and what is going on with it. When interviewed on 11/18/25 at 3:43 p.m., RN-B stated only major wounds were added for an LDA. RN-B stated documentation from the paper form of the body audit done upon admission was found and it was noted to be a skin tear and the mepelix was placed by the facility upon admission. RN-B stated the skin tear was not placed in R17's body audit that was in the EMR and the paper form was for the MDS nurse to review. RN-B verified there was there was no further assessment or description of the skin tear in R17's medical record.A follow up interview on 11/19/25 at 11:06 a.m., DON stated with evening admissions, RN-B was usually emailed with any resident skin injuries to add an LDA, and ensure documentation was completed, however there wasn't an email sent. DON expected staff to follow this process to ensure an LDA was placed to monitor the skin tear and indicate if treatment was provided. A facility policy titled Wound Care dated 12/10/24, directed staff to dress minor skin variations with a non-adherent dressing. Furthermore, staff were directed to record the type of wound care provided and all assessment data obtained when inspecting the wound on a flow sheet or progress note.

Based on interview and document review, the facility failed to ensure allegations of abuse were reported to the State Agency (SA) immediately (within two hours) for 1 of 3 residents (R1) reviewed for allegations of abuse. Findings include: R1's 5-day Minimum Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition with diagnoses which included diverticulitis with recent surgery on the gastrointestinal tract. A Facility Reported Event (FRI) submitted to the SA on 6/11/25 at 4:25 p.m. indicated on the evening shift of 6/6/25 R1 told a social worker a nurse had put their hands on R1's neck, and pushed her back into bed. R1 was not sure if the nurse was going to choke her. R1 was in shock over what happened, but was not physically harmed. On 6/16/25 at 3:31 p.m., R1 stated she told nursing assistant (NA)-A, registered nurse (RN)-A had tried to choke her on the evening of 6/6/25. NA-A told her he would report it to someone higher. RN-A came back into R1's room and was questioning her. R1 stated she was afraid of RN-A that evening. On 6/16/25 at 3:57 p.m., RN-A stated she was the nurse caring for R1 on 6/6/25. She heard an alarm sounding in R1's room, and went to investigate. She found R1 with the upper part of her body face down on her bed with her feet on the floor. She assisted R1 into a sitting position on the bed by stabilizing R1's shoulders. She settled R1 into a comfortable position with the call light in reach, and left the room. Later that evening, NA-A told her that R1 had reported to him RN-A had tried to choke her. She went back to the patient room to talk to R1 about the situation. She did not report the allegation to the administrator or director of nursing (DON). On 6/16/25 at 4:21 p.m., NA-A was unavailable for interview. On 6/17/25 at 1:03 p.m., the DON stated R1 told the social worker about the event on 6/11/25. The social worker immediately told the DON who started the investigation. She confirmed this allegation should have been reported to the DON or the administrator on 6/6/25 when R1 told NA-A about the incident. The DON confirmed RN-A worked with R1 following the incident. No formal re-education was provided to staff about the importance of reporting all details immediately to the administrator or DON. The undated facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Patient Property directed any nursing home employee who becomes aware of abuse, mistreatment, neglect or misappropriation shall immediately report to the nursing home administrator.

Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 resident (R171) observed with medications at the bedside. Findings include: R171's Entry Tracking Record dated 11/25/24, indicated R171 was admitted to the facility on [DATE]. R171's face sheet dated 12/4/24 at 11:23 a.m., indicated the following diagnoses: reactive airway disease, closed fracture of the right humerus (upper arm), closed left hand fracture, osteoporosis (a disease that weakens bones) with pathological fracture (a fracture due to underlying disease), closed nondisplaced fracture of first metacarpal (bone near the thumb) bone of the left hand, closed displaced (out of alignment) fracture of shaft of first metacarpal bone of left hand. R171's temporary care plan (TCP) dated 11/25/24, indicated intact cognition. Additionally, the TCP indicated on 12/4/24, R171 could SAM inhalers at the bedside. R171's physician's orders indicated the following orders: 11/25/24, fluticasone-vilanterol (Breo Ellipta) 100-25 MCG (microgram)/ACT (actuation) inhaler 1 dose daily. 11/25/24, umeclidinium (Incruse Ellipta) 62.5 MCG/ACT inhaler 1 puff daily. R171's physician's orders lacked information R171 could self administer inhalers. R171's admission progress note dated 11/25/24 at 3:09 p.m., indicated R171 was unable to use arms to eat, was non-weight bearing on the left wrist and had a sling to the right shoulder. R171's SAM dated 12/4/24, indicated R171 wished to self administer medications and was appropriate for R171 to self-administer the Incruse Ellipta and Breo Ellipta and medications would be stored at the bedside. During interview and observation on 12/3/24 at 8:51 a.m., and 9:02 a.m., registered nurse (RN)-A picked up the Incruse Ellipta inhaler 62.5 mcg/ACT and was looking for the Breo Ellipta that was located on R171's bedside table. RN-A provided R171 with the Breo Ellipta inhaler and some water. RN-A stated she had to check to see if R171 could have the Breo Ellipta at the bedside and stated staff looked in the summary and the medication administration record (MAR) to know if a resident could self administer their medication. RN-A viewed the computer and stated there was nothing located in the medical record that indicated R171 could self administer the medication and stated she would put the medication back in the drawer. Further, RN-A stated an assessment was completed on admission to determine whether a resident could self administer a medication. During interview on 12/4/24 at 9:40 a.m., the director of nursing (DON) stated the nurse asks residents whether they would like to keep any medications at the bedside and stated the assessment is completed and placed in an orange book at the nursing stations and then a tag line located at the top of the electronic medical record (EMR) is placed if a resident can SAM. The DON reviewed R171's record and stated she did not locate anything and stated she did not recall R171 having a SAM and stated if they don't want to SAM, medications were not left at the bedside until they were reassessed. A policy, Self-Administration of Drugs, dated September 2024, indicated patients who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. As part of their overall evaluation, the staff and practitioner will assess each patient's mental and physical abilities, to determine whether a patient is capable of self-administering medications. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including ability to read and understand medication labels, comprehension of the purpose and proper dosage and administration time for his or her medications, ability to remove medications from a container and to ingest and swallow them, and ability to recognize risks and major adverse consequences of his or her medications. If the staff or IDT determines that a patient cannot safely self-administer medications, the nursing staff will administer the patient's medications.

Based on observation, interview, and document review, the facility failed to ensure that an opened medication was labeled and contained the correct expiration date for one of one resident (R126), and failed to ensure an expiration date was documented on an opened medication for one of one resident (R176) reviewed. Further, staff were not aware of the correct expiration date of an insulin medication once opened. Findings include: The Admelog website, products.sanofi.us/admelog/admelog.pdf indicated opened Admelog insulin vials must be used within 28 days or be discarded, even if they still contained Admelog. R126: R126's face sheet form dated [DATE] at 11:32 a.m., indicated R126 had a diagnosis of type two diabetes. R126's physician's orders form indicated the following order: [DATE], insulin lispro (Humalog, Admelog) injection vial, inject 10 units three times a day with meals. During interview and observation on [DATE] between 8:10 a.m., and 8:45 a.m., registered nurse (RN)-B pulled a multi-dose vial of Admelog insulin 100 units/milliliter (ML) out of the medication cart. The insulin did not contain a label that identified who the insulin belonged to. Further, the insulin was not in a bag. RN-B stated at 8:29 a.m., the insulin was not labeled, but stated she knew it was R126's insulin because R126 was there the day prior and stated she could go into the refrigerator and waste the bottle, however stated there was none in the refrigerator. At 8:43 a.m., RN-B opened a new multi-dose vial of Admelog insulin and stated she assumed the insulin expired after one month and added an expiration date of [DATE], and administered the insulin to R126 at 8:45 a.m. During interview on [DATE] at 12:34 p.m., RN-D stated all insulins were discarded 28 days after opening. During interview on [DATE] at 11:24 a.m., the pharmacist consultant (PC) stated insulin bottles stored in drawers with multiple residents should contain identifiable information on who the insulin belonged to. R176: R176's face sheet form dated [DATE] at 11:15 a.m., indicated R176 had type two diabetes mellitus without complication, with long-term current use of insulin. R176's physician's orders form indicated the following order: [DATE], insulin lispro (Humalog, Admelog) injection vial 4 units three times a day with meals. During interview and observation on [DATE] between 10:19 a.m., and 10:29 a.m., licensed practical nurse (LPN)-A explained the process of dispensing medications from the Pyxis medication cart. LPN-A stated when administering medications, opens the chart and reviews medications. LPN-A stated all insulin bottles were multi-use vials and were dated when opened, and expired after 30 days. Further, LPN-A verified R176 had a multi-dose vial of Admelog that was opened on [DATE], but did not contain an expiration on the bottle. During interview on [DATE] at 10:56 a.m., LPN-A stated she clarified the expiration date for Admelog was actually 28 days with RN-D. During interview on [DATE] at 9:40 a.m., the director of nursing (DON) stated their policy indicated insulins were labeled with the patient name and date of birth, physician, and medical record number and were dated when opened and further, the vial was scanned and the order showed up for staff to be certain they had the correct medication. The DON stated it was important to have a label in order to know who the medication belonged to. During interview on [DATE] at 11:01 a.m., the DON stated they were looking at the open date and have not always written the expiration date but the rule was 28 days. A policy, Labeling of Medication Containers, dated [DATE], indicated all medications maintained in the facility shall be properly labeled in accordance with current state and Federal regulations. Labels for individual drug containers shall include all necessary information such as the expiration date when applicable. Further, labels for small multi-dose containers will include all necessary information: the patient's name, the patient's MRN (medical record number), attending physician, and the date opened.

Based on observation, interview and document review, the facility failed to follow nationally recognized best practices regarding isolation precaution for communicable diseases for 1 of 4 residents (R7) this had the potential to affect 8 residents who resided on the unit. Additionally, the facility failed to ensure hand hygiene was performed during incontinent cares for 1 of 1 resident (R6) reviewed for infection control practices. Findings include: R7's admission minimum data set (MDS) dated [DATE], indicated R7 was cognitively intact, did not refuse cares, and incontinent of bladder and bowel. R7 had impairment to both upper extremities. R7 required substantial/maximal assistance for dressing and toileting hygiene, partial/moderate assistance for toilet transfers, and supervision or touching assistance for eating. Diagnoses included end stage renal disease, urinary tract infection in the last 30 days, diabetes mellitus, and hemiplegia (loss of ability to move one side of the body) or hemiparesis (partial muscular weakness to one side of the body). R7 was on isolation for active infectious disease. R7's order included Vancomycin 250 mg four times a day orally for Clostridioides difficile (C. diff; a germ which causes diarrhea and inflammation of the colon) with start date of 1/24/24 and enteric isolation for c. diff with start date of 1/29/24. An observation and interview on 1/29/24 at 1:29 p.m., RN-A indicated R7 had C. diff. R7's door had a sign which indicated contact precautions and directed staff to use alcohol-based hand rub, gloves, gowns, and dedicated or disposable equipment. A magnet located on the side of the door directed staff to wash hands with soap and water, gown, and glove. An observation on 1/30/24, at 9:03 a.m., nursing assistant (NA)-A walked to the doorway of R7's room and was handed a clear plastic water mug with a cover and straw. NA-A took the mug into the nurse's station, removed the cover and placed it on the counter. NA-A then filled the mug with ice and water from the ice machine. The mug was placed on the counter and the cover placed back on. The mug was then returned to R7's doorway and handed off to staff inside. When interviewed on 1/30/24 at 9:07 a.m., NA-A stated R7 was on TBP for C-Diff. NA-A verified R7's mug was just refilled with ice water and further stated they were not sure if the mug could come out of R7's room to fill. NA-A then asked licensed practical nurse (LPN)-A. LPN-A verified residents on TBP should have a new mug filled and brought into the room. Used mugs needed to be sent to wash and bringing items in and out was an infection risk. NA-A then acknowledged a clean mug should have been filled. 48299 HAND HYGIENE during incontinence cares: R6's admission minimum data set (MDS) dated [DATE], indicated R6 was cognitively intact and did not refuse cares. R6 required assistance with toileting hygiene, dressing, mobility, and transfers. R6's care sheet dated 1/30/24, indicated R6 was on contact isolation for extended-spectrum beta-lactamases (ESBL; a bacteria which cannot be killed by many antibiotics used to treat infections) in urine, incontinent of bladder and continent of bowel, and transferred using a mechanical lift with two to three staff. During observation on 1/31/24 at 8:55 a.m., NA-B assisted R6 with activities of daily living with personal protective equipment (PPE) which included a gown and gloves. NA-B removed R6's incontinence product and wiped R6's bottom with gloved hands while R6 was laying on their side. Bowel movement was noted on the wipe and NA-B grabbed a clean incontinent product and tucked the product under R6 without performing hand hygiene or changing their gloves. NA-B assisted R6 to lay on their back and wiped R6's perineal area with different wipes and the same gloves. NA-B turned R6 on to their other side and R6's brief was secured. NA-B removed their gloves, did not perform hand hygiene, and placed new gloves on their hands. NA-B assisted R6 to dress with pants and a shirt, and NA-B assisted R6 to transfer from their bed to wheelchair using a mechanical lift. During interview on 1/31/24 at 9:27 a.m., NA-B stated staff should perform hand hygiene between glove changes and change their gloves and perform hand hygiene after cleaning bowel movement and before touching a clean incontinent brief. NA-B stated they perform peri-cares from bottom and up and start with the bottom or peri-area depending on where bowel movement is if there is so. When interviewed on 2/1/24 at 2:31 p.m., the Director of Nursing (DON) expected staff to follow the signage posted outside of the residents' room and wear the appropriate PPE for any task inside the room. All used PPE should be removed and disposed of inside the residents' room and appropriate handwashing to occur. Used items or supplies should remain inside the room, and should be disposed of in the room. Resident items should not be going in and out of the room of resident's room who require TBP. Furthermore, DON expected staff to remove gloves and perform hand hygiene when moving from soiled or dirty areas to clean areas during resident care as well as after glove removal. A facility policy titled Infection Control Guidelines for All Nursing Procedures no date, directed staff to wash hands after removing gloves, and staff must wash hands with soap and water when likely exposure to C. Diff. A facility policy titled Isolation- Categories of Transmission Based Precautions no date, directed staff to use TBP when caring for residents who have suspected or confirmed communicable diseases or infections that can be transmitted to others. The facility's policy Standard Precautions undated, directed staff to wash hands after removing gloves and remove gloves promptly after use, before touching non-contaminated items and environmental surfaces.

Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 5 of 5 (R7, R6, R74, R4) residents reviewed for vaccinations. Findings include: R7's admission MDS dated [DATE], indicated R7 was cognitively intact and had diagnoses of diabetes and chronic kidney failure. Furthermore, R7's MDS indicated R7 was up to date with the pneumococcal vaccine. R7's facility immunization record dated 12/26/23, indicated R7's PPV status was up to date and was received 10/9/17. R72's immunization record lacked what PPV dose(s) had previously been given. R7's Minnesota Immunization Information Connection (MIIC) report printed 2/5/24, indicated R7 had recieved PCV13 on 10/19/17. Review of the current CDC recommendations 03/15/23, indicated one dose of the PCV20 given at least one year after the PCV13 would complete R7's pneumococcal vaccinations. R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact and had diagnoses of stroke. Furthermore, R6's MDS indicated R6 was up to date with the pneumococcal vaccine. R6's facility immunization record dated 11/22/23, indicated R6's PPV status was up to date and was received 8/3/21. R6's immunization record lacked what PPV dose(s) had previously been given. R6's MIIC printed 2/5/24, indicated R6 had recieved PSV23 on 8/3/21. Review of the current CDC recommendations 03/15/23, indicated one dose of the pneumococcal conjugate vaccine (PVC)15 or PCV20 given at least one year after the PSV23 would complete R6's pneumococcal vaccinations. R74's admission MDS dated [DATE], indicated R74 was cognitively intact and had diagnoses of pneumonia and stroke. Furthermore, R74's MDS indicated R74 was up to date with the pneumococcal vaccine. R74's immunization record dated 1/8/24, indicated R74's PPV status was up to date and was received 4/13/16. R74's immunization record lacked what PPV dose(s) had previously been given. R74's MIIC printed 2/5/24, indicated R74 had recieved the PSV23 on 12/18/14 and the PVC13 on 4/16/16. Review of the current CDC recommendations 03/15/23, indicated shared clinical decision making was needed to determine if a dose of the PCV20 should be given. R4's admission MDS dated [DATE], indicated R4 was cognitively intact and had diagnoses of high blood pressure and impaired mobility. Furthermore, R4's MDS indicated R74 was up to date with the pneumococcal vaccine. R4's immunization record dated 1/9/24, indicated R4's PPV status was up to date and was received 12/8/09, 11/30/15, and 3/11/22. R4's immunization record lacked what PPV dose(s) had previously been given. R4's MIIC printed 2/5/24, indicated R4 had recieved the PSV23 on 3/11/22 and the PVC13 on 1/30/15 Review of the current CDC recommendations 03/15/23, indicated shared clinical decision making was needed to determine if a dose of the PCV20 should be given. When interviewed on 2/1/24 at 9:07 a.m., registered nurse (RN)-A stated when a resident was admitted , the admission nurse either asks the resident about their vaccination status and if they are up to date. This was documented on the paper immunization record. RN-A further stated staff could also look up the immunizations in the electronic medical record (EMR) to determine when the vaccines were received. When interviewed on 2/1/24, at 2:31 p.m., the Director of Nursing (DON) stated nurses screened residents and identified if they were up to date with the pneumococcal vaccination. If residents were up to date, that was documented. If residents were due, the vaccination was offered. DON acknowledged work was recently started to streamline the process and help staff identify if a resident was up to date or not per the CDC recommendations. DON acknowledged there was work to be completed to ensure nurses understood what up to date meant and how to determine the resident's up to date status. This was important to do to protect residents from the risks of being unvaccinated. A facility policy Pneumococcal Vaccine dated directed staff to assess the pneumococcal vaccination status upon admission. Furthermore, administrations will be made in accordance with current CDC recommendations at the time of the vaccination.

Based on observation, interview and document review, the facility failed to ensure medications were passed without an error rate greater than 5 percent (%) by failing to follow administration instructions for 1 of 6 residents (R74) observed for medication administration. There were 30 opportunities for medication administration with two errors. This resulted in an error rate of 6.67%. Findings include: R74's admission Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment with diagnoses including pneumonia, acute (short-term) respiratory failure, heart failure and atrial fibrillation (an irregular heart rhythm). R74's physician orders observed for morning medication pass included the following: - potassium chloride (Klor-Con M) extended release 20 milliequivalents (mEq) oral tablet once daily, should be swallowed whole, for treatment of low potassium levels, dated 1/23/24. - furosemide (Lasix) tablet 40 milligrams (mg) oral tablet once daily for treatment of heart failure, dated 1/17/24. - metoprolol tartrate (Lopressor) oral tablet 25mg twice daily, to be taken with food, for treatment of atrial fibrillation, dated 1/16/24. - metronidazole (Flagyl) oral tablet 500mg twice daily for treatment of pneumonia, dated 1/16/24. - levofloxacin (Levaquin) oral tablet 750mg once daily, do not give within 2 hours of calcium, iron, magnesium supplements or antacids, for treatment of bacterial pneumonia, dated 1/17/24. - ferrous sulfate enteric coated (EC) oral tablet 325mg once daily on Mondays and Thursdays for treatment of low iron levels, dated 1/18/24. - clopidogrel (Plavix) 75mg oral tablet once daily for treatment of heart disease, dated 1/09/24. During observation of medication administration on 2/01/24 at 8:20 a.m., registered nurse (RN)-B was preparing R74's morning medications. She scanned each individual medication package and verified the medication, the dose, the route, time and expiration date on the packaging against R74's medication administration record (MAR). RN-B scanned one levofloxacin (antibiotic) tablet with administration instructions that advised, do not give within 2 hours of calcium, iron, magnesium supplements or antacids, and put the tablet into the medication cup. RN-B then scanned one ferrous sulfate tablet (type of iron supplement) and put that tablet into the medication cup. RN-B scanned one potassium chloride tablet with administration instructions that advised it, should be swallowed whole, and put the tablet into the medication cup. RN-B gave the medication cup to R74, who requested the bigger tablets be split in half so she could swallow them. RN-B performed hand hygiene, applied gloves, and retrieved each large tablet and used a pill splitter to split each tablet, including the potassium chloride tablet. RN-B gave the cup back to R74 and monitored while she took her medications. During interview on 2/01/24 at 9:59 a.m., RN-B reviewed R74's MAR and verified potassium chloride had administration instructions advising not to split the tablet and acknowledged splitting the tablet during morning medication pass. RN-B reviewed administration instructions for levofloxacin and verified the instructions advised not to administer with iron, which RN-B acknowledged doing. RN-B reported being unaware of any potential adverse effects of administering the antibiotic with iron. RN-B stated R74's provider would be updated on the medication errors and a request for a different form of potassium would be made. During interview on 2/01/24 at 10:46 a.m., the pharmacist stated potassium chloride tablets are coated for extended release and by not swallowing them whole, they could lose their effectiveness. If a resident was unable to tolerate swallowing the tablet whole, the pharmacist recommended contacting the provider for either a liquid or effervescent form of potassium. The pharmacist stated levofloxacin is less effective when taken with iron because there is decreased absorption, which could lead to decreased effectiveness of the antibiotic The pharmacist recommended if a nurse came across these two medications being scheduled at the same time, the nurse could contact the pharmacist by message or phone call to adjust the timing to ensure administration instructions were followed. During interview on 2/01/24 at 1:05 p.m., the director of nursing (DON) stated if a medication's administration instructions advised the nurse not to split the medication, the nurse could offer the resident to take the medication whole with applesauce. The DON stated the expectation was not to split the tablet and contact pharmacy for recommendations as there could be negative outcomes related to splitting potassium tablets. The DON stated the expectation of nurse who encountered administration instructions for levofloxacin to not administer with iron, which had the same scheduled administration time, would be to stop the process and determine which medication could be held. The DON expected the nurse to contact the pharmacist for further advisement. The DON stated if a nurse made a medication error, the nurse was expected to report the error to the DON and they would work together to correct it. An undated facility policy titled MED31 - Administering Oral Medications advised following medication administration guidelines.

Based on observation, interviews and document review the facility failed to ensure the infection control program included ongoing trending and analysis of community transmission Covid 19 levels to prevent the spread of infections. This deficient practice had the potential to affect all 19 residents who reside at this facility Findings include: The CDC COVID Data Tracker indicated [NAME] County community transmission rate was listed as high on 7/22/22. Review of the CDC guidance dated 2/2/22 indicated, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic indicated staff working in health care facilities should follow standard and transmission based precautions, utilize source control, which included a well fitting facemask. HCP working in counties with substantial or high transmission should also wear eye protection such as goggles or a face shield covering the front and sides of the face during all resident encounters. The MDH COVID-19 PPE and Source Control Grids dated 4/7/2022 indicated HCP in congregate care settings including nursing homes, for any community transmission level if working with residents/clients with suspected or confirmed [CONDITION(S)]-CoV-2 infection use PPE gown; gloves; eye protection; N95 or higher level respirator face mask. For community transmission levels high and substantial HCP use PPE face mask (source control) and eye protection. Upon observations on 7/22/22, at 9:40 a.m. housekeeper (HSK)-A walked out resident's room wearing a mask, but no eye protection. At 9:41 a.m. nursing assisting (NA)-A was witnessed in a resident's room assisting with cares wearing a facemask, but no eye protection. At 9:42 a.m. registered nurse (RN)-A went into a resident's room without wearing goggles, also at 9:42 occupational therapy assistant (OT)-A was seen speaking with a resident within six feet of the resident without eye protection. At 9:43 a.m. (NA)-B was on the unit in the resident care area without wearing eye protection. Upon interview on 7/22/22, at 9:50 a.m. the Administrator verified staff on the unit were not wearing eye protection. Stating We stopped wearing eye protection back in April after an MDH update call saying we could, I can look up the date of that call. She stated that the CDC website is checked weekly by herself, and the map shows Minnesota as being green and is a low community status. The Administrator and the DON verified they were looking at the community level, not the community transmission level and were unaware there was a difference between the community levels and the community transmission levels. The Administrator and DON verified when looking at the community transmission level on the CDC website that [NAME] County was red indicating a high risk for transmission. The Administrator and the DON verified they were aware that when the community transmission levels are high the PPE and source control indicates face mask and eye protection to be worn working with residents without suspected or confirmed Covid 19 infection. Upon observation on 7/22/22, at 10:25 a.m. the Administrator and the director of nursing (DON) provided all the staff on the unit with goggles for eye protection. Upon interview on 7/22/22, at 10:29 a.m. NA-A stated staff wear full PPE, which includes masks, eye protection, gloves, and gown only in rooms with residents who are quarantined and up until a few minutes ago staff were told they only need to wear a mask with other residents. We stopped wearing goggles a while ago. Upon interview on 7/22/22, at 10:35 a.m. RN-A reported the facility stopped wearing goggles maybe in April. He stated there was a sign at the front desk indicating the community was at a low level and only a mask was required, except in quarantined rooms. Upon interview on 7/22/22, at 10:41 a.m. OT-A stated she was just given goggles again today and told the facility was in a high status for outbreak. Upon interview on 7/22/22, at 10:42 a.m. HSK-A stated, I was told today that we needed to wear goggles again, we have not had to. Upon interview on 7/22/22, at 12:48 p.m. resident (R1) stated staff have always worn a mask but have not worn goggles. She stated PT/OT told me that has just changed today and asked she surveyor, is there a new variant out? Facility policy Coronavirus Disease (COVID-19) Infection Prevention and Control Policy dated 4/21, indicated the facility leadership and clinical staff to implement all reasonable measures to protect the health and safety of patients and staff from respirator pathogens such as the coronavirus disease (COVID-19). The facility will adhere to the recommendations of Federal and State agencies. The response to current outbreak of coronavirus is based on the most current recommendations from health policy officials, state agencies and the federal government. The CDC and MDH will lead and be the resources for changes in the policy as recommendations and rule change. Infection prevention and control measures are based on established guidelines governing all communicable diseases. During COVID-19 staff should always wear surgical masks, except when eating or drinking. Eye protection should be worn during all patient care encounters.

Based on observation, interview, and document review, the facility failed to determine if the practice of self-administration of medications (SAM) was safe for 1 of 1 resident (R115) observed to self-administer an inhaler. Findings include: R115's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R115's physician orders dated 9/14/21, directed to administer [MEDICATION(S)] inhaler 2 puffs every four hours as needed for cough/wheezing. R115's physician orders dated 9/14/21, directed to administer [MEDICATION(S)] nebulizer (respiratory medication) suspension 0.5 milligrams / 2 milliliters every 12 hours for asthma/[CONDITION(S)]. The physician's orders did not identify R115 could self-administer medications, including the nebulizer treatment. On 9/20/21, at 1:00 p.m. during a random observation, R115 was observed seated on the wheelchair in her room. During the observation a nebulizer machine was observed on a bedside table to the left of the bed and an inhaler was observed on the right side of the bed on a bedside table. On 9/21/21, at 1:39 p.m. the [MEDICATION(S)] inhaler continued to be observed on the bedside table, along with a nebulizer machine on a bedside table on the opposite side. During an interview on 9/21/21, at 1:39 p.m. R115 stated using the inhaler a couple times since being admitted to the facility. R115 further stated she only used the inhaler as needed for [CONDITION(S)] symptoms or shortness of breath. During an interview on 9/21/21, at 1:44 p.m. registered nurse (RN)-A stated nebulizer and inhaler medications would have been documented in the resident's chart if they were going to self administer their medications. RN-A further stated the nurse manager or the director of nursing (DON) usually completed the assessment so the resident could self administer medications. During an interview on 9/21/21, at 1:47 p.m. DON stated a SAM form can be completed by any nurse and the nurses would review any medications that the resident wanted to self administer. During an interview on 9/21/21, at 1:59 p.m. RN-A indicated R115 used a nebulizer twice a day and when she gave R115 a nebulizer treatment, she would set it up, pull the curtain closed for privacy and leave the room. RN-A further stated she would return to the room to shut the nebulizer machine off. During an interview on 9/22/21, at 11:24 a.m. DON acknowledged R115 did not have a SAM assessment completed. An undated Self Administration of Drugs policy directed as part of their overall evaluation, the staff and practitioner will assess each patient's mental and physical abilities, to determine whether a patient is capable of self-administering medications.

Based on interview, and document review, the facility failed to actively screen staff at the point of entry to the facility, in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19. Findings include: When interviewed on 6/18/20, at 11:30 a.m. nursing assistant (NA)-A stated she started the shift at 7:00 a.m. and no one watched her complete the Covid-19 self-screening. Sometimes there is someone watching me and sometimes no one. NA-A further stated no one had come to look at her since starting her shift to verify that she was well. NA-A confirmed she was also not screened at the main entrance to the hospital. When interviewed on 6/18/20, at 11:36 a.m. registered nurse (RN)-A stated arrived to the unit about 6:30 a.m. and self-screened for Covid-19 without anyone watching. When interviewed on 6/18/20, at 12:17 p.m. regarding staff COVID screening, registered nurse (RN)-C stated, We just get screened up on the unit, not downstairs at the hospital entrance. We come in for the shift, we walk up and we take our temperature, we report it on the paper and answer the questions on the paper. If we are not running a fever it is ok for us to punch in, if we are having any symptoms then we need to notify a supervisor, we are completing our own screening, they (designated staff) are not sitting there waiting for us to sign in. When interviewed on 6/18/20, at 12:55 p.m. regarding staff COVID screening, RN-B stated, We follow all of that on the spreadsheet for our screening. We check our temperature, symptoms, in and out. We complete the screenings on own, especially before and after business hours, then the administrator and DON will review the screenings when they come in. When interviewed on 6/18/20, at 1:03 p.m. the administrator stated someone from administration was usually in the facility to verify the screening process. The administrator further stated if the staff member was not observed when they arrived, administration would find them during the shift and ask how they were feeling. The evening supervisor was supposed to check-in the night shift and verify the screening was done and then initial the log. When interviewed on 6/18/20, at 1:43 p.m. the administrator confirmed the verification of staff temperature and screening had not been completed for the p.m. shift on 6/14/20, and that the evening supervisor failed to initial the log. The administrator further confirmed several other missing initials and temperatures and that staff would be disciplined for not recording their temperature. The administrator confirmed initialing the, staff initials on verification of temp and screening, by NA-A's screening for today (6/18/20). The administrator further stated, I am not sure I saw (NA-A) today. I heard her say hello, but did not look at her. When interviewed on 6/18/20, at 1:15 p.m. director of nursing (DON) stated staff did not receive formal education on the screening process. DON further stated staff received an email with instructions for screening and administration watched everyone the first week or so. DON further stated they did not have a competency or sign off sheet. The facility email with subject Employee Screening at CVTCC following CDC guidelines dated, 3/17/20, instructed staff to take temperature at the start of shift. Verify that they are feeling well. Take temperature at the end of shift. Report any changes/spikes in temperature to the supervisor. Report travel activity. The facility email with subject Changes in screening at CVTCC dated, 4/9/20, indicated change in screening location and that each employee must go through screening process before punching in or going to office space. The email indicated, Administration, Nursing Administration and the occasional Nurse Supervisor will be monitoring the screening. The Minnesota Department of Health (MDH) document, COVID-19 Toolkit updated 06/05/20, directed, Actively screen all staff for fever and symptoms of illness before starting each shift. In addition to facility staff, conduct health screening for other essential health care personnel including therapy personnel, hospice, home care, [MEDICAL TREATMENT], ombudsman, state surveyors, chaplain at end of life, mortician, etc. (Active screening means that a trained person should physically monitor temperature of staff entering the building and ask questions regarding other COVID-related symptoms. The Centers for Disease Control and Prevention (CDC) document, Preparing for COVID-19 in Nursing Homes updated 6/19/20, directed, Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature* and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace.

Based on observation, interview and document review, the facility failed to ensure medications were stored and labeled properly for 2 of 3 residents (R35 and R69) reviewed for medication storage. Findings include: During observations of multiple medication storage areas throughout the facility, medications for R35 and R69, which included insulin vials, lacked dates to indicate when they were opened, or when the medications expired. During the medication storage tour on 3/6/17 at 7:28 p.m., with licensed practical nurse (LPN)-A, in the 8300 unit medication cart, multiple opened, used and undated medication vials were stored in medication carts. Observations included the following: R35's Humalog insulin and Lantus insulin (for type 2 diabetes mellitus) vials were opened, used and undated. R69's Humalog insulin and Lantus insulin (for type 2 diabetes mellitus) vials were opened, used and undated. On 3/6/17 at 7:34 p.m., LPN-A verified the medications needed to be labeled and stored properly. LPN-A added that opened medications should be dated when opened and expired medications should be removed from the medication cart. On 3/7/17 at 11:50 a.m., LPN-B confirmed the medications should be labeled and stored properly. LPN-B explained that staff were supposed to date medication (Insulin vials) when opened. LPN-B indicated, R35's Humalog insulin was delivered on 2/2/17 and Lantus insulin was delivered on 2/2/17. R69's Humalog insulin was delivered on 2/8/17 and Lantus insulin was delivered on 2/8/17. Medication storage and expiration guidelines dated 08/2015, directed staff, INSULIN 10 ml VIALS Opened- Room Temp, 28 Days After 1st Use, DATE WHEN OPEN Yes. Policy and procedure title ADMINISTERING MEDICATIONS undated, indicated, 8. The expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date shall be recorded on the container, or the dispensed date will be used.

Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for 1 of 30 residents (R230) in the sample. Findings include: Resident (R230)'s call light was observed to be out of reach on 02/25/13 and 02/26/13. R230 was admitted on [DATE] for rehabilitation and clinical monitoring post hospitalization for stroke with right-sided weakness. Review of Temporary Care Plan, dated 02/17/13, indicated R230 needed extensive assistance of two staff members for bed mobility, transfers, mobility and was receiving physical and occupational therapies. In addition, R230 required assistance of one staff with dressing, grooming, toileting, bathing, and eating. On 2/25/13, at 6:07 p.m. R230 was waving for surveyor to enter his room. Upon entry he indicated he wanted to get into his bed. R230 was sitting in his wheelchair next to his bed with his over the bed table in front of him. His call light was on the bed however, the R230 could not reach it. During observations on 02/26/13 at 8:33 a.m. R230 was sitting in the wheelchair at his bed side with right arm in a sling and his call light was placed out of reach on the far side of his bed. R230 made a hand gesture with his left hand for the surveyor to enter his room and pointed towards his bed and requested to lie down. Surveyor asked if R230 could reach his call light and he stated "no." Nursing assistant (NA)-A entered room with a breakfast meal tray, NA-A stated it was time to eat and started feeding R230. During an interview with NA-A on 02/26/13 at 10:36 a.m. regarding R230's call light was not within reach, he indicated that he, "didn't realize that it wasn't within reach and it should be within reach." During an interview with the administrator on 02/27/13 at 11:27 a.m., she stated all staff members were trained to make sure when residents are in their rooms that their call lights are within reach and provided a copy of the facility policy regarding call lights needed to be within reach. The facility policy titled, "PCO7-Answering the Call Light", revised in February 2013, revealed, "When the patient is in bed or confined to a chair be sure the call light is within easy reach of the patient."

Based on document review and interview, the facility did not develop a comprehensive and individualized plan of care for sleep disturbance for 1 of 4 residents (R11) in the sample reviewed for sleep medication use. Findings include: Record review revealed R11 was admitted to the facility 12/13/12 for rehabilitation following spinal surgery. The Physician order [REDACTED]. at bedtime as needed for sleep and anxiety. The Medications Administration History showed that the resident received this medication nearly every night since 1/8/13. The Temporary Care Plan and the current Care Plan, dated 1/1/13, did not contain any problem related to sleep disturbance or the use of [MEDICATION NAME]. The record did contain Observation Report forms completed by staff every shift. This form included a generic checklist of non-pharmacological interventions that could be attempted for a resident regarding sleep. When interviewed on 2/27/13 at 2 p.m., the assistant director of nursing stated that the non-pharmacological sleep interventions checklist on the Observation Report form is the same for all residents and the use of [MEDICATION NAME] for sleep by R11 should be included on the resident's care plan.

Based on document review and interview, the facility did not provide assessment for initiation of sleep medication, monitoring of all identified target behaviors, monitoring of effectiveness of non-pharmacological interventions for sleep, and monitoring for side effects of a psychoactive medication on night shift for 1 of 4 residents (R11) in the sample reviewed for use of sleep medication. Findings include: Record review revealed R11 was admitted to the facility 12/13/12 for rehabilitation following spinal surgery. The Physician order [REDACTED]. at bedtime as needed for sleep and anxiety. The Medications Administration History showed that the resident received this medication nearly every night since 1/8/13. No sleep assessment or sleep monitoring at the time of initiation of the [MEDICATION NAME] was in the record. A Consent For Use Of Psych Meds form, dated 1/7/13, listed [MEDICATION NAME] as the drug requiring consent and the target behaviors being monitored for the [MEDICATION NAME] use were listed as restless, sleep disturbance, constant worrying, and difficulty initiating or maintaining sleep. No monitoring of the "restless" or "constant worrying" target behaviors could be located in the record. No documentation of effectiveness of non-pharmacological interventions for sleep was found in the record. Monitoring for side effects of the [MEDICATION NAME] was documented on the Inter Disciplinary Flow Sheet for the day and evening shifts, but not the night shift. When interviewed on 3/4/13 at 3:30 p.m., the assistant director of nursing stated that there was no monitoring of sleep at the time of initiation of the [MEDICATION NAME]. The resident complained of sleep disturbance and a physician's orders [REDACTED]." She acknowledged that the effectiveness of non-pharmacological sleep interventions were not documented. She also acknowledged that side effects monitoring was not included on the night shift flowsheets, and stated that those forms had been changed recently and the side effects monitoring portion may have been accidentally left out of the night shift Inter Disciplinary Flow Sheet.

Based on document review and interview, the facility's consulting pharmacist did not advise the facility of irregularities in monitoring of all identified target behaviors, monitoring for side effects of psychoactive medication, and documenting effectiveness of non-pharmacological interventions related to sleep disturbance for 1 of 4 residents (R11) in the sample reviewed for use of sleep medication. Findings include: Record review revealed R11 was admitted to the facility 12/13/12 for rehabilitation following spinal surgery. The Physician order [REDACTED]. at bedtime as needed for sleep and anxiety. The Medications Administration History showed that the resident received this medication nearly every night since 1/8/13. A Consent For Use Of Psych Meds form, dated 1/7/13, listed trazodone as the drug requiring consent and the target behaviors being monitored for the trazodone use were listed as restless, sleep disturbance, constant worrying, and difficulty initiating or maintaining sleep. No monitoring of the "restless" or "constant worrying" target behaviors could be located in the record. Monitoring for side effects of the trazodone was documented on the Inter Disciplinary Flow Sheet for the day and evening shifts, but not the night shift. No documentation of effectiveness of non-pharmacological interventions for sleep was found in the record. When interviewed on 3/4/13 at 3:30 p.m., the assistant director of nursing confirmed there was no monitoring of the identified target behaviors of "restless" and "constant worrying." She acknowledged that the effectiveness of non-pharmacological sleep interventions were not documented. She also acknowledged that side effects monitoring was not included on the night shift flowsheets, and stated that those forms had been changed recently and the side effects monitoring portion may have been accidentally left out of the night shift Inter Disciplinary Flow Sheet. The Record of Medication Regimen Review in the record showed that a drug regimen review had been completed by a consulting pharmacist on 12/20/12, 1/3/13, and 2/1/13. This form contained no documentation of irregularities with reference to monitoring of target behaviors, monitoring of side effects of trazodone, or effectiveness of non-pharmacological interventions for sleep disturbance. When interviewed on 2/28/13 at 11:40 a.m., the director of nursing stated that more details regarding sleep were added to the Target Behavior section of the Inter Disciplinary Flow Sheet form within the last 1-2 months. She explained that these were added after a conversation in which the consulting pharmacist advised the facility that they needed to collect more information regarding a resident's sleep when the resident is using a sleep medication. Sections were added to the Inter Disciplinary Flow Sheet to address hours of sleep on a shift, sleep patterns, and interventions attempted. During interview on 2/28/13 at 12 p.m., the consulting pharmacist stated that he attended quality assurance meetings at the facility and in those meetings he had discussed the need for more documentation of information regarding the sleep of residents using sleep medication, and since those discussions some of the forms used by the facility have been changed. When asked if he felt all the changed needed had been completed, he replied that it was an ongoing process. On 3/1/13 the facility's consulting pharmacist provided a written statement to the facility stating that he had discussed his recommendations to the facility regarding sleep monitoring with a surveyor on 2/28/13 and wrote, "I shared with (surveyor's name) that I had identified a potential problem regarding the documentation associated with the used of PRN trazodone, and had communicated my concerns to the Director of Nursing via regular consulting notes for several residents. I also shared with (surveyor's name) that, in my role as part of the Quality Assessment and Assurance team, I had worked with the Director of Nursing to develop and implement a system to address the system concerns I had identified. The Director of Nursing and her staff have implemented this system, and I continue to monitor and evaluate the overall use of PRN medications of all types used by residents in the facility."

Based on observation, interview, and document review, the facility failed to ensure appropriate hand hygiene was maintained prior to and after direct resident contact for 1 of 2 residents (R217) in the sample whose dressing change was observed. Findings include: On 2/27/13, at 10:09 a.m. R217's dressing change was observed. The registered nurse (RN)-A used an alcohol based foam hand sanitizer prior to donning gloves. With gloved hands RN-A removed R217's soiled dressing. RN-A then removed his soiled gloves and left the room to obtain additional supplies. RN-A did not wash his hands or use a alcohol based foam hand sanitizer to clean his hands prior to leaving the resident's room. When RN-A returned he cleaned his hands with the alcohol based foam hand sanitizer, applied a pair of gloves and proceeded to apply a [MEDICATION NAME] (an antiseptic) swab to the surgical incision on the resident's foot. RN-A then poured one ounce of Hibicleanse into a 500 mls (milliliters) bottle of normal saline (NS). RN-A then poured some of the solution into the cap of the bottle, placed a gauze pad in the cap to saturate it with the solution and proceeded to clean the pressure ulcer on R217's right heel with the gauze pad. With his gloved hands RN-A then picked up a second bottle containing 500 mls of NS, poured some of the NS into the cap of the bottle, placed a gauze pad in the cap to saturate it with the solution and proceeded to rinse the pressure ulcer on R217's right heel with the gauze pad. With his gloved hands, RN-A then reached into a wash basin containing dressing supplies to obtain a gauze dressing to pat dry the wound. With his gloved hands RN-A then reached into the same wash basin to obtain a paper ruler to measure the wound. With gloved hands RN-A reached into the basin again to obtain a non-adherent pad and applied this to the resident's pressure ulcer. With gloved hands RN-A reached into the basin again to obtain a roll of gauze and proceeded to wrap the R217's foot. With gloved hands RN-A reached into the basin again to obtain a elastic bandage and proceeded to wrap R217's foot with the bandage. RN-A then removed his soiled gloves and proceeded to apply a soft, Velcro shoe, adjust the position of R217's lower extremities on a pillow and placed the wound care supplies in the basin and returned the basin to R217's closet prior to washing his hands. On 2/27/13, at 10:40 a.m. RN-A stated the dressing change was not a sterile procedure and he believed he maintained a clean technique. When informed that after removing the soiled dressing and gloves he left the room without washing hands or using hand sanitizer RN-A confirmed this and stated, he used a foam sanitizer after he left the room and "I guess you would not have known that." When RN-A was informed that he handled the NS bottles and reached into the basin multiple times to obtain dressing supplies with his soiled gloves and then returned the supplies to the cabinet in the resident's room for later use. RN-A stated, he will dispose of the contaminated supplies as soon as we are finished talking. On 2/28/13, at 3:30 p.m. the director of nursing (DON) and the facilities infection control nurse stated staff are expected to wash their hands with soap and water after removing gloves when performing wound care. The facility's Wound Care policy "revised November 2013" directed staff to establish a clean field. Place all items to be used during the procedure on the clean field, wash and dry their hands thoroughly prior to beginning the wound care, after removing the soiled dressing, and again when finished with the dressing change and before repositioning the resident.

Based on document review and interview, the facility failed to specify immediate reporting of all alleged or substantiated cases of abuse or neglect to the state agency in their written abuse prevention policy. This had the potential to impact 27 of 27 residents in the facility. Findings include: The Abuse Reporting Program, undated, indicated the following: "Per changes in reporting procedures effective in 2009, a verified abuse/maltreatment/neglect incident must be reported online to the Office of Health Facility Complaints (OHFC) with a copy faxed to the Common Entry Point (CEP) within 24 hours." The Office of Health Facility Complaints and Common Entry Point are state agencies designated for the intake and processing of all alleged or substantiated cases of abuse or neglect. An interview conducted with the administrator and director of nursing (DON) at 11:15 a.m. on 4/18/12, revealed both believed the facility had 24 hours to conduct a preliminary investigation, before reporting alleged or substantiated cases of abuse or neglect to the state agency. Both explained that reporting time would be shorter if a resident sustained [REDACTED]. An interview conducted with the director of social service (DSS) at 11:20 a.m. on 4/18/12, revealed the facility procedure was to conduct a preliminary investigation, [MEDICATION NAME] up to 24 hours, before reporting substantiated or alleged cases of abuse or neglect to the state agency. The DSS explained that reporting time would be shorter if a resident sustained [REDACTED].

Based on observation and interview, the facility failed to maintain 18 months of the nurse staffing data posting which had the potential to affect 27 of 27 residents residing in the facility and/or their families, and any other members of the public who wished to view the data. Findings include: On entrance to the facility on [DATE], the nurse staffing data was observed posted in the main hallway. The posting listed the facility name, the current date, the total number and actual numbers of licensed and unlicensed nursing staff, and the current census. Interview with the staffing coordinator at 1:00 p.m. on 4/18/12, revealed the daily nurse staffing data posting was not maintained in the facility at the end of the day, and the staffing coordinator stated was not aware that the postings were to be maintained for 18 months.

Based on observation, record review and staff interview, the facility failed to ensure the environment was free of safety hazards related to side rails on 12 of 32 beds in which R197 and R43 occupied. Findings include: During the initial tour of the facility starting at approximately 3:00 p.m. on 1/25/11, large spaces between the vertical bars of upper side rails on beds in rooms 8325-1 and 8328-1 were noted. These spaces appeared to be greater than 4 ? inches, as required by Guidance for Industry and FDA Staff - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document issued on: March 10, 2006, for " Zone 1 " of a side rail. At approximately 10:00 a.m. on 1/26/11, the spaces between the vertical bars of the upper side rail bars on beds 8325-1 and 8328-1 were measured with the director of nursing (DON), and found to be greater than six inches in width. A tour of the remainder of the facility was then conducted with the DON, and upper side rails with spaces greater than six inches between the vertical bars were noted on the following beds: 8103-1 and 2, 8105-1 and 2, 8107-1, 8108-1 and 2, 8109-1, 8215-1 and 8323-1. The DON stated during the tour that some of the beds had come from the previous facility and some from the hospital. The DON confirmed that at the time of the tour the following beds were not currently occupied by a resident: 8105-1 and 2, 8107 and 8109. When queried regarding the cognitive level of residents occupying the other beds, the DON stated side rail assessments were completed on all residents at the time of admission, and that resident ' s occupying the beds were all cognitively intact. A review of R197 ' s record indicated R197 was admitted to the facility from the hospital on [DATE], after having sustained multiple pelvic fractures as a result of a motor vehicle accident (MVA). A review of the record indicated a side rail assessment completed on 1/23/11, identified R197 as needing and using the side rails for positioning due to recent pelvic fractures; that R197 was capable of using the side rails safely, and requested to use them to aide with positioning. Record review also indicated R197 was alert, oriented and able to make their own decisions. The temporary care plan addressed the use of the side rails as a positioning only device for R197. R43 was admitted to the facility from the hospital on [DATE], with [DIAGNOSES REDACTED]. A side rail assessment completed on 1/21/11, indicated R43 used the upper rails on each side of the bed for positioning when in bed. Record review indicated side rails assessments were completed for residents in beds 8103-1 and 2, 8108-1 and 2 and 8323-2. All the assessments indicated the residents residing in these beds were able to demonstrate safe use of the side rails.

Based on record review, policy review, and staff interview, the facility failed to comprehensively assess the pressure ulcer of 1 of 3 residents (R192) in the sample reviewed for pressure ulcers. Findings include: R192 was admitted on [DATE]. The facility's admission assessment, dated 12/28/10, shows that R192 had a stage II dermal ulcer (partial thickness skin loss involving the epidermis, dermis or both but not through the skin. May appear as an abrasion, blister or shallow crater) of the coccyx area and a blister on the right foot upon admission. R192 did not receive timely, thorough, and accurate assessment of pressure ulcers. The first comprehensive assessment of the pressure ulcer in the coccyx area, which included staging and measurement, was recorded on 1/17/11 on a "WEEKLY PRESSURE ULCER RECORD" form. The form did not include an assessment of the heel right blister. The resident's admission assessment listed a "6x6 diam {diameter}" blister to the right heel. The only other assessment of a heel blister in that resident's record was on a "WEEKLY PRESSURE ULCER RECORD" form dated 1/10/11, and the form described a 1.2 centimeter (cm) x 2.6cm open blister to the resident's left heel. There was no mention of a right heel blister on 1/10/11. The "Assessment and Recognition" section of the facility's "Pressure Ulcers/Skin Breakdown-Clinical Protocol" undated, read, "In addition, the nurse shall assess and document/report the following: ...b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue." The medical record lacked evidence that the ulcers were correctly identified and assessed. When the facility's clinical manager was interviewed regarding these pressure ulcers on 1/27/11, she stated that the ulcers should have been assessed on 1/3/11, but the facility's wound nurse was on leave and staff nurses should have completed the assessments. When asked about the heel blister, she stated that the only blister the resident has ever had on his feet while in the facility was on his left heel and the admission assessment describing a right foot blister must have been a mistake. The documentation for both pressure ulcers showed that the ulcers are healing.