Every finding on record at Clarkfield Care Center

Based on interview and document review, the facility failed to document the date when transmission-based precautions (TBP) were implemented for 2 of 3 residents (R2 and R27). Findings include: R2's comprehensive Minimum Data Set (MDS) assessment accepted on 3/18/26, identified his cognition was intact. R2 was dependent on staff for transfers and bathing, he required substantial/maximal assistance with dressing. Review of the facilities resident infection prevention surveillance logs identified R2 had a confirmed upper respiratory infection identified on 1/30/26. He was placed on droplet precautions on 1/31/26 through 2/6/26. He displayed symptoms of fever, new increased cough, shortness of breath, and had oxygen saturations of less than 94% on room air (normal 95% to 100%) which was a reduction of greater than 3% from his baseline. The treatment was oseltamivir (an antiviral medication used to treat infections) 75 milligrams (mg) two times daily for 5 days. The infection was resolved on 2/5/26. Review of R2's nursing progress notes identified on:1/30/26 at 11:39 p.m., licensed practical nurse (LPN)-A entered a nursing progress note identifying she had completed a respiratory assessment on R2. He had a non-productive cough, auditory wheezing, HIS temperature was 98.8 degrees Fahrenheit (F), and his oxygen saturations were at 90%. His heart rate was 114 beats per minute (BPM) (Normal 60-100 BPM), HIS blood pressure was 154/68 Millimeters of mercury (MM/HG), and his rate of respirations were 20 breaths per minute (BPM) (normal 16-20). R2 was tested for covid infection and the results were negative. Cough syrup was given. The progress note made no mention that R2 had been placed on TBP.1/31/26 at 7:02 a.m., registered nurse (RN)-A identified she had completed a respiratory assessment and noted R2 had increased congestion with A blood pressure of 124/79 MM/HG, a heart rate of 80 BPM, respirations 30 BPM, A non-productive cough, and decreased urine output. She informed R2 she would be calling the emergency department (ED) for guidance.1/31/26 at 7:06 a.m., RN-A identified she called 911 for an emergency transport to the hospital ED.1/31/26 at 12:43 p.m., RN-A identified she had received a call from the hospital with an update on R2. He had been diagnosed with influenza A and A urinary tract infection. They would be discharging R2 back to the facility with new orders. R27's quarterly Minimum Data Set (MDS) assessment accepted on 3/23/26, identified her cognition was intact and she was independent with activities of daily living (ADL)'s. Review of the facilities infection prevention surveillance identified R27 had a confirmed respiratory infection (pneumonia) that was identified on 1/12/26. The symptoms were new/increased cough, reduced oxygen saturations, and pleuritic chest pain. The treatment was cefdinir (antibiotic medication used to treat infections) 300 MG two times a day for 3 days. There was no information in the resident surveillance or medical record to identify when or if R27 had been placed on TBP to reduce the risk of transmission of infection to other residents and staff. Interview on 4/8/26 at 8:01 a.m., with the infection preventionist identified she agreed with the above information and would expect nursing to place residents on TBP upon identifying s/s of infection. In addition, the date that precautions were put into place should have been documented in the medical record. Interview on 4/8/26 at 11:24 a.m., with the administrator identified, she would expect all staff to follow the facilities infection prevention policies and procedures. Review of the facility provided 1/26/26, Infection Prevention and Control Program policy identified a resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of the facility provided 1/16/26, Infection Surveillance policy identified the RN's and LPN's are to participate in surveillance through assessment of resident and reporting changes in condition to the resident's physicians and management staff, per protocol for notifications of changes and in house reporting of communicable diseases and infections. Examples of notification triggers include signs and symptoms of infection, starting an antibiotic, microbiology test is ordered, a resident is placed on isolation precautions, whether empirically or by physician order, or microbiology test results show drug resistance.

Based on interview and doc review the fac failed to ensure a Hospice care plan was provided for 1 of 1 resident R7Findings include: R7's 3/23/26, accepted Significant Change, Minimum Data Set (MDS) assessment identified R7, had severe cognitive impairment and was readmitted following acute care hospitalization with diagnoses including hypertension, dementia, malnutrition, anxiety disorder, depression, macular degeneration (legally blind). He required maximal assistance from staff for activities of daily living (ADLs), and a wheelchair was needed for mobility. R7's 2/26/26 at 3:22 p.m. progress notes identified he was admitted to hospice services with a terminal diagnosis of senile degeneration of the brain. Interview on 4/7/26 at 9:28 a.m. with trained medication aid (TMA)-A identified R7 was on Hospice services. He required he required total assistance with ADLs, except eating which required set up. TMA-A was not aware if there was a hospice schedule or care plan and thought there might have been some information at the nursing station. Interview on 4/7/26 at 9:44 a.m. with licensed practical nurse (LPN)- B identified R7 was still on hospice services, but the frequency of visits had decreased due to his improvement. The hospice nurse was supposed to have made a visit on Monday, but she had not come, and LPN-B was not aware of the reason, or when she planned to visit. There was not a schedule to identify visits, and the facility's care plan noted R7 was on hospice, but failed to identify services hospice was to provide, and services the facility was responsible for. LPN-B reported hospice staff were not able to document in the facility's electronic medical record. They gave staff a verbal update and later faxed a copy of their visit notes to the facility. Documents provided had been scanned into the electronic medical records system. Interview on 4/8/26 at 9:09 a.m. with the hospice registered nurse (RN)-B identified R7 had been improving and had not needed medication for pain or comfort. Hospice had decreased the frequency of their visits following discussion at their Interdisciplinary Team (IDT) meeting due to his improved status. A schedule and integrated care plan should have been developed and provided to the facility at the time of admission, but that had not occurred. She would immediately provide a copy of the hospice care plan to the facility. The agreement of what services and equipment hospice provided should have been in a binder at the nursing station, but nothing was able to be provided by facility staff. Interview on 4/8/26 at 1:00 p.m. with the director of nursing (DON) identified her expectation that hospice documentation was to include identifying responsibilities for services and equipment hospice was to provide in the care plan provided at the time of admission to hospice. A policy for hospice services was requested but not provided by the end of the survey.

Based on interview and document review the facility failed notify the provider of a change in condition timely for 1 of 1 resident (R25) reviewed for hospitalization . Findings include: R25's 12/18/24, quarterly Minimum Data Set (MDS) assessment identified R25 with diagnoses of congestive heart failure, hypertension and was cognitively intact. The MDS indicated R25 required substantial assistance with activities of daily ling and did not utilize oxygen. R25's February 2025, medication administration record lacked indication R25 utilized oxygen. The facility Standing Orders dated 7/26/24, included orders for oxygen at 2 liters per minute per nasal canular for complaints of shortness of breath or chest pain and call provider or ER if oxygen's saturation do not improve to 90% or above. The standing orders did not include order for increasing the oxygen higher than 2 liters. Review of R25's progress notes (PN) identified the following information: 1) PN dated 2/13/25 at 12:53 p.m., R25 complained of fatigue as well as coldness in her lower extremities. Her vital signs were blood pressure (BP)109/64, pulse (P) 110, temperature (T) 97.3, respirations (R) 15, and oxygen saturation (O2) 93%. Nursing staff encouraged R25 to be evaluated in the emergency room as R25's BP [blood pressure] and HR [heart rate] have not been stable over the last 3-4 days. R25 had been offered to go to the emergency room s, however, R25 refused. 2) PN dated 2/14/25 at 11:06 a.m., nurse was called to R25's room as R25 was unable to stand with assistance of staff or a sit to stand mechanical device. R25 reported feeling dizzy and light-headed vital signs were identified as BP 30/unknown, P 30, R17, T 97.0 F and O2 was at 86%. The writer contacted the emergency department (ER) and was advised to send resident to ER. 3) PN dated 2/14/25, at 3:29 p.m., a nurse- to- nurse report from the emergency room indicated R25 had been diagnosed with a bladder infection and would be returning to the facility. 4) PN dated 2/14/25 at 5:46 p.m., indicated R25 had returned to the facility at 4:55 p.m. 5) PN dated 2/15/25 at 5:35 p.m. indicated the night nurse had been placed on oxygen during the night. During the day morning hours, R25's oxygen saturation (amount of oxygen in the blood) was noted to be 91%. R25 had been alert and orientated before breakfast, however, began to show increased confusing after lunch. At 4:20 p.m. R25's vital signs were BP 118/77, P 118, R 20, T 97.7, O2 79%. The writer identified they had increased R25's oxygen to 3 LPM/NC (liters per minute per nasal cannula) and oxygen saturation increased to 86%, then increased to 4 LPM/NC and oxygen saturation increase to 89%, then increased to 5 LPM/NC and oxygen saturation increased to 90-91%. Now this afternoon R25 has been noted to have increased shortness of breath, be lethargic, has had no appetite today. Writer informed R25 she was sending her to the ER and resident voiced understanding. The progress notes lacked identification of the night nurse's assessment and why or what circumstances lead to R25 being placed on facility standing orders. The progress notes further lacked the identified assessments of the vital signs being monitored throughout the day on 2/15/25 other than the one done at 4:20 p.m. Review of R25's blood pressure records identified on 2/14/25 at 8:10 a.m., R25's BP as 146/95, then on 2/15/25 at 7:08 a.m., BP as 178/149, and the last documented BP was on 2/15/25 at 7:12 a.m., of 113/72. There were no further documented blood pressure readings. During interview on 3/11/25 at 11:38 a.m., registered nurse (RN)-B indicated she had care for R25 on 2/15/25. licensed practical nurse (LPN)-A had placed R25 on oxygen around 5:00 a.m. RN-B stated she could not recall why R25, required oxygen, but R25 did not display any type of concerns during the morning shift. However, at 4:20 p.m. R25 began displaying respiratory distress and was transferred back to the hospital. Upon review of the record, RN-B confirmed the documentation lacked rational as to why R25 required oxygen at 5:00 a.m. and the physician was not notified. The record lacked further assessment of R25 during the day until R25 displayed signs of respiratory distress and was transferred back to the hospital. RN-B confirmed the provider had not been updated until R25 had been sent to the ER later that afternoon. During interview on 3/11/25 at 11:54 a.m., with RN-A identified when a resident was started on oxygen per the facility standing orders the nurse should be updating the provider as that would be a change in condition. During interview on 3/11/25 at 4:05 p.m., with LPN-A identified she had missed documenting her assessment and vitals she obtained on R25 the morning of 2/15/25. She revealed she had placed R25 on oxygen per the facilities standing orders around 5:00 a.m., just before the change of shift. R25 had complained of being short of breath and her oxygen saturations were 88-89% and LPN-A reported she had asked R25 if she had used oxygen while at the hospital and she had said yes and that it had helped so she started her on the oxygen. LPN-A confirmed she had not updated the provider however, had reported the information to the day charge nurse. During interview on 3/11/25 at 2:20 p.m., with the administrator/director of nursing confirmed that if a nurse-initiated oxygen per the facility standing orders the nurse should update the provider of the change in condition. She would expect the provider to be updated and for the nurse to document their assessment of the resident in the resident's medical record. Review of undated, Notification of Changes policy identified times to promptly notify the resident's medical provider and representative of change in condition. The policy identified any time there was clinical complications or circumstances that required a need to alter the resident's treatment.

Based on interview and document review, the facility failed to notify the designated State Mental Health Authority (SMHA) (Yellow Medicine County) for 1 of 1 resident (R11) with new onset mental illness. Findings include: R11's 12/11/24, annual Minimum Data Set (MDS) assessment indicated R11 had been admitted in October of 2022 and R11's cognition was intact. R11 had the diagnoses including atrial fibrillation, heart failure, hypertension, renal failure, diabetes, arthritis, dementia, depression, and psychotic disorder. R11 required substantial assistance with cares and received, antipsychotic, antidepressant, diuretic, and antiplatelet medications. R11's diagnosis list printed 3/10/25, identified new diagnoses which included unspecified mood affective disorder diagnosed on [DATE], unspecified psychosis not due to a substance or known physiological condition diagnosed on [DATE], and restlessness and agitation diagnosed on [DATE]. R11's care plan printed 3/10/25, indicated R11 was dependent on staff for meeting his emotional, intellectual, physical, and social needs related to unspecified psychosis, major depression, and dementia. R11 displayed behaviors of being sexually inappropriate, yelling, arguing with staff, swearing, refusing cares, hallucinations, delusion, wandering, and using abusive language that was initiated on 5/26/23. R11 had delirium or an acute confusional episode related to unspecified psychosis and received an antipsychotic medication that was initiated 12/15/23. R11's 10/25/22, Initial Pre-Admission Screening (PAS) results identified a diagnosis of depression and did not indicate the need for a Level II PASARR to be completed. The record lacked documentation which would indicate the local mental health authority had evaluated R11 for appropriate placement via a level II (Resident Review) following the new diagnoses of unspecified mood disorder, unspecified psychosis, restlessness and agitation. During interview on 3/11/25 at 2:54 p.m., with registered nurse (RN)-A confirmed R11 had received a PAS upon admission to the facility, which indicated he did not require a level II screening. However, confirmed while in residing at the facility, R11 had received new mental health diagnoses. The facility did not notify the local mental health authority to request a resident review to determine if R11 required additional mental health services. RN-A she was unaware residents who received a new diagnosis of a mental health disease were to be re-evaluated by the local mental health authority. During interview on 3/12/25 at 8:01 a.m., with the administrator/director of nursing who confirmed if a resident received a new mental health diagnosis the local authority should be contacted to complete a level II screening. She was unaware that RN-A was not aware she needed to contact the local mental health authority. Review of the undated, Resident Assessment-Coordination with PASARR Program Policy identified the facility would coordinate assessments to ensure individuals with a mental disorder or related condition received care and services in the most integrated setting appropriate to the resident needs. The social service or designee would be responsible for resident PASARR screening and referring to the appropriate authority. The facility would reach out to the appropriate authority for any resident that received a new mental health disorder or condition not previously identified on the initial PAS for a level II screening.

Based on interview and document review the facility failed to assess, investigate, and document for 1 of 1 resident (R11) who had a newly identified burn. Findings include: R11's 12/11/24, annual Minimum Data Set (MDS) assessment identified R11 had been admitted in October of 2022 and R11's cognition was intact. R11 required substantial assistance with cares and had pain that he rated a 5 on scale of 1-10. R11 took a scheduled pain, antipsychotic, antidepressant, diuretic, and antiplatelet medication. R11 was on oxygen. R11 had the diagnoses of atrial fibrillation, heart failure, hypertension, renal failure, diabetes, arthritis, dementia, depression, and psychotic disorder. Review of R11's Skin Assessments identified: 1) 7/18/24, skin issue identified as other located on left gluteal fold. Area has 2 small open areas each measuring 0.5 cm x 0.5 cm a Mepilex dressing was applied. This was identified as the first observation. 2) 12/18/24, skin issue identified as burn located on upper right side of chest. The area measured 2 cm x 2.5 cm and scabbed. Note of assessment identified that on 12/18/24 residents obtained a burn to right upper chest, redness now surrounds the areas, resident was seen by provider on 12/19/24 and ordered Bacitracin. This was identified as the first observation. 3) 12/25/24, skin issue identified as burn located on upper right side of chest. The area measured 2 cm x 2.3 cm scabbed area, improving. 4) 1/2/25, skin issue identified as burn located on upper right side of chest. The area measured 2 cm x 2.3 cm scabbed area, improving. 5) 1/22/25, skin issue identified as burn located on upper right side of chest. The area measured 0.2 cm x 0.2 cm irregular shaped scab, improving. There were no more skin assessments located in R11's medical record. Review of R11's progress notes between 12/12/24 through 3/10/25 had no mention of R11 having a burn on his right upper chest. Interview on 3/10/25 at 5:58 p.m., with administrator/director of nursing identified that a nursing assistant had reported to RN-A that there was a area of concern on R11's chest. RN-A had thought that the nurse who was originally told had made a progress note but I guess they did not. She reported that RN-A had investigated how R11 got the burn and that they had discussed it at their interdisciplinary team meeting (IDT). She confirmed that there was no incident report completed for the injury and there should have been. She further confirmed the last skin assessment completed for R11 was done on 1/22/25 and she was unsure why there had been no further skin assessments completed as that one identified the area was still open. Interview on 3/10/25 at 6:47 p.m., with registered nurse (RN)-A identified a nursing assistant that no longer worked at the facility had reported the burn to the nurse that was on duty which she could not recall who that was. She revealed the nurse should have documented the assessment of the burn and made an incident report. She revealed she should have followed up and made sure there had been documentation of the burn and an incident report completed but she had not done that. She further identified she should have documented further on R11's skin assessment that the burn had healed confirming she just stopped the skin assessments. R11's provider did order Bacitracin for the burn but identified that also had not been documented in R11's progress notes. Review of 12/19/24, physician order identified provider ordered Bacitracin twice a day to right chest. The order lacked reason for Bacitracin order and an end date. Review of R11's undated, care plan identified the facility had not made revisions follow R11's burn incident to include interventions to prevent further incidents. Interview on 3/10/25 at 7:09 p.m., with R11 who revealed he got a burn on his shoulder area. He reported it was from one of those hand warmers that you stick in your gloves. He revealed he got the hand warmer from another resident and had used it to try to loosen the muscle in his shoulder area. He reported that the nurse did come and look at the burn and told him he could not use that hand warmer. He reported the nurse looked at it about 2 weeks ago, but it has been healed now for a while. Interview on 3/11/25 at 2:20 p.m., with administrator/director of nursing identified she would expect if an injury such as a burn was identified the nurse would assess the burn, investigate how it occurred, document the findings and notify the provider and family. Review of the undated, When to Notify for All Licensed Nurses, protocol identified that the nurse should notify the administrator/director of nursing, the assistant director of nursing immediately when an incident with a serious injury occurred such as burns, major lacerations, head injury, hematoma etc.prior to filing a State Agency report as there was only 2 hours to report timely. Review of 2/15/24, Accidents and Incidents Investigating and Recording policy identified regardless of incident or accident, including injuries of an unknown source, staff must report to the department supervisor and fill out an accident or incident report form on the shift the accident or incident occurred. The nurse should assess the resident and notify the provider of the incident or accident. The policy identified the details that were required to be documented under risk management that included that the resident's care plan needed to be updated with immediate interventions.

Based on observation, interview, and document review, the facility failed to follow physician orders for 1 of 2 residents (R7) reviewed for oxygen therapy. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 was cognitively intact and had diagnoses of chronic respiratory failure and pneumonia. R7 used oxygen therapy. R6's undated care plan identified the goal was to have no signs or symptoms of poor oxygen absorption. Interventions were for staff to administer medication as ordered, monitor effectiveness and side effects, elevate head of bed to prevent shortness of breath when lying flat, maintain a clear airway and instruct R7 to clear her own secretions with effective coughing, to use humidified oxygen of 1 to 2 liters (L) as needed, and to keep oxygen (O2) greater than 90%. R7's Order Summary Report printed 3/10/25, identified R7 was to receive oxygen via nasal cannula (flexible tube that enters your nose to deliver oxygen) continuously at 2 LPM (liters per minute) starting 12/16/24. During observation on 3/10/25 at 11:04 a.m., R7 sat in her recliner with nasal cannula in her nose and the tubing was connected to the oxygen concentrator. The oxygen flow meter was set at 2.5 liters. During observation and interview on 3/10/25 at 12:04 p.m., licensed practical nurse (LPN)-B stated R7 was to receive 2 liters of oxygen. LPN-B observed R7's oxygen flow meter, and voiced it was set at 2.5 LPM. LPN-B decreased the flow rate to 2 LPM. She identified staff nurses were to check and identify appropriate oxygen settings on each shift and to follow physician orders for oxygen use. During interview on 3/12/25 at 5:33 p.m., director of nursing stated they expected staff nurses to follow oxygen orders as directed by the primary physician. Review of current, undated Oxygen Administration policy identified staff nurses were responsible for resident's safety with oxygen use. In addition, staff nurses were to administer oxygen therapy under the direction of physician orders. Lastly, staff nurses were to verify and check oxygen equipment to ensure oxygen concentrator equipment and safety checks were completed.

Based on interview and document review, the facility failed to coordinate with the provider and pharmacy to ensure a prescribed medication was available and administered for 1 of 1 residents (R10) reviewed who did not receive ordered medication. Findings include: R10's 2/26/25, quarterly Minimum Data Set (MDS) assessment identified R10's cognition was intact. R10 had no behaviors and required assistance with cares. R10 was frequently incontinent of urine. R10 was on a scheduled pain medication and rated her pain a 4 on scale of 1-10. She had no skin concerns and took a daily antidepressant, blood thinner, and diuretic (water pill). R10 was on oxygen therapy and planned to remain in the facility. Interview on 3/10/25 at 12:34 p.m., with R10 identified she had a yeast infection that was not resolved yet. She reported she was to be getting Monistat but had not received that for the last 2 weeks as staff told her they had to get a new order. In the meantime, she reported she itched, and it hurt when she voided. Review of progress notes identified: 2/19/25, communication with provider, R10 continues to complain of burning and itching in vaginal area. Question if she would benefit from Monistat cream. 2/20/25, received order for Monistat care instant itch relief external cream 1%, apply to vaginal area topically two times a day for vaginal itching and change to as needed when clear. 2/21/25, Monistat 1% cream no prescription. 2/28/25, Monistat 1% cream no prescription. 3/1/25, Monistat 1% cream no prescription. 3/2/25, Monistat 1% cream no prescription. 3/3/25, Monistat 1% cream no prescription. 3/4/25, Monistat 1% cream no prescription. 3/5/25, Monistat 1% cream no prescription. 3/6/25, Monistat 1% cream no prescription. 3/7/25, Monistat 1% cream no prescription. 3/8/25, Monistat 1% cream unavailable, pharmacy was awaiting new prescription from provider and will send when received. 3/9/25, Monistat 1% cream no prescription. 3/10/25, Monistat 1% cream no prescription. 3/11/25, provider communication that R10 had complained of itching in her vaginal area and had pain when voiding. Provider ordered Monistat for 10 days. 3/11/25, resident seen by provider during routine rounds. Resident continues to complain of burning and itching. Resident reported that the Monistat did not help but then asked the provider for Monistat. R10 reported that she had never complained of burning and itching since she had been a resident there. The provider discontinued the order for Monistat and ordered Estradiol gel nightly for 2 weeks. Review of R10's February 2025, Administration Record identified Monistat Care Instant Itch Relief external cream 1%, apply to vaginal area typically two times a day for vaginal itching and change to as needed when clear. Charted administered 2/21/25, through 2/27/25, then charted as other 'see progress note' on 2/28/25. R10's March 2025, Administration Record identified Monistat Care Instant Itch Relief external cream 1% was charted as 'other see progress note' 3/1/25 through 3/11/25. During interview on 3/11/25 at 2:13 p.m., trained medication assistant (TMA)-A identified that the facility had the Monistat for R10 but then ran out and they could not get any more. She reported they were to fax the pharmacy a week before a resident runs out of a medication, and if they did not get that medication in from the pharmacy, they were to notify the charge nurse who then contacted the pharmacy. During interview on 3/11/25 at 2:20 p.m., administrator/director of nursing identified that licensed practical nurse (LPN)-B had been dealing with the pharmacy related to getting R10's Monistat. The pharmacy had sent a very small tube, and it ran out right away. The pharmacy kept saying they needed a new prescription. During interview on 3/11/25 at 2:41 p.m., LPN-B reported R10 had an order for Monistat, and according to the pharmacy, they only had an order for as needed (PRN) and the pharmacy was waiting on a new prescription from the clinic before they sent out another tube of Monistat. She revealed she did not know if anyone from the facility had reached out to R10's provider for a new prescription. She identified if the facility did not have a medication supply, they were to reach out to pharmacy first and then the pharmacy usually reached out to the clinic. If the facility still did not receive the ordered medication the facility was to reach out to the provider. A policy related to what staff were to do if a medication supply was not available was requested however, the administrator/director of nursing reported the facility did not have one.

Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 24 residents. Findings include: Review of undated, current Quality Improvement Incentive Payment (QIIP) tool identified a plan to monitor moderate to severe pain in the first 100 days. The goals were to assess resident pain levels for verbal and nonverbal residents, offer non-pharmacological interventions, such as topical medications with massage, and therapy exercises. The documentation lacked a thorough analysis of data collected to identify what specific measures needed to be taken. Interview on 5/13/24 at 5:33 p.m., with registered nurse (RN)-B, who is the facility assistant director of nursing, stated all employees were assigned QAPI program training on EduCare online. She stated she would attend QAPI meetings and was aware the facility was working on pain management monitoring under the guidance of the QIIP. She stated the QIIP tool was used to identify areas of improvement in the facility and evaluate if the goals were met through the data input. Interview on 5/15/24 at 7:37 a.m., with director of nursing (DON) and current facility administrator, stated the facility was working on pain management for short term residents. She stated the QIIP tool had been implemented to improve the facility's quality measures and had no additional documentation to support the QIIP program. She stated she was the new administrator of the facility, and her goal would be for compliance of quality care, interventions to improve staff education and meet financial goals. The DON agreed the current QIIP tool would need improvements and would implement better processes to reflect accurate data collection and analysis. Interview on 5/15/24 at 8:06 a.m., with the executive administrator (Admin)-B stated the facility did not have evidence showing the analysis for it's current identified QAPI concerns and did not have a process in place for execution of the QIIP tool. Review of 2/15/24 Quality Assurance Performance Improvement Policy (QAPI) identified the facility would coordinate quality assessment and assurance activities under the QAPI program. The facility would develop and implement appropriate plans of action to correct the deficiencies. They were to regularly review and analyze data collected under the QAPI program and act upon that data to make improvements.

Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific Quality Assurance Performance Improvement (QAPI) Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the ability to affect all 24 residents. Findings include: Interview on 5/13/24 at 5:18 p.m., with activity director stated she would attend the QAPI meetings regularly along with the facility administration, board members and the city administrator. She stated she was not aware if employees could attend QAPI and had not seen employees attend QAPI. Interview on 5/13/24 at 5:22 p.m., with nursing assistant ( NA)-A and (NA)-B stated they knew nothing about the QAPI goals and was not aware of the QAPI meetings. Interview on 5/13/24 at 5:22 p.m., with registered nurse (RN)-A stated she had not attended QAPI nor aware she could attend. She stated she had completed EduCare (online general training) on QAPI programs in the facility during her initial training. RN-A was aware the QAPI committee met quarterly to discuss finances. She was unaware of specific goals or what the facility was monitoring overall. Interview on 5/13/24 at 5:53 p.m., with licensed practical nurse (LPN)-A stated she knew that QAPI evaluated the quality of care but had no knowledge of when QAPI was held nor what the QAPI goals were. She was unaware of anything specific the committee was working on. Interview on 5/14/24 at 2:11 p.m., with the maintenance supervisor stated he would attend QAPI meetings quarterly and each department would discuss issues and collaborate to find solutions. He stated the facility had monitored psychotropic medications in the resident care areas, but unaware of anything specific the committee was working on. Interview on 5/14/24 at 2:15 p.m., with director of nursing (DON) and current administrator stated she was not aware if employees could attend the QAPI meetings and would make sure to inform all staff going forward of QAPI activities and their respective roles. Interview on 5/14/24 at 02:25 p.m., with NA-C stated she had training on the computer for generalized QAPI training and was not aware of what the facility would discuss at the meetings. Interview on 5/15/25 at 8:07 a.m., with executive administrator (Admin-B) stated staff were not aware they could attend the QAPI meetings and that QAPI was open to all to attend. Review of 2/15/24 Quality Assurance/Assessment and Performance Improvement Plan identified the facility would train employees on using the QAPI process and employees would participate on the performance improvement plan (PIP) team. The facility QAPI program would be sustained during transitions in leadership and staffing and would provide staff education and involvement in the QAPI process. Lastly, the (PIP) team would identify staff participation or other facility needs to the QAPI quality manger. The QAPI quality manger would be appointed by the administrator and executive leadership team to ensure compliance of QAPI activities.

Based on interview and document review, the facility failed to ensure data submitted to the QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 20 residents. Findings include: Review of the 2/6/23, quarter 1 QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee identified: 1) An employee engagement survey had an 80% response for feed back from employees for the period of 10/17/22 through 10/31/22. Review of the employee survey revealed questions were posed to staff about meaningful work, growth opportunities, effective management team, and effective supervision. 40 of 50 employees responded. There was no indication of analysis of the data collected from the employees related to the survey or how the facility would use the data collected to identify goals they wanted to achieve. 2) They collected data of residents receiving nutritional supplements as of 1/11/23. There were 8 out of 24 residents receiving nutritional supplements. There was a decrease of 6% of supplements use by residents from the last quarter with a goal to continue to work towards reducing resident supplement use. There was no identified action plan or analysis of the data collected to identify why the facility had determined it needed to reduce supplement use. 3) Fall report data collected had decreased from 7 falls from last quarter, with a reported plan in place. There was no mention what that plan was or they had specific information related to each fall to identify when falls occurred, or the events surrounding the fall or any patterns to prevent falls. There was no evidence the Governing Board had oversight to determine what action needed to be taken with identified areas of concern as was reported during interview with the Life Enrichment Assistant (A)-A. Review of the 4/11/23, quarter 2 QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee identified: 1) There was no mention of follow-up related to the employee engagement survey from the last QAPI meeting. 2) Number of current residents receiving nutritional supplements were decreased to 5 of 22 residents as of 4/7/23. There was a decrease of 10% from last quarter. The goal was to continue to work towards reducing supplement use, however, there was no identified action plan, and no analysis of data collected. 3) Fall report data identified falls in January, February, and March 2023 included the time the falls occurred. The facility did identify an intervention for management staff will be out walking in the halls more frequently as falls occurred between 10:00 a.m. and 2:00 p.m. in an attempt to prevent residents with impulsivity to deter falls. This was to be reported at the next QAPI meeting. There was no mention what method management was going to use to deter any falls that happened during these timeframes, or what the goal was. Nursing staff were to perform root cause analysis (RCA) however, there was no benchmark to identify how the RCA was to be done. There was no evidence the Governing Board had oversight to determine what action needed to be taken with identified areas of concern as was reported during interview with the Life Enrichment Assistant (A)-A. Interview on 7/12/23 at 7:55 a.m., with nursing assistant (NA)-B identified she was unaware of what QAPI was or what that entailed. She was aware the facility management did have a meeting with staff once. Management asked the staff to all work together and if there was any input from staff to make things better. Interview on 7/12/23 at 3:10 p.m., with the administrator identified she confirmed the above-mentioned meeting minutes lacked details, specific plans for improvements, or thorough analysis of all data submitted. At 3:25 p.m., the administrator returned to the conference room and stated if there were further question the consultant administrator would answer them, as she was not aware of why the facility lacked specific data related the identified measures they were monitoring or thorough analysis. Interview on 7/13/23 at 8:27 a.m., with the Life Enrichment Assistant (A)-A identified each department brings data forth to the QAPI committee about their department and if there were any concerns with that data. At the meeting if a concern was identified the Governing Board was to decide how to proceed with the data QAPI gathered and what steps need to be taken to make improvement. Interview on 7/13/23 at 10:31 a.m. with consulting administrator identified in quarter one, the facility had been working on falls and agreed there had been no documentation of a thorough analysis of the data collected to identify what specific measures needed to be taken, or how the facility would achieve compliance. She confirmed dietary had a goal to reduce supplement use but there was no action plan or analysis of data collected. Additional interview on 7/13/23 at 11:39 a.m., with consulting administrator identified they had no further documentation of data or thorough analysis noted in the QAPI meetings. We talk about the information . but we have no documentation that would support the submission of specific data occurred, measurements of that data, or thorough analysis was shown on the QAPI meeting minutes or a supplemental addendum to the QAPI minutes was provided in order to show evidence those areas had been appropriately reviewed and monitored. Review of 4/18/23, Quality Assurance/Assessment and Performance Improvement Plan identified the Board of Directors [Governing Body] and administrator had the authority and accountability for the quality of care delivered. The committee was to meet quarterly with the medical director to achieve the desirable outcomes for resident care. During the quarterly meeting the committee was to evaluate the activities identified under the QAPI program. The QAPI committee was to monitor data submitted areas of concern and determine the effectiveness of interventions.

Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 20 residents. Findings include: Review of the PIP Project provided for review, identified Moderate to severe pain in the first 100 days. QAPI meets quarterly. The QAPI team included the medial director, pharmacy consult, department heads, city council board, and administrator. There was no identified action plan for improvement, no delegation of who was to implement interventions, what type of data would be collected, who would oversee the plan, and who would analyze the data to see if modifications were needed. Interview on 7/12/23 at 3:10 p.m., with the administrator identified the performance improvement project (PIP) plan was moderate to severe pain in the first 100 days. She was unaware of what the plan was and what type of interventions were being done. She stated we just picked that for more money. The administrator agreed that the PIP plan should have identified specific action plans, what data would be monitored and who would analyze the data and report finding to the QAPI committee. At 3:25 p.m., the administrator returned to the conference room and stated if there were further question the consultation administrator would answer them. Interview on 7/13/23 at 8:29 a.m., with trained medication aide (TMA)-A identified the facility had a problem they were working on and it had something to do with pain in the first 100 days. She reported she did not attend the meetings and was unaware of what interventions were being done to improve pain. Interview on 7/13/23 at 8:38 a.m., with registered nurse (RN)-B identified the facility was working on the subject of pain in the first 100 days and pointed to the door at the nurses station where a piece of paper was taped to the door that read: QIIP project moderate to severe pain in the first 100 days. RN-B was unaware of what the facility was doing for the project and reported she would have to ask the director of nursing (DON). Interview on 7/13/23 at 10:31 a.m. with the consulting administrator identified the PIP project was the subject was pain in the first 100 days. She revealed the facility had been working on this project for quite some time already and staff would have received training on the PIP project through, all staff meetings, through report and staff should know what the project was and what the facility was doing. The nursing assistants should be implementing non-pharmacological interventions prior to contacting the nurse for a resident with pain. She agreed that the one page paper that had been posted within the facility lacked any specific details as to what was to be done, who was responsible, what data would be collected, and who would oversee that the action plan was being implemented. Additional interview and document review on 7/13/23 at 11:39 a.m., with consulting administrator provided a piece of paper with the facility letter head that read: Pain in Short Term Residents (less than 100 days of stay) What the facility can do to combat pain: 1) Talk to the resident to determine an acceptable pain level. 2) Offer non-pharmacological interventions. i.e. ice/heat/positioning. 3) Offer topical medications with massage. 4) Offer pain PRN medication before therapy. 5) Ensure pain assessments are completed more frequently (this wil be assigned). 6) If resident is non-verbal/cognition decline staff will use the non-verbal pain scale (located on the med-cars). 7) Open communication with therapy to see if exercises/stretches are recommended for pain relief. The consulting administrator agreed who was to be responsible for implementing the identified intervention was not identified, what data would be monitored and collected, what the specific goal was, and who would be analyzing data collected. She was unable to provide any analysis of the PIP project. Review of 4/18/23, Quality Assurance/Assessment and Performance Improvement Plan identified the Board of Directors and administrator had the authority and accountability for the quality of care delivered. The committee will meet quarterly with the medical director to achieve the desirable outcomes for resident care. The QAPI committee will identify gaps in performance where opportunities for improvement are identified and the committee will prioritize focus areas for PIP development at least annually. The PIP committee will identify a project lead staff who will be responsible to coordinate, organize, and direct the activities of that specific PIP plan. The committee will evaluate the measures in place and make adjustments as needed.

Based on interview and document review, the facility failed to provide mandatory training on the facility's Quality Assurance/Assessment and Performance Improvement Plan (QAPI) that included the goals and various elements of the program or how the facility intended to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program for 1 of 8 sampled staff (trained medication aide (TMA)-A, nursing assistant (NA), registered nurse (RN), and director of nursing (DON)) reviewed for QAPI training. Findings include: Interview on 7/12/23 at 7:55 a.m., with nursing assistant (NA)-B identified she was unaware of what QAPI was or what that entailed. She was aware the facility management did have a meeting with staff once. Management asked the staff to all work together and if there was any input from staff to make things better. She could not recall if she had completed QAPI training online or not. Interview on 7/13/23 at 8:29 a.m., with TMA-A identified she had QAPI training, she reported that staff get training online yearly. Interview on 7/13/23 at 8:38 a.m., with registered nurse (RN)-B identified she was unsure if she had completed training on QAPI and would need to ask the director of nursing (DON). Review of the sampled staff for QAPI training records identified: TMA-A had a hire date of 3/16/1999 and not completed annual QAPI training NA-A had hire date 6/9/23 and completed QAPI training on 6/12/23. NA-B had a hire date of 4/21/22 and completed QAPI training on 4/28/22. NA-C hire date 5/25/23 and completed QAPI training on 5/28/23. RN-A had hire date 6/13/96 and completed QAPI training on 12/19/22. RN-B had hire date of 5/16/22 and completed QAPI training on 5/17/22. RN-C had hire date of 9/21/22 and completed QAPI training on 9/23/22. DON hire date 2/19/03 and completed QAPI training on 5/12/22. The overall QAPI training was an on-line course titled QAPI, Compliance and Ethics that was an hour long. There was no evidence to support the training was facility specific on what the QAPI committee had identified as areas for improvement, what action plans were in place or what was being monitored. Interview on 7/13/23 at 10:54 a.m., with consulting administrator identified upon hire staff are assigned mandatory training and annually thereafter. She reported that human resources along with the administrator monitored the staff training to ensure completion. She agreed that TMA-A had no record of annual QAPI training. She would expect that staff are completing their assigned mandatory training timely. Review of October 2022, Training Requirements policy identified training for all new and existing employees included elements and goals of the facility's QAPI program. The DON or designee was the training program contact person and worked closely with the Compliance Officer, administrator, and other facility leaders in developing training programs. Human resources would maintain records of completed training's by staff. Review of 4/18/23, Quality Assurance/Assessment and Performance Improvement Plan identified the Board of Directors and administrator had the authority and accountability for the quality of care delivered. All new staff would be educated on the principles of QAPI an then annually thereafter to include identification of areas for improvement,and how to get involved in the QAPI process.

Based on interview and document review the facility failed to ensure an eye appointment was made after being requested for 1 of 1 residents (R1). Findings include: R1's Admission Record identified R1 had been admitted to the facility in May 2022. R1 had diagnoses of type 2 diabetes, anxiety, and depression. R1's 6/7/23, annual Minimum Data Set (MDS) assessment identified R1's cognition was intact. R1 took a daily insulin injection, a daily anti-anxiety and anti-depressant medication. R1's 6/7/22, care plan identified she had impaired visual function related to her diabetes. R1 would use appropriate visual devices (glasses) to promote participation. The facility would arrange a consultation with an eye care practitioner as required. The facility would ensure appropriate glasses were available. The facility would remind R1 to wear her glasses when she was awake, and staff would ensure eye glasses were clean, free from scratches, and in good repair. Review of the 12/6/22, Care Conference Summary form identified members present in attendance were the social service designee (RN-A), the dietary manager, R1's sister, and R1. The facility had reached out to R1's county case worker to see where previous dental, vision, and podiatry visits were scheduled at, and set up upcoming visits. Review of the 3/7/23, Care Conference Summary form identified members present in attendance were the social service designee (RN-A), the dietary manager, R1's sister, the county case worker, and R1. R1 had requested an eye appointment. There was no indication staff were going to follow up with scheduling R1's request. Review of the 6/7/23, Care Conference Summary form identified members present in attendance were the social service designee (SSD), a therapist, the county case worker, R1's sister, and R1. There was no mention that an eye appointment had been made or if R1 had been to an eye appointment as requested previously in March 2023. Interview on 7/10/23 at 7:00 p.m., with R1 identified she had not received any follow-up from staff on requests for an eye appointment made during care conference. She reported she also had asked licensed practical nurse (LPN)-A to make the eye appointment however, could not recall when she had asked her. Interview on 7/11/23 at 4:12 p.m., with LPN-A identified she had not been at the last 2 care conferences when R1 had inquired about the appointment, but the staff at the meeting should have notified her to make the appointment or they should have addressed it following the care conference meeting. There had been a message to R1's county case worker back in December of 2022, to find out who R1 normally used for optometry appointments as she was made aware R1 had been inquiring about making appointments during care conferences. LPN-A failed to follow-up with making a vision appointment on R1's behalf. Review of 12/6/22, email SSD sent to R1's county case worker identified the SSD had inquired about R1's past appointments and where R1 normally went for optometry. On 12/8/22, county case manager replied identifying that R1 had went to optometry in Willmar in the past but she was unsure of the name of the provider. Interview on 7/12/23 at 7:12 a.m., with the director of nursing (DON) who agreed if a resident requested an appointment, the facility should make that appointment. The DON's expected, when a resident requested an appointment the facility would make the requested appointment for the resident and relay that information to the resident or give a status update if the appointment could not be made. Interview on 7/12/23 at 1:40 p.m., with administrator identified her expectation would be staff would make appointments or assist with making appointments for residents when they requested them, and provide follow-up to the status of that appointment. Interview on 7/12/23 at 3:39 p.m., with the SSD identified she felt R1 may have had problems with her insurance and that was why an eye appointment did not get made but was unsure. The SSD confirmed R1 had requested an eye appointment at care conferences. She had reached out to R1's county case worker back in December to see where R1 had previously went for vision appointments. The SSD reported the ball just got dropped for making the eye appointment for R1. She agreed there should have been some kind of follow up to ensure the appointment was made, and if there was an issue getting it scheduled, communication should have been relayed to R1 of the status of that appointment request. Interview on 7/13/23 at 10:54 a.m., with the consulting administrator identified her expectation was staff were to act on requests for eye appointments, set up transportation if needed, and relay any information about that appointment status to the resident affected. A policy or protocol for assisting residents with making appointments was requested however, the DON revealed the facility had none.

Based on observation, interview and record review the facility failed to properly secure smoking materials and follow their Smoking Policy for 1 of 1 resident (R15). Findings include: R15's admission record printed 7/13/23, identified R15 was admitted with diagnosis of esophageal obstruction, alcohol abuse, dysphagia, and nicotine dependence. R15's 4/26/23, quarterly Minimum Data Set (MDS) assessment identified he was able to complete activities of daily life independently and cognition was intact. R15's undated care plan identified that he could smoke independently and all smoking supplies were to be stored in the east medication room cabinet. Observation on 7/10/23 at 7:22 p.m., R15's cigarettes and lighter were laying on his overbed table in R15's room. Interview on 7/10/23 at 7:22 p.m., R15 stated the nurses let me keep a few cigarettes and my lighter in my room. Interview on 7/12/23 at 10:30 a.m., director of nursing (DON) identified it was her expectation that all cigarettes were to be locked up at the nurses station, she expected residents to request smoking supplies and nursing to ensure those supplies were collected and locked in medication room after the resident was finished smoking to ensure safety of all residents at the facility. Review of 1/13/23, Smoking Policy identified that all smoking materials will be kept in a safe place and would not be allowed in resident rooms.

Based on interview and document review the facility failed to ensure a dental appointment was made after being requested for 1 of 1 residents (R1) reviewed for dental. Findings include: R1's Admission Record identified R1 had been admitted to the facility in May of 2022. R1 had diagnoses type 2 diabetes and heart failure. R1's 6/7/23, annual Minimum Data Set (MDS) assessment identified R1's cognition was intact, R1 required extensive assistance from one staff for personal hygiene. R1 ate independently. R1 had no natural teeth. R1's 6/7/22, care plan identified oral/dental health problems related to the absence of natural teeth. R1 was noted to refuse to wear her dentures. R1 was to be encouraged to let staff assist her with mouth care at least daily. Staff were to monitor and report any signs or symptoms of oral/dental problems needing attention. Staff were also to monitor for pain, abscess, debris in her mouth, lips cracked or bleeding, loose or broken dentures, abnormalities with her tongue or mouth. Staff were to assist of 1 staff in providing mouth care and personal hygiene. Review of the 12/1/22, Nursing Assessment identified R1 had own teeth. There mention of R1 having dentures. At that time, it was noted R1 did not wish to see a dentist. The section for dentures was left blank. The section related to complications for chewing, swallowing problems, persistent nausea, vomiting, or diarrhea, tube feeding or Enteral order revealed R1 had no concerns. R1 had a diabetic diet with no consistency modifications in order to eat. Review of the 12/6/22, Care Conference Summary form identified members in attendance were the social service designee (SSD), the dietary manager, R1's sister, and R1. The facility had reached out to R1's county case worker to see where previous dental visits were and was to set up upcoming visits. Review of the 3/7/23, Care Conference Summary form identified members in attendance were the SSD, the dietary manager, R1's sister, the county case worker, and R1. R1 had requested a dental appointment and needed to see a dentist. Review of the 3/7/23, Nursing Assessment identified once again R1 had own teeth and did not wish to see a dentist. The section for Dentures was left blank. The section related to complications for chewing, swallowing problems, persistent nausea, vomiting, or diarrhea, tube feeding or Enteral order identified R1 had no complications. There was no diet and consistency needs identified in order for R1 to eat. Review of the 6/6/23, Nursing Assessment identified R1 did not have her own teeth, and did not wish to see a dentist. The section for Dentures was left blank. There was no indication staff had identified the inconsistencies in their assessment. Review of the 6/7/23, Care Conference Summary form identified members in attendance were the SSD, a therapist, the county case worker, R1's sister, and R1. There was no mention a dental appointment had been made from R1's previous request. Interview on 7/10/23 at 7:00 p.m., with R1 identified she had requested a dental visit. R1 reported she did not wear her dentures as they did not fit. R was not worried about having her dentures adjusted but felt she needed a dental appointment to have her gums checked. R1 had initially requested to have a dental appointment set up when she first came to the facility but that never occurred. R1 had asked staff about getting a dental appointment made, during her previous care conferences. She had not had an appointment and staff never relayed this had been followed up on. Interview on 7/11/23 at 4:12 p.m., with LPN-A identified she had not been at the last 2 care conferences when R1 inquired about getting a dental appointment. Staff at the meeting should have notified her to make the appointment or they should have addressed it following the care conference meeting and followed up with R1. LPN-A was aware R1 had been requesting a visit, but she had not followed up on this herself. She agreed a staff member should have been assigned to ensure R1's appointment had been made. Review of 12/6/22, email from the SSD to R1's county case worker identified the SSD had inquired about R1's past appointments and where R1 normally went for dental appointments. On 12/8/22, county case manager replied R1 had went to optometry visits in Willmar. There was no mention of where R1 had gone in past for dental appointments. Interview on 7/12/23 at 7:12 a.m., with the director of nursing (DON) identified she agreed if a resident requested an appointment the facility should make that appointment. Her expectation was when a resident requested an appointment the facility would make the requested appointment for the resident and if unable, should provide follow-up with R1 to make her aware of the status. Interview on 7/12/23 at 1:40 p.m., with administrator identified her expectation would be staff would make appointments or assist with making appointments for residents when they requested them. Interview on 7/12/23 at 3:39 p.m., with the SSD identified R1 had requested a dental appointment. She had emailed R1's county case worker to find out who R1 normally seen. LPN-A normally set up appointments for residents but any nurse could set up appointments. The ball just got dropped for making R1's dental appointment. She indicated there should have been some kind of follow up by staff to ensure that the appointment occurred, and if staff were unable to make any appointment, the resident affected should be notified. Interview on 7/13/23 at 10:54 a.m., with the consulting administrator identified her expectation was staff were to act on requests for dental appointments and set up transportation if needed. A policy or protocol for assisting residents with making appointments was requested however, the DON revealed the facility had none.

Based on interview and document review the facility failed to perform root cause analyses and identify appropriate interventions to prevent the falls for 2 of 2 residents (R10 and R119). Both residents' falls resulted in actual harm when R10 suffered a neck fracture and R119 suffered pelvic fractures as a result. Findings include: R10 Review of the 1/12/22 at 1:25 p.m., facility incident report identified nursing staff walked past R10's room and heard him hollering for help. R10 was found lying face down on the floor in front of wheelchair with his legs under the wheelchair with his body partially covering the top of the wheelchair foot pedals. R10's call light was attached to the front of his shirt. Staff log-rolled R10 onto his back, noting he had blood on left index finger with small skin tear. A bruise was noted on R10's right side of his forehead. Vital signs (blood pressure, heart rate etc.) were taken and found to be within normal limits. Neurological checks (determines potential brain abnormalities) were initiated and showed his pupils had normal assessment finding as well. Staff asked R10 what happened. R10 replied I don't know .I was reaching for something help me off the floor. R10's 12/26/21, Significant Change Minimum Data Set (MDS), identified he had severe cognitive impairment, exhibited no behaviors, and required extensive assistance from 1 or 2 staff for most all Activities of Daily Living (ADL). R10 had diagnoses of [CONDITION(S)], high blood pressure, arthritis, [CONDITION(S)], depression, and long-term use of blood thinners. R10's Care Area Assessment (CAA) triggers identified R10 had cognitive loss with dementia. Staff were to anticipate and meet his needs. R10 triggered for falls due to balance issues and was assessed as at risk for falls. R10 required staff support for transfers and safety needs. R10's medications included aspirin (NSAID) for heart health and daily [MEDICATION(S)] use, both which thin the blood and increase the risk for bleeding. R10's current, undated care plan identified he was at high risk for falls and was on 30-minute safety checks. His call light was to be kept within reach and his bed was to be in lowest position with floor mat while in bed. His wheelchair was to have Dycem cushion (a non-slip material) on top of his wheelchair seat, to decrease his risk of sliding off. His personal possessions were to be placed within reach upon having been seated in his chair or lying in his bed to reduce his risk of self-transferring or over-reaching. Nursing staff to place R10 back into his recliner after each meal. There was no mention of how staff would ensure 30-minute checks were completed or that the 30-minute intervals of supervision was sufficient to prevent falls in between checks. Review of R10's progress notes and electronic medical record identified there was no system to ensure 30 min checks were being performed or how 30-minute intervals were identified to be adequate for supervision. There was also no evidence a root cause analysis had been performed to identify if 30 minute checks were appropriate for supervision to prevent falls. Observation on 2/28/22 at 2:00 p.m., of R10 identified he was in his bed with the bed in low position, a mat on the floor beside the bed, and a soft cervical collar in place. Further observations of R10 between 2:15 p.m. and 5:30 p.m., identified he continued to be sleeping in his bed. At 5:45 p.m. an unidentified staff member was seated at R10's bedside encouraging him to eat supper, which he refused. Observation and document review on 3/1/22 at 10:00 a.m., of R10 identified he was seated in his recliner in room sleeping. At times will moan or make a vocalization and then appears to return to sleeping. R10 was no longer wearing cervical collar. Review of the physicians orders identified it had been discontinued. Observation on 3/01/22 at 2:00 p.m., of R10 identified he was lying in bed sleeping with his bed in low position and a fall mat on the floor. At 3:00 p.m. continued to be lying in bed sleeping with bed in low position and mat on floor. Observation on 3/2/22 at 7:00 a.m. through 10:00 a.m., identified R10 was lying in bed sleeping with his bed in low position and mat on the floor. At 10:00 a.m. R10 was observed dressed and well groomed, seated in his recliner watching TV. No staff were providing direct supervision at any time, other than when attempting to cue R10 to eat. Interview on 3/03/22 at 10:07 a.m., with licensed practical nurse (LPN)-A identified R10 was in his wheelchair the day of the incident. LPN-A heard a noise, investigated it, and found R10 lying face down on the floor with his lower legs on the wheelchair foot pedals. R10 had a hematoma on the right side of his forehead, and a skin tear on his finger. The MD was contacted as R10 was receiving [MEDICATION(S)] which put him at high risk for bleeding complications. R10 was ordered to be transferred to the ED for evaluation. The facility was notified R10's fall resulted in a cervical fracture. He would return with a cervical collar in place. LPN-A identified R10 reported he was reaching for something and fell . It was suspected he had hit the corner of the table and that caused the head and neck injury. LPN-A identified no new interventions had been identified or a root cause analysis completed she was aware of to identify the need for increased supervision. Interview on 3/04/22 at 9:43 a.m., with LPN-B and nursing assistant (NA)-C identified R10 was supposed to be transferred into his recliner after meals or persuaded to attend an activity. R10 happened to be left seated in his wheelchair at the time of the fall. R10 was known to attempt self-transfer at times. When this would occur, it was usually when he was left alone seated in his wheelchair. Interview on 3/04/22 at 9:54 a.m., with NA-A identified R10 was supposed to be transferred into his recliner or bed after meals. NA-A reported he did not think R10 was supposed to be unattended if he was in his wheelchair. NA-A reported R10 was impulsive, but when he was in his recliner he was usually comfortable and normally would not attempt to self-transfer. If he was in his wheelchair, he was likely to attempt to self-transfer, usually into his recliner. Interview on 3/04/22 at 10:40 a.m. with registered nurse (RN)-B identified following a fall on 11/11/21, when R10 had fallen from his wheelchair when left unattended, his care plan had been updated to include staff were to ensure he was transferred from his wheelchair to his recliner after meals. This usually stopped self-transfer attempts in the absence of direct supervision. RN-B stated the care plan had not been followed on 1/12/22 when R10 fell from his wheelchair while in his room unattended. She further identified she expected staff to follow the care plan. She was not aware of any reason why staff had deviated from the care plan and left R10 was in his wheelchair unattended. She confirmed the noon meal was served at 11:15 a.m. and the fall occurred at 1:25 p.m R10 should have been transferred into his recliner after that meal and not left unsupervised in his wheelchair. Interview on 3/4/22 at 3:31 p.m. with the MD identified he was aware R10 had a history of attempting to self-transfer and resulting falls, but he was not aware the facility had not followed the care plan on 1/12/22, when R10 had fallen in his room. The MD voiced his expectation for the facility to follow R10's plan of care for supervision to keep him as safe as was possible. He further identified that when in his recliner R10 did not usually attempt to self-transfer according to nursing staff. R119 Review of the 6/21/21 at 9:15 a.m., report to the SA identified R119 was found lying on the floor in her room by RN-C as they were passing by her room. R119 was assessed and found to be bleeding from an abrasion on her temporal area in addition to a quarter sized bump at the site. Vital signs and neurological assessments were initiated according to facility protocol. R119 was assisted into her wheelchair and positioned by the east nursing station to allow for frequent monitoring by staff. Later, at approximately 12:00 p.m., while being assisted to the toilet by staff, R119 voiced complaints of hip and buttock pain. R119's MD was updated, and orders were received for evaluation in either the ED or the local clinic. R119 was transported to the ED via ambulance. At 4:15 p.m., RN-B contacted the ED for an update and was informed R119 had suffered a pelvic fracture and was being admitted to acute care. R119's 3/24/21, MDS identified she had severe cognitive impairment, required extensive assistance with all ADLs, except eating, and had a history of multiple falls. R119's diagnoses included Alzheimer's disease, major depressive disorder, Type 2 diabetes, dementia, [CONDITION(S)]. R119's current, undated care plan identified she was at high risk for falls with a known history of falling due to her impaired cognition. Staff were to apply anti-rollback breaks on her wheelchair, ensure her brakes were unlocked when R119 was in her wheelchair, provide 15-minute safety checks, and assist R119 to lay down when restless after ambulating and toileting. Staff were also to assist her with standing or stretching her legs and toileting every 2 hours while awake, assist with ambulating in the halls, and assist her to the bathroom when she was exhibiting signs of being restless. Staff were to ensure her call light was within reach. Staff were to supervise R119 when she was out of her room and ensure she always wore shoes or gripper socks. R19 was known to have poor safety awareness related to her cognitive impairment. R119 had a history of self-transferring. If staff found her attempting to self-transfer or ambulate on her own with rolling walker, staff were to intervene and walk with her. Staff were to catch her whenever she was seen up and walking without staff assistance. Staff were to fall the facility fall protocol. Additional interventions identified staff were to keep her room door open at all times when R119 was not supervised, place a floor mat next to her bed on floor when R119 was in bed. Management was to ensure staff followed care plan safety interventions with direct care staff to ensure care plan was followed. Staff were to toilet R119 when she was seen crawling out of bed onto her floor mat. Staff working with resident were to have been re-educated on better techniques to use while R119 was restless or anxious. R119's care plan goals were to help minimize risk for injury with falls. There was no mention a root cause analysis was performed to ensure R119 was appropriately supervised or that 15-minute checks would be enough when R119 was exhibiting potential unsafe behavior to prevent falls. Interview on 3/03/22 at 9:53 a.m., with RN-B identified R119's family had previously been considering Hospice services due to her decline in cognition but had been informed she was reportedly not eligible due to not having weight loss. RN-B reported R119 had dementia and would frequently attempt to self-transfer. There was discussion with family about safety concerns and a possible transfer to another facility who had a specific dementia unit, but family declined. They were aware of the potential for harm as a result of frequent falls. When R119 was in her room, the door was left open except during cares. RN-B identified when R119 was in her room staff were not able to observe her unless they happened to be passing by or had entered her room. RN-B identified the facility was not able to provide 1:1 supervision due to staffing issues. R119 was well known to suddenly attempt to self-transfer without warning. RN-B identified following her fall with pelvic fracture, she was admitted to Hospice. R119 was not a surgical candidate to fix her fracture. Interview on 3/03/22 at 1:13 p.m. with LPN-A identified R119 was a high fall risk. Her family was aware she continued to have falls and remained involved in her plan of care. R119 required the assist of 1 staff with a gait belt and use of her walker. LPN-A reported the care plan did identify R119 would often attempt to self-transfer and walk unattended. Staff were to monitor her when this would occur and assist her for safety. LPN-A identified there was not specific criteria in place to monitor R119's location or provisions in place when she was unsupervised and attempted to stand and ambulate. LPN-A identified staff were supposed to be aware when R119 was becoming agitated. At the time of her fall with fracture, R119 was observed 5 minutes prior to the fall and left alone again, unsupervised. She did not recall if R119 had been agitated prior to the fall. LPN-A reported 1:1 monitoring had been discontinued after being in place from 10/21/20 through 3/14/21 after previous falls. LPN-A confirmed R119 did not have 1:1 monitoring in place at the time of the fall. She was in her room without staff supervision. Interview on 3/03/22 at 3:59 p.m., with RN-C, regarding R119's fall, identified he recalled R119 was in her recliner in her room at the time, unsupervised, just before her fall and recalled he did not think she had been exhibiting agitation at that time. He found R119 after her fall, when he was passing down the hall approximately 5 minutes after he had last seen her in her room. He found her lying on the floor in front of her recliner. R119 had some bleeding and a lump on her temporal area but had denied pain. She was not able to state what had happened. Following his nursing assessment, he had contacted ED on-call provider to update them on the fall and been instructed to monitor R119 for additional issues for changes in range of motion or pain. R119 was assisted from the floor to her wheelchair by 2 staff and positioned by the East nursing station to allow staff monitoring. Later, when staff attempted to toilet R119, she was not able to stand. RN-C updated the MD and orders were received to send her to the ED for evaluation. Interview on 3/04/22 at 9:37 a.m., with LPN-B identified R119 had frequent falls due to attempts at self-transfer. R119 had dementia, would forget her limitations, and thought she was able to walk. Staff were to toilet R119 every 2 hours. Sometimes that helped deter her from attempting to self-transfer, other times not. LPN-B identified at times R119 needed 1:1 supervision for safety, because of her repeated attempt self-transfer. R119 would suddenly stand from a sitting position in her recliner or wheelchair and was known to be impulsive and not understand to wait for assistance. LPN-B reported she was not certain why 1:1 monitoring was stopped previously, but felt it was likely due to there not always having staff available to provide the 1:1 monitoring. Interview on 3/04/22 at 9:54 a.m., with NA-A identified R119 had dementia and Alzheimer's and was always restless. R119 would was repeatedly attempted to get out of bed or her chair and wander into other resident's rooms and had been known to attempt elopement. R119 was difficult to redirect and would become agitated easily. Neither location and/or activity provided impact her unsafe behaviors. NA-A reported, at one time R119 had 1:1 supervision due to her behaviors and falls, but he was not certain why it had been stopped. NA-A confirmed when R119 was in her room, staff were not able to visualize to enable appropriate supervision unless they happened to pass by or enter her room. NA-A was not working at the time of R119's fall and subsequent fracture, but stated he was familiar with R119 and her behaviors prior to that time. Interview on 3/2/22 at 2:03 p.m., with the director of nursing (DON) identified R119 had experienced multiple falls, and the facility had attempted to put interventions in place to avoid any significant injury. The facility was not able to provide the necessary 1:1 supervision for a resident due to staffing constraints. There was no documentation to support a root cause analysis occurred prior to the decision to identity R119 would be safe without the required increased supervision previously identified. There was also no root cause analysis performed on R10 to ensure 30 minute checks were appropriate supervision or if increased supervision was required. Review of the 3/31/21, Accidents and Incidents Investigating and Recording policy identified an investigation must be completed with a Root Cause Analysis documented. Information to be included was the date and time of the incident, nature of injury or illness, circumstances surrounding the incident, where the incident took place, the resident or injured person's account of the incident, physician contact and response, notifications to appropriate persons, actions taken following the incident, follow up and update to the care plan for immediate intervention.

Based on observation, interview and record review the facility failed to provide nail care to 2 of 10 residents (R2 and R13) who required assistance with Activities of Daily Living (ADL). Findings include: R2's 18/22, significant change Minimum Data Set (MDS) identified R2 required total assist of 2 staff for transfers, locomotion, bed mobility and extensive assist with all other ADL's. R2's 12/29/21, care plan made no mention of personal hygiene, oral care or bathing. Observation on 2/28/22 at 5:01 p.m., of R2 identified R2's right hand had brownish-black dirt-like debris under her thumb nail and under her 4th digit finger nail. R2's finger nails were noted to have small amounts of old red nail polish on the edges of some of her finger nails. Observation on 3/2/22 at 7: 10 a.m., during morning cares identified nursing assistant (NA)-A washed R2's hands with soap and water but failed to clean or trim R2's nails underneath. Following cares, R2's right hand was noted to still have brownish-black dirt-like debris under her thumb nail and 4th digit finger nail. Observation and interview on 3/3/22 at 9:25 a.m., with NA-C who confirmed R2 right thumb nail and 4th digit finger nail had dark brown debris under both nails, NA-C revealed that R2 had a bath earlier this morning by NA-A and her finger nails should have been cleaned at that time. NA-C stated that the licensed nurse cuts R2's finger nails as she is diabetic. NA-C stated if staff notice dirty nails when completing cares they should be cleaning them at that time. Interview on 3/3/22 at 11:00 a.m., with NA-A who revealed he gave R2 a bath earlier in the morning and confirmed R2's finger nails were noted to be dirty at that time. He stated he was unable to find a nail brush to clean them with but that was on his to-do list. Interview on 3/3/22 at 11:14 a.m., with registered nurse (RN)-B confirmed during her skin assessment of R2 after her bath that R2 did have dirty finger nails. RN-B stated she had planned on getting a nail clippers and cleaning R2's finger nails but had gotten side tracked. RN-B stated she would make sure R2's finger nails were cleaned. RN-B's expectation was staff would clean resident's finger nails during cares if they notice they were dirty. If they are not able to trim nails because resident's were diabetic, they should get the nurse to do so. Review of grievance log identified on 2/14/22, family had concern with R2's dirty finger nails and had removed R2's finger nail polish on 2/9/22, so that R2's dirty fingernails would be easier to be seen. Interview on 3/3/22 at 3:42 p.m., with director of nursing (DON) identifed her expectation was staff would clean resident's fingernails if they observed them to be dirty. The DON further identified that she had a list of expectations for duties she has each staff sign when hired, which included providing resident nail care. R13's 1/17/22, admission MDS identified R13 had severe cognitive impairment, and required extensive assistance of 2 persons for bed mobility, transfers, locomotion on/off unit, dressing, eating, toileting and personal hygiene. Observation on 3/01/22 at 2:03 p.m., of R13 identified she was lying on her back in bed, sleeping. The nails of her left hand were very long, approximately 1/4 to 1/2 inch, and had yellowish discoloration with brown dirt-like debris under the nails of her thumb and first 3 finger nails that were visible resting on the doll. Observation on 3/02/22 at 8:31 a.m., during morning cares provided by NA-A and NA-B, R13 had yellowish discoloration on the nails of her left hand with brown dirt-like debris visible underneath her nails. R13's thumbnail on her right hand was observed to be long and unkempt in appearance. The nails on R13's left hand remained with the dirt-like substance. Observation and interview on 3/03/22, at 11:32 a.m., with registered nurse (RN)- A of R13 identified R13's left hand continued to have a brown, dirt-like substance around the nail beds and under her nails. RN-A stated nail care included trimming and/or cleaning of nails and was to be done on bath days and with daily cares as needed. Observation and interview on 3/02/22 at 1:56 p.m., with the DON of R13's hands identified she agreed R13's nails had a brown, dirt-like substance beneath her nails on her left hand. Her expectation was resident hands were to be maintained clean and appropriately trimmed by staff if a resident was unable to do so themselves. Review of the 1/3/22, Providing Nail Care Policy identified routine cleaning and inspection of nails was to be provided during ADL care on an ongoing basis.

Based on observation, interview, and document review, the facility failed to assess and develop interventions for new-onset behaviors related to cognitive decline for 1 of 1 resident (R1) with dementia who smoked. Findings include: R1's 5/20/21, Significant Change Minimum Data Set (MDS) identified R1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no behaviors identified during the review period and R1 was independent in wheelchair for locomotion. Review of 6/26/21, report filed to the State Agency (SA) identified on 6/26/21 at 11:00 a.m., R1 reported to nursing staff of an incident occurring at 3:00 a.m. that same day. R2 was outside with her while she was smoking. R1 and R2 often spoke to each other. R1 reported R2 knew she did not have any money and she was getting low on cigarettes. R1 reported R2 made the statement to her, I will borrow you any money you want if i can play with your [breasts]. Later, (that same morning when R1 must have requested money again) R2 said, You know what you have to do . R1 was asked if she felt safe, to which she responded she did. R1 had plans to avoid R2 for now. R1 then passed by R2's room that same day at 10:45 a.m R2 was reported to say, You didn't come get me. R1 reported to staff she was out of cigarettes and would not be going outside to smoke. R1 had to pass by R2's room to go to the outside designated smoking area. R1 reported she informed her family member (FM-A) but had not reported the incident to staff immediately after it occurred. FM-A had instructed R1 to report the incident to staff. R1 then reported the incident. The facility identified R1 planned to avoid R2. 15-minute checks were initiated on R2. Law enforcement (LE) was notified. LE advised staff to keep an eye on [R2]. The facility began to interview residents and staff. Education was provided to staff to report any inappropriate behaviors by R2. There was no mention how staff were going to monitor R2's interactions with other residents in between the 15 min intervals if that occurred, nor had they verified if R1 was actually out of money or if she had had any similar incidents before. R2 was also not immediately interviewed. R1's current, undated care plan identified R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had been instructed by her physician to cease smoking to promote wound healing and agreed to use the nicotine patch when not smoking cigarettes. R1 had been assessed safe to smoke independently. R1 was to smoke in designated areas only and dress appropriately for the weather. R1's care plan further identified that she was forgetful related to dementia and did not always wear appropriate clothing for the weather when going outside. R1 was identified to frequently asked for cigarettes. There was no mention staff had identified the cause of R1 asking other residents for cigarettes or if R1 was refusing to use the prescribed nicotine patch as ordered. There was also no mention R1 was cognitively impaired which affected her ability to recall if she had money to purchase cigarettes. Interview on 6/30/21 at 11:11 a.m., with the licensed practical nurse (LPN)-A identified R1 was known to have asked R2 for money previously and borrowed money from him in the past. R1 was up all hours of the night and would go outside to smoke during the night. Residents were allowed to go out to smoke anytime they requested. R1 was impulsive and a chain smoker. She can not remember anything you tell her 10 minutes later. Staff assist residents to get their smoking materials stored in the medication room. The residents who go outside are assisted out the door and they have to ring the door bell to come back in. There was no indication LPN-A identified R1's memory issues and lack of money to purchase cigarettes was a concern nor that storing personal cigarettes in the medication room was a breech in infection control. Interview on 6/30/21 at 1:55 p.m., with R1 identified she reported she was currently out of money and cigarettes. When asking about the above-mentioned incident, R1 recalled she had asked R2 if she could borrow 20 dollars. R2 had told R1 she could borrow all the money that she wanted, if she would let him play with her [breasts]. R1 revealed this was the first time R2 had made a sexual comment like that to her. R1 reported they had given each other hugs prior to this situation. R1 had asked R2 for money 1 other time in the past she was aware of. R2 had lent her the money and she reported she paid him back. R1 felt R2 was not joking when he made the inappropriate comment to her. R1's family refused to purchase or obtain cigarettes for her. The activity staff at the facility routinely assisted her to get her cigarettes. R1 reported she had no further interactions with R2 since he had made the inappropriate comment and she feels safe at the facility. Interview on 6/30/21 at 2:08 p.m., with R2 identified, R1 runs out of money the last 2 weeks of every month. R1 has hounded R2 for money all the time. R2 admitted he made an inappropriate comment to R1 when she asked to borrow money once more, telling R1 he would loan her money if you show me your [breasts]. R2 agreed he should not of made that comment, but he was so tired of [R1] asking me for money that he thought making a comment like that would stop her from asking. R2 had told staff R1 was asking him for money. He recalled even telling some kitchen staff, but could not recall the identities of staff he had told. R2 reiterated he told staff R1 kept wanting to borrow 20 dollars to buy more cigarettes. R1 would advise R2 she was out of money and needed cigarettes. R1's behaviors began at or around about Christmas time (December 2020) and had continued. R2 had given R1 money last month. Staff had to get the money back to him. There was no indication staff identified this as a grievance and investigated R2's claims. Interview on 6/30/21 at 2:26 p.m., with the nursing assistant (NA)-B identified she had not heard R1 ask others for money but had only heard R1 ask others for cigarettes. R1 typically ran out of cigarettes by the end of the month. She smoked approximately 1 pack per day. There was no indication NA-A had reported to nursing staff R1 had behaviors of asking other residents for cigarettes to ensure those claims were investigated for potential causes or if R1 actually ran out of money to identify a new behavior and implement interventions. Interview on 6/30/21 at 2:46 p.m., with the assistant director of nursing (ADON) identified R1 reported the inappropriate comment that R2 had made to her on 6/26/21. The ADON revealed she initiated 15-minute checks for R2 to monitor his where about's and actions. She contacted the sheriff and started an investigation. The ADON revealed R1 had asked R2 for money a lot of times. [R1] had borrowed money from [R2 ] before. There was no indication the ADON had identified R1 had any cognitive decline related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview on 7/1/21 at 8:32 a.m., with the ADON identified she was the social services designee. The ADON stated R1 was impulsive and prior to her admission at the facility, she would go to McDonalds and buy a Big Gulp drink 3 times a day and not remember she had gone. The ADON was unaware R1' memory loss was affecting her ability to manage her financial affairs. The ADON revealed it was hard to come up with a plan so that R1 would not ask for money. R1 did not remember things. R1 was forgetful at times after smoking, that she soul ask for another cigarette, unaware she had smoked moments before. Facility staff were aware R1 was borrowing money from R2 approximately 1 month ago. Staff spoke with both R2 and R1 about not borrowing and lending money. No specific investigation was made to identify if R1 was actually out of money, lacked cigarettes. No interventions were implemented. She was unaware of R1's financial status and had not investigated the reason R1 reported to be lacking money. Interview on 7/1/21 at 9:20 a.m., with the business office manager (BM-A) identified R1 came to the office and asked to borrow money. R1 said FM-A was going to be dropping off money that afternoon. BM-A told R1 she needed to wait for FM-A to bring the money. FM-A had been depositing money with the facility monthly. As of June, 2021, R1 had approximately $700.00 in her account. By July, 2021, R1 only had $200.00 in her account. At the beginning of July 2021, R1 requested more money. BM-A gave her $100.00 at that time. BM-A then went on vacation. While she was gone, R1 had requested additional funds and was given all but $4.00 from her account. Interview on 7/1/21 at 9:25 a.m., with the activity aid (AA)-A identified she had heard R1 ask other residents and staff for cigarettes when she was out of cigarettes. When R1 would ask me for cigarettes, she would redirect her to the activity director. AA-A revealed she had not heard R1 ask either staff or residents for money. Further interview on 7/1/21 at 10:11 a.m., with R1 identified she was seeing a counselor, but they had never really talked about quitting smoking. R1 believed she currently had $80.00. The activity director would likely get her more cigarettes today. She stated she preferred not to use a nicotine patch. R1 reported she typically had enough money to purchase cigarettes. R1 stated, I have early onset dementia so it's hard for me to remember. Interview on 7/1/21 at 12:55 p.m., with the activities director (AD) identified she had been purchasing cigarettes for R1 since May when she took over as AD. Activity staff would purchase cigarettes for R1. The activity staff kept receipts and turned those receipts into the business office. She was unaware if anyone identified why R1 was out of money, nor if she was capable of handling her own financial affairs with her dementia diagnosis. Interview on 7/1/21 at 1:16 p.m. with the director of nursing (DON) identified R1 would change her mind frequently . she can tell you something different every 10 minutes. The DON revealed she had a conversation with R2 on 6/14/21, regarding her being made aware R1 allegedly owed R2 money. R2 reported R1 owed him $30.00. R2 said R1 asked him for money another time and he gave her the money to which he reported R1 paid him back. When the DON interviewed R1, R1 denied recalling she had borrowed any money. Later in that conversation, R1 had remembered she had borrow money from R2 previously. There was no indication the DON had identified R1's declining cognition and memory issues as a concerns when handling her finances, or was becoming a behavior. Review of December 2016, Care Plan Comprehensive Person-Centered policy identified staff were to assess and develop interventions that were targeted to the resident's problem areas and problem causes, not just address the symptoms of the problem. Care planning was to be individualized and revised when conditions changed.

Based on observation, interview and document review, the facility failed to ensure 2 of 3 residents (R1 and R2) were provided appropriate supervision and intervention to prevent falls. This resulted in harm for R2 was not properly supervised, fell , and required emergency services for a head injury requiring staples. Findings include Review of facility report submitted to the State Agency (SA) on 1/22/21 at 10:46 p.m., it was identified R2 sustained a fall resulting in a scalp laceration requiring staples. The report indicated nursing assistant (NA)-D had been in R2's room to assist R2 to stand with a walker from her wheelchair. The report indicated NA-D turned from the resident to put the wheelchair away, when she heard R2 say help me! When NA-D turned back around she saw R2 falling and attempted to catch R2, but R2 struck her head on the door. Further, the report indicated licensed practical nurse (LPN)-A who was called to the resident's room, found R2 sitting on the floor in front of her nightstand. R2 was bleeding from a laceration on her scalp and expressed pain rated at an 8 of 10, on a 1 (lowest) to 10 (highest) pain scale. The report also indicated R2 was assessed and denied dizziness, nausea and changes in vision. R2's neurological checks were within normal limits. LPN-A cleansed R2's wound and sent R2 to the emergency department (ED) for evaluation. The report indicated R2 required staples to close the wound. According to the facility's 5 day investigation report submitted to the SA on 1/27/21 at 2:46 p.m., the facility had determined R2 was transferred to a standing position with her walker, and NA-D turned to put the wheelchair away. When NA-D turned away, R2 cried out and fell backwards, striking her head on a door, resulting in a head laceration. R2 was sent to the ED for assessment and received five staples to her scalp. The investigation report indicated R2 required limited assistance of one staff during transfers and indicated R2's care plan, incident report, description of the incident from NA-D, and hospital records were reviewed. After a full review, NA-D was educated on following care plans and definitions of types of transfer assistance for residents including limited assistance. NA-D was educated on how to use the Kardex (part of the care plan) to make sure resident care was provided appropriately. NA-D was also required to view a video on providing resident care, and had to sign an affirmation of understanding. The investigative report identified the resident suffered a laceration and received five staples to the back of her head. The report also indicated R2 had experienced a similar incident on 7/30/20, where the resident had stood up, fallen and required treatment at the ED for staples to her scalp. There was no indication other staff had received any additional education to meet R2's needs due to her impulsiveness and risk for falling. R2's hospital ED report identified on 1/22/21, R2 was treated for a laceration to the back of her head following a fall. The laceration required 5 staples to the resident's scalp. The ED report also indicated R2 had a history of frequent falls. On 1/22/21, a CT scan was performed of R2's head and C-spine, which were negative. R2 was discharged back to the facility with instructions for a return visit in 7 days to remove the staples directions to ALWAYS use a walker when ambulating. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2's cognition was intact, R2 required limited assistance of one staff for transfers, walking, and locomotion on the unit, required extensive assistance of one staff for toileting, and was unsteady going from a seated to standing position but was able to stabilize with staff assistance. The MDS indicated R2 was not steady during turns and required assistance from staff to stabilize herself, and R2 used a walker and wheelchair for mobility. R2's diagnoses were identified to include left sided [CONDITION(S)] (inability to move one side of body), left knee pain, [CONDITION(S)], [CONDITION(S)], muscle weakness, and abnormalities of gait and mobility. Staff were to ensure R2's call light was within reach and encourage her to use it, and R2 required prompt response for all request for assistance. R2's care plan, (current at the time of the incident) identified R2 required assistance of 1 staff for bed mobility and transfers, and required use of a mechanical sit-to-stand lift with extensive assistance of two staff. Staff were to encourage R2 to use the call light to call for assistance. R2 had limited physical mobility related to [CONDITION(S)] and [CONDITION(S)] from a stroke. R2 was to use a walker and limited assistance. R2 had impaired cognitive function and impaired thought process, and her current assessments identified she had moderate cognitive impairments. Staff were to ask yes and no questions to determine R2's needs, cue supervise and reorient as needed. R2 was at high risk for falls related to impaired mobility, and antidepressant and antipsychotic use. Review of R2's fall incident reports and progress notes identified the following on: 1) 12/11/20, at 9:20 a.m., R2 requested to go outside to smoke. Staff ensured R2 had her phone with her, and assisted R2 outside. Staff had not received a call from R2 to alert them she was done smoking. Staff went to check on R2 and found her halfway up the sidewalk lying in the grass. R2 had a small amount of blood on the left side of her cheek. R2 had a swollen lip, and lacerations on both sides of the bridge of her nose that measured 0.5 centimeters (cm). R2 reported she had forgotten how to access her phone contacts. R2 was educated on how to access her contact list in her cell phone to call for help, and to not use the wheelchair as a walker. There was no indication staff had assessed R2 for decreased cognition. R2's progress notes identified R2's fall was reviewed, and the most recent fall had occurred on 7/30/20. Resident was outside and just finished smoking at the time of the fall. The area was not icy, and the pavement on the sidewalk was even. R2 lost her balance and fell into the grass. R2 was determined to no longer be safe to smoke outside without supervision. 2) 12/21/20 at 8:10 p.m., R2 was found sitting on the floor by her bed. The report identified R2 stated she slid out of bed and hit her left knee and buttocks as she slid out of bed. R2 had no injuries and was assisted back to bed. The report made no mention of any new interventions having been implemented after the fall to prevent future falls. R2's progress notes identified on 12/24/20, the IDT team had reviewed R2's fall. No injuries were noted from the fall. Staff had instructed R2 not to sit at the edge of the bed, and since R2 had short legs, the bed was to be placed in the lowest position. 3) 12/25/20, R2 was found sitting on the floor with her back against the bed and legs in front of her. R2 had her call light in her hand, but had not activated it. R2 was fully clothed and wearing her walking shoes. The fall was unwitnessed, and she had no injuries, R2's walker was out of her reach. The notes indicated R2 had decided to walk to her recliner on her own without the use of her walker. R2 felt unsteady and attempted to step back to sit on her bed but did not make it and fell . R2 landed on her bottom. The report identified the factors related to the fall included R2's walker was out of reach, and R2 had not called for assistance. The report did not identify any revised interventions to help prevent future falls. According to the interdisciplinary team (IDT) notes dated 1/2/21, the IDT team reviewed R2's fall from 12/11/20, and identified R2 had no new illnesses and was stable. The review indicated R2 had been on isolation related to COVID exposure, but had no changes to her medications and environmental issues were not a concern. The IDT identified R2 required assistance of one staff and was able to transfer independently according to her wishes. As a result of the review, a sign was placed in R2's room to remind her to ask for assistance. According to the IDT notes dated 1/26/21 at 10:20 a.m., the IDT reviewed R2's falls from 12/21/20, 12/25/20, and R2's fall from 7/30/20. R2's risk factors were identified to include R2 was unsteady and used the wheelchair for mobility. R2 required limited assistance for transfers and ambulation, and had complained of being dizzy at times. R2's orthostatic vitals were being monitored for three days. The IDT determined medications and environment had not contributed to R2's fall. Education was provided to NA-D regarding use of the Kardex and how to ensure provision of assistance required by resident care plans. 4) 1/30/21 at 4:40 p.m., 8 days after R2 had fallen, requiring staples to her scalp, R2 was found on the floor in the center of her room. R2 reported to staff she'd attempted to transfer to the bathroom and lost her balance. R2 denied hitting her head and sustained no injuries. R2's post-fall assessment identified R2 had limited mobility and gait imbalance. R2 had bladder incontinence and had used her walker without assistance to get to the bathroom. After the fall, R2 was reminded to use the call light to call staff for assistance. A post fall review by the IDT dated 2/3/21 at 10:20 a.m., indicated the IDT had reviewed R2's fall and those from 1/22/21, 12/25/20, and 12/21/20, but found no specific patterns to the falls. As a result of the IDT review, R2 was to be reminded to ask for assistance. There was no indication the facility identified R2 required increased supervision. 5) 2/1/21 at 1:15 a.m., R2 was found sitting on the floor by her bed. R2 reported she had a nightmare and slid out of bed. R2 was assisted back to bed after assessment revealed no injuries were found. A fall mat was then placed at her bedside, and the bed was placed in the lowest position. On 2/3/21 at 10:25 a.m., the IDT team reviewed R2's fall with her previous falls. The IDT identified R2 required limited assistance with transfers and had severe arthritis in her right knee, but found no specific patterns to R2's falls. The IDT identified R2 frequently used the call light for assistance, had no new medications, and there were no environmental factors contributing to the falls. R2 had no injuries and orthostatic vitals were completed for three days. There was no indication staff had identified the need for increased supervision. R1's 12/30/20, Minimum Data Set (MDS) identified R1 had poor cognition. R1 had delusions and hallucinations and wandered. R1 required extensive assistance of one staff for bed mobility, transfers, walking in her room, hallways, and corridors. R2 also required supervision while moving through the facility. R1 used a walker and wheelchair. She was unsteady and only able to stabilize with staff assistance to stand from a seated position and while turning to face the opposite direction while walking. R1 was able to walk without human assistance. R1's diagnoses included Alzheimer's disease, Major Depressive Disorder, dementia, [CONDITION(S)], repeated falls, and type 2 diabetes with [CONDITION(S)]. Review of the 3/4/21 at 9:42 a.m., report filed to the SA identified R1 was found on the floor of her room on 3/3/21, at 11:45 p.m. R1 sustained injuries of a 4 centimeter (cm) by 1 cm laceration above her left eyebrow, and large hematoma (bruise with swelling) on her forehead. The nurse immediately contacted the emergency department (ED), and was instructed to provide ice to the hematoma, and monitor R1's neurological status, and vital signs through the night. R1 was assisted to bed with the bed in the lowest position with mattress was placed next to the bed. R1's neurological status was monitored, and safety checks were completed every 15 minutes. The next morning, R1 was transferred to the ED the morning of 3/4/21, for evaluation of her head injury. Review of the 3/8/21 at 4:17 p.m., 5-Day investigation report submitted to the SA identified R1's nurse notes, incident report, reporting policies, physician orders, diagnoses, and ER report were reviewed. R1's care plan was noted to have been followed at the time of the incident. The cause was determined to be R1 had attempted to transfer without assistance. R1 fell , and struck her head resulting in a 4 cm x 1 cm laceration above her left eye. R1 neurological status, vital signs were assessed, and the ED contacted. Instructions given by the ED were to continue monitoring R1's neurological status and vital signs and apply ice to the hematoma. During the night, R1 refused ice packs, and R1's facial swelling worsened. R1 was sent to the ED on the morning of 3/4/21, to evaluate excessive swelling. R1 received an order for scheduled Tylenol for pain management. R1 had a history of falls with similar incidents on 10/10/2020, which resulted in a thumb fracture, and on 10/19/20, R1's fall resulted in a head injury that was evaluated at the ED. R1's 3/4/21, ED report identified R1 sustained no fractures from the fall. R1's Risk management reports identified between 9/1/20 and 3/10/21, R1 had 19 falls. On 10/19/20, R1 had one fall resulting in major injury. R1's 3/10/21, care plan identified R1 had a history of falls, dementia, and impaired cognition. R1 was at high risk for falling. R1 required limited assistance of one staff, a gait belt, and a walker to ambulate, toilet, transfer, and toilet. R1's fall interventions included to have staff have one to one observation with nursing staff was restless, and one to one with activities. Staff were to provide safety checks approximately every 15 minutes. R1 was to remain in line of sight in the dining room. R1 had anti-back brakes on the wheelchair. Staff were to assure R1's brakes were unlocked when in the wheelchair. R1's call light was to be kept in reach, clipped directly to her shirt, not the wheelchair. R1 was to have adequate lighting, and her room door always open. When R1 was restless, staff were to attempt distraction techniques, offer word search books, to find a show on R1's sensory screen, engage in conversation, and offer R1 an activity blanket. R1 required assistance of one staff to stand. Staff were to assist R1 to stretch and toilet hourly while awake and, ambulate R1 in the hallway. R1 was able to have compassionate care visits. While in bed, R1 wore gripper socks. R1's bed was to be in the lowest position with a fall mattress at the bedside. Staff were to toilet R1 at 11:30 p.m., 12:30 a.m., 2:30 a.m., and 4:30 a.m. Observation and interview on 3/10/21 at 3:17 p.m., of R1 identified R1 was in her room seated in her wheelchair. R1 had anti-back brakes on the back of her wheelchair. R1's call light was fastened to the arm of the wheelchair. R1's face had blotches of purple bruises with yellow margins scattered across her forehead and cheeks. Purple discoloration was observed in her laugh lines and along her jaw line. A scabbed area was identified on her left eyebrow. R1 was calm and alert. A bedside table was placed in front of her with a magazine and word find book. R1's television was on. R1 was unable to recall falling and was unsure why she had bruises on her face. Observation and interview on 3/11/21, at 11:45 a.m., with NA-C and R1 identified R1 was in the dining room being assisted to eat by NA-C. R1 was tired and nodding off during the meal. NA-C assisted her to her room and assisted R1 to bed. R1's bed was lowered to the floor and the mattress was placed at bedside. R1's call light was placed on the mattress next to R1. An interview with NA-C identified R1 had episodes when she was very active, trying to pick things off the floor and wandering, and times when she was completely lethargic. Interview on 3/11/21 at 12:57 p.m., with LPN-B identified R1 was up very early. R1 had been active for the past few days. Staff tried to regulate her sleep cycle, but R1 only became agitated. R1 sometimes became agitated when staff were with her one to one, if one to one's agitated her, staff were to keep her in line of sight. R1 was supposed to have one to one and distance supervision, staff tried to communicate with each other to ensure R1 had appropriate supervision, however, when the TMA was passing medications and supervising R1, R1 was left outside the door when passing meds. It was not a perfect situation, but staff worked with what they had, and TMA-A felt R1's care was covered. Interview on 3/11/21 at 1:30 p.m., with LPN-A identified on 3/3/21, he worked the night shift with two nursing assistants (NA)-A and NA-B. Each NA was assigned to a separate wing. During the shift, R1 was her usual self. She was confused, active, talkative, and picking at magazines. R1 was active, wheeling herself around the hallway looking for children. When the NAs were busy, R1 was placed at the East wing nurse's station with LPN-A to try to keep her in line of sight. Prior to the fall, several call lights were on. NA-A and NA-B were in rooms with residents. LPN-A remained at the with R1. NA-A needed assistance in an unidentified resident's room. NA-B was in the other hallway assisting residents. LPN-A was the only staff available to assist NA-A. LPN-A left R1 unsupervised, outside the unidentified resident's room and closed the door. LPN-A asked R1 to wait outside the door. When LPN-A left the room to get linen, R1 was no longer waiting at the door. LPN-A passed R1's room to get linen and observed R1 sitting in her wheelchair by her dresser behind the door. LPN-A passed R1's room a second time and had not observed R1 because the door blocked his view. LPN-A returned to the nurse desk. LPN-A did not check on R1 or bring her back to the nurse's station. Between 5 and 10 minutes later, NA-B reported R1 was on the floor. LPN-A had not checked to see if R1 was offered the toilet. R1 had a hematoma on her forehead and a laceration on her eyebrow. LPN-A assessed R1's neurological status and cleansed the wound and immediately called the ED. LPN-A was instructed to apply ice to R1's hematoma and to continue to monitor her neurological status through the night. R1 was brought to the nurse station An ice pack was applied to the hematoma, and R1 was monitored. R1 was assisted to bed around midnight. R1 refused to allow ice packs, during the night. R1's swelling worsened, and she was sent to the ED in the morning. Historically, R1 had times of restlessness, and she would wander the hallways, and enter other resident's room. R1 had a history of falls. Many interventions were attempted such as 1:1 supervision when she was restless. R1 refused one to one interaction sometimes. When R1 was not receptive to 1:1 supervision, staff were to keep R1 with the nurse at the nurses' desk or with the person passing medications. When all staff were pulled into resident rooms, R1 was not always directly supervised. Interview with on 3/11/21 at 2:45 p.m., with trained medication aid (TMA)-A, identified R1 was frequently restless, and hallucinated. When she was alert, she was often active and attempted to transfer without assistance and pick items up off the floor. R1 had many interventions, including keeping her within staff's line of sight when she was restless. Staff also were to monitor her every 15 minutes, when she was restless, R1 was placed with the TMA on the med cart or with the nurse when NAs were busy. R1 was often left unsupervised while passing meds. Staff did what they could to keep R1 in line of sight, but when passing meds, sometimes R1 was not always in line of sight when they had to enter rooms. Interview on 3/11/21 at 3:05 p.m., with registered nurse (RN)-A identified she had investigated the R1 and R2's falls. R1 had an extensive history of falls. All investigation notes were provided with the SA reports and IDT follow-ups were included in the nurse notes in the electronic medical records. R2's fall investigation identified NA-D had not provided appropriate supervision for R2 at the time of the fall and was provided re-education regarding resident assistance and following the care plan. R2. R2 had a history of not calling and not using her walker to ambulate at the time of her falls. R2 was supposed to use her walker according to her care plan. R2's falls were evaluated during IDT meetings. NA-B agreed no patterns were identified regarding R2's falls. RN-A agreed a more thorough investigation of the falls could determine staff had no ensured R2's walker was within reach. R1 had fallen in October 2020, and fractured her thumb. R1 was a busy lady and had a history of wandering. Many interventions were implemented, and supervision was the most effective intervention. R1 was not always receptive to one-to-one supervision, so staff were to keep R1 in their line of sight. Review of the circumstances of R1's fall on 3/4/21, identified R1 was left unsupervised during care for another resident, and had not checked on R1 before returning to the nurses' desk. RN-A had not included this information in the investigation report and agreed staff could have checked R1 in her room before returning to the nurse desk, offered her the toilet, and brought her to the desk for closer observation. She also agreed R1's care plan was not followed during the time of the fall, and IDT had not identified this as a factor of R1's falls. Review of the staff education documentation with RN-A identified education was not provided to all staff after any of R1 or R2's falls. Interview on 3/11/21 at 3:14 p.m., with the administrator identified falls were reviewed at the weekly interdisciplinary team meetings (IDT). R1 had an extensive history of falls and had fallen less recently. R1 had sustained injuries from her falls and had interventions in place to ensure R1's safety. Review of R1's fall on 3/4/21, identified staff had left R1 out of line of sight while providing another resident's care. After providing care, and before returning to the nurse station, staff had not observed R1 to see if she was still restless. The administrator was unsure what else could have been done at the time R1 fell but agreed staff should have checked on R1 after cares before returning to the nurse desk to see if R1 was restless, and if she was, staff should have continued to supervise R1 at the nurses' desk. The administrator agreed the IDT fall reviews had not identified any other instances of the care plan not being followed and agreed a more thorough root cause analysis during IDT was needed to identify fall trends. When trends were identified, education should be provided to all staff. Review of the March 2019, Fall Prevention policy identified the policy purpose was to provide a systematic way for the IDT to prevent, monitor, and assess resident falls in the facility. A post-fall analysis was to occur by the IDT to determine the cause of a fall to prevent future falls. The policy suggested several modifiable fall risks to consider but made no mention of staff supervision as a modifiable risk. There was no indication the policy was reviewed annually. Review of the facility's policy, Accidents and Incidents-Investigating and Recording policy dated 3/21/19, identified the charge nurse, department supervisor, or director must conduct a fall scene investigation including the circumstances surrounding the incident, corrective action taken, and follow-up information. Review of the facility's undated policy, Falls-Clinical Protocol, identified as part of the assessment and recognition; staff were to define possible causes for the fall within 24 hours of the fall. Causes referred to factors associated to or directly resulting in a fall. There may be multiple factors in varying degrees contributing to a falling problem. Staff were to evaluate, and document falls and include when and where the fall occurred and any observations of the events. The facility staff and physician were to continue to collect and evaluate information until either the cause of falls was identified, or it was determined no cause was able to be found, or that finding a cause would not change the outcome or the management of falling and fall risk. When underlying causes were not readily identified or corrected, staff were to try various relevant interventions, based on the resident's fall assessments until falling reduces or stops, or until a reason was identified for its continuation. There was no indication whether the policy was reviewed annually.

Based on observation, interview and document review the facility failed to have an appropriate infection control surveillance program that was completed daily, ongoing and comprehensive, and also failed to ensure appropriate use of eye protection (PPE) while providing direct care for 1 of 1 resident (R4). In addition, the failed to identify diarrhea as a sign and symptom of COVID 19 and immediately isolate 1 of 3 residents (R2) in accordance with with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19. This had the potential to affect all 25 residents residing in the facility. Findings include: SURVEILLANCE / PPE Observation on 12/15/20 at 10:05 a.m., of nursing assistant (NA)-A identified she had a mask on but her eye protection was resting on top of her head, not covering her eyes. R4 was in her room, sitting in wheelchair with oxygen in place and began coughing NA-A entered the room approached R4, touched her back and leaned down in front of the residents face. NA-A asked R4 if she was ok and stayed with her and within 1-2 feet of R4's face as she continued to cough for 1 minute. R4 had no further coughing and NA-A exited the room. Observation and interview on 12/15/20 at 10:12 a.m., with NA-B identified she was observed standing at the nurses station with no eye protection in place. Interview on 12/15/20 at 10:15 a.m. with NA-A and NA-B, identified staff were to wear a medical mask and eye protection whenever in resident rooms. Both NA's confirmed they had not worn appropriate PPE while providing direct care or on the medical unit. Review of the October through December 2020, monthly infection control data lacked evidence of a comprehensive collection of infection data or a comprehensive analysis of data. An antibiotic stewardship log was completed for infections that required antibiotic use. No other infections were tracked on the log. The infection preventionist (IP) provided a separate list, not included in the surveillance she identified as an isolation list. The list had information from 4/2/20 through 12/14/20, and included if a resident was placed on isolation from COVID, symptoms noted, and when they were removed from isolation. However, it failed to identify any other potential [MEDICAL CONDITION] infections which were not COVID positive, or had been treated with antibiotics. Interview on 12/17/20 at 11:57 a.m., with IP identified The above mentioned IC data provided was all the data that was available regarding surveillance of infections. There were no [MEDICAL CONDITION] infections, except those marked COVID positive identified to have occurred in the facility since March . Any infection information was listed on the antibiotic stewardship form or the COVID isolation log. Infection tracking, trending, and analysis was to be done at the end of the month. It was not daily, ongoing, or cumulative or included any undiagnosed [MEDICAL CONDITION] symptoms or infections not treated with antibiotics. She had not filled in the facility's formal Infection tracking and trending logs as per policy. Interview on 12/17/20 at 12:40 p.m., with the director of nursing (DON) identified she was unaware the infection tracking and trending logs were not being completed. Her expectation was they would be completed and kept current on a daily basis with a comprehensive collection and analysis of that data. She agreed, all infections, especially those [MEDICAL CONDITION] in nature or not treated with antibiotics needed to be included on surveillance so potential infections could be tracked in the facility. Staff was to wear eye protection at all times when working with residents and had been previously educated regarding eye protection. No audits of PPE wear or infection surveillance monitoring was provided. Interview on 12/17/20 at 2:39 p.m., with the administrator identified staff had been educated to wear eye protection whenever within 6 feet of a resident. He was unaware the infection tracking and trending logs were not being completed, along with analysis of data. His expectation was a comprehensive collection of infection tracking, trending, and analysis of data was to be completed daily, ongoing and be cumulative to identify potential infections from spreading as per the policy. Review of the 5/6/20, Eye Protection for All Staff education policy and procedure identified staff who have direct contact within 6 feet of a resident were to wear eye protection. Review of the 2017, Infection Prevention and Control Program Manual Surveillance policy identified the the intent of the program was to prevent, recognize, and control the onset and spread of infection to the extent possible. The program must include an ongoing system of surveillance to identify possible communicable disease or infections before they can spread to other persons in the facility. The facility was to have a facility wide system for the prevention, identification, investigation and control of infections of residents, staff, and visitors. The infection preventionist was to collect, analyze and provide infection data and trends. She was to then utilize the information collected to analyze the data to identify opportunities for improved care and process and identify an action plan for follow up and corrective action and reporting.

Based on interview and record review the facility failed to failed to ensure residents were free from accident hazards for 1 of 3 residents (R1) when a staff used a four-wheeled walker as a transportation device. The resident fell from the four wheeled walker and sustained a head injury that resulted in harm. The facility had implemented corrective action 7/3/19, so the deficient practice is being issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set assessment dated [DATE], identified R1 had a [DIAGNOSES REDACTED]. A progress note dated 7/2/19, revealed while R1 was on an outing with activities, the resident had fallen and hit her head. The fall was witnessed by nursing assistant (NA)-A. R1 was transferred to the local emergency room and then transferred to the St. Cloud Hospital for assessment of a potential subarachnoid and subdural bleed (bleed in the membrane space that surrounds the brain). Family was notified. The local emergency room record was reviewed and identified R1 had a CT (computed tomography, a scan which allows doctors to see inside the body) with findings that showed a small amount of traumatic subarachnoid hemorrhage in the left frontal sulcus and a small area of subdural hemorrhage along the free margin of the anterior falx. R1 was then sent to the St. Cloud Hospital. The neurosurgery progress notes dated 7/2/19, revealed mild to moderate generalized cerebral atrophy, scalp soft tissue swelling, negative for acute hemorrhage or definite [MEDICAL CONDITION](stroke). R1 was admitted overnight for observation for status [REDACTED]. NA-A was interviewed on 7/10/19, at 2:06 p.m. NA-A said the activity outing on 7/2/19, involved a lot of walking and NA-A was with R1 who used a four wheeled walker. There were three buildings that NA-A and R1 walked to and at the third building R1 told NA-A that she was cold and wanted to go outside. NA-A and R1 went outside to a parking lot between all the buildings and R1 sat on the platform of the four wheeled walker. When it was time to go to another building for lunch, R1 told NA-A that she was tired of walking and was not going to walk and NA-A should push her on the walker. NA-A said she looked around and there was no other staff that she could get a hold of to come and assist her and R1. NA-A said she knew it was wrong to push R1 on the walker but was afraid that if she left R1 alone, to go and get assistance, R1 was confused and could have walked off or fallen. NA-A said R1 sat on the walker and faced NA-A as NA-A pushed R1 backwards on the walker, she went very slow, hit an even part of the ground, and R1 fell backward and hit her head. NA-A attempted to catch R1 but was unsuccessful. Although the facility failed to ensure R1 was free from accident hazards, and R1 sustained an injury requiring hospitalization , the facility had immediately revised policies and corrective actions as of 7/3/19. Corrective action was immediately taken with NA-A, and all other staff were also educated, regarding the safe use of a four wheeled walker, and that transportation of any resident seated on a walker was not allowed as of 7/3/19. In addition, the facility updated R1's care plan to include the proper use of her walker (not to be used to sit on push with R1 on it), and all staff were informed of the revision. The activity and nursing department staff modified protocols to ensure wheelchairs were available for any upcoming outings. The facility's corrective action was verified during the onsite survey on 7/10/19 as having been in place as of 7/3/19, therefore, this deficient practice is being cited at Past Non-compliance.