Every finding on record at Covenant Living of Golden Valley Care & Rehab CTR

Based on interview and document review, the facility failed to discuss discharge instructions with resident and resident representative upon discharge for 1 of 3 resident (R1). Additionally, the facility failed ensure correct disposition of medications for 2 of 3 residents (R1) when R1 received R2's medications upon discharge. Findings include: R1's face sheet, undated, indicated admitted to the facility of [DATE]. R1's diagnoses included atrioventricular block and unspecified diastolic (congestive) heart failure. R1's Minimum Data Set (MDS) dated [DATE], identified intact cognition and no verbal behaviors during the assessment period. R2's face sheet, undated, indicated admitted to the facility of [DATE]. R1's February 2025 Medication Administration Record (MAR) did not indicate administration for sulfamethoxazole or lisinopril. R2's February 2025 MAR indicated administration for sulfamethoxazole 800 milligrams one tablet oral two times daily and lisinopril 20 milligrams one tablet by mouth two times daily. Facility form titled Discharge Sending Medications Homes dated [DATE], indicated sulfamethoxazole 800 milligrams one tablet oral two times daily was listed on R1's form. Lisinopril pharmacy sticker was not visible on form. Discharge Sending Medication Home indicated, I certify the medication listed (pharmacy card stickers) above are released to me, with R1's signature and dated [DATE]. The form failed to have evidence of a witness/nurse signature. During interview on [DATE] at 1:21 p.m., assistant director of nursing (ADON) stated their discharge process included a review of medications with the resident and to answer any questions. ADON was not aware of any medications sent home with the wrong resident and if this were to occur, management should have been notified. During interview on [DATE] at 2:42 p.m., registered nurse (RN)-A stated he worked on the transition care unit at the facility and completed discharge process with the residents. RN-A stated he did not recall completing R1's discharge. RN-A denied sending R2's medication, sulfamethoxazole home with R1, discovering the error later, and then ordering more sulfamethoxazole for R2 later. RN-A stated if an error like that occurred, he would contact his supervisor. During interview on [DATE] at 3:49 p.m., pharmacist (Pharm) stated on [DATE] there was a request by the facility to fill R2's sulfamethoxazole and the facility would be responsible to pay for the additional medications. Pharm stated the facility reported to have used their emergency kit supply of sulfamethoxazole until requesting more on [DATE]. Lisinopril was not reordered but no doses were verified to be omitted for R2. During interview on [DATE] at 4:02 p.m., director of nursing (DON) stated they were not aware of the medication errors until this survey. DON indicated he believed RN-A knew of the error as was the one who ordered more medications for R2, and had not received authorization before ordering. DON stated upon discharge the nurse was to review the discharge paperwork, including the medications that were being sent home with the resident (and/or resident representative). He indicated this was likely not done as the medication disposition error would have been caught at that time if the process was followed. DON added, during their investigation, when reviewing R1's discharge records, the medication sticker for R2's sulfamethoxazole was included in R1's record, solidifying the error. Review of R1's discharge paperwork lacked evidence RN-A discussed discharge paperwork and medications with R1 and family. Additionally, no RN signature was found on the Recapitulation of Stay records. During interview on [DATE] at 2:47 p.m., R1's family member (FM) stated no discharge paperwork or medications were reviewed at the time of discharge. Upon R1 returning home it was discovered another resident's medications (sulfamethoxazole and lisinopril) were sent home with her. FM recalled R1's medications were handed over from RN-A to the family in a bag. FM indicated a serious concern related to this error as, if his mother would have taken these medications, it could have caused her significant harm. Facility policy titled Adverse Consequences and Medication Errors, revised date ,d+[DATE], indicated a procedure was to review the resident's medication regimen for efficacy and actual or potential medication -related problems on an ongoing basis. Monitor the resident for medication-related adverse consequences when there is a medication error (wrong or expired medication). In the event of a significant medication-related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare. Promptly notify the provider of any significant error. Facility polity titled Transfer or Discharge, Resident-Initiated, dated ,d+[DATE], indicated medical record would contain documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, discharge care plan and document discussions with the resident or representative, containing details of discharge planning and arrangements for post-discharge care.

Based on interview and record review, the facility failed to maintain confidential clinical records for 2 of 3 residents (R1 and R2) when two of R2's Pharmacy Cards were sent with R1 who was discharging home. Findings include: R1's Minimum Data Set (MDS) dated [DATE], identified intact cognition. R1's February 2025 Medication Administration Record (MAR) did not indicate an order for sulfamethoxazole or lisinopril. R2's MDS dated [DATE], identified intact cognition. R2's February 2025 MAR indicated an order for sulfamethoxazole 800 milligrams one tablet oral two times daily and lisinopril 20 milligrams one tablet by moth two times daily. R2's pharmacy card identified protected information such as his first name, middle initial, last name, his doctor's name and information, the medication and prescribed route/dosage and what the medications were prescribed for (high blood pressure, antibiotic for infection). R2 is protected by the Health Insurance Portability and Accountability Act (HIPPA) which includes protected health information includes medical history, test information, and any personally identifiable information. The 18 HIPPA identifiers include patient names, geographical elements, dates related to health or identity, telephone numbers, social security numbers and more. During interview on 5/7/25 at 1:21 p.m., assistant director of nursing (ADON) stated upon discharge the nurse was to review medications with the discharging resident and or representative; ADON was not aware wrong medications was discharged with the wrong resident. During interview on 5/7/25 at 2:42 p.m., registered nurse (RN) denied sending R1 home with R2's medication. During interview on 5/7/25 at 4:02 p.m., director of nursing (DON) stated they were not aware a resident was discharged with another resident's medications but was able to verify R2's medication sulfamethoxazole pharmacy card sticker was in R1's discharge record. During interview on 5/9/25 at 2:47 p.m., R1's family member verified and provided pictures of R2's medication sulfamethoxazole and lisinopril which was sent home with R1 upon discharge.

Based on interview and document review, the facility failed to ensure physician-ordered medication was acquired and provided in a timely manner to reduce the risk of pain and complication for 1 of 1 resident (R1) reviewed whose pain medication was sent from the pharmacy however, was never provided as ordered. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact had medically complex diagnosis, surgical wound with surgical wound care, ulcerative colitis (an inflammatory bowel disease that causes chronic inflammation and ulcers in the superficial lining of the large intestine). Identified R1 required assistance with activities of daily living (ADL's) had mild pain, which was occasional and occasionally affected sleep. R1's Care Plan dated 2/04/25, indicated R1 had chronic pain syndrome, alteration in comfort and pain related to PMR (Polymyalgia rheumatic, inflammatory condition. It causes joint and muscle pain and stiffness, mainly in the shoulders and hips) chronic pain, abdominal pain secondary to sigmoid colectomy. R1's care plan directed staff to assess location, quality, and intensity of pain as indicated, receive opioid medication as ordered, assess for non-pharmalogical interventions, occupational therapy to provide and assist, Methocarbamol for pain/muscle spasms. R1's Admission Orders dated 2/04/25, indicated R1 was to receive gabepentin 4%/lidocaine 2% gel topical gel (used for pain) apply two times a day. R1's Medication Administration Record dated February 2025, indicated R1 had not received the scheduled gabapentin 4 % - lidocaine 2% gel twice daily from 2/04/25 through 2/13/25 (over nine days). During an interview on 2/26/25 at 10:20 a.m., R1 stated she admitted to the facility on [DATE], and was to receive her pain gel with lidocaine and gabapentin for several days after admission. R1 stated she used the gel on her right hip and shoulder for pain relief and it helped her sleep. During an observation and interview on 2/26/25 at 1:20 p.m., registered nurse (RN)-B stated the gabepentin/lidocaine gel was not available at the facility for R1. RN-B stated she knew the DON called the pharmacy about it and they documented it was unavailable on the medication administration record (MAR). During an interview on 2/26/25 at 4:30 p.m., the director of nursing (DON) stated he was aware of the gel cream and was informed by their pharmacy at first it was delivered on 2/04/25, and he searched all of the medication carts and was unable to find the gel. The DON then stated he called the pharmacy and was told they were unable to make the compound with the lidocaine and gabapentin. The DON stated he had frustrations with the pharmacy and was planning to have a meeting with them to discuss his concerns. The DON stated the process was for the staff to call the pharmacy if they had not received a medication and the facility had a back-up pharmacy to call as needed. DON stated the system did not work as planned. During an interview on 2/27/25 at 10:10 a.m., R1's nurse practitioner stated she was never informed R1 had not received her gel pain cream for over nine days and had she been informed, she would have checked to see if it was an insurance issue or ordered some other pain cream for her hips and shoulders during that timeframe. During an interview on 2/27/25 at 10:51 a.m., pharmacy director (PD) stated the gel was shipped to the facility on [DATE], the tracking form indicated it was filled on 2/04/25, at 5:20 p.m. and loaded in the bin and the only re-fill seen on their end was noted to be on 2/25/25, which would be delivered today. The PD stated they received the original order from the hospital R1 discharged from and their compound book indicated it was made at their pharmacy on 2/04/25. PD stated they had an electronic manifest with a staff nurse signature who signed for the medication on 2/04/25, at the facility. A policy was requested prior to exit of survey however,was not received.

Based on observation, interview, and document review, the facility failed to ensure the multidisciplinary team was involved for 2 of 3 residents (R111and R257) reviewed for self administration of medications(SAM). Finding include: R111's face sheet undated, indicated R111's diagnoses included chronic obstructive pulmonary diease (COPD) and a personal history of pulmonary embolism. R111's admission Minimum Data Set (MDS) dated [DATE], indicated R111 was moderately cognitively impaired, independent with eating after set-up, and required extensive assistance with the rest of his activities of daily living. During initial observation and interview on 8/28/23 at 1:20 p.m., two inhalers were noted at bedside. One on the over the bed table (OBT) to his right and one the bed side chest of drawers to resident's left. The inhaler on the OBT was budesonide-formoterol (a bronchodilator) HFA 160 mcg-4.5 mcg, which had a faded prescription label with R111's name and directions. On the chest of drawers was an inhaler of Albuterol (PROAIR HFA - a bronchodilator) which lacked a label. R111 stated he had COPD and used them when he needed. An observation on 8/29/23 at 9:18 a.m., both inhalers were remained in the same locations as the day before. During an observation on 8/30/23 at 8:40 a.m., the inhalers were no longer in the locations previously observed. However, the chest of drawer's top drawer was open and both inhalers were noted inside. R111's Physician Order Report (print date of 8/30/23) indicated budesonide-formoterol HFA (hydrofluoroalkane - the propellant of the inhaler) 160 micrograms (mcg)-4.5 mcg/actuation aerosol inhaler(2 puffs) HFA AEROSOL WITH ADAPTER every day. R40's physician orders lacked evidence of R40's approval to self-administer medications. However, the report lacked orders for the Albuterol inhaler. R111's electronic medical record included a Assessment for Self-Administration of Medications assessment form (dated 8/14/23). However, the assessment form was blank and unsigned. On 8/30/23 at 9:24 a.m., unit manager (RN)-C verified two inhalers in R111's room. Further, RN-C stated R111 only had an order for the budesonide-formoterol HFA 160 mcg-4.5 mcg inhaler. R111 had cognitive issues, and he would not have been a candidate for self-administration. She was uncertain why a blank self-administration assessment had been entered into R111's medical record. RN-C thought a family member may have brought R111's inhalers into him. RC-C stated facility staff should have returned and reported to the nurse any medication left in a residents room. R257's face sheet, undated, indicated R257's diagnoses included acute respiratory failure, unspecified whether with hypoxia or hypercapnia. R257's admission MDS, still in progress, indicated R257 was cognitively intact and independent with eating. However required extensive assistance with the rest of her activities of daily living. During observation and interview on 8/28/23 at 2:31 p.m., R257 had an inhaler, with a spacer attached, on nightstand at bedside. The inhaler on the nightstand was albuterol (a bronchodilator), which lacked a label. R257 stated she used the inhaler when she needed it. An observation on 8/29/23 at 9:07 a.m., inhaler was in the same locations as the day before. R257's Physician Order Report (print date of 8/30/23) indicated albuterol sulfate HFA 90 micrograms (mcg)/actuation aerosol inhaler (2 puffs) HFA AEROSOL WITH ADAPTER every four hours as needed. R257's physician orders lacked evidence of approval to self-administer medications. R257's electronic medical record lacked an assessment for Self-Administration of Medications. On 8/30/23 at 8:29 a.m., RN-A verified the inhaler in R257's room. RN-A was unaware if R257 had a self-administration order and/or assessment. She went to unit manager RN-B for instruction. RN-B educated RN-A on the process, which consisted of completing the assessment on the computer. When a resident passed the assessment an order would need to be obtained from the provider before the resident could self-administer medications. During interview on 8/30/23 at 8:31 a.m., RN-B stated when a resident verbalized desire to self-administer medication any nurse could do the assessment and obtain an order from the provider. Once the order was received, a note would appear under the medication in the electronic medication record (EMR) indicating the resident could self-administer medication. RN-B confirmed R257 did not have a self-administration assessment completed and there was no order in the EHR from provider. During interview on 8/30/23 at 10:32 a.m., DON stated when a resident had told facility that they would like to self-administer any medications, a self-administer assessment would be completed by nursing and an order would be obtained from the provider. DON stated it was important for the assessment and order for self-administration were completed as the facility needed to make sure the resident was able to safely self-administer medications and understand the risks/benefits of the medications. DON stated it was a huge safety reason. In a review of the facility policy, entitled: Self Administration of Medications (reviewed February 2021), indicated the following: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident ' s cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self -administration; b. The resident is able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication; d. The resident comprehends the medication ' s purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. 48013

Based on observation, interview, and document review, the facility failed to ensure physician recommendations and orders were clarified and addressed to provide pain medication and promote comfort for 1 of 2 residents (R297) reviewed for pain management. Findings include: R297's Face Sheet, printed 5/12/22, identified R297 admitted to the transitional care unit (TCU) of the nursing home in early May 2022 from the hospital with an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R297's Individual Resident Care Plan, dated 5/3/22, identified R297's initial care needs upon admission to the nursing home. The section of the care plan labeled, Pain Control, identified R297 had actual pain in her right leg. However, the remainder of the section, including spaces to be pain management interventions, was left blank and not completed. On 5/9/22 at 6:37 p.m., R297 was seated in her wheelchair while in her room. R297's right leg was extended outward and R297 stated she was waiting for a heat pack from the staff as her pain is terrible in her right leg which stemmed from a fall prior to admission. R297 described the pain as pins and needles and voiced it extended down her leg into her ankle and toes. R297's Twin Cities Physicians SKILLED note, dated 5/9/22, identified R297 was seen by the physician assistant (PA) for her pain control at family' request. The note identified R297 reported poor pain control on 5/4/22, and her acetaminophen orders were changed as a result. R297's listed pain medications, as of 5/9/22, including acetaminophen 1000 milligrams (mg) three times a day and aspirin 81 mg daily for four week period. The note included dictation, Message from [R297's family member] . concerned about her pain control. Went to see [R297] again today and she reported her pain is okay when she is lying in bed but much worse when moving around . Discussed with [R297's family member], and we decided some low dose [MEDICATION(S)] [a narcotic medication] would help her participate in therapies with less pain. Since she reported the pain is also bad in the middle of the night, will schedule a dose for bedtime. The note concluded with a section labeled, Assessment and Plan, which outlined several new recommendations including [MEDICATION(S)] 2.5 mg twice a day (every morning and bedtime) for seven days then consider a reduction. However, R297's corresponding Twin Cities Physicians order sheet, dated 5/9/22, identified the (PA) orders from the 5/9/22 visit. These included: 1) [MEDICATION(S)] 4% patches to be applied to R297's right hip for 12 hours, then removed for 12 hours; 2) [MEDICATION(S)] topical gel 1% (an anti-[CONDITION(S)] medication) applied to the right hip four times a day; and, 3) Apply ice to the right hip in 20 minute increments four time a day for three days. The completed physician orders did not include any orders for [MEDICATION(S)] despite being listed in the plan of the corresponding progress note by the PA, and despite having been reviewed and discussed with R297's family member to help R297 have better pain control and potentially participate better with therapies. The orders were dated with a handwritten 5/9/22 by the nursing home staff. R297's subsequent Resident Vital Sign Report (for pain), dated 5/10/22 to 5/11/22, identified R297 rated her pain between a 1.0 and 2.0 (on a scale of 0-10 with 10 being the worst rating). During subsequent observation on 5/10/22 at 2:11 p.m. R297 was lying in bed while in her room. R297's eyes were closed and she appeared comfortable with no obvious grimacing or physical signs or symptoms of pain present. When interviewed on 5/10/22 at 2:12 p.m. registered nurse (RN)-A stated he was assigned to care for R297 and explained she admitted to the nursing home with a hip fracture. R297 used a pain patch and Tylenol for pain relief, and RN-A stated there was no current order for [MEDICATION(S)]. RN-A reviewed R297's physician note, and corresponding physician orders, and stated the [MEDICATION(S)] was never started despite being listed on the note as the PA's plan to address R297's pain control. When discussing the process in place for nursing staff to review completed physician notes, RN-A stated he was unaware who, if anyone, was responsible to read the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated he was unaware if the note, and corresponding orders, were clarified with the PA to ensure the correct pain control was being implemented. RN-A stated the note and corresponding orders should have been clarified to remove confusing questions and ensure the actual plan was being done to provide comfort for the resident. When interviewed on 5/10/22 at 2:30 p.m. the registered nurse unit manager (RN)-C explained physician orders were received by the health unit coordinator (HUC) and then scanned into the electronic medical record (EMR). RN-C stated there was poor communication between the nursing home and medical provider group and often staff were never told of who was being seen. RN-C explained there was no staff assigned or directed, to her knowledge, to review incoming physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, RN-C stated it was important to ensure conflicting or unclear notes and orders were clarified to provide continuity of care to the patient and voiced this inconsistency and potential error would not have been identified had the surveyor not brought it to their attention. On 5/12/22 at 10:36 a.m. the interim director of nursing (DON) was interviewed and stated she had investigated the issue. The PA rounded and dictated the progress note after having a discussion with R297's family member, then sent the order for the [MEDICATION(S)] to the incorrect inbox which caused it to not be received by the nursing home. The DON stated she discussed the situation with the PA and neither of them believed R297 was harmed as a result of the incident; however, the PA wanted to still start the medication as intended and would review R297 in a few days to ensure adequate pain control was being implemented. The DON stated she reviewed the process for order and note scanning with the medical record personnel and moving forward, they were going to begin looking at notes and orders for inconsistencies. The DON stated it was important to ensure physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility' policy on pain management and/or physician order clarification was requested and not provided.

Based on observation, interview, and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) dressing was monitored and changed in accordance with the standard of care to reduce the risk of complication for 1 of 1 resident (R26) reviewed for intravenous (IV) care. Findings include: A National Library of Medicine (NIH) [MEDICATION(S)] Plus article, peer-reviewed 10/2021, identified a PICC as a long, thin tube inserted through a vein into the upper arm which . goes into a large vein near your heart. This helped to carry nutrients or medications into the human body or draw blood, if needed. A section of the article labeled, Dressing Changes, identified a dressing was used to reduce the risk of infection and keep the PICC insertion site dry and clean, directing You should change the dressing about once a week. R26's admission Minimum Data Set (MDS), dated [DATE], identified R26 had severe cognitive impairment and required extensive assistance with most activities of daily living (ADLs). Further, the MDS identified R26 received intravenous (IV) medication while a resident at the nursing home. On 5/9/22 at 3:47 p.m. R26 was observed lying in bed while in her room. R26 had a visible PICC line inserted into her right inner arm which was covered with a clear dressing. The insertion site was slightly red-colored and the dressing was intact with minor peeling around the perimeter; however, a piece of paper tape was present along the bottom of the dressing which read, 05/01/22 [eight days prior]. R26 stated she was getting antibiotics through the PICC and was not sure when it was going to be removed. Further, R26 stated she was unsure how often the staff were changing the clear dressing over the insertion site but denied any symptoms of potential infection (i.e., chills, fever, respiratory difficulty). R26's Standing Orders for Skilled Nursing Facilities, dated 1/6/21, identified a section labeled, IV Line Management, which directed, Initiate routine IV line and site care per facility protocol. R26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's subsequent physician order, dated 5/10/22, identified R26's infection had improved; however, R26 was to continue the IV antibiotics through 5/12/22 and have the PICC removed afterward. However, none of the reviewed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Geriatrics Follow Up Visit note, dated 4/11/22, identified R26 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The note identified on 4/8/22, R26 was found to have a DVT (deep vein [CONDITION(S)]) in her arm with the PICC, so she was sent to the emergency department (ED) to have another PICC placed due to requiring ongoing antibiotics. R26's Care Plan Report, printed 5/12/22, identified R26 had an active cranial infection and listed a goal of R26 having no signs or symptoms of active infection. The care plan listed several interventions to help R26 meet this goal including monitoring for antibiotic side effects, reporting worsening symptoms to the physician, and personal protective equipment, if indicated. However, the care plan lacked any recorded interventions or care direction for the PICC line despite R26 receiving IV medication through the device since admission to the nursing home over a month prior. During subsequent observation on 5/11/22 at 7:55 a.m., R26 continued to have the PICC line present in her right arm with a clear dressing. The clear dressing continued to have slight peeling present along the perimeter; however, the tape was now removed and the dressing had faint blue-colored, illegible writing on the bottom where the tape had been prior. Immediately following this observation, registered nurse (RN)-B knocked and entered R26's room to administer the scheduled antibiotic. RN-B was questioned on the PICC line dressing and voiced she had not changed it recently. When interviewed on 5/11/22 at 8:03 a.m. RN-B explained PICC line dressings were changed per the order provided from the physician. RN-B stated the dressing should technically be changed every three days for a standard of care; however, again reiterated they go by the specific physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-B reviewed R26's treatments and verified it lacked evidence R26's PICC line dressing had been changed. RN-B expressed she had noticed there was poor charting with IV line care, including dressing changes, and she raised the issue with the infection control and prevention nurse a few weeks prior; however, had not received any follow-up or new direction since then. Further, RN-B again stated the dressing should be changed in accordance with physicians' orders and documented in the medical record. If there were no orders, then the facility has to implement something to ensure it's changed and tracked. R26's medical record was reviewed and lacked any evidence the PICC line dressing had been changed after 4/8/22 when the new PICC was placed in the ED. On 5/11/22 at 9:03 a.m. the registered nurse unit manager (RN)-C was interviewed and explained PICC line dressings should be changed every seven days unless otherwise directed in the physician orders. R26 admitted to the nursing home with the PICC line in place and continued to receive IV antibiotics through it. RN-C stated with the dressing being first observed with a 5/1/22 date, it had likely been missed and not changed on the weekly basis it should be. Further, RN-C stated all PICC line dressing changes should be recorded in the medical record and it was important to ensure the dressing was actually being changed and recorded as the risk of infection is huge. When interviewed on 5/12/22 at 10:15 a.m. the infection control and prevention registered nurse (RN)-D stated the facility' policy was to change a PICC line dressing weekly and should be entered and recorded in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-D stated it was important to ensure the dressing was changed on a weekly basis to help reduce the risk of infection and added she could not recall any staff reaching out to her with concerns about IV management in the past weeks. Further, RN-D stated education was just provided to the nurses during a skills fair the month prior and, again, verified the dressing should be changed weekly. A provided Central Venous Catheter Dressing Changes policy, dated 4/2016, identified transparent, semi-permeable membrane dressing were to be changed every 5 - 7 days and as needed. The date and time of the dressing change, objective description of the insertion site, and and complications from the dressing change were to be recorded in the medical record.

Based on interview and document review, the facility failed to ensure weight monitoring was completed as identified on the care plan for 1 of 2 residents (R26) reviewed for weight loss. Findings include: R26's admission Minimum Data Set (MDS), dated [DATE], identified R26 had severe cognitive impairment and required extensive assistance with most activities of daily living (ADLs). During interview on 5/9/22 at 3:42 p.m., R26 stated she felt she was getting enough food and fluids and was working with speech therapy to help improve her swallowing. R26 voiced no concerns with unplanned weight loss or weight gain. However, R26's completed progress note, dated 4/29/22, identified the registered dietitian (RD)-A spoke with R26's family member who was concerned about R26 losing weight and muscle mass. The note outlined there had been no weight collected on R26 since admission on 4/12/22 and the newest weight entered was the exact same, at 269 lbs. The note identified, RD questions accuracy of 4/26/22 as weights typically show some fluctuation . spoke w/ [with] [family member] and resident, resident stated I think I've lost a little muscle and weight due to not moving as much . discussed w/ resident and daughter, recommend daily weights to obtain weight accuracy. Both parties agreed. Daily weights ordered 4/26/22 . MD [medical doctor] notified of daily weight request. R26's Care Plan Report, printed 5/12/22, identified R26 was at risk of impaired nutritional status and unintentional weight loss. The report listed several goals for R26 which included, Weight to remain stable 271 # [lbs] +/- 3% with no sig[nificant] wt [weight] changes, along with several interventions to help R26 meet these goals including, DAILY WEIGHT IN PLACE 4/26/22 FOR WEIGHT ACCURACY. However, R26's Resident Vital Sign Report, printed 5/12/22, identified R26's collected and recorded weights in the medical record. This included the following since the daily weights were ordered and/or care planned by the RD: 4/26/22 - 269.00 lbs. 4/27/22 - ADL Not Scheduled. 4/30/22 - ADL Not Scheduled. 5/3/22 - 252.60 lbs. 5/4/22 - ADL Not Scheduled. 5/4/22 - 253.00 lbs. 5/6/22 - ADL Not Scheduled. 5/11/22 - ADL Not Scheduled. There were no recorded weights, or documented refusals, for the remainder of the days not listed on the report. Further, R26's medical record was reviewed and lacked any further evidence these daily weights had been obtained and documented despite being requested and/or ordered by the RD and care planned on 4/26/22. When interviewed on 5/11/22 at 10:19 a.m., nursing assistant (NA)-A stated R26 had a good appetite and typically finished all her provided meals. NA-A stated she was aware R26 was on a daily weight, and explained it was supposed to be collected, recorded in the computer, and given to the nurse. NA-A added she was unaware if R26 had sustained any weight loss since she admitted to the nursing home. When interviewed on 5/12/22 at 9:44 a.m., registered nurse unit manager (RN)-C stated R26 was on a daily weight and the NA(s) should be obtaining it and recording it in the computer. RN-C added she believed it was happening but added, I don't know how consistent it's been. RN-C stated she was aware some orders for daily weights had not been completed and voiced she felt the nursing home was making strides in improving the collection and recording of them. When interviewed on 5/12/22 at 9:56 a.m., RD-A stated R26 was weighed and showed significant weight loss which resulted in the discussion with R26 and her family member and the recommendation to implement a daily weight to better monitor them. The order for daily weights started on 4/26/22 and RD-A verified, They [daily weights] have not been done consistently. Further, RD-A stated she felt, R26 was stable, getting enough nutrition and but the weights should have been completed. A facility policy on weight monitoring and/or weight management was requested but not provided.

Based on interview and document review, the facility failed to ensure as-needed (PRN) psychoactive medications were limited to 14 days of use or re-evaluated by the medical provider to ensure necessity and reduce the risk of complication for 1 of 5 residents (R26) reviewed for unnecessary medication use. Findings include: R26's admission Minimum Data Set (MDS), dated [DATE], identified R26 had anxiety disorder, depression and post-traumatic stress disorder ([CONDITION(S)]). Further, R26 displayed severe cognitive impairment, demonstrated no behaviors (including rejection of care or delusions), and required extensive assistance with most activities of daily living (ADLs). R26's Physician Order Sheet, dated May 2022, included [MEDICATION(S)] (an antianxiety medication) 30 milligrams (mg) twice a day, [MEDICATION(S)] (an antidepressant medication) 10 mg once a day, and [MEDICATION(S)] (an antianxiety medication) 0.5 mg twice a day as-needed (PRN). The [MEDICATION(S)] had a listed start date of 4/6/22. R26's Care Plan Report, printed 5/12/22, identified R26 . is receiving antianxiety drugs on a regular basis, and listed a goal for R26 which read, Symptoms of anxiety will be controlled with minimal side effects over the next 90 days. The care plan listed several interventions to help R26 meet this goal including providing activities, monitoring for side effects of the medications, and providing a quiet atmosphere. R26's April 2022 Medications report, dated 4/2022, identified R26's consumed medications for the month as signed out by the nursing home staff. This identified R26's [MEDICATION(S)] PRN order which identified it was administered once on 4/29/22 with the results being recorded, Pain = 05 - It was administered. There was no recorded anxiety symptoms or resolution on the report. In addition, R26's May 2022 Medications report, dated 5/2022, identified R26 continued to have an active order for the PRN [MEDICATION(S)], however, had received no doses in the month period thus far. However, both of these reports lacked any recorded or directed stops date for the PRN medication. R26's Interim Medication Regimen Review, dated 4/6/22, identified the consulting pharmacist had reviewed R26's physician orders and made several recommendations including, PRN [CONDITION(S)] orders needs a 14 day stop date. Then ask MD to re-evaluate continued need for the following medication(s): [MEDICATION(S)]. The completed report was signed on 4/22/22 by nursing home staff. However, R26's medical record was reviewed and lacked any recorded physician statements or clinical justification supporting the ongoing use of PRN [MEDICATION(S)] outside of the 14-day period since it was ordered on 4/6/22 (over 30 days prior). Further, there was no evidence the medication use had been extended outside of the 14-day required timeframe (i.e., 60 days) or had a stop date determined, despite the identified concern documented by the consulting pharmacist on their medication regimen review on 4/6/22. When interviewed on 5/11/22 at 1:21 p.m. registered nurse (RN)-B stated R26 did not display any anxiety or behavioral symptoms and described her as pretty calm and pleasant. RN-B reviewed R26's current medication orders in the electronic record and verified R26 continued to have PRN [MEDICATION(S)] ordered and available for administration. RN-B stated she was unsure when, or if, a stop date was determined for the medication. RN-B explained she was aware most PRN [CONDITION(S)]'s needed to be stopped or have new orders written after 14 days; however, she did not know the protocol for how [MEDICATION(S)] specifically was addressed. RN-B added, I didn't even know she was on [MEDICATION(S)] [[MEDICATION(S)]] to be honest. When interviewed on 5/12/22 at 9:46 a.m. registered nurse unit manager (RN)-C stated she had reviewed R26's medical record, and she acknowledged there was no stop date identified for the PRN [MEDICATION(S)] nor was there evidence it's use had been re-evaluated by the medical provider. As a result, RN-C stated they have a message out to the provider for it to be addressed. RN-C reviewed the completed medication regimen review, dated 4/6/22, and explained those reports were forwarded to the nurse managers to be addressed. R26's report was reviewed and signed by the physician; however, it lacked any written direction or associated notes on how to address the identified PRN [MEDICATION(S)]. RN-C stated it was important to ensure PRN [CONDITION(S)] were provided only when needed or discontinued timely to reduce the risk of a resident developing abnormal movements [tardive dyskinesia]. On 5/12/22 at 10:48 a.m. the interim director of nursing (DON) was interviewed. The DON explained the pharmacy recommendation was signed by the physician, however, the issue was not addressed as the physician never checked either box to indicate a response. As a result, they had just contacted the physician and obtained orders to discontinue the medication. The DON explained she had noticed some issues with medication management, including timely follow up on the consulting pharmacist reviews, since she started working at the nursing home and was actively working with the consulting pharmacist to get them resolved. However, the DON stated the PRN [MEDICATION(S)] should have been addressed with the medical provider or discontinued and explained they have to lean back on our providers to ensure orders or directions are given when the recommendations are made. A provided Medication Management policy, dated 1/2022, identified an unnecessary medication included any medication used for excessive duration and without adequate indication for use. The policy outlined, PRN orders for [CONDITION(S)] drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and document review, the facility failed to ensure conflicting directives and medical record entries for emergency care and treatment were clarified to ensure resident wishes would be implemented in an emergent situation for 1 of 2 residents (R293) reviewed for advanced directives. Findings include: R293's HealthPartners Discharge Summary, dated [DATE], identified R293 admitted to the hospital for right hip pain associated with a hip fracture and listed a discharge date of [DATE]. The summary listed a section labeled, Assessment/Plan, for R293's discharge which included, Code Status: DNAR [do not attempt resuscitation]. R293's electronic nursing home Face Sheet, printed [DATE], identified R293 had an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the Face Sheet identified R293's family member (FM)-D as their power of attorney (POA) and listed a section labeled, Advance Directives, which recorded, DNR - Do Not Resuscitate. However, located in R293's hard chart was an undated, signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The following section, B, outlined several options for medical treatments to be completed if the patient has a pulse or is breathing including, Full Treatment, and, Selective Treatment, and, Comfort-Focused Treatment (Allow Natural Death). This had a black-colored handwritten X placed next to the option which directed comfort-focused treatment which was in conflict with the POLST instructions from the previous section which directed selecting CPR required Full Treatment be selected. The POLST was signed by FM-D and a nursing home staff member; however, was unsigned by a medical provider. R293's medical record was reviewed and lacked evidence these conflicting documents were clarified with R293, or their POA, to ensure their correct wishes would be implemented if R293 was found without a pulse and/or not breathing. On [DATE] at 8:37 a.m. R293's FM-D stated R293 admitted from the hospital after a hip fracture and was in the late stages of dementia. As a result, the hospital team and FM-D elected to make R293 a DNR and just let her go if she was to stop breathing or be found without a pulse. FM-D stated he recalled talking to a nurse at the nursing home about this upon R293's admission, however, could not recall any education on the POLST. Further, FM-D stated he believed the nurse completed the POLST located in R293's chart and was unaware CPR (i.e., full code) had been checked. FM-D verified this was incorrect and R293 should be recorded on the POLST as a DNR. When interviewed on [DATE] at 9:37 a.m. registered nurse (RN)-A stated he was the nurse assigned to care for R293, and explained he had only worked at the nursing home a few weeks. RN-A stated if a resident would be found without a pulse or not breathing, then he would immediately review their face sheet for directions on how to respond (i.e., full code or allow death). RN-A stated he could not recall what location he had been directed or trained to check when he started at the nursing home, however, would review the face sheet strictly out of habit. RN-A explained if approached with R293 being found without a pulse or not breathing, he would check R293's face sheet which directed DNR and he would not implement CPR. RN-A then reviewed R293's EMR and completed POLST and stated those are conflicting, RN-A stated it was important to ensure advance directive information matches in all locations (i.e., EMR and POLST) otherwise, in the event of cardiac or respiratory arrest, the staff don't know what to believe. On [DATE] at 1:50 p.m. the interim director of nursing (DON) stated training with nurses was completed upon hire for POLST and the advance directive process. She acknowledged this process resulted in the information being kept in multiple places. The DON explained the POLST should be completed by the nurse upon admission, and if the resident has cognitive impairment then the family should be consulted for wishes. The form was then sent to the medical provider for signature. When a resident experienced cardiac or respiratory arrest and their POLST was unsigned, it should be cross-checked with their physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed R293's POLST and EMR and stated the conflicting documentation and records made it really not clear what R293's wishes were and she would ensure clarification from the family was obtained. A provided Advance Directives policy, dated ,d+[DATE], identified a resident's written advanced directives would be reviewed upon admission by the social services director or designee. If present, information about an advance directive was to be, . displayed prominently in the medical record. The policy outlined, the physician would provide information to the resident or legal representative regarding the resident's health status, treatment options and expected outcomes, and the resident had the right to refuse treatment adding, A resident will not be treated against his or her own wishes. In addition, an Emergency Procedures - Cardiopulmonary Resuscitation policy, dated ,d+[DATE], identified sudden cardiac arrest was the leading cause of death among adults and directed if an individual is found unresponsive and not breathing normally, CPR should be initiated unless obvious signs of clinically irreversible death (i.e., decapitated) or, . it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual. However, the policy lacked any further information or direction on where to check in the medical record for this information. Further, a provided Do Not Resuscitate Order policy, dated ,d+[DATE], identified CPR would not be used when a DNR order was in effect. These orders were to be signed by the physician and . maintained in the resident's medical record, using a state-approved form which included a POLST.

Based on observation, interview, and document review, the facility failed to ensure staff were wearing appropriate personal protective equipment (PPE), specifically eye protection per Centers for Disease Control and Prevention (CDC) requirements. This had the potential to affect all residents residing on the Fireside Unit. In addition, the facility failed to ensure proper hand hygiene when provided during care for 1 of 4 residents (R39) and failed to ensure proper hand hygiene was performed when handling oral medications for 1 of 4 residents (R9). Findings include: During observation on 4/20/21, at 1:19 p.m. nursing assistant (NA)-C and NA-D were observed on Fireside unit exiting resident room [ROOM NUMBER] wearing an isolation gown, gloves, and surgical mask, however NA-C and NA-D were not wearing eye protection. There were two signs posted outside of room [ROOM NUMBER]'s door indicating resident was on both droplet and contact precautions. In addition, there was an isolation cart outside of the door. On 4/20/21, NA-C stated room [ROOM NUMBER] was on isolation. She just came to the facility not long ago. We [staff] are required to wear a gown, gloves, mask when we [staff] are in the room. Further, NA-C stated we [staff] also wear eye protection. However, when asked why NA-C was not wearing eye protection, NA-C stated I can't see if I don't wear my glasses. I will fall. In addition, when asked why the use of proper PPE is important, NA-C stated even though [room [ROOM NUMBER]] does not have COVID-19, you [staff] have to use protection On 4/20/21, at 1:40 p.m. NA-D indicated when a resident is newly admitted to the facility, the resident is placed on a 14 day quarantine. When asked what PPE is required to be worn in room [ROOM NUMBER], NA-D stated gown, mask, gloves and a faceshield. I have a faceshield, but I left it in the breakroom and forgot it in there from break. NA-D stated the importance of wearing the appropriate PPE is protect yourself if the person [resident] has it, you [staff] shouldn't come in contact with it. On 4/20/21, at 1:53 p.m. NA-C continued to not have eye protection on, in resident care areas. On 4/20/21, at 2:44 p.m. registered nurse (RN)-B indicated when a resident is newly admitted to the facility, the resident is placed on a 14 day quarantine. RN-B stated we [staff] have to wear gloves, gown, mask, goggles or a faceshield when providing cares. In addition, RN-B indicated staff were expected to wear eye protection and if staff have prescription glasses then there are bigger goggles that go over them or the face shield. The prescription glasses don't substitute for the goggles. Facility document titled Coronavirus- (COVID-19) dated 4/16/20, indicated Full PPE should be worn per CDC [Centers for Disease Control and Prevention] guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. Further review of facility document, indicated PPE includes: gloves, isolation gowns, facemasks and eye protection that covers both the front and sides of the face. CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic dated 2/10/21, eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions. Further review of CDC guidance, states the PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: respirator, eye protection, gloves, and gowns. During an observation on 4/21/21, at 7:30 a.m. resident room [ROOM NUMBER] had signage which indicated PPE was necessary prior to entering. Further, there was a cart outside the door containing clean PPE and disinfecting spray. During an observation on 4/21/21, at 8:23 a.m. nursing assistant (NA)-B was wearing a surgical mask and regular glasses however, no face shield or goggles. NA-B donned gown and gloves, retrieved the room tray and entered room [ROOM NUMBER]. When questioned, NA-B stated she was not able to wear the eye protection because it gave her a headache and was given permission by administration to not wear it. During an observation on 4/21/21, at 9:05 a.m. speech therapist (ST)-D was wearing a surgical mask and regular glasses, however, no face shield or goggles. ST-D donned gown and gloves then reached to open the door of room [ROOM NUMBER]. ST-D confirmed she was not wearing eye protection and stated her understanding was only when entering a COVID positive room was eye protection required. ST-D stated she would double check with her supervisor before entering the room. During an interview on 4/21/21, at 11:06 a.m. the infection preventionist (IP) stated staff were expected to wear masks and eye protection when doing close contact or cares. Further, IP stated no staff had been given any type of waiver to excuse them from wearing eye protection. Her expectation was any staff going into care areas should wear mask and goggles. During an interview on 4/21/21, at 1:42 p.m. director of nursing (DON) stated all direct care staff should wear goggles at all times. During an interview on 4/22/21, at 8:24 a.m. the administrator stated all staff should follow precaution posted on quarantined doors and should always be wearing a mask and eye protection. And stated she was not aware of anyone given a waiver from wearing eye protection. During an interview on 4/22/21, at 10:25 a.m. the director of rehab services (DPT)-E stated she was responsible for education of all rehab service people. DPT-E stated all staff had been trained to wear appropriate PPE, to follow posted precautions and to always wear a mask and eye protection. R39's annual Minimum Data Set (MDS) dated [DATE], indicated R39 was moderately cognitively impaired and required extensive assistance for bed mobility, locomotion, transfers, dressing, toileting and personal hygiene. R39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 04/21/21, at 8:14 a.m. NA-A assisted R39 with morning cares. NA-A was wearing a face mask, eye protection and gloves during cares. NA-A was observed leaving R39's room with a bag of trash in one hand and a bag of soiled linens in the opposite hand. NA-A entered the soiled room and disposed of the bags. While still in the soiled room, NA-A applied liquid soap onto her hands and began rubbing her hands together. While rubbing the soap into her hands, NA-A noted that there were no paper towels in the soiled room. NA-A then exited the soiled room while still rubbing the liquid soap into her hands. NA-A then used a clean paper towel to turn on the water in a sink in the common area. During this time, no lathering was observed on NA-A's hands. The soap on NA-A's hands was visibly gone. NA-A then rinsed off her hands under water. NA-A only rinsed her hands, she did not rub her hands together under the water. NA-A then dried her hands with clean paper towels, used another clean paper towel to turn off the water and disposed of the used paper towels in the trash bin near the sink. Next, NA-A knocked on R39's door, entered the room, knocked on R39's bathroom door, opened the bathroom door, spoke with R39, then closed the bathroom door. R39 was seated on her walker, facing the bathroom sink, with the water running. NA-A then stood outside of R39's bathroom door for approximately two minutes before she opened the bathroom door, entered the bathroom and turned off the bathroom sink water using a clean paper towel. Next, NA-A opened a drawer, took out a comb, closed the drawer and handed the comb to R39. After R39 used the comb, NA-A opened the drawer, placed the comb in the drawer and closed the drawer. Next, NA-A unlocked R39's walker brakes and turned R39, while seated on the walker, around to face the bathroom grab bars. NA-A locked the walker brakes, touched R39's hand and placed it onto the grab bar, and instructed R39 to use the grab bar to stand. While R39 was standing, NA-A unlocked the walker brakes, moved the walker to the side of R39, and instructed R39 to take the walker while NA-A guided R39's hand to the walker by R39's elbow. NA-A then used the alcohol-based hand rub (ABHR) before exiting R39's room. NA-A pulled a chair away from a table in the common area and assisted R39 to sit. Next, NA-A was observed putting liquid soap onto her hands and rubbing her hands together until the soap was visibly gone from NA-A's hands. No lathering was noted on NA-A's hands. NA-A then turned on the water with a clean paper towel, rinsed her hands, dried her hands with clean paper towels, used a clean paper towel to turn off the sink, and disposed of the paper towels. During an interview on 4/21/21, at 8:45 a.m. NA-A confirmed NA-A did not apply water to her hands prior to rubbing her hands together with liquid soap. NA-A confirmed that hand-washing instructions were posted at each sink indicating that hands need to be wet prior to applying soap to lather the hands. Further, NA-A confirmed that she should wet her hands first before stating, I should follow the rules. During an interview on 4/21/21, at 9:12 a.m. the unit nurse manager (RN-A) stated staff are expected to perform hand hygiene following the steps posted by each sink. RN-A stated the posted hand hygiene document titled, Hand Hygiene How To is posted at every sink. This document directed staff to follow those instructions: 1. Wet, 2. Soap, 3. Wash 20 seconds, 4. Rinse, 5. Dry, 6. Turn off water with paper towel. RN-A stated that staff are expected to follow these steps. During an interview on 4/22/21, at 10:01 a.m. the director of staff development/infection preventionist (IP) stated that staff educated on hand washing annually through a Relias computer module, monthly at staff meetings, and periodically during daily huddles. IP stated that hand washing audits have been completed weekly by IP and the unit nurse managers. IP stated the audits are done so that all staff and all shifts are audited. IP stated that IP and the unit nurse managers watched the staff wash their hands during the audits to ensure competency. Review of facility policy titled Hand Hygiene/Handwashing revised August 2015, indicated that the facility considered hand hygiene the primary means to prevent the spread of infections. Policy indicated that all personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Policy indicated the completion of hand hygiene before and after direct contact with residents. Policy indicated the hand washing procedural step, vigorously later hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9's cognition was intact and required extensive assistance for bed mobility, locomotion, transfers, dressing, toileting and personal hygiene. R9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/21/21, at 7:20 a.m. licensed practical nurse (LPN-A) assisted R9 with medication administration. LPN-A used the alcohol-based hand rub (ABHR) at the med cart. LPN-A then unlocked the med cart, open a drawer, removed five pill bottles and placed the bottles on the med cart. LPN-A then opened a second drawer, removed six medication bubble cards and placed the bubble cards on the med cart. LPN-A then removed each medication tablet, as per the EMAR, and placed each tablet into a medication cup. LPN-A was then observed moving the tablets around in the souffle cup with her ungloved fingers. LPN-A then used her ungloved fingers to transfer the tablets individually from one medication cup to another. LPN-A did not perform hand hygiene prior to handling the medication tablets. During an interview on 4/21/21, at 8:00 a.m. LPN-A confirmed that she used her fingers to count the medication tablets. LPN-A confirmed that she repeatedly touched R9's oral medications with her fingers. LPN-A stated that she should wear gloves to handle medication tablets. During an interview on 4/22/21, at 10:00 a.m. IP stated that nurses and trained medication aides (TMA) are taught hand hygiene and when gloves are required. IP stated that the nurses and TMAs have been instructed to wear gloves if they need to touch the medications. IP stated that nurses and TMAs have been taught to use a pill counting tray and wear gloves to count tablets. IP stated that the expectation is that the nurses and TMAs should not touch oral medications with their bare hands. Review of facility policy titled Hand Hygiene/Handwashing revised August 2015, indicated that the facility considered hand hygiene the primary means to prevent the spread of infections. Policy indicated that all personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Policy indicated hand hygiene completed before handling medications. Review of facility policy titled Administering Oral Medications revised October 2010, indicated that for tablets or capsules from a bottle, pour the desired number into the bottle cap and transfer to the medication cup. For unit dose tablets or capsules, place packaged medications directly into the medication cup. Policy indicated do not touch the medication with your hands as part of the procedure.

Based on interview and document review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R1) reviewed who was hit by a staff member in the facility. R1's minimum (MDS) data set [DATE], indicated no impairment of cognition. Moderate assistance with dressing and max assistance with transfers and repositioning. R1's care plan revised on 12/24/20, indicated R1 is a vulnerable adult and unable to protect self from harmful situations due to reduced mobility. Risk for bleeding related to anticoagulant (blood thinner) therapy for [MEDICAL CONDITION] (heart arrhythmia). Alternation in ability to perform activity of daily living related to [MEDICAL CONDITION], fatigue, tremors, history of falls, instability with gait and balance, advanced age, [MEDICAL CONDITIONS]. R1's progress notes dated 1/13/21, at 11:27 a.m. during care conference VA had expressed concerns over some cares that staff are addressing. R1's progress noted dated 1/14/21, at 9:29 a.m. by clinical manager (CM)-A During head to toe assessment resident was noted to have bruises on both arms: Rt (right) arm: 2 bruise 1 cm in diameter each above elbow and 2 bruises 1 cm in diameter below elbow. Lt (left) arm: one bruise 1.5 in diameter below elbow and one bruise 1.5 cm in diameter mid forearm. Resident said that the bruises on her arms are from her bumping against her w/c (wheelchair) arm rests during self-transfers. Will monitor for changes. During interview on 1/14/20, at 11:00 a.m. R1 stated Mr. (NAME REDACTED) (alleged perpetrator) (AP) took care of me a few nights ago. He was rough with everything he did. R1 stated AP is rough and he should not be working with people like me. R1 further stated that AP came into her room and stated whaa then pushed her on her arm. R1 denied any injury. R1 then stated that he then picked up her legs and threw them in the bed. R1 stated that none of the other aids have ever treated her this way. R1 further stated that this has been going on for a while with AP and his rough cares. R1 stated when AP was ready to leave the room she told him goodbye Mr. (NAME REDACTED) Rough. R1 stated that this made her feel like he was more of an enemy than a friend. R1 stated she feels safe in the facility and hopes that she never sees AP again. R1 was not able to describe AP just that he was her male nurse the other night and I should talk with the nurse to find out his name. During interview on 1/14/21, at 11:47 a.m. nursing assistant (NA)-A stated she is not aware of any rough cares with R1, however she would report immediately to the nurse if she had witnessed any rough cares or was made aware of any rough cares for the safety of the residents. During interview on 1/14/21, at 11:52 a.m. licensed practical nurse (LPN)-A stated he was just made aware about the rough cares with R1. LPN-A stated that R1 is alert and oriented and if she said something happened it happened. LPN-A further stated that if he was made aware of any abuse he would make sure resident is safe and then would report to nurse manger, director of nursing (DON), or administrator immediately. During interview on 1/14/21, at 11:59 CM-A stated she was made aware of incident during R1's care conference with R1 and R1's niece. CM-A stated R1 said AP was rough with her and that AP said something to her and then hit her, and then he threw her legs in the bed. CM-A further stated R1 stated she told AP goodbye Mr. (NAME REDACTED) Rough. CM-A stated R1 stated he should not be working with her any longer. CM-A stated AP was suspended immediately pending investigation. CM-A stated if R1 stated it happened, then it did, as she is accurate in what she says. CM-A stated she conducted head to toe assessment and R1 had bruising above and below elbows, however R1 stated this was due to bumping them on her wheelchair arm rest. CM-A denied any bruising to upper arms wear AP hit her. CM-A stated abuse is never ok and is not tolerated. During interview on 1/14/21, at 1:40 p.m. registered nurse (RN)-B stated abuse is never ok as they are there to help the residents and if staff don't want to work then they should just go home. RN-B further stated if she was made aware of rough cares she would make sure the resident was safe, remove the staff, and report immediately. During interview on, 1/14/21, at 1:48 p.m. RN-A stated if made aware of abuse she would make sure resident is safe, remove staff and then let nurse manager know immediately. During interview on 1/14/21, at 2:13 p.m. AP stated he is unsure of what incident they are talking about, he would never abuse anyone. Stated R1 was tripping and he held her back to prevent her from falling. denies hitting R1 or throwing her legs into the bed. AP stated he would never hurt anyone. During interview on 1/14/21, at 3:25 p.m. CM-B stated abuse is never ok nor is rough cares. Rough cares and abuse should be reported immediately after making sure the resident is safe and the AP is sent home immediately. During interview on 1/14/21, at 3:31 p.m. DON stated she reported on 1/13/21 about abuse with AP and his rough cares. DON stated she immediately suspended AP and then as of 1/14/21 had terminated AP's emplopyment as abuse is never ok and is not tolerated. DON stated R1 reported AP came into her room and said whaa then hit her on the arm, and then picked her legs up and threw them in the bed and R1 felt that this was rough. DON stated this behavior is not tolerated and is considered abuse in different forms. DON stated there were a few facility investigations with other residents who stated that they are glad he is not working on there side any longer. DON stated would need to speak with the individual who did the interviews. During interview on 1/14/21. at 3:52 life enrichment director stated R1 made staff aware of incident during a care conference that Mr. (NAME REDACTED) hit her arm and then threw her legs on the bed. Life enrichment director further stated they reassured her that she is safe and they were going to fix this concern. Life enrichment director further stated one resident had stated that she was glad that AP was no longer working her side. Life enrichment director stated that abuse is not ok as these residents are vulnerable adults and they cannot protect themselves. During interview on 1/14/21, at 4:00 p.m. administrator stated she was made aware of abuse from R1 during a care conference by the nurse manager and they reported it immediately. Administrator stated the police responded and they went into R1's room together to speak with R1. Administrator stated R1 stated AP came in room and stated whaa and hit her on the arm, then grabbed her legs and threw them into bed, and before he left she told him goodbye Mr. (NAME REDACTED) Rough. AP was suspended immediately and fired. Administrator stated that on 1/15/21, they are having another session about abuse and this has been ongoing training since 12/4/20. During interview on 1/14/21, at 6:00 p.m. NA-B stated abuse is never ok and would report immediately to nurse if witness any type of abuse or if a resident had reported abuse or rough cares. Policy Abuse Prevention Program revised 6/10/20, The policy of Covenant Retirement Communities is zero tolerance of any for of abuse, neglect, or expoitation.

Based on interview and document review, the facility failed to report an allegation of potential physical abuse to the administrator and State Agency (SA) within two hours, as required, for 1 of 1 residents (R4) whose allegation of abuse was reviewed. Findings include: R4's admission Minimum Data Set ((MDS) dated [DATE], indicated R4 had no cognitive impairment. R4 required assistance with bed mobility, dressing, toilet use, personal hygiene. R4's [DIAGNOSES REDACTED]. R4's care plan dated 11/12/20, indicated R4 required physical assistance from staff for dressing and grooming, trim nails, and use of full body mechanical lift with transfers. Physical assistance of one to two with bed mobility. Required physical staff assistance with incontinent cares and hygiene. R4's progress note dated 11/26/20, indicated R4 reported to registered nurse (RN)-A that R4 was being abused and showed RN-A old bruises on her hands and said they were caused by staff that had just been in to change her. R4's progress note dated 11/30/20, indicated R4 reported to RN-B that bruising on hand resulted from hitting her hand on the grab bars. Progress note also indicated that RN-B determined the bruise on R4's right hand was in line with grab bar on right side of bed. On 12/2/20 at 12:40 p.m. observed R4 sitting in her wheelchair next to her bed, eating lunch. She had a quarter size dark purple/black bruise under each eye and scattered dark pink bruising on her forearms, more so on her right forearm. R4 indicated the areas under her eyes were [MEDICAL CONDITION] the fall she took when she was at home. R4 indicated all the aides have such strong hands and sometimes it pinches her. So I grab their wrists and say, how do you like it now?! R4 confirmed she was taking blood thinning medication. On 12/2/20, at 2:02 p.m. RN-B stated he expected reports of abuse be reported within two hours to the SA. RN-B expected, if the abuse was witnessed, the alleged perpetrator was to be removed from the floor and an investigation was to be started. RN-B confirmed R4's report of abuse on 11/26/20 to RN-A should have been reported to the SA within two hours. On 12/2/20, at 3:00 p.m. director of nursing (DON) stated she expected to be notified of reports of abuse immediately and would report abuse within two hours to the SA. On 12/2/20, at 3:53 p.m. RN-A stated that abuse should be reported in 24 hours. He stated management was coming back to work on Friday 11/27/20 and that he thought they would have read the progress note he wrote about R4 the day before stating that she had been abused. RN-A stated if abuse is evident or witnessed, he would make a call to management right away. He determined that the bruises that R4 showed him were not new as he had been working with her the previous three days and had visualized them during previous shifts. On 12/02/20, at 4:35 p.m. observed R4 resting in her bed, watching TV. R4 stated she was comfortable and felt safe in the facility. Facility document, Abuse Prevention Policy revised 6/10/20, indicated reporting of suspected abuse must be reported immediately but not later than two hours.

Based on observation, interview, and document review, the facility failed to monitor bruising for 1 of 1 residents (R4) who received anticoagulant therapy (a medication to thin the blood) Findings include: R4's admission Minimum Data Set ((MDS) dated [DATE], indicated R4 had no cognitive impairment. R4 required assistance with bed mobility, dressing, toilet use, personal hygiene. R4 [DIAGNOSES REDACTED]. R4's signed hospital discharge orders dated 11/12/20, included an order for [REDACTED]. On 11/27/20 and 11/30/20, R4's INR was 3.2. R4's care plan dated 11/12/20, indicated R4 required physical assistance from staff for the following: dress, grooming, transfers with use of full body lift, bed mobility, incontinence care and personal hygiene. R4's care plan also indicated R4's skin check daily and to report redness, changes or concerns to licensed staff. R4's skin to be assessed weekly, by skilled nursing staff, noting areas of redness. R4's care plan failed to address monitoring R4 for signs of bleeding, such as bruising, related to use of anticoagulants. R4's admission assessment dated [DATE], indicated R4 was a risk for skin breakdown not related to pressure as well as skin breakdown related to pressure. This assessment identified R4 had bruising at admission, but failed to identify the location, size and color of each bruise. According to instructions on R4's admission assessment dated [DATE], areas of concern were to be addressed on facility form Skin Investigative Flow Sheet. This form was requested but was not provided by the facility and was not found in R4's medical record. Progress notes dated 11/26/20, 11/30/20 and 12/1/20, identified various areas of bruising, but failed to consistently identify shape, size, location and color. On 12/2/20, at 12:40 p.m. R4 was observed sitting in her wheelchair. R4 had a quarter sized bruise, dark purple/black under each eye and scattered old bruising on her arms, more so on her right forearm-lighter pink/purple in color. On 12/3/20, at 12:52 p.m. Director of nursing (DON) indicated she expected R4's skin to be checked weekly. DON stated it should be documented on skin sheets. DON indicated the clinical managers were expected to keep records the weekly skin checks, but was not able to confirm if R4 was on the weekly skin check list. This clarification was requested but was not provided. On 12/3/20, at 1:35 p.m. DON stated instructions were put into the electronic treatment record for licensed staff to check R4's skin daily, but the order was not confirmed by another staff. Therefore, licensed staff had not received the prompts to complete and document the daily skin checks. DON confirmed, daily skin checks were not documented for R4. DON also confirmed, daily skin documentation was not completed for R4. Facility document, Anticoagulation-Clinical Protocol, revised September 2012, indicated the staff will monitor for possible complications in individuals on anticoagulation therapy, and will manage related problems.

Based on interview and record review, the facility failed to ensure appropriate infection control practices related to coronavirus disease 2019 (COVID-19) (an infectious disease caused by severe acute respiratory syndrome coronavirus 2) by failing to consistently document required daily COVID-19 symptom screens for 4 of 4 residents (R1, R2, R3 and R4) that tested positive for COVID-19. This had the potential to affect all residents and staff at this facility. Findings include: R1's Face Sheet indicated a primary [DIAGNOSES REDACTED]. R1 tested positive for COVID-19 on 5/27/20 and on 6/9/20. R1's care plan dated 6/17/20, indicated R1 was to be monitored for fever, cough, sneezing, sore throat and respiratory issues every four hours. R1 was to have lung sounds evaluated every shift and physician is to be updated with changes. R1's oxygen saturation (O2 sat) (measures the percentage of hemoglobin, the protein molecule in red blood cells that carries oxygen), was to be monitored every four hours. R1's vital signs were to be obtained every four hours and the facility COVID-19 Triage Evaluation form was to be completed. The facility's COVID-19 Triage Evaluation form, undated, included the following: blood pressure, temperature, pulse, respiration, oxygen saturation, fever within last 24 hours, chills, repeated shaking with chills, oxygen saturation less than 95%, adventitious lung sounds, shortness of breath, new cough, sore throat, pain with taking a deep breath, diarrhea, emesis, abdominal pain, muscle pain, headache and new loss of taste or smell. R1's treatment order dated 4/21/20, indicated to complete COVID-19 Triage Evaluation assessment one time daily. R1's record review indicated R1 did have at least daily monitoring of vitals including O2 sat. However, R1's record lacked evidence that comprehensive COVID-19 symptoms were evaluated per the daily COVID-19 Triage Evaluation form. Dates the COVID-19 symptoms were lacking for R1 included 5/31/20, 6/7/20, 6/9/20, 6/13/20 and 6/15/20 through 6/22/20. R2's Face Sheet indicated a primary [DIAGNOSES REDACTED]. R2 tested positive for COVID-19 on 6/8/20. R2's treatment ordered dated 4/15/20, indicated to complete COVID-19 Triage Evaluation assessment one time daily. R2's record review indicated R2 did have at least daily monitoring of vitals including O2 sat. However, R2's record lacked evidence that comprehensive COVID-19 symptoms were evaluated per the daily COVID-19 Triage Evaluation form. Dates the COVID-19 symptoms were lacking for R2 included 6/4/20, 6/10/20, and 6/13/20 through 6/21/20. R3's Face Sheet indicated a primary [DIAGNOSES REDACTED]. R3's treatment order dated 4/15/20, indicated to complete COVID-19 Triage Evaluation assessment one time daily. R3's record review indicated R3 did have at least daily monitoring of vitals including O2 sat. However, R3's record lacked evidence that comprehensive COVID symptoms were evaluated per the daily COVID-19 Triage Evaluation form. Dates the COVID-19 symptoms were lacking for R3 included 5/31/20, 6/1/20 through 6/4/20, 6/6/20, 6/9/20, 6/12/20 through 6/13/20 and 6/16/20 through 6/21/20. R4's Face Sheet indicated a primary [DIAGNOSES REDACTED]. R4's care plan dated 6/10/20, indicated R4 was to be monitored for fever, coughing, sneezing, sore throat and respiratory issues every four hours. R4's lung sounds were to be evaluated every shift. R4's vital signs were to be obtained every four hours and the facility COVID-19 Triage Evaluation form was to be completed. R4's treatment order dated 4/15/20, indicated to complete COVID-19 Triage Evaluation assessment one time daily. R4's record review indicated R4 did have at least daily monitoring of vitals including O2 sat. However, R4's record lacked evidence that comprehensive COVID symptoms were evaluated per the daily COVID-19 Triage Evaluation form. Dates the COVID-19 symptoms were lacking for R4 included 5/24/20, 5/27/20, 6/1/20 through 6/2/20, 6/10/20 and 6/13/20 through 6/22/20. During interview on 6/22/20, at 11:25 a.m. RN (registered nurse)-A stated COVID positive residents vital signs were checked every four hours. Each COVID positive resident was asked questions related to or monitored for COVID-19 specific signs and symptoms each morning. Vital signs that were check included, blood pressure, pulse, respiration, oxygen saturations, and temperature. During interview on 6/22/20, at 11:35 a.m. LPN (licensed practical nurse)-A stated the contents of the COVID-19 Triage Evaluation assessment included: fever, chills, oxygen saturation, shortness of breath, cough, pain with deep breath, diarrhea, abdominal pain, muscle pain, headache and loss of taste or smell. During interview on 6/22/20, at 11:58 a.m. RN-B stated the COVID-19 Triage Evaluation assessment was scheduled to be completed daily for all residents, regardless if they were positive or negative for COVID-19. In addition, vital signs were checked on residents who tested positive for COVID-19, every four hours. During interview on 6/22/20, at 3:00 p.m. the Administrator stated she was aware of the assessments that were not in the computer. She stated this was a computer documentation system problem but the assessments are being completed as scheduled. During interview on 6/22/20, at 3:54 p.m. RN-C stated the daily assessment involved questions and monitoring for fever over the last 24 hours, chills, shaking with chills, O2 sat less than 94%, adventitious lung sounds (abnormal sounds that are heard when listening to a patient's lungs and airways), shortness of breath, new cough, sore throat, pain with breathing, diarrhea, abdominal pain, muscle pain, and loss of taste or smell. It was expected that all residents were screened daily using the COVID-19 Triage Evaluation assessment, that included residents who tested positive for COVID-19. The assessment was used for COVID-19 positive residents as a tool to help determine if they were able to be taken out of isolation. During interview on 6/22/20, at 3:54 p.m. RN-B stated he looked for the missing assessments for R1, R2, R3, and R4 and was unable to find them. RN-B stated he did not look at the assessments every day, but the nurses who completed them did look at them to determine if there were changes from the previous day. The facilities Suspected or Confirmed (COVID-19), policy, revision date 4/16/20, stated to actively screen all residents daily for fever and symptoms of COVID-19. Older adults with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. Atypical symptoms may include new or worsening malaise (general feeling of discomfort, illness or uneasiness), new dizziness, or diarrhea.

Based on interview and document review the facility failed to develop policies and procedures to include information to report allegations of abuse to the State Agency (SA) within the required two hour timeframe. This had the potential to affect all 64 residents currently residing in the facility. Findings include: The facility Abuse Prevention Program revised 5/14/19, identified employees are required to report all occurrences of possible abuse, mistreatment or neglect of any resident and crimes against a resident or misappropriation of a residents property immediately to their supervisor and the supervisor shall immediately report to the supervisor or person on call. However, the policy lacked direction to report any suspicion of abuse to the SA within two hours. During an interview on 4/28/20, at 4:15 pm the administrator confirmed the Abuse Prevention Program was a corporate policy and any suspicion of abuse was to be reported within two hours to the SA.

Based on observation, interview and documentation review, the facility failed to obtain interdisciplinary team (IDT) approval prior to allowing 1 of 1 residents (R22) to self administer medication for nebulizer (process of delivering medication via mist inhalation) treatment. Findings include: R22's 14 day minimum data set (MDS) indicated R22 is cognitively intact, needed extensive assistance of two staff with bed mobility and transfer. R22 needed assistance of one staff for dressing, eating, toileting and personal hygiene. R22 had a [DIAGNOSES REDACTED]. R22's care plan dated 7/10/2019, indicated R22 has self care deficits related to end stage [MEDICAL CONDITION], ataxic movements, cognition, communication deficits, weakness, fall risk and difficulty staying on task. R22's physician order [REDACTED]. During an observation on 8/5/2019, at 2:32 p.m. R22 was observed to be alone in room sitting upright in bed. R22 had on an oxygen mask with a chamber filled with 1/4 inch of a clear liquid and was attached by clear tubing to a nebulizer device. R22 removed mask and attempted to turn off nebulizer device, but could not reach it. R22 turned on call light and two staff members entered R22's room and stated they would get R22's nurse. Licensed practical nurse (LPN)-A entered the room at 2:33 p.m. turned off the nebulizer device and disconnected the chamber. LPN-A stated the chamber was empty then washed and left to air dry on a paper towel. During interview on 8/8/2019, at 8:56 a.m. registered nurse (RN)-F reviewed a form titled Assessment for Self-Administration of Medications and stated the lower half of the form titled Interdisciplinary Team Evaluation lacked documentation that R22 could self-administer medications. The form was completed by RN-F and dated 7/12/2019. The instructions on the form indicate before performing this assessment, verify that there is a physician order [REDACTED]. Proceed by checking appropriate response below for each of the 19 items listed. The resident must be able to perform each step indicated below prior to beginning self-administration of medications. The IDT will be responsible for approving self-medication using this assessment as a guide. The form indicated R22 was unable to to perform eight of 19 items. RN-F stated she does not stay with R22 when giving him his nebulizer treatment. Additionally, RN-F stated that if R22 was using a face mask for R22's nebulization she would not consider it self administration after the staff had set up the medication. R22's record lacked an order for [REDACTED]. During an interview with R22 on 8/8/2019, at 1:11 p.m. R22 indicated he can remove the nebulization mask and he does not recall staff giving R22 instruction on how to use the mask. R22 further indicated he takes off the mask when he wants to and that R22 tries to be sure the chamber is empty. Policy Self-Administration by Resident dated 11/17, indicated residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's IDT has determined that the practice would be safe and the medications are appropriate and safe for self-administration.

Based on observation, interview, and document review, the facility failed to ensure insulin was labeled with directions for use for 1 of 2 residents (R5) reviewed during medication storage. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE] included a [DIAGNOSES REDACTED]. R5's (MONTH) 2019 Physician order [REDACTED]. 7/9/18: Humalog U-100, 4 units subcutaneous daily at 5 a.m. Hold for blood glucose less than 90. Give addition to sliding scale. 1/22/19: Humalog U-100, 5 units subcutaneous daily at 8 a.m. and 6 units daily at 11:30 a.m. Hold for blood glucose less than 90. Give in addition to sliding scale. 5/8/19: Humalog U-100, sliding scale subcutaneous 3 times daily at 7:30 a.m., 11:30 a.m. and 5 p.m. blood sugars 150-199 give 1 unit. Blood sugars 200-249 give 2 units. Blood sugars 250-299 give 3 units. Blood sugars 300-349 give 4 units. Blood sugars greater than 350 give 5 units and call MD. 7/30/19: Basaglar KwikPen U 100. Give 20 units subcutaneous daily at 8 a.m. 7/31/19: Accu-check (blood sugar) 4 times daily at a.m., 1., 5 p.m., and 8 p.m. Give insulin only if eats 50% or more. Update nurse practitioner if blood sugar less than 70 or greater than 350. If greater than 350 recheck blood sugar prior to administering further insulin doses. During observations on 8/8/19, at 9:46 a.m. of medication storage of cart #3 with registered nurse (RN)-E, R5 had 2 insulin pens stored in the cart. These 2 pen included [MEDICATION NAME] (Humalog) U-100 insulin pen. This pen was labeled with R5's name, room number and medical record number. The label lacked directions for use and the second pen was Basaglar U-100 insulin pen. The pen was labeled with R5's name, room number and medical record number. The label lacked directions for use. The medication room refrigerator contained 2 boxes of R5's insulin. One box was identified as [MEDICATION NAME] (Humalog) U-100. Directions on the box were consistent with order. Directed to administer 5 units subcutaneous with breakfast, 6 units with lunch and 4 units with dinner. The box lacked directions for sliding scale. The second box was identified as Basaglar U-100. Direction on the box were not consistent with the current order. Direction on the box indicated to inject 18 units subcutaneous every evening, however the current order directed to administer 20 units subcutaneous daily at 8 a.m. RN-E stated R5's [MEDICATION NAME] and Basaglar arrive from the pharmacy in a multi-pack of 5 pens. RN-E stated R5's box is labeled with directions, however, the individual insulin pens stored and used on the medication cart lacked directions. RN-E stated she follows the directions that are on the Medication Administration Record [REDACTED] During an interview on 8/8/19 at 10:16 a.m. the director of nursing (DON) stated each insulin pen is to be labeled with directions for use. The directions on the pen and on the Medication Administration Record [REDACTED]. The facility's policy Medication and Medication Labels, dated 5/16, indicated each prescription medication will be labeled to include: Resident's name, Specific directions for use, including route of administration, Medication name, strength of medication, prescribers name, date medication is dispensed, quantity dispensed, expiration or en-of-use-date, name address and telephone number of dispensing pharmacy, prescription number, accessory/precautionary labels indicating storage requirements and special procedures, dispensing pharmacists initials, lot number, and any other information required by state or federal regulations. If the prescriber's directions for use change or the label is inaccurate, the nurse may place a direction change or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information. When such a direction change label appears on the container, the medication nurse checks the resident's Medication Administration Record [REDACTED]. If directions for use change, the provider pharmacy is informed prior to the next refill of the prescription so the new container will show an accurate label.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was implemented during wound care for 2 of 3 residents (R5, R6) reviewed for pressure ulcers and 1 of 3 residents (R2) observed during blood glucose monitoring. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 required extensive staff assistance with dressing and personal hygiene. R5 had 2 stage 4 pressure ulcers (PU's). Interventions included pressure ulcer care. R5's (MONTH) 2019 Physician order [REDACTED]. Cleanse with wound cleanser, pat dry, and apply skin prep to intact skin to protect from tape. Pack wounds gently with alginate Ag and cover with abdominal (abd) pad. Secure with [MEDICATION NAME] tape. During observations on 8/7/19, at 9:53 a.m. registered nurse (RN)A entered R5's room to complete the morning dressing change to R5's sacral and right IT pressure ulcers. RN-A washed her hands with soap and water and donned (put on) gloves. R5 was laying on her left side in bed. An abd dressing was taped over R5's sacrum and right IT. With gloved hands, RN-A removed R5's right IT dressing, then sacral abd dressing. RN-A removed the alginate Ag packing from the sacral and right IT PU's. RN-A doffed (removed) her gloves. RN-A did not complete hand hygiene prior to donning new gloves. RN-A measured the sacral PU and applied the skin barrier to the surrounding skin. RN-A cleaned the sacral PU with wound cleaner. RN-A picked up the alginate Ag, with her gloved, but un-sanitized hand and packed the alginate Ag into the sacral PU. RN-A covered the PU with an abd dressing. Registered nurse (RN)-B entered the room, donned gloves, and held the abd in place, while RN-A taped the dressing in place. RN-A doffed her gloves, washed her hands, and donned new gloves. RN-A applied wound cleanser to the right IT PU. RN-A measured the right IT PU. RN-A doffed her gloved and donned new gloves. RN-A did not complete hand hygiene prior to donning new gloves. RN-A, picked up scissors and cut the alginate Ag, placing the alginate in the PU, then covering the PU with an abd dressing. RN-B held the dressing in place while RN-A taped the abd dressing in place. RN-A doffed her gloves and washed her hands with soap and water. During an interview on 8/7/19, at 10:22 a.m. RN-A stated hand hygiene is completed prior to applying gloves and after removing the gloves. RN-A stated gloves are to be applied prior to wound care and when going from dirty to clean. When asked about the lack for hand hygiene between glove changes, RN-A stated she was nervous. R6 admission Minimum Data Set ((MDS) dated [DATE], indicated R6 was cognitively intact, required extensive assistance of two staff for bed mobility, transfers, toileting and hygiene and indicated R6 had an unstageable pressure ulcer (PU) on the sacrum. During observation on 8/7/2019, at 10:52 a.m. licensed practical nurse (LPN-A) and director of nursing (DON) entered R6's room to change the dressing to R6's PU located on R6's left sacral area. DON stated LPN-A would act as the clean nurse indicating LPN-A would be using the clean dressing materials and DON would be the soiled nurse handling the contaminated dressing materials. R6 was instructed to roll to the right. DON removed R6's contaminated dressing and packing materials wearing gloves. LPN-A donned gloves and cleaned R6's wound with normal saline (NS). LPN-A cleaned from inner to outer aspects. LPN-A then doffed gloves and did not perform hand hygiene. LPN-A then used bare hands to mix a 50/50 solution of NS and [MEDICATION NAME] (a cleaning agent) while touched clean supplies with bare hands. LPN-A then donned gloves and soaked a 4 X 4 inch gauze dressing in the 50/50 mix of NS and [MEDICATION NAME] using a tongue depressor. With gloved hands, LPN-A then used soaked gauze dressing to pack R6's wound. LPN-A then covered the wound with a dry dressing and secured the dressing with tape. LPN-A then removed a marker from her pocket to date the pressure dressing then returned the marker back in her pocket. LPN-A then doffed gloves and performed hand hygiene and collected trash, dirty dressings and tired up clear plastic garbage bag with bare hands. LPN-A then washed hands with soap and water. During interview with DON and LPN-A on 8/7/2019, at 11:10 a.m. LPN-A stated she did not perform hand hygiene between glove changes and should have. The DON stated the expectation was hand hygiene should always be performed between glove changes using a sanitizing agent or soap and water if gloves are viably contaminated. DON also stated there would be house wide education on hand hygiene. Review of policy titled Handwashing/Hand Hygiene dated 8/2015, indicates the facility considers hand hygiene the primary means to prevent the spread of infections. A section titled Policy Interpretation and Implementation further indicates staff will wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and [DIAGNOSES REDACTED]icile (infections of the gastrointestinal tract). Further the policy directs staff to use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: before moving from a contaminated body site to a clean body site during resident care and after removing gloves. The policy further indicated the use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. R2's 7/30/19 admission Minimum Data Set (MDS) included a [DIAGNOSES REDACTED]. R2's (MONTH) 2019 Physician order [REDACTED]. During observations on 8/7/19, at 7:09 a.m. licensed practical nurse (LPN)-A placed an assure platinum blood glucose monitor in a disposable paper bowl, along with test strip, cotton ball, single use lancet, and alcohol wipe on top of the medication cart. LPN-A prepared R2's oral medication, placing the medication in a medication cup. LPN-A carried the bowl with supplies and medication cup to R2's room. LPN-A donned gloves and used the lancet to obtain a drop of blood onto the test strip from R2's finger. LPN-A did not perform hand hygiene prior to donning the gloves. The monitor displayed an error code. LPN-A explained to R2 the test did not work. LPN-A carried the paper bowl with the monitor and used supplies and cup of medication out of the room, back to the medication cart. LPN-A did not remove her gloves prior to leaving the room. LPN-A disposed of the used supplies in the sharps container then stated Oh, my gloves. LPN-A doffed the gloves and without performing hand hygiene, LPN-A opened the medication cart with a key, opened a drawer, and obtained another test strip and lancet, and placed both in the paper bowl. LPN-A then completed hand hygiene with a sanitizer prior to returning to R2's room with paper bowl containing monitor supplies and medication cup. Upon entering R2's room, LPN-A gloved and used the lancet to R2's finger and applied a sample of R2's blood to the test strip. LPN-A doffed her gloves; however, did not perform hand hygiene. LPN-A, with un-sanitized hands, placed a multi-use blood pressure cuff on R2. Once completed, LPN-A placed the blood pressure cuff back in the basket then, without performing hand hygiene, LPN-A left the room to obtain water and crackers for R2. LPN-A picked up the paper bowl with used blood glucose supplies and the medication cup containing medication out of the room, while wheeling the BP machine. LPN-A did not perform hand hygiene prior to leaving the room. Another nurse took the BP machine from LPN-A to complete a BP on another resident. LPN-A disposed of the lancet in the sharps container. LPN-A used the keys, opened the medication cart drawer. LPN-A placed the cup of medication in the top drawer. LPN-A obtained a bleach wipe and wiped down the blood glucose monitor with bare hands. LPN-A placed the monitor in a plastic bag and placed the bag into the medication cart. LPN-A then performed hand hygiene using a sanitizer. LPN-A obtained crackers from the kitchen, then ice water from the medication cart before returning to R2's room. LPN-A stated she forgot the medication and returned to the medication cart, obtained the cup containing R2's medication from the top drawer. LPN-A returned to R2's room and administered R2's oral medication. LPN-A left R2's room without performing hand hygiene. Once at the medication cart, without performing hand hygiene, LPN-A donned gloves and entered the tub room. LPN-A performed a skin check on another resident, touching the resident with her gloved hands. Upon leaving the tub room, LPN-A returned to the medication cart, removed her gloves and performed hand hygiene with a sanitizer. LPN-A stated hand hygiene is to be completed before and after leaving a residents room and when removing gloves. LPN-A stated she missed hand hygiene related to being nervous of being observed. During an interview on 8/8/19, at 10:16 a.m. the director of nursing (DON) stated staff are to perform hand hygiene when entering a residents room, when exiting the room, and between residents. Gloves are worn with wound care and when performing blood glucose monitoring. Gloves are to be changed between dirty and clean tasks and hand hygiene is completed whenever gloves are removed. The facility's policy Handwashing/Hand Hygiene, revised (MONTH) (YEAR), directed all personnel to follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use alcohol-based hand rub or soap and water included: before and after direct contact with residents, before preparing or handling medications, after handling clean or soiled dressings and contaminated equipment. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used when anticipating contact with blood or body fluid.

Based on observation and interview the facility failed to date and label food stored in the main kitchen refrigerators, freezer and dried storage. This had the potential to affect all 26 residents receiving food prepared in the kitchen and served in the dining room. Findings include: During the tour of the kitchen on 5/29/18, starting at 1:31 p.m. the following food safety concerns were observed and confirmed by the dietary manager (DM). - The big walk in refrigerator had the following undated items noodle turkey tetrazzini, grape juice in a plastic pitcher, sausage in two separate containers and pureed sausage, pulled white turkey and hoagie buns. -Cook's cooler had the following undated items, cheese soup, two golden broccoli containers and pesto in a container. -The cook's freezer had three different flavors of ice cream in separate three gallon size containers, each with approximately one quarter gallon of ice cream which was undated. -Dry storage had opened hamburger buns, English muffins and sliced bread, and white chocolate cookies opened and undated During an interview while touring kitchen on 5/29/18, at 2:14 p.m. DM stated she will have to take inventory of all undated and unlabeled food and throw it all out. DM told Cook (C)-A, we have to get rid of everything with no dates. A policy was requested, but nothing was provided specific to undated food items.

Based on interview and document review, the facility failed to ensure the ombudsman was notified of a facility initiated hospital transfer for 1 of 1 residents (R12) reviewed for hospitalization s. Findings include: R12's admission Minimum Data Set (MDS), dated [DATE], indicated a [DIAGNOSES REDACTED]. R12's Clinical Notes Report identified the following; -5/17/18, at 2:15 PM indicated R12's hemoglobin (blood test) results came back low. R12 transferred to the hospital via ambulance at 1:45 PM for an evaluation. -5/18/18, at 2:27 AM indicated R12 was admitted to the hospital. -5/18/18, at 2:48 PM indicated R12 remained in the hospital. R12's family chose not to hold the bed and removed R12's belongings from the facility. R12's medical record lacked notification of the ombudsman of the facility initiated transfer. During an interview on 5/31/18, at 8:46 a.m. social worker (SW)-A stated social services does not send notice of hospital transfers to the ombudsman. During an interview on 5/31/18, at 8:48 a.m. the director of nursing (DON) stated social workers are responsible to notify the ombudsman of hospital transfers. During an interview on 5/31/18, at 9:28 a.m. the administrator stated the facility process of notification of facility initiated transfers and discharges were to notify the ombudsman of a difficult transfer or discharge. The administrator stated difficult situations included residents who were unsafe or in unsafe family situations. The administrator stated, when the situation was not deemed difficult, it was not the facility's practice to notify the ombudsman of facility initiated discharges or hospital transfers. The administrator stated no notifications of facility initiated hospital transfers were sent to the ombudsman for the month of (MONTH) (YEAR). During an interview on 5/31/18, at 1:28 PM the administrator stated the facility had no policy related to ombudsman notification.

Based on observation, interview and document review, the facility failed to comprehensively assess pressure ulcer risk factors after the development of pressure ulcers, and failed to implement interventions to prevent the deterioration of an existing pressure ulcer, and the development and deterioration of a new pressure ulcer for 1 of 3 residents (R71) reviewed for pressure ulcers. R71 experienced actual harm due to the development and deterioration of a new pressure ulcer. Findings include: R71's pressure ulcer to the left heel was identified on 8/1/16, at 5:21 p.m. during an interview with registered nurse (RN)-D. RN-D stated R71 had one pressure ulcer, an unstageable ulcer to her left heel (a pressure ulcer where the wound bed is covered with eschar or slough and unable to determine thickness of the tissue loss). RN-D stated the pressure ulcer to the resident's left heel had first been identified after a hospitalization . She also stated the unstageable pressure ulcer was first documented on 6/29/16, as a suspected deep tissue injury (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue). R71 was observed on 8/2/16, at 2:17 p.m. sitting in her wheelchair. R71 was wearing non-skid socks on both feet, but her feet were in direct contact with the hard foot pedals without any cushion. At the time of the observation, R71 stated she required staff assistance to move out of her chair. On 8/3/16, at 7:25 a.m. nursing assistant (NA)-B was heard to ask R71, who was lying on her right side in bed, if she wanted to get up for a shower. When R71 responded affirmatively, NA-B was observed to pull down the blankets. R71 was observed to be wearing non-skid socks on both feet. The resident was not observed to be utilizing any kind of pressure reduction boot. In addition, R71's feet were positioned such that the outer side of her right foot was laying directly on the mattress with the left foot on top of the right foot. When NA-B prepared R71's wheelchair for transfer, it was noted the wheelchair did not have a pressure reduction cushion on the seat. Instead, the wheelchair seat was noted to have a chair pad type cushion, resembling a cushion from a rocker. After R71 had been transferred to the wheelchair, it was observed there were two pressure reducing blue boots lying on the floor. On 8/3/16, at 7:48 a.m. registered nurse (RN)-A conducted R71's weekly skin observation while the resident was in the tub room. RN-A was observed to check each of R71's feet along with the rest of her body. R71's right foot was observed to be covered with a bandage on the outer part of the foot. RN-A stated the dressing was covering an abrasion, however, when RN-A removed the dressing, a round open area was observed. RN-A stated the open area was no longer an abrasion, but had deteriorated since she had viewed it the week before. The open area to the right foot was left uncovered while NA-B proceeded to shower R71. After R71's shower NA-B applied non-skid socks to both feet and placed her feet directly on the foot pedals of the wheelchair. During interview on 8/3/16, at 8:24 a.m. NA-B stated she thought R71 should be repositioned every couple of hours but was not sure. NA-B added that R71 would be repositioned when staff assisted her with toileting. NA-B also said she thought R71 was to wear the pressure reduction boot to her left foot while in bed, but was not sure whether R71 was supposed to have a boot on one foot, or both feet. NA-B confirmed two pressure reducing boots had been on the floor in R71's room that morning, and that R71 had not been wearing any boot when NA-B had assisted R71 with getting up. On 8/3/16, at 9:47 a.m. RN-A entered R71's room to measure R71's wounds. R71's unstageable pressure ulcer to the left heel had eschar (thick leathery dead tissue) covering the wound bed, the edges were intact, there was no redness to the surrounding skin, and there was no odor or drainage. The pressure ulcer measured 1.5 centimeters (cm) x 1.0 cm. RN-A measured the area on R71's right outer foot as 1.0 cm x 1.0 cm. The wound bed was described as covered with slough, the ulcer was round, the edges were intact, with pinkness on the surrounding skin, and there was no odor or drainage. RN-A stated the area on the outer right foot was likely caused by pressure, as it is a bony area of her foot. RN-A also stated the facility had stopped putting shoes on R71 about a week ago because they felt R71's shoes were causing pressure. RN-A stated any open skin areas are to be measured and documented every week as part of the weekly skin assessment. RN-A stated the nurse manager initiates a skin investigative flow sheet to assess and document a pressure ulcer weekly. She further said the weekly skin assessment includes a head to toe assessment of the skin, including feet and heels, and the nurses are expected to chart the assessment in the progress notes. RN-A further stated when a new pressure area was identified, a Risk Watch (facility process for reporting occurrences) was to be filled out and the physician, family and nurse manager were to be notified. RN-A was unsure if a Risk Watch had been initiated for R71 when the stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough and may present as an intact or ruptured blister)pressure ulcer on the right foot had been identified. However, RN-A stated she had notified the physician and nurse manager after having completed a Risk Watch after observation of the open area the week prior. RN-A stated the nurse manager was responsible for assessing wounds and updating any interventions, although any RN could update or revise a resident's care plan. RN-A also stated she was not sure where R71's wheelchair cushion had come from, but thought R71's family had brought it in for her because it was not a facility wheelchair cushion. A pressure ulcer Care Area Assessment (CAA) dated 3/3/16, indicated R71 required staff assistance to move sufficiently to relieve pressure over any one site, was confined to a bed or chair all or most of the time, needed a special mattress or seat cushion to reduce or relieve pressure, and required a regular schedule for turning. The CAA further indicated R71 was at risk for pressure ulcers due to frequent incontinence, impaired mobility, weakness and impaired cognition. The CAA identified that R71 was able to make frequent position changes on her own, which may not be real significant. The CAA also identified staff observed her skin daily with cares and weekly by licensed personnel on bath days. R71's quarterly Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. The MDS also identified R17 needed extensive assistance for bed mobility and transfer assistance. The MDS further indicated that R17 experienced occasional urinary and bowel incontinence. The MDS also indicated that a formal assessment tool and clinical assessment had been used to determine R71's pressure ulcer risk, and R71 was at risk to develop pressure ulcers. This quarterly MDS indicated at that time, R71 had no current pressure ulcers, but utilized a pressure relieving device for the chair and bed. R71's physician orders [REDACTED]. R71's care plan dated 5/23/16, indicated R71 was at risk for skin breakdown related to incontinence, impaired mobility, impaired cognition, occasional pain and diabetes mellitus. Interventions included: cushion to wheelchair and pressure relieving mattress to bed, dietary consult, check skin for areas of redness/report any changes to the nurse, not to massage skin over pressure areas, keep fluids next to R71 at all times/provide cues and assist R71 to drink fluids with medications and in between meals, perform complete assessment of the skin and note areas of redness and nutritional supplements as recommended. On 6/30/16, the care plan identified a purple non-blanchable area to the left heel, and included interventions of a heel protector while in bed, weekly skin monitoring, and remove shoes as they are causing pressure areas. However, the care plan lacked interventions on how to protect R71's feet from pressure when up in her wheelchair. On 7/20/16, the care plan identified a small abrasion to lateral left foot, and an intervention to cover area with [MEDICATION NAME] (a dressing used for the treatment of [REDACTED]. An undated NA task sheet directed staff R71 would request to be toileted and repositioned, but needed staff assistance. The task sheet also indicated the NAs were to check R71's heels daily. R71's progress notes from 7/6/16, through 7/20/16, indicated the following related to a stage 2 pressure ulcer on the right foot: - 7/6/16, at 6:43 p.m. included documentation R71 had another blister to the right foot, skin is intact and R71 denies pain. - 7/15/16, at 11:22 p.m. included documentation of a blister to the right foot that was healing and the skin was intact. - 7/20/16, at 10:36 a.m. included documentation that there was an abrasion observed to the right lateral foot. The wound measured 0.5 cm x 0.5 cm without drainage, odor, wound base was red and surrounding skin was intact and blanchable. Shoes were inspected and were removed and gripper socks were applied. [MEDICATION NAME] (foam dressing) applied for protection. The physician, family and nurse manager were notified. The physician was notified of the stage 2 pressure ulcer 7/20/16, 14 days after it was first observed on 7/6/16. The clinical record lacked a reassessment of R71's skin after the development of the unstageable pressure ulcer to the left heel, and following the development and worsening of the stage 2 pressure ulcer to the right foot. The clinical record also lacked weekly documentation of stage, size, drainage and odor of the pressure ulcer on the right foot. During interview on 8/3/16, at 12:48 p.m. RN-B stated that she had not been notified of the stage 2 pressure ulcer on the right side of the R71's foot until it had opened up last week. RN-B confirmed she was responsible for wound rounding in the facility, but had yet to observe R71's pressure ulcer to the right foot, and had not yet initiated a skin investigative flow sheet. RN-B stated the report she had received from RN-A regarding the observation of the wound following R71's shower earlier that day, was that now R71 had an unstageable pressure ulcer to the outside of her foot, due to the presence of slough in the wound bed. RN-B stated usually when she receives a report regarding an open area or an area of concern, she reviews the risk watch and reviews the progress notes and then follows up with the nurse practitioner or physician. She stated open areas are discussed in an interdisciplinary team (IDT) meeting where they discuss possible root causes and implement interventions. RN-B stated the conversations in the IDT meetings are not documented in the clinical record. RN-B verified that a comprehensive assessment of R71's skin risk was not completed after identifying the left heel suspected deep tissue injury, to reduce the chances of developing other pressure ulcers, or when the stage 2 pressure ulcer had been identified. RN-B stated the facility does not complete a comprehensive re-assessment when a pressure ulcer is identified. R71's pressure ulcer on her right foot started as a stage 2 pressure ulcer identified on 7/6/16 according to the progress notes, however, it was not measured until 7/20/16, when it measured 0.5 cm x 0.5 cm. The next measurement was obtained on 8/3/16, by RN-A during care observed by the surveyor. At that time, the wound size was identified as having increased to 1.0 cm x 1.0 cm. and had worsened to an unstageable pressure ulcer. RN-B was unaware that R71 was not utilizing a facility pressure reduction wheelchair cushion and it was not assessed by therapy to be appropriate in reducing pressure ulcers. During interview on 8/3/16, at 2:44 p.m. the director of nursing (DON) stated she would expect the RNs to complete a comprehensive skin assessment for newly identified pressure ulcers, along with putting appropriate interventions into place. The DON stated care planned interventions were expected to be followed, and she would have expected the nurses to recognize a blistered area needed to be reported as a possible stage 2 pressure ulcer. She said this was important in order to determine follow up, and to identify any treatments/interventions to be implemented. The facility's policy Presence of a Pressure Ulcer dated 9/1/10, identified staff are to assess pressure ulcer location, stage, size, shape, depth and surrounding tissue, along with drainage type, color, odor and amount. It further directed to identify the wound bed, wound edges and any related pain. The policy also directed staff to review the care plan and update as needed. Within one week the skin care team or representative would review all new pressure ulcers and care plans. The skin care team would then ensure all risk factors were documented in the medical record and identified on the care plan. In addition the policy directs monitoring of the pressure ulcer daily on the treatment sheet.

Based on interview, closed record review, and policy review, the facility failed to provide care and services to prevent the development of an avoidable pressure ulcer for 1 of 3 residents (R89) in the sample who developed avoidable stage II pressure ulcers. Findings include: R89 was admitted on [DATE], with the following [DIAGNOSES REDACTED]. R89 did not receive appropriate care or services to prevent the incidence of an avoidable stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) This practice resulted in actual harm due to the development of a two stage II pressure ulcers. The admission Minimum Data Set (MDS) was completed on [DATE], which indicated R89's brief interview for mental status was 15 of 15 (no cognitive impairment), no behaviors, and with assistance for activities of daily living (ADL) bed mobility, transfer and walking was supervision and setup help only. R89 had an indwelling catheter and was continent of bowel. R89 was not identified at risk of developing pressure ulcers and did not have any pressure ulcers present. The MDS indicated in the skin and ulcer treatment section that a pressure reducing device for R89 ' s bed was applied. The care area assessment (CAA) triggered pressure ulcers related to the ADL assistance for bed mobility. The analysis of the findings in the CAA noted R89 triggered pressure ulcers as he required supervision or hands on assist with bed mobility. R89 was able to turn side to side independently, was continent of bowel and had an indwelling catheter. The risks for pressure ulcers included diabetes, [MEDICAL CONDITION], use of catheter and oxygen with tubing. The admission care plan dated [DATE], identified R89 as being at high risk - initiate care plan - tissue tolerance, special mattress, heel protectors/elevate heels, barrier cream, wheelchair cushion, repositioning. There were interventions for prevention or treatment of [REDACTED]. It also indicated the need for physical and occupational therapy (OT) referral to maximize remobilization or positioning. The therapy assessments dated [DATE], were reviewed and did not indicate any skin concerns. The tissue tolerance " test " (an assessment to determine repositioning needs) - lying was dated [DATE], noted there was a pressure reduction device on the bed and noted was independent with mobility and able to shift own weight and move self between the recliner and wheelchair and did change position a few times at night. There were no redness noted over bony prominence and no further need to assess so the assessment was not completed further. However, on [DATE], the facility received a physician order [REDACTED]. The sitting tissue tolerance was dated [DATE], the entire two hours assessment was done and resulted with no redness noted. The " test " noted R89 was " Is indep with mobility. Sleeps in recliner due to dx {diagnosis} of [MEDICAL CONDITION], per his request. Able to shift his own weight and move self in between recliner and w/c {wheelchair}, and he does change his position a few times a night. No redness noted over bony prominences and no further need to assess. " The facility did not complete another tissue tolerance "test" after R89 developed the pressure ulcers. On [DATE], the nursing notes dated [DATE], at 9:58 p.m. noted open area on buttocks during skin inspection/bath. The two areas are 2.5 cm in diameter on each side of the buttocks. The writer wrote a nursing order to apply barrier cream every shift with toileting and physician updated via fax. R89 had three Braden (a tool used for predicting pressure sore risk) scales completed. The first was done on [DATE], with score of 20 of 23 and skin was intact and able to reposition self. The second was completed on [DATE], with the same results. The third was dated [DATE], with a score of 20 and noted skin was rarely moist due to indwelling catheter in place and friction and shear are a potential problem due to [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. The facility did not complete another tissue tolerance after R89 had developed the two stage II ulcers. The care plan was revised on [DATE]. The problem identified for at risk for skin breakdown related to impaired mobility, [MEDICAL CONDITION], diabetes, use of indwelling catheter, and oxygen tubing. The interventions included to perform complete assessment of skin, note areas of redness especially where tubing may be against the skin, provide limited one assist with transfers and position change and to monitor penis and scrotum as were red and swollen related to [MEDICAL CONDITION]. The goal was to have complete healing and the interventions were to use barrier lotion with each peri care, to change position every two hours and to monitor for any new areas on bath days. However, the interventions did not indicate what pressure devices R89 had in place in the recliner to reduce the pressure on the two stage II buttocks areas. On [DATE], the doctor responded to the fax with an order to apply barrier cream to the open areas and if the facility had a wound care nurse the nurse should look at the resident. No skin investigation flow sheet was documented at that time as per the facility's skin protocol. Also, the medical record lacked evidence to indicate what pressure relieving devices was put into place to reduce pressure on the buttocks. The friction and shear was not identified on the [DATE], plan of care. The last Braden was dated [DATE], noted frequently slides down in bed or chair, required frequent repositioning with maximum assistance and [DIAGNOSES REDACTED], agitation lead to almost constant friction. The notes included the skin was rarely moist due to the indwelling catheter in place. The friction and shear concerns were potential problems due to [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and high blood sugars. It noted R89 had several opens on his bottom and staff was applying barrier cream. The facility failed to re-assess R89's pressure ulcers as stated in the skin protocol, undated. On [DATE], the nursing notes documented the stage II open areas as being on the left side of the buttock. The top opening measured 1.8 cm by 0.5 cm and the bottom measured 1.5 cm by 0.7 cm - circumference measurement and had two small opening that varied in size. " Then the right side of the buttock had the left side of the buttock had a 2.5 cm by 0.7 cm - circumference measurement and had seven small opening that varied in size " . The medical record noted conflicting information as to where the pressure were located and how they sized. The skin investigation flow sheet was dated [DATE], which had the same information recorded on it and included the wound edges were intact, the wound bed was moist and pink, and the surrounding skin was intact. The form indicated the plan of care was updated and the doctor was notified on [DATE], and no change in response to treatment. There was no mention of the coccyx area ulcers and the additional various open areas on the plan of care. Also, the care plan dated [DATE], did not indicate the ulcers were on the coccyx just the buttocks. R89 ' s stage II ulcers had increased in number and size. On [DATE], there was a dietary note which recorded a new stage II pressure ulcer on coccyx and recommended [MEDICATION NAME] (a protein supplement) three times a day to provide additional protein to promote wound healing and help with [MEDICAL CONDITION]. The protein supplement was not addressed on the plan of care. According to the skin protocol, undated, the licensed nurse was to refer R89 to the dietician regarding the two stage II pressure ulcers. The medical record lacked evidence that the protocol was followed until [DATE]. On [DATE], the weekly skin investigative flow sheet documented the coccyx area with measurements as two sores 2.5 cm in diameter each with wound bed pink, surrounding skin pink/red and wound edges rolled edges. The skin care team reviewed and changed to [MEDICATION NAME] ([MEDICATION NAME] dressing) to coccyx and change every 72 hours and as needed. The order was received on [DATE], from the nurse practitioner. The nursing summary dated [DATE], noted the buttocks were red and barrier cream applied and [MEDICATION NAME] to coccyx ulcer. There was no mention of the open areas on the buttocks. On [DATE], R89 ' s plan of care was revised to indicated R89 had a decline in health related to [MEDICAL CONDITION], diabetes, decreased heart function and refusing to sleep in bed but sleeping in recliner and resistive to position changes. The goal was to have complete healing of stage II ulcers. The interventions were to follow treatment orders with placing [MEDICATION NAME] dressing to open areas, antibiotics as ordered for urinary tract infection, continue to encourage to change position, attempt to toilet as needed for bowel movements, continue with indwelling catheter and to continue with encouraging resident to lay down. The skin assessment indicated R89 ' s left stage II ulcer had again increased in size as the varied seven areas and stage II converged into one large area and the plan of care [DATE], was not revised for interventions for the enlargement. The medical record and care plan also did not indicate what pressure devices R89 had in place to reduce the pressure on the two stage II buttocks areas. The [DATE], care plan did not include the change in condition from [DATE], and additional interventions that were put into place. The treatment sheets for April and [DATE] directed staff to apply the barrier cream to buttocks every shift with toileting until resolved was started on [DATE]. There was also a treatment to inspect skin or open area on buttocks everyday until resolved which was started on [DATE], with five of thirteen days were left blank on the treatment sheet. R89 expired on [DATE]. The skin management protocol, undated, was reviewed. The protocol instructions read that the Braden scale will be completed weekly the first four weeks for a total of five standardization risk assessments. According the protocol at the time a pressure ulcer was discovered a licensed nurse must document at least weekly, notify the family and physician, transfer orders to the treatment sheet or record, review and revise care plan and consider initiating a turning schedule from for 24 hours or an off loading schedule to gather data to revise pressure reduction efforts, referral to registered dietitian for all stage II or greater pressure ulcers Monitor pressure ulcer daily which can be noted on the treatment sheet (five of thirteen days were left blank on the treatment sheet). Within one week the skin care team reviews all new pressure ulcers and the care plan, initiate weekly progress note by licensed nurse and initiate the skin investigation flow sheet and the PUSH tool (Pressure Ulcer Scale for Healing. The facility referenced the PUSH tool; however, the facility could not provide the tool upon request during survey). If no progress for healing was noted in one to two weeks the staff was to notify the physician for treatment order review. The care planning section noted at the time of admission, based on risk factors, an initial care plan would be initiated, and then as risk factors change, intervention will be modified. If a pressure ulcer develops, the care plan will be modified to include appropriate protocols by stage based on resident's assessment. The care plan would be reviewed weekly and revised as needed by the skin care team representative. The wound care program had information that the facility had a skin care team and skin care team meeting and also weekly wound rounds which included the nurse manager, floor nurse and nursing assistant. The skin protocol was not followed for R89 ' s stage II pressure ulcers. On [DATE], at 10:50 a.m. Nurse Manager-A was interviewed regarding pressure ulcer care and treatment. She stated R89's coccyx area was excoriated for being damp as a result of indwelling catheter by passing. (Even though Nurse manager-A indicated R89 had excoriated buttocks; the facility ' s documentation indicated the areas were related to pressure). She was not able to provide documentation that the skin was moist as result of the catheter issues. The facility documented the excoriation as pressure ulcers at a stage II. She stated she believed the residents skin was broke down from wiping so the use of barrier cream was appropriate. She stated the barrier cream was generally used for three days and if no improvement the doctor would be updated. The staff was expected to document on the open areas weekly on Tuesday ' s as that was the skin assessment day. The wound or skin team was the nurse managers, director of nursing (DON) and the assistant director of nursing (ADON). When a resident develops an open area a Braden assessment and tissue tolerance assessment are completed. A skin investigation form was to be completed and measures taken with any open areas. Weekly, the wound team does rounds and measurements can be taken by the team or staff nurse. R89 should have had a skin investigation form started on [DATE], when the open areas were first discovered. The care conference was held on [DATE], at which time she believes the care plan was updated to include the open area. The approach included to use barrier cream with each peri care and to reposition every two hours was documented but did not contain a date of the entry. She stated she thought OT was contacted to assess the resident for pressure relieving devices but no documentation could be found. She stated all the mattress in the facility were pressure relieving so the staff were trying to have R89 sleep in the bed instead of the recliner. She was not able to locate documentation of a pressure relieving device for the recliner or wheelchair. She stated the resident slept in a recliner until near the end of live so no additional pressure relieving device to the bed was started or the recliner. At 2:30 p.m. Nurse Manager-A stated after reviewing the measurements documented of the open areas the area on the left buttock had gotten larger from [DATE] to [DATE] and the right side had remained the same. Then on [DATE], both areas were back to the same measurements as on [DATE]. She stated they had tried interventions but could not produce any documentation of what was done or how effective the interventions were for R89. She stated the care plan should have contained the intervention and been revised after the [DATE], skin investigation flow sheet competition. She was able to provide repositioning sheets for R89 for [DATE] thru [DATE]. She was not able to provide documentation of the repositioning which was noted to have been started on [DATE]. She was not able to produce the PUSH tool data either. R89 developed multiple stage II pressure ulcers and the facility did not provide adequate care and care planning which placed the resident at harm.