Every finding on record at Cura of Long Prairie

Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner to promote dignity for 4 of 4 residents (R3, R4, R5, R6 ) reviewed for complaints of long call light wait times.Findings include: R3R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was admitted to the facility on [DATE]. R3's cognition was intact, minimal bilateral hearing loss, utilized hearing aids, and had no behaviors. R3 had limited impairment with range of motion of the upper one side extremity and used a walker and wheelchair for mobility. R3 required substantial/maximal assistance with toileting hygiene and lower body dressing, partial/moderate assistance with toilet transfers, and supervision or touching assistance with sit to stand, chair/bed-to chair transfers, and was able to walk 150 feet. R3 was frequently incontinent of bladder and bowel. R3 diagnoses included anemia (low red blood count), depression, osteoarthritis, disorder of synovium and tendon of left shoulder (inflammation and pain that can significantly affect joint mobility and overall function).R3's care plan dated 3/1/26, identified:Self-care deficit related to bilateral shoulders. Staff were directed to use assist of one for transfers due to stiff shoulders and may need extra help with toilet. Offer ambulation with front wheeled walker to bathroom versus wheelchair and may opt to use wheelchair if fatigued.Alteration in elimination related to incontinence of bowel and bladder and diagnosis of constipation. Staff were directed to offer/assist with toileting before and after meals, upon walking, and prior to bedtime.Potential for impaired thought process related to difficulty making decisions, forgetfulness, impaired decision making, and periods of confusion. Staff were directed approach warmly and positively, provide constant caregiver as able, and validate resident's thoughts and feelings.R3's Bowel and Bladder assessment dated [DATE], identified offer assist with toileting upon waking, bedtime, as well as before and after meals. Assist with clothing, hygiene, and transfer to toilet. R3 had a history of urinary tract infections (UTI), intact cognition with no memory loss. R3 had two to three soft bowel movements (BMs) a day and usually continent with occasional bowel incontinence. R3 received daily MiraLAX (laxative). R3 had mixed bladder incontinence (both urge and stress), frequent urinary incontinence but remained occasionally continent of urine. She was incontinent 16 times and continent 5 times during the week prior to the assessment, required more help with toileting transfers and hygiene due to left shoulder stiffness and pain. Elimination plan: Assist as needed/requested (cognition intact, aware of bowel/bladder needs, but required mobility assistance) and prompt voiding (scheduled toileting that required the caregivers prompting) criteria: able to use toilet and feel sensation and request toileting.Grievance dated 1/30/26, filed by R3 identified R3 stated her call light was on for a long time and R3 ended up being very late for breakfast. This caused her to feel weak and did not want to go to exercise. Follow-up dated 1/30/26, social worker completed a resident investigation and apologized for the event. Re-educated staff members regarding understanding of expectations.The call light response time log was reviewed for the date range of 4/2/26 through 4/8/26. R3's call light response times were not responded to in a timely manner on the following dates:On 4/2/26, the call light was activated at 4:51 p.m. and was responded to 42 minutes 31 seconds after it was activated.On 4/2/26, the call light was activated at 7:37 p.m. and was responded to 18 minutes 56 seconds after it was activated.On 4/2/26, the call light was activated at 8:19 p.m. and was responded to 20 minutes 47 seconds after it was activated.On 4/5/26, the call light was activated at 6:54 a.m. and was responded to 22 minutes 23 seconds after it was activated.On 4/6/26, the call light was activated at 2:01 p.m. and was responded to 19 minutes 9 seconds after it was activated.On 4/6/26, the call light was activated at 6:19 p.m. and was responded to 20 minutes 9 seconds after it was activated On 4/6/26, the call light was activated at 6:57 p.m. and was responded to 32 minutes 1 second after it was activated.On 4/6/26, the call light was activated at 8:38 p.m. and was responded to 23 minutes 34 seconds after it was activated.On 4/7/26, the call light was activated at 12:58 p.m. and was responded to 20 minutes 21 seconds after it was activated.On 4/7/26, the call light was activated at 2:25 p.m. and was responded to 23 minutes 21 seconds after it was activated.On 4/8/26, the call light was activated at 8:23 a.m. and was responded to 30 minutes 8 seconds after it was activated.On 4/8/26, the call light was activated at 1:24 p.m. and was responded to 20 minutes 48 seconds after it was activated. (*identified in interviews)On 4/8/26, the call light was activated at 6:32 p.m. and was responded to 21 minutes 31 seconds after it was activated.During an observation/interview on 4/8/26 at 2:25 p.m., R3 sat in her recliner fully dressed by the window. She stated, I am having a very bad day. R3 reported problems with constipation and tried to have a BM every day. R3 stated, after lunch she placed her call light on, required assistance to bathroom to have a BM. When I have the urge to go, I am unable to wait a long time. R3 added, when I have to go, I have to go. R3 provided the following example: I was in my wheelchair right outside my door and flagged down the physical therapy person for assistance. They offered to take me to the bathroom. Then two more staff stopped by my room and asked the physical therapy person why they were assisting me to bathroom. The physical therapy person told them I waited a long time to go to the bathroom and really needed to go. When the physical therapy person left the room the two other staff helped me to the bathroom. R3 stated she was unable to have a BM and added, how darn miserable is that, had to go so bad, no one would take me. I cannot believe this was the way they treated me. Staff cannot tell me they did not have a chance to help me for over an hour. R3 stated she had issues with constipation all her life, was surprised she was able to hold it that long, it cannot be good for me. R3 stated it was a bad day for surveyor to stop by; R3 did not want to make waves with staff, R3 wanted to be treated like other residents, but did not have a choice, This is the way I'm treated. I am not ok with it! R3 had tears in her eyes and stated she complained to staff about long call light times before today and nothing had been fixed. R3 stated she had small urine accidents due to being unable to get to bathroom, wore a pad. R3 felt this was minor compared to lack of having a BM when she needed to go so bad. R3 reported, long call light wait times happened at least once a week, and more during the day shift. R3 stated it seemed she had to push her call light many times before someone came to help her, If I could only get around, take myself to bathroom, there would not be any concerns. I'm afraid of falling.R4R4's quarterly MDS dated [DATE], identified he was admitted to facility on 5/22/24. R4 had intact cognition and had no behaviors. R4 had impaired range of motion to one lower extremity and used a walker and wheelchair for mobility. R4 required substantial/maximal assistance with toileting hygiene, upper/lower body dressing, sitting to lying, sit to stand and all transfers. He required partial/moderate assistance with walking 10 feet. R4 was occasionally incontinent of bladder and always continent of bowel. R4's diagnoses included: anemia (iron deficiency), renal insufficiency, diabetes mellitus (DM), seizure disorder/epilepsy, depression, morbid obesity (331 pounds), and shortness of breath/trouble breathing with exertion. R4 received anticonvulsant and diuretic (increases the production of urine to promote removal of fluid from the body) medications.R4's care plan dated 3/4/26, identified:Alteration in elimination related to occasional incontinence of bladder due to impaired mobility, uses medications that may impact urinary tract functioning, and impaired cognition. Staff were directed to keep call light within reach when in room, offer toileting every two to three hours and as needed (PRN), and provide peri cares with incontinence episodes.Potential for injury related to impaired mobility, edema, and impaired skin integrity. Staff were directed to encourage him to utilize call light, signs in room to remind him of the need for staff assistance with transfers toileting, and per elimination plan of care.Self-care deficit related to limited mobility, obesity, pain, and vision impairment. Staff were directed to provide toileting assistance of one and walker.R4's bowel and bladder assessment dated [DATE], identified no memory loss. Bladder elimination observations during review showed R4 was fully continent of urine and incontinent, though maintained continence greater than two hours due to decreased mental awareness, decreased or loss of mobility or personal unwillingness. R4 had one episode of bladder incontinence during the lookback period. R4 senses and was able to alert staff when he needed to void, required prompted voiding, and wore a brief. Staff did most of R4's toileting hygiene, clothing management and provided substantial assist with clothing management and boost to standing. Incontinence likely related to functional status and required assistance with emptying urinal. Mode of elimination was commode or urinal, required staff assist every two to three hours and usually asked for assist.R4's NA Bladder/toilet use documentation from 4/2/26 through 4/8/26, identified: On 4/2/26, limited assistance required at 5:31 a.m., 1:31 p.m., 9:09 p.m., and 11:11 p.m.On 4/3/26, limited assistance required at 9:48 p.m. and independent at 11:10 p.m.On 4/4/26, limited assistance required at 7:43 a.m.On 4/5/26, limited assistance required at 5:59 a.m., 9:00 a.m. and independent at 11:40 p.m.On 4/6/26, limited assistance required at 8:34 a.m. and 9:46 p.m.On 4/7/26, limited assistance required at 8:58 a.m., 9:26 p.m. and independent at 2:47 p.m.On 4/8/26, limited assistance required at 5:30 a.m., 1:59 p.m., 9:23 p.m., and 11:17 p.m.The call light response time log was reviewed for the date range of 4/2/26 through 4/8/26. R4's call light response times were not responded to in a timely manner on the following dates:On 4/2/26, the call light was activated at 6:41 a.m. and was responded to 19 minutes 51 seconds after it was activated.On 4/7/26, the call light was activated at 3:50 p.m. and was responded to 13 minutes 33 seconds after it was activated.On 4/7/26, the call light was activated at 6:06 p.m. and was responded to 15 minutes 17 seconds after it was activated.On 4/8/26, the call light was activated at 6:12 a.m. and was responded to 14 minutes 17 seconds after it was activated.On 4/8/26, the call light was activated at 12:35 p.m. and was responded to 16 minutes 27 seconds after it was activated (*observation).During an observation/interview on 4/8/26 at 12:38 p.m., R4 sat in his wheelchair fully dressed with gripper socks on his feet, and well groomed, in his room with television on. R4 stated he had already pushed his call light, he needed assistance to use the urinal. In the past it had taken up to 30 minutes at times to get staff assistance. Now it was dinnertime so would most likely take longer for the staff to answer it. R4 stated, the long wait times had been going on for a while now. He required assistance with standing up, pulling his pants down, and urinal placed, he was unable to do it alone. R4 stated it was hard to wait at times, to use the urinal. R4 reported no urine accident yet, but he came close. He had told staff about long call wait times and how he could just pee on the floor, they could clean it up and change his socks. R4 stated, This would be embarrassing. I wish I could do more for myself. R4 stated he wasn't sure he could hold it much longer; there had already been 15 minutes of waiting for staff to help him. R4 was able to transfer himself to the toilet but had difficulty pulling his pants down and was afraid of falling. He required assistance wiping his bottom and peri cares after he used the bathroom, especially with a BM. At 12:51 p.m., nursing assistant (NA)-A entered R4's room, turned call light off, and asked him what he wanted. R4 stated he needed help getting his pants undone, pulled down, and urinal placed. NA-A closed door to the room, applied gait belt, placed walker in front of him, and applied brakes on wheelchair. R4 placed hands on arms rests of wheelchair and pushed himself up to a standing position, grabbed walker, while NA-A held onto gait belt. NA-A undid R4's pants, pulled them down to his knees, removed a urine soiled brief (verified by NA-A), and placed a towel on wheelchair. R4 lowered himself down onto wheelchair and placed the urinal while visiting with NA-A. At 1:00 p.m., NA-A applied gloves, grabbed the urinal with yellow urine in it, emptied urinal, and R4 stood up in front of wheelchair. NA-A completed peri cares, applied clean brief, pulled up pants, bagged garbage, removed gloves, and exited the room. R4 stated he was embarrassed about being incontinent, could not hold it any longer, and had to go in his pants. R4 stated he had talked about the long call wait times with other residents while staff were present but wait times did not seem to get any better. R5R5's admission MDS dated [DATE], identified R5 was admitted to the facility on [DATE], from a hospital. R5 had impaired vision and intact cognition without behaviors. R5 used a walker and wheelchair for mobility with impaired range of motion on one lower extremity. R5 required substantial/maximal assistance with toileting hygiene, lower body dressing, lying to sitting, and dependent for all transfers. R5 was occasionally incontinent of bowel and bladder. R5's diagnoses included hip fracture, anemia, renal insufficiency, urinary tract infections, arthritis, and impaired gait and mobility.R5's care plan dated 3/5/26, identified R5 had an alternation in elimination related to incontinence of bowel and bladder due to impaired mobility and history of UTI. Staff were instructed to keep call light within reach when in room, R5 was independent with toileting and would use the call light if assistance was needed.R5's bowel and bladder assessment dated [DATE], identified R5 took diuretics (urgency/frequency) and beta-blockers (can lead to urinary retention). R5 required assistance with ambulation, transfers, wheelchair mobility, and utilized the stand lift with total assist of two staff. R5 was able to identify the need or urge to void/defecate (have a BM) and used the call light. R5 was continent of bowel and incontinent of bladder (one to two years) more than once a week but not daily. R5 had to rush to the bathroom when she felt the urge to void. The call light response time log was reviewed for the date range of 4/3/26 through 4/8/26. R5's call light response times were not responded to in a timely manner on the following dates:On 4/5/26, the call light was activated at 8:43 a.m. and was responded to 15 minutes 48 seconds after it was activated.During an observation/interview on 4/8/26 at 3:00 p.m., R5 stated she used the call light located on her right wrist and requested assistance to the bathroom. Most of the staff were good about answering her call light quickly but she had waited up to 20 minutes at times, the urine comes too fast, so I do not make to bathroom in time. R5 stated this made her feel upset and embarrassed. R5 had hip surgery and was afraid of falling again. They have many great staff, but some are young, turnover is high, some don't really want to work, and most are on their cell phones quite a bit.R6R6 admission MDS dated [DATE], identified R6 was admitted to the facility on [DATE]. R6 had intact cognition with behaviors that occurred one to three days out of seven: physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing), verbal behavioral symptoms directed toward others (threatening, screaming, and cursing at others), rejection of care, and other behavioral symptoms not directed towards others (e.g. physical symptoms such as hitting or scratching self, rummaging, public sexual acts, disrobing in public, throwing or smearing food of bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R6 had impaired upper extremity range of motion (ROM) bilaterally and lower extremity ROM impairment on one side. R6 required partial/moderate assistance with oral, personal and toilet hygiene, sit to lying, lying to sitting on side of bed, and dependent for sit to stand, all transfers. R6 was always continent of bowel and bladder. R6 had diagnoses of anemia, arthritis, osteoporosis (causes bones to become weak and brittle), Non-Alzheimer's dementia, anxiety, depression, spinal stenosis, epilepsy, and constipation. She had two or more falls since admission without injury.R6's care plan dated 3/25/26, identified:Potential for falls related to impaired mobility, cognition, use of antidepressant, antipsychotic, antianxiety, diuretic medications, history of falls and limited range of motion upper and lower extremities. Staff were directed to keep call light within reach in bedroom and encourage her to utilize it.Potential for alteration in elimination related to impaired mobility. Staff were directed to offer assistance with toileting upon waking, before and after meals, before bed, PRN and observe for changes incontinence level, if significant/unusual update medical provider.Self-care deficit related to lumbar stenosis (narrowing) and weakness. Staff were directed to provide assist of two and patient assist lift (PAL) for transfers and toileting.R6's Bowel and Bladder assessment dated [DATE], identified R6 required assistance with all transfers, wheelchair mobility, was chairfast/bedfast, had limitations to accessing bathroom, used a wheelchair/walker for mobility. R6 was dependent and required a high level of staff assist with transfers, toileting hygiene, and used a four-point lift. R6 had a diagnosis of dementia/Alzheimer's. R6 received diuretics, antipsychotics, and antispasmodics (muscle relaxation leading to urinary incontinence) medications. R6 was continent of bowel and bladder, used a call light, able to report when she needed to void and so far, had not had any urinary incontinence.R6's urinary continence NA documentation from 4/1/26, through 4/9/26, identified on 4/4/26 at 1:23 p.m. and 4/6/26 at 4:34 p.m. R6 was incontinent of bladder.The call light response time log was reviewed for the date range of 4/3/26 through 4/8/26. R6's call light response times were not responded to in a timely manner on the following dates:On 4/2/26, the call light was activated at 8:43 a.m. and was responded to 20 minutes 19 seconds after it was activated.On 4/3/26, the call light was activated at 6:30 a.m. and was responded to 17 minutes 36 seconds after it was activated.On 4/3/26, the call light was activated at 2:02 p.m. and was responded to 14 minutes 29 seconds after it was activated.On 4/3/26, the call light was activated at 3:46 p.m. and was responded to 18 minutes 12 seconds after it was activated.On 4/5/26, the call light was activated at 5:42 a.m. and was responded to 22 minutes 23 seconds after it was activated.On 4/6/26, the call light was activated at 8:45 a.m. and was responded to 15 minutes 53 seconds after it was activated.On 4/7/26, the call light was activated at 6:05 a.m. and was responded to 16 minutes 26 seconds after it was activated.On 4/7/26, the call light was activated at 7:02 a.m. and was responded to 16 minutes 4 seconds after it was activated.On 4/8/26, the call light was activated at 6:41 a.m. and was responded to 37 minutes 4 seconds after it was activated.On 4/8/26, the call light was activated at 10:57 am and was responded to 18 minutes 43 seconds after it was activated.On 4/8/26, the call light was activated at 8:26 p.m. and was responded to 20 minutes 46 seconds after it was activated.On 4/8/26, the call light was activated at 11:31 p.m. and was responded to 22 minutes 54 seconds after it was activated.During an observation on 4/9/26 at 12:01 p.m., R6 sat on her bed fully dressed. She stated she was admitted on [DATE]. R6 used her call light for assistance to bathroom and getting dressed. R6 stated she had waited up to 25 minutes for staff assistance at times and, almost peed in my pants, staff told her they were sorry. R6 was frustrated, it made her feel, upset and pissed off, when I'm unable to get to bathroom when needed. R6 reported long call wait times happened every couple of days and more often during mealtime. R6 stated she placed her call light on today before lunch for assistance to bathroom, staff didn't answer her call light for at least 20 minutes. The staff have many residents to care for and not enough help. R6 stated, on those dam water pills, I have to pee many times during the day, especially in the morning. R6 reported no incontinence as of yet, and hoped to keep it that way. R6 stated, I'm so frustrated I'm not able to take myself to bathroom when needed.During an interview on 4/8/26 at 3:22 p.m., NA-B stated the expectation for staff was to answer call lights within five minutes. When staff are in another resident's room they are expected to get there as soon as possible. After meals many residents are on the call light to be taken to bathroom and laid down. R3 complained today about her call light not being answered after lunch and R3 had to go to the bathroom. According to R3, her call light was on for at least 20 minutes. NA-B informed R3, he [NA-B] had left the area, assisted a resident on a different lane and NA-C came with him. NA-B stated another NA was expected to cover the floor and should have answered R3's call light sooner. R3 had been taken to the bathroom at least four times from 6:00 a.m. to 3:00 p.m. and sometime it took a while to answer her call light, especially when busy with other residents. NA-B stated resident calls light should be answered as soon as possible to make them feel important, meet their needs, prevent falls, and, it's rude to leave them sit in a chair for a length of time when they have to go to the bathroom. NA-B stated residents had complained to staff prior to this day about long call light wait times and staff should have told a nurse about concerns.During an interview on 4/8/26 at 4:00 p.m., NA-C stated resident call lights should be answered within six minutes. There were certain times during the day, such as early morning and around mealtimes, that did not get done. NA-C stated answering the call lights within six minutes would be important to help prevent falls, self-transfers, prevent the residents wetting themselves, and bad things could have happened, such as a resident falling to the floor. NA-C was aware R3 had complained of long call light times. R3 was one of the first residents brought back from dining room to her room, one of the first residents up for the day in the morning and had frequently waited up to 30 minutes after a meal to be taken to bathroom, until more staff were around to assist her.During an interview on 4/9/26 at 2:07 p.m., NA-D stated staff were expected to answer resident call lights within five to seven minutes. When call lights were not answered within 10 minutes, a resident could fall if they tried to self-transfer. NA-D had witnessed a resident fell last week with their call light on and they attempted to self-transfer to bathroom. NA-D stated it was important to answer call lights within seven minutes so that bad situations could be prevented such as falls. We do not know if call lights were placed on for something simple or important. Answering call lights as quickly as possible was important to provide toileting and help avoid frustration among residents who had to go to bathroom and are not able to get there without assistance. Staff were expected to provide toileting in a timely manner. This caused frustration among residents when they had to go and were not able to get to bathroom in time. NA-D stated there were many residents all over the building who expressed their concerns with long call light times. NA-D gave the following example: Last week in the dining room, those residents that are more verbal talked about how frustrated they were when staff don't answer call lights for a long time, they some residents pushed the check mark to cancel the call light, and placed the call light on again so that it popped up as a recent call light going off. NA-D overhead R4 state to other residents that same day during a general conversation he was frustrated, needed the bathroom, and could not get assistance. NA-D did not tell anyone about R4's concern; unsure it was a problem that happened often. NA-D stated staff tried their best to answer call lights quickly but got delayed when an emergency happened in another room or when charting. It was easy to get distracted, long call light times really should not have happened if staff communicated well. NA-D stated, Yesterday, [4/8/26] after lunch break [R3] complained she had to wait 20 minutes to get her call light answered. She was frustrated. I tried to calm her down and provided an apology for the long wait to get her call light answered. NA-D stated she was on a different wing with two call lights on and the other NA assisted another resident on a different wing. R3 had told NA-D when she felt the need to have a BM, she required assistance to go right away, whenever R3 waited too long it backed up and then she was unable to go.During an interview on 4/9/26 at 2:35 p.m., director of nursing (DON) stated the facility did not have a call light policy. There was not a specific maximum wait time for call lights in any of the facility's policies. We look at facility needs, staffing, and whether the staff were just in the residents' room and helped them. A staff float was added to assist with meals and trays during high volume call light times which seemed to be identified as a trend during meals. During the evenings there was a rush to bed and the need for expansion of more staff was identified. DON encouraged to complete purposeful rounding, alternate staff breaks so that staff were available on each lane at all times, ask residents if there was anything else they could get them before leaving the room, especially with those who were call light happy. Staff were expected to answer call lights as soon as possible to provide residents' safety, dignity as priority for anyone, and meet the residents' needs.Facility Policy Resident Rights dated 1/2024, identified the facility will protect and pro-actively promote the rights of each resident. Each resident of the facility has a right to dignified existence, self-determination, communication with, and access to, people and services inside and outside the facility. Residents have the right to be informed of their rights and to exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility and to be supported by the facility in the exercise of his or her rights.Facility policy Quality of Life - Dignity dated 10/2025, identified each resident shall be cared in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times, assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance. Staff shall treat cognitively impaired residents with dignity and sensitivity, for example: Addressing the underlying motives or root causes for behaviors or statements and not challenging or contradicting the residents' beliefs or statements.Requested Call Light policy on 4/9/26 and informed by DON facility did not have one.

Based on observation, interview and document review, the facility failed to ensure proper personal protective equipment (PPE) was used when providing cares for 1 of 1 residents (R24) reviewed for enhanced barrier precautions (EBP). Findings Include: R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment and one unhealed stage two pressure ulcer and a skin tear. R24's undated care plan included R24 was on EBP to prevent the spread of multi drug resistant organisms (MDRO). The care plan instructed to use gown and gloves with high-contact resident care activities. During medication pass observation on 4/28/25 at 7:17 p.m., nursing assistant (NA)-A, NA-B, and trained medication assistant (TMA)-A were observed repositioning R24 in her bed and assisting with drinking water. All three staff made contact with bedsheets, pillows and the resident during repositioning multiple times while not wearing PPE. During interview on 4/28/25 at 7:24 p.m., NA-A and NA-B confirmed R28 was on EBP and that they were not wearing gowns during repositioning. They both stated they would only wear a gown if they were changing R28's brief or doing other personal cares. During interview on 4/28/25 at 7:36 p.m., TMA-A confirmed R28 was on EBP for wounds to her buttocks. TMA-A stated PPE would be worn any time someone was providing wound care or changing her brief. During interview on 4/29/25 at 3:00 p.m., infection prevention registered nurse (RN)-A stated staff should wear PPE when providing personal cares. RN-A stated a sign was hung outside the door which indicated when PPE should be worn. During interview on 4/29/25 at 3:20 p.m., director of nursing (DON) confirmed staff should be wearing PPE when adjusting bedding and repositioning. DON stated immediate reeducation would be provided with staff to ensure all staff understood the expectations. Facility Enhanced Barrier Precautions dated March 2025, included the facility would follow Center for Disease Control (CDC) to reduce the transmission of MDROs through the use of gown and gloves during high contact resident care activities.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll during 1 of 1 quarters (Quarter 4) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Payroll Based Journal (PBJ), [NAME] Report 1705D indicated the facility had excessively low weekend staffing during quarter 4 of fiscal year 2023, which included dates between July 1 to September 30th. Daily staff schedules during quarter 4 indicated adequate staff on weekends. During interview on 1/9/24 at 10:31 a.m., director of nursing (DON) stated weekly schedules were created by either the DON or Administrator. Staffing reports were submitted to the corporate office and the corporate office would submit data to CMS. Facility policy requested and not provided.

Based on observation, interview, and record reviews facility failed to protect personal health information for 2 of 2 residents (R11 & R34) related to code status. Finding include: R34's annual minnimum data set (MDS) dated [DATE], indicated severely impaired cognition, and diagnoses of Parkinson's disease (Unable to control movements), malnutrition (poor nutrition), atrial fibrillation (irregular heartbeat), and hypertension (high blood pressure). R11's quarterly MDS dated [DATE], indicated intact cognition, diagnoses of anemia (low iron), hypertension (high blood pressure), renal insufficiency (poor kidney function), and hemiplegia (reduced function of one side). During observation on 1/7/24 at 11:50 a.m., do not recesutate (DNR) (No life saving measures) labels were noted on room number plates outside of rooms for residents R34 and R11. During an interview on 1/7/24 at 3:36 p.m., R11 stated it was her desire to be a DNR, understood it, and it should be in her record. R11 stated she had never asked any staff to post that information to be publicly seen. During an observation on 1/8/24 at 10:01 a.m., DNR labels remained on R34 and R11's room number plates. During an interview on 1/8/24 at 10:01 a.m., two sons for R34 stated, DNR status was correct. Neither son had requested it be posted in a public space. During an observation on 1/9/24 at 7:14 a.m., DNR label still noted on door frames for residents R34 and R11. During an interview with on 1/9/24 at 9:40 a.m., certified nursing assistant (CNA)-A stated no recolection of a conversation or any information about R11 or R34 having a DNR posted in a public space or on the name plates of their doors. During an interview on 1/9/24 at 1:31 p.m., registered nurse (RN)-A stated she was unaware residents R34 and R11 had DNR next to their name on the room number plates. RN-A stated code status was private information and staff referred to the chart. The facility used a green and red coding system on the hard charts as well. RN-A stated DNR labels should not have been on the room number plates. During an interview on 1/9/24 at 4:33 p.m., Director of Nursing (DON) stated personal information like that of a DNR should never be posted publicly. A facility policy titled Confidentiality of Information and Personal Privacy with a review date of 1/24 was provided. Policy indicated: The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records and access to resident personal and medical records will be limited to authorized staff and business associates.

Based on interview and document review the facility failed to notify the ombudsman of facility-initiated discharges and transfers to the hospital for 4 of 4 residents (R45, R195, R5, R8,) who were discharged to home or transferred to the hospital. Findings include: Facility provided form Discharges since 2022 indicated R45 discharged home 8/25/2023 and R195 discharged home on 8/15/2023. Facility provided form Residents that have discharged to hospital and come back since 2022 indicated R5 transferred to the hospital on 11/22/2023 and returned 11/26/2023. Further, R8 transferred to hospital on 11/17/2023 and returned 11/20/2023. Review of facility provided documentation lacked evidence the ombudsman was notified for transfer or discharge of R45, R195, R5, R8. On 01/09/24 at 03:00 p.m., social services designee (SSD)-E stated she did not send updates to the ombudsman unless a resident was already working with the ombudsman. On 01/09/24 at 04:51 p.m., SSD-E confirmed the ombudsman was not sent the notifications for discharge to home for R45 and R195. Further, she stated no notification was sent to the ombudsman for transfer to hospital for R5 and R8. She confirmed the ombudsman was notified of six residents discharged home since 12/15/22. SSD-E stated she had not followed the appropriate procedure and should have notified the ombudsman. Facility provided policy titled Discharge Planning, directed ombudsman notification was required for transfers or discharges to a hospital or emergency department.

Based on observation, interview, and document review, the facility failed to implement interventions to prevent further development of decreased range of motion for 1 of 1 residents (R8) reviewed for positioning. Findings include: R8's diagnosis report printed 1/9/24, indicated diagnosis of dorsalgia (back/neck pain), muscle weakness, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (weakness on the left side following a stroke). R8's annual minimum data set (MDS) dated [DATE], indicated moderate cognitive impairment and impaired functional range of motion on both side of the body on both upper and lower extremities. Passive range of motion and active range of motion was completed 0 days reviewed during lookback period. R8's care area assessment (CAA) indicated resident was at risk for pressure ulcers, pain, contractures due to impaired mobility. During interview on 1/9/24 at 12:22 p.m., R8 stated staff do not offer her a pillow to support her head while sitting. During interview on 1/8/24 at 1:03 p.m., registered nurse (RN)-B stated R8's neck had been in bent position with head off to left side for about a year. RN-B was not aware of if R8 had been evaluated by physical therapy or occupational therapy for positioning. During interview on 1/8/24 at 3:07 p.m., registered occupational therapist (OT)-A stated if a resident has an issue with posture or pressure injury, staff can request an order from the provider for an occupational therapy evaluation. Occupational therapy would evaluate posture and make recommendation for supports. Suggestions for interventions and repositioning could also be made. Orders and evidence of evaluation completed by physical therapy or occupational therapy requested and not provided. Facility policy Resident Mobility and Range of Motion effective January 2024 indicated that residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on observation, interview and document review, facility failed to properly assess 2 of 5 residents (R19, R27) reviewed for accidents. Findings include: R19's admission minimal data set (MDS) dated [DATE], indicated intact cognition (able to fully understand), diagnoses of anxiety, depression, post traumatic stress disorder (history of trauma from past event), chronic respiratory failure (history of poor lung function), and personality disorder (changes in personality). R19's care plan initiated 12/1/23 indicated cigarettes and lighter will be kept in the medication cart, resident will need to request them. R19's smoking assessment dated [DATE], indicated R19 had a history of smoking, currently using cigarettes, demonstrated independence with being able to get to designated smoking area and use of tobacco products. Document indicated cigarettes and lighter were locked up when not in use and resident requested them. Assessment lacked evidence R19 had been assessed to safely keep cigarettes or lighter in their possession. During an interview on 1/7/24 at 2:40 p.m., R19 sated he had not gone out to smoke today and probably wouldn't over the next few days as it was too cold outside. R19 stated he was supposed to ask for cigarettes and lighter from the nurse. However, he kept them in his coat pocket, in the closet. During an interview on 1/9/24 at 12:37 p.m., trained medical assistant (TMA)-A stated she was familiar with R19's history of smoking and used tobacco products. TMA-A stated R19 smoked on his own and was to return the items to the medication carts on the hall near his room when done. During an interview on 1/9/24 at 12:40 p.m., registered nurse (RN)-A stated R19 smoked independently and was to return the cigarette and lighter to the medication carts near his room. RN-A opened medication carts near R19's room, neither cigarettes nor lighter were found. During an interview on 1/9/24 at 1:30 p.m., RN-A stated R19 confirmed he had his cigarettes and lighter but was not willing to help her find them. RN-A stated she would be returning to find the items soon. RN-A stated the assessment was to be followed and smoking supplies needed to be kept in the medication cart. R19 had not been assessed to keep posession of the materials. Facility document, titled, smoking policy and procedure, last reviewed 1/2024, indicated that all residents who choose to use tobacco are evaluated and assessed for safety. 49035 R27's diagnoses report printed 1/9/24, included Parkinson's disease with dyskinesia (involuntary, uncontrolled muscle movements), dementia, and weakness. R27's restorative nursing program initiated 5/25/23, revised on 8/13/23, included Walking with assist of 1 and walker with wheelchair to follow twice a day for 15 minutes each. Restorative nursing program to be overseen by nurse and periodically reviewed. R27's order summary report printed 1/9/24, included an order dated 9/19/23, for physical therapy evaluation and treatment due to weakness and increased need for staff assistance with transfers. R27's significant change Minimum Data Set (MDS) dated [DATE] included care area assessment for activities of daily living. R27 was noted to have balance problems due to poor safety awareness, impaired vision and hearing, diagnoses of Parkinson's Disease and dementia. R27's physical therapy discharge date d 10/25/23, indicated assessment for safety of walking program was part of plan of care. Physical therapist dictated resident was not appropriate for walking program as he heavily retro pushes and did not demonstrate safety with physical therapist. Discharge plans and instructions printed on discharge included use of a mechanical lift and R27 was not safe for walking program. R27's care plan reviewed 10/26/23, included resident had impaired cognitive function related to dementia, difficulty making decisions, unable to make safe decisions. Resident showed moderate cognitive impairment. Resident at risk for falls due to Parkinson's Disease. Feet become frozen and resident would be unable to ambulate. During observation on 1/8/24 at 3:37 p.m., two staff attempted to ambulate R27 with walker, gait belt and wheelchair to follow. Resident stated I can't. Staff encouraged resident. Resident was able to stand with walker and hands-on assistance from nursing assistants. Resident again stated he could not walk and sat down in wheelchair. During interview on 1/8/24 at 4:07 p.m., nursing assistant (NA)-C reported it was rare that R27 ambulated. NA-C stated R27 usually refused. During interview on 1/8/24 at 4:15 p.m., clinical nurse manager (CM-A) stated physical therapy gave recommendations on walking and restorative programs. CM-A reviewed physical therapy discharge instructions and agreed R27 was deemed unsafe for walking program. CM-A stated it would have been important to follow therapy instructions because they were the experts. Facility documentation lacked evidence of a risk/benefit discussion with R27 and R27's representative in regards to continuing a walking program after physical therapy indicated resident was unsafe. Further, documentation lacked evidence R27 was reassess for safety for walking program after discharge from physical therapy. Facility policy titled Restorative Nursing Services effective January 2024, indicated residents would receive restorative nursing care as needed to help promote optimal safety and independence. Resident or resident representative would be included in determining goals and the plan of care.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R34) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R34's annual minimum data set (MDS) dated [DATE], indicated severely impaired cognition (unable to understand), diagnoses of Parkinson's Disease (Unable to control movements), malnutrition (poor nutrition), atrial fibrillation (irregular heartbeat), and hypertension (high blood pressure). R34 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R34's Immunization record indicated that no pneumococcal immunization had been administered, offered, or refused. R34's Pneumococcal Vaccination Consent Declination indicated refusal by resident representative dated 10/12/22. Consent Form offered residents and representatives the PPSV23 and PCV13 immunization but did not identify the PCV20 or other immunizations. During an interview on 1/9/24 at 1:06 p.m., infection preventionist (IP) indicated immunizations were reviewed upon admission, and vaccines were then offered to residents and representatives. IP stated residents and/or their representatives were educated about immunizations. Declinations were recorded on a declination form. IP stated there was no evidence the facility offered the immunization to R34. During an interview on 1/9/24 at 2:13 p.m., IP stated after reviewing additional medical records for R34, she could not find that the PCV20 had been offered. IP stated even if the resident or the representative do not want vaccines, that it should at least be offered with education, and a declination signed. A facility policy titled Pneumococcal Immunization, Long Term Care with a review date of 6/23 was provided. Policy indicated: Residents will be offered the pneumococcal vaccination and administered, according to the MDH and CDC recommended interval for the vaccines, unless contraindicated, already immunized, or the resident and/or the resident representative declines, the vaccine. Facility document indicated the pneumococcal vaccines for PCV13, PCV15, PCV20 and PPSV23.

Based on observation, interview, and document review, the facility failed to ensure all items on room trays were covered for 6 of 8 food trays observed on one cart during delivery of dinner to residents. This had the potential to affect 6 of 8 residents that received food trays from the cart. Findings include: On 8/2/21, at 5:31 p.m. dietary aide (DA)-A was preparing meal trays to be delivered to resident rooms. The main entree was scooped onto the plate by the dietary server, from the steam table, covered with a dome lid and handed to DA-A. The covered plates were placed on each tray with beverages and applesauce, and the trays were placed onto a metal four-shelved cart, with two trays on each shelf. DA-A then placed a white bath towel over the two trays on the first cart shelf. The remaining six trays were not covered when the metal cart was pushed out of the dining room and down the hallway, to deliver to resident rooms. There were no covers on the beverages, which included water, milk and juice, and there were no covers on the small bowls of applesauce. On 8/2/21, at 6:00 p.m. DA-A verified that the applesauce and beverages were not covered when the six trays were transported. DA-A stated that the Dietary Director (DD) and the Dietician (D) had been asked if the bottom three trays should have been covered. Additionally, DA-A stated, we asked about the next shelves, and they told us no because the shelf above covered. On 8/4/21, at 12:51 p.m. DD acknowledged the beverages and applesauce on six trays of the four-shelved cart were not covered, stating, that's the way it's being done, but we'll change that. The Food Storage policy, last approved 7/21, indicated Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination.

Based on observation, interview, and document review the facility failed to ensure voiced dental concerns were addressed and acted upon for 1 of 1 resident (R22) reviewed for dental care. Findings include: R22's admission Minimum Data Set (MDS), dated [DATE], identified R22 had intact cognition and required supervision with personal hygiene tasks. The MDS further identified R22 had no natural teeth or tooth fragments. A Care Area Assessment (CAA) dated 12/20/20, indicated R22 had no natural teeth or tooth fragments. R22's Order Summary Report dated 7/9/21, indicated R22's physician ordered a dental consult for dentures on 7/13/21, and was signed off by a registered nurse (RN) on 7/13/21. A nurse progress note dated 7/13/21, revealed R22 inquired about a new set of dentures. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A Clinical Issues form dated 7/12/21 through 7/22/21, indicated R22 needed staff to look into a dental consult for R22. The Clinical Issues form lacked indication that staff had called for a dental consultation. During an interview on 8/2/21, at 2:36 p.m. R22 stated he tried to go to the dentist but had not gotten there yet. R22 stated he had requested from staff to go to the dentist however, had not heard back from the staff. During an interview on 8/5/21, at 8:47 a.m. with registered nurse (RN)-A revealed the appointment had not been checked off as completed. During an interview on 8/5/21 at 8:49 a.m. with RN-B stated there is an appointment to be done for R22 but we have not gotten it done yet. RN-B stated the appointment was not scheduled yet. A facility policy Dental Services-Long Term Care dated 1/2021, indicated oral health services are offered to meet the resident's needs and/or preferences. Facility personnel will assist the resident/family in making dental appointments and transportation arrangements as necessary.

Based on observation, interview and record review, the facility failed to follow the care plan resulting in a fall for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm when R1 sustained a head injury, was transported to the emergency department and later died . The facility had implemented corrective action, so the deficient practice is being issued at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had a BIM's (brief interview for mental status-cognitive test) of 9 out of 15, indicating moderate cognitive impairment. In addition, the MDS indicated R1 required extensive assistance with transfers and walking in room. R1's [DIAGNOSES REDACTED]. R1's current care plan indicated a self-care deficit related to LUE (left upper extremity) impairment, and R1 required assistance of two staff when walking, 1 staff to follow with wheel chair and the other to assist with client using wheeled walker when walking in room. R1's Kardex, printed [DATE], indicated: Walk in Room: 2 staff with w/c (wheel chair) to follow and client using wheeled walker. A Facility Reported Incident dated [DATE], stated, on [DATE] at 4:30 p.m. R1 was being ambulated by nursing assistant (NA)-A when he became weak. NA-A was not able to catch the resident which resulted in a fall to the floor and hitting his head on the bed as he fell . The report indicated an investigation was completed and revealed R1's care plan was not being followed, R1 required assist of two when walking but only one staff was present at the time of the incident. The report indicated R1 had a laceration to the back of his head, a subdural hematoma with declining condition and had been transported to the emergency department. During an interview on [DATE], at 2:35 p.m. NA-A stated R1 fell and hit his head on [DATE] while she was assisting him to walk to the bathroom from the lift recliner in his room. NA-A stated she applied a gait belt and was in front of R1 when he stood and had taken a couple steps but then started to lean backwards. NA-A stated she attempted to get behind R1 but was unable to catch him, and R1 fell to the floor and hit his head in two places. NA-A stated she immediately requested help from the licensed practical nurse (LPN)-[NAME] Further NA-A stated, It was a misunderstanding. I thought he was assist of one and he was actually assist of two. NA-A shared she worked until 7:00 a.m. the next morning because of a call in. However, it was later that same evening during a review of paper work when NA-A realized R1 was care planned as assist of two with walking. NA-A stated When I noticed he was a two assist, I couldn't find a nurse, I still felt responsible. NA-A stated she'd talked with the DON the day following the incident, initially NA-A stated she had planned to terminate her contract but the DON was encouraging her to wait. Later the DON contacted NA-A and informed her the client likely died from his injuries sustained in the fall and was terminated at that time. During an interview on [DATE], at 3:57 p.m. LPN-A stated she was called to the room when R1 fell . LPN-A stated she did not like the way he looked, and called for the registered nurse (RN)-A in charge to assist. LPN-A stated R1 was not responding verbally, and there was blood on the back of his head. LPN-A stated emergency services were called to assist and R1 was transported to the emergency department. LPN-A stated, at the time of the incident, I thought he (R1) was a one assist for walking but found out he was assist of two. During an interview on [DATE], at 3:39 p.m. RN-A confirmed she was called to the unit when R1 fell . RN-A said R1 was not responding, had weakness in his arm and was slurring his speech. RN-A stated they proceeded to care for R1 until emergency services arrived. Further, RN-A indicated she asked NA-A and LPN-A what level of assistance R1 required and both indicated R1 was assist of one. RN-A stated she'd gathered information and everything was turned over to the director of nursing (DON) to complete the investigation. RN-A stated she was not aware at the time that R1 was an assist of two. Hospital documentation, dated [DATE], at 5:02 p.m. stated patient presents with Code Stroke. He presents with left-sided weakness of the upper and lower extremities. Findings consistent with a thin subdural hematoma overlying the right cerebral convexity measuring up to 7 mm in size. Subarachnoid hemorrhage is also identified within the right cerebral hemisphere. During an interview on [DATE], at 3:03 p.m. DON stated she was made aware of the fall and proceeded with her investigation. DON interviewed NA-[NAME] She was attempting to walk (R1), so not following the care plan. She (NA-A) knew he was a two assist but screwed up. DON stated staff were also informed in huddles to make sure the care plan was followed and provided a signature log with 13 signatures dated [DATE] & [DATE]. Documentation of a huddle held on [DATE] & [DATE] stated check Kardex for when transferring resident showed an additional 11 staff signatures. DON stated all staff were notified by e-mail, dated (MONTH) 7, 2019 to check resident Kardex when providing care, DON stated we haven't hit everyone. Further, DON had printed all resident Kardex and placed in pink binder on each wing prior to the on-site investigation. During an interview on [DATE], at 8:53 a.m. NA-B stated he was taught to look at the Kardex during orientation 5 years ago, but recently he had received and email reminding staff to look at the Kardex before providing cares. During an interview on [DATE], at 9:03 a.m. NA-C stated there was annual training to look at the Kardex in P[NAME] (point of care), in the resident's closet or in the pink binder at nursing station. NA-C stated there had been emails sent out to everyone and all staff have computer and email access. During an interview on [DATE], at 9:07 a.m. NA-D stated she tries to look at the Kardex in the morning and recently had received an email about the Kardex being updated for residents. An email sent by DON on [DATE], at 4:08 p.m. stated, I just wanted to remind you that the Kardex in PCC is the best resource for you to see how to care for our residents. I have also on each wing also put in a bright pink binder that says My Story each residents Kardex. So you now will have in PCC in the Kardex, in the pink binder and in the door of each residents closet the most up to date Kardex. Please review these and make sure you know how to correctly care for the residents. If you see changes that are needed please let the nurse and/or charge nurse know so we can update the Kardex. I cannot stress how important it is that you follow what is on the care plan/Kardex for caring for the residents. During an interview on [DATE], at 3:28 p.m. R1's daughter stated the staff were always very kind but had a concern that at the time of the fall, her father was not being assisted correctly. R1's daughter stated the death certificate says the cause of death was a subdural hematoma caused by [MEDICATION NAME] force injury from standing height. A facility policy on Comprehensive Care Plans, last approved ,[DATE], indicated the facility must develop and implement a comprehensive person-centered care plan for each resident. Further, the services provided must be provided by a qualified person in accordance with each resident's written plan of care. Although the facility failed to ensure R1 was free from accidents, and R1 sustained an injury leading to his death, the faciltiy had revised policies and corrective actions as of [DATE]. Corrective action was taken with NA-A, and all other staff were also educated regarding the use of the Kardex. In addition, the facility printed all residents' Kardex and placed in a binder at the nurses station as another resource for staff to look when assisting residents.

Based on observation, interview and document review, the faciltiy failed to provide sufficient nursing staff to meet activities of daily living (ADLs) for 2 of 2 residents (R5, R9) who were dependent upon staff for bathing assitance; for 1 of 1 residents (R15) who was not provided timely care for toileting assistance, for 6 of 6 residents (R44, R38, R32, R48, R5, R9), 2 of 3 family members (FM-A, FM-C), and 8 of 8 staff members (RN-A, NA-G, NA-E, LPN-E, RN-D, NA-D, LPN-B, NA-C) who voiced concerns about lack of sufficient nursing staff in the facility. This had the potential to affect all 57 current residents of the nursing home. Findings include: ACTIVITIES OF DAILY LIVING NOT COMPLETED R5's quarterly Minimum Data Set (MDS), dated [DATE], indicated R5 was cognitively intact, had no rejection of care, was frequently incontinent of bladder and occasionally incontinent of bowel, and required extensive assistance for ADLs (activities of daily living) with physical help in part of bathing activity. Review of the Facility Bath Schedule, updated 5/7/19, indicated R5 was scheduled for a bath on Tuesdays and Fridays. During an interview on 7/8/19, at 2:10 p.m. R5 stated she gets a bath on Tuesdays, and is supposed to get a bath on Friday, however, stated, Sometimes it's two to three times a month that I don't get my Friday bath. R5 indicated that the bath aide or the restorative aide get pulled when staffing is short, therefore, residents that are scheduled for their bath that day, miss their bath. R5 stated, It's frustrating to go a whole week without a bath.Review of the Point of Care, Follow Up Question Report, from 5/10/19 through 7/12/19, indicated R5 received a bath on Tuesday, 6/18/19, Tuesday, 6/25/19, and Tuesday, 7/2/19, not twice weekly as R5 prefers and as scheduled. R9's quarterly MDS, dated [DATE], indicated R9 was cognitively intact, had no rejection of care, and was independent for most ADLs but did require physical help in part of bathing activity. Review of the Facility Bath Schedule, updated 5/7/19, indicated R9 was scheduled for a bath on Tuesdays and Fridays. During an interview on 7/9/19, at 9:11 a.m. R9 stated, Staffing is a problem. I don't always get my Friday bath. The bath aide is pulled often off of the unit. You have to wait again until the next bath day. It's frustrating. They need somebody to help. Review of the Point of Care, Follow Up Question Report, from 5/10/19 through 7/12/19, indicated R9 received a bath on Tuesday, 6/18/19, Tuesday, 6/25/19, and Tuesday, 7/2/19, not twice weekly as R9 prefers and as is scheduled. TOILETING ASSISTANCE R15's quarterly MDS, dated [DATE], identified R15 had severe cognitive impairment, required extensive assistance with transfers, personal hygiene, and toilet use, and was frequently incontinent of urine and bowel. R15's care plan, revised on 4/29/19, included R15's bladder record, indicated voiding every two hours and directed staff to assist with urinal as close to every two hours as possible, keep call light within reach, and anticipate and meet needs. The care plan further included R15 had alteration in elimination related to constipation, incontinence of bowel and bladder, and had an inability to self toilet related to impaired mobility. During an interview on 7/9/19, at 8:40 a.m. family member (FM)-B stated, Sometimes it's discouraging for (R15) because they're short staffed, you know. Sometimes (R15) has to wait a half hour to get someone in the room to help him. (R15) knows when he has to go to the bathroom. When you gotta go, you gotta go. He doesn't understand that they are short staffed. (R15) has an accident a couple times a week, that I'm aware of. That bothers him. During an interview on 7/11/19, at 1:15 p.m. R15 indicated he has had times when his call light doesn't get me the help I need. I sit and wait, having to go to the bathroom. Sometimes it's a half hour. Nobody comes. Yes, it bothers me, I'm humiliated when I have an accident. Review of R15's Device Activity Report, from 6/10/19 through 7/10/19, revealed that R15, on several occasions, had to wait 20 minutes up to 100 minutes for assitance after putting on his call light. -On 6/10/19, at 6:19 p.m. R15's call light was on for 30 minutes, 37 seconds. -On 6/11/19, at 6:31 p.m. R15's call light was on for 21 minutes, 2 seconds. -On 6/14/19, at 4:24 p.m. R15's call light was on for 100 minutes, 28 seconds. -On 6/14/19, at 7:08 p.m. R15's call light was on for 23 minutes, 30 seconds. -On 6/16/19, at 8:12 p.m. R15's call light was on for 29 minutes, 9 seconds. -On 6/20/19, at 4:06 p.m. R15's call light was on for 25 minutes, 37 seconds. -On 6/21/19, at 12:05 p.m. R15's call light was on for 41 minutes, 50 seconds. -On 6/22/19, at 12:38 p.m. R15's call light was on for 22 minutes, 47 seconds. -On 6/22/19, at 6:31 p.m. R15's call light was on for 48 minutes, 15 seconds. -On 6/23/19, at 6:17 p.m. R15's call light was on for 66 minutes, 30 seconds. -On 6/24/19, at 6:24 p.m. R15's call light was on for 59 minutes, 30 seconds. -On 6/25/19, at 5:00 p.m. R15's call light was on for 70 minutes, 50 seconds. -On 6/30/19, at 6:37 p.m. R15's call light was on for 22 minutes, 1 second. -On 7/1/19, at 6:24 p.m. R15's call light was on for 28 minutes, 9 seconds. -On 7/3/19, at 7:07 p.m. R15's call light was on for 24 minutes, 26 seconds. -On 7/5/19, at 7:33 p.m. R15's call light was on for 31 minutes, 46 seconds. RESIDENT CONCERNS REGARDING STAFFING R44's significant change MDS, dated [DATE], indicated R44 was cognitively intact. The MDS indicated R44 was independent with eating, but required extensive assistance with all ADLs. R44 stated in interview on 7/8/19, at 6:28 p.m., I went to the bathroom, I was on the toilet for 35 minutes. I didn't like that .they cant help it. They are short of help. Some work double time all the time. R38's annual MDS, dated [DATE], indicated R38 was cognitively intact, required supervision for eating, and required extensive assistance with all ADLs. When interviewed on 7/8/19, at 7:18 p.m. R38 stated, We need two aides on this unit because everyone wants to go to bed at the same time. R38 stated the facility only staffs one nurse and one nursing assistant (NA), and the wait could be more than ten minutes because the two staff were helping other residents. R38 stated a resident came into his room and staff were not around to help remove the resident. When interviewed on 7/12/19, at 8:20 a.m. R38 indicated the restorative aide would get pulled from doing restorative exercises with residents and would have to work the floor. R38 stated some NAs will not work on the unit unless there are two NAs, because there are a lot of needs on the unit. R38 stated it was hard for the nurse to get medications administered due to the number of behaviors on the unit. R32's annual MDS, dated [DATE], identified R32 had severe cognitive impairment, was totally dependent for locomotion on and off the unit, and required extensive assistance for all ADLs. During an interview on 7/10/19, at 9:30 a.m. R32 stated, I can't go no place. R32 indicated his biggest complaint is that he can't get himself around, and stated, I have to tell them over and over again .no resolution .I tell the nurses. R32 added, I've been left behind after an activity. R48's 30 day MDS, dated [DATE], indicated R48 was cognitively intact, required supervision for eating, and required extensive assistance for all ADLs. During an interview on 7/8/19, at 5:37 p.m. R48 stated she had to wait up to 45 minutes on occasions when the NA's are busy. Review of R48's Device (call light) Activity Report, from 6/12/19 through 7/12/19, revealed that R48, on several occasions, had to wait 20 minutes up to 138 minutes for assistance after putting on the call light. -On 6/12/19, at 6:28 p.m. R48's call light was on for 45 minutes, 28 seconds. -On 6/13/19, at 3:36 p.m. R48's call light was on for 25 minutes, 43 seconds. -On 6/13/19, at 6:46 p.m. R48's call light was on for 33 minutes, 40 seconds. -On 6/14/19, at 11:59 a.m. R48's call light was on for 28 minutes, 31 seconds. -On 6/14/19, at 6:04 p.m. R48's call light was on for 31 minutes, 25 seconds. -On 6/15/19, at 6:04 p.m. R48's call light was on for 31 minutes, 16 seconds. -On 6/6/19, at 7:59 a.m. R48's call light was on for 26 minutes, 14 seconds. -On 6/16/19, at 6:11 p.m. R48's call light was on for 70 minutes, 47 seconds. -On 6/17/19, at 12:14 p.m. R48's call light was on for 29 minutes, 57 seconds. -On 6/18/19, at 6:45 p.m. R48's call light was on for 26 minutes, 8 seconds. -On 6/19/19, at 8:57 a.m. R48's call light was on for 22 minutes, 50 seconds. -On 6/19/19, at 6:20 p.m. R48's call light was on for 24 minutes, 15 seconds. -On 6/20/19, at 6:11 p.m. R48's call light was on for 138 minutes, 43 seconds. -On 6/21/19, at 12:07 p.m. R48's call light was on for 33 minutes, 10 seconds. -On 6/21/19, at 2:08 p.m. R48's call light was on for 20 minutes, 50 seconds. -On 6/24/19, at 9:36 a.m. R48's call light was on for 20 minutes, 41 seconds. -On 6/25/19, at 11:10 a.m. R48's call light was on for 24 minutes, 50 seconds. -On 6/25/19, at 7:35 p.m. R48's call light was on for 64 minutes, 47 seconds. -On 6/26/19, at 5:58 p.m. R48's call light was on for 24 minutes, 5 seconds. -On 6/26/19, at 7:44 p.m. R48's call light was on for 22 minutes, 50 seconds. -On 6/27/19, at 11:01 a.m. R48's call light was on for 23 minutes, 17 seconds. -On 6/27/19, at 9:04 p.m. R48's call light was on for 26 minutes, 29 seconds. -On 6/28/19, at 8:28 a.m. R48's call light was on for 30 minutes, 14 seconds. -On 6/29/19, at 6:56 p.m. R48's call light was on for 63 minutes, 24 seconds. -On 6/30/19, at 7:35 p.m. R48's call light was on for 21 minutes, 48 seconds. -On 7/2/19, at 6:11 p.m. R48's call light was on for 24 minutes, 34 seconds. -On 7/3/19, at 6:25 p.m. R48's call light was on for 25 minutes, 53 seconds. -On 7/5/19, at 7:49 p.m. R48's call light was on for 33 minutes, 45 seconds. -On 7/9/19, at 7:33 a.m. R48's call light was on for 21 minutes, 30 seconds. R5's quarterly MDS, dated [DATE], indicated R5 was cognitively intact, was independent with eating and personal hygiene, and required extensive assistance with all other ADL's. During an interview on 7/10/19, at 9:30 a.m. R5 stated she had trouble getting someone to trim her toenails. R9's quarterly MDS, dated [DATE], indicated R5 was cognitively intact, was independent with ADLs, however, required physical help in part of bathing activity. During an interview on 7/10/19, at 9:30 a.m. R9 stated, (There's) not enough staff .I have had to wait an hour. Review of R9's Device Activity Report, from 6/10/19 through 7/10/19, revealed that R9, on several occasions, had to wait 22 minutes up to 63 minutes for assistance after putting on the call light. -On 6/13/19, at 2:03 p.m. R9's call light was on for 63 minutes, 56 seconds. -On 6/25/19, at 5:42 p.m. R9's call light was on for 23 minutes, 57 seconds. -On 7/5/19, at 4:40 a.m. R9's call light was on for 36 minutes, 25 seconds. -On 7/6/19, at 4:07 a.m. R9's call light was on for 23 minutes, 1 second. -On 7/7/19, at 2:51 a.m. R9's call light was on for 22 minutes, 35 seconds. FAMILY MEMBERS COMPLAINTS ABOUT STAFFING When interviewed on 7/12/19, at 9:50 a.m. family member FM-A stated staff have forgotten to bring her loved one supper, and has had to go to find someone to bring it for her, resident hasn't eaten because her teeth are in the bathroom, not in her mouth, the call button is not near her and is not able to reach it. FM-A stated she reports things to the social services staff, the director of nursing (DON), and the administrator, however, things are not resolved. FM-A stated her loved one's wheelchair brakes did not work on her wheelchair, so they got her another wheelchair that also had broken brakes. FM-A stated, Staff should notice this, not family members of the resident. It is common sense things and when taken care of, a month later, you are back to the same issues. FM-A stated, Staff should know theses things. I should not have to tell them. At meal times, no one is on the lane. (Loved one) is always in her room and she refuses come out. You would think someone would check in every 45 minute to one hour to see how things are going. During an interview on 7/12/19, at 3:10 p.m. FM-C stated, They need more people to work. The hiring practice here has gotten terrible .There is one aide on the whole west end .Pool aides work 3-4 doubles a week. During an interview on 7/15/19, at 9:05 a.m. FM-C stated everything changed when (DON) came here. FM-C stated, No one is here to advocate for any of the residents, I feel the need to speak up. STAFF CONCERNS RELATED TO SUFFICIENT STAFFING When interviewed on 7/11/19, at 10:18 a.m. registered nurse (RN)-A stated, I do feel like we are short on staff. On Rose Lane, it's the heaviest with cares. Everyone is a lift (for transfers). People wander, self transfer. There's only one aide and a nurse, it really should be two aides and a nurse. RN-A stated, I do think the falls are attributed to staff not being able to be everywhere. RN-A indicated there was a female resident that they want her to be one to one, but we don't have the staff for that. RN-A stated many residents frequently attempt to self transfer. RN-A indicated the bath aides and restorative aides get pulled sometimes to help on the floor as a last resort. RN-A stated, (DON) focuses on getting staff, but we struggle to keep staff. It may be related to our staffing. During an interview on 7/11/19, at 10:55 a.m. NA-G indicated there were two bath aides. NA-G stated, It's hit and miss. Residents were getting mad because they weren't getting their baths. (They) get pulled, (residents) miss their second bath .We're short, it's not fair to the residents. We should have more staffing. NA-G indicated sometimes the restorative aide gets pulled to work the floor .It's overwhelming, it's go, go, go .Everyone feels the same way. We used to have plenty. When interviewed on 7/11/19, at 11:19 a.m. NA-E indicated, It's chaos, it's not good. I get frustrated. NA-E stated when restorative aide gets pulled, residents complain, and stated range of motion and exercising is hard to make up when it's been missed. NA-E stated she has complained numerous times, They keep admitting new people and not changing the staffing. Pay here is a big issue. We lose a lot (of staff) to that. NA-E stated, We've had numerous (staff) that have come on and leave because of the staffing. Weekends are worse because they are no support people to help out. Even during the week it's gotten bad. We've lost a lot of quality, good staff. I don't think the residents are getting good care. NA-E indicated bringing in pool staff was a big blow to the staff here, because they get more pay, and it damaged the morale of staff. NA-E stated, The quality of care isn't what it should be. They are doing what they can do with what they have. On 7/11/19, at 3:05 p.m. during an observation of a female resident, licensed practical nursing (LPN)-E followed the resident into the nurse's station, into another resident's room, encouraging the resident to sit, to go into her own room, walking off of the unit, and walking around offices. LPN-E continued to walk with resident for several minutes, steering her in the right direction, and attempting to keep the resident safe. LPN-E whispered, I'm sick of this. When interviewed, LPN-E stated, It's just me and the nursing assistant. This has been this way for months. It's a safety issue. LPN-E indicated residents are in the recliners, all alone, in the common area, when nurse and NA are in the rooms with residents that require a two person transfer. NA-E stated, People send their loved ones here to be supervised and taken care of, and I feel it's a safety issue. During an interview on 7/12/19, at 8:32 a.m. RN-D stated a recent direct admit from the doctor's office was quite a surprise. RN-D indicated the resident was okay when admitted , however, a couple of days later, everything changed and the resident was a challenge. RN-D stated, We've been trying to hire. People keep quitting. We recruit staff, train them, and they quit. No notice or anything. We don't have anyone knocking down our doors. During an observation on the 400 unit at 7/12/19, at 8:56 a.m. RN-B was sitting at the nurse's desk, working on resident charts. The phone rang, and the voice on the other end could be heard stating help was needed on Rose Lane. RN-B placed a call to LPN-A on the west wing and asked that someone be sent to Rose Lane to help. At 9:00 a.m. RN-B walked over to Rose Lane and offered to hang out for a few minutes, to monitor for safety. When interviewed on 7/12/19, at 9:31 a.m. NA-D indicated there were six residents that require a two person transfer with a full lift, four residents that use a standing lift, and one resident that requires a stand by assist on one wing. NA-D stated one resident wanders all over and needs to be watched. NA-D indicated repositioning of residents doesn't get done on time, resident walks don't get done, and staff don't typically get a full break. NA-D stated, It's so frustrating. I can't do my job how I'm supposed to get it done. I always feel rushed. NA-D stated she has talked to DON multiple times, but DON blames the administrator. NA-D stated, We don't see (administrator), ever. NA-D indicated five staff quit in one month. NA-D stated (DON) says we have aides that are coming or going through the class. We get one here and there, and then they quit. I've thought about it multiple times, but then who is going to take care of the residents. During an interview on 7/12/19, at 10:35 a.m. LPN-B indicated there was no one to help and if they do go to ask other aides for help, they sit there and they do not help. LPN-B stated residents do not get repositioned, medications are late, and residents don't get nothing because the focus is on residents with behaviors and they can't be left alone. LPN-B stated, We have to keep them safe .It would be nice if office people could just come and sit with them. LPN-B stated call lights don't get answered because they are transferring someone and can be in a room for 5-10 minutes, so many residents will self transfer. LPN-B stated, If someone is one to one with behaviors, we cannot toilet anyone. You have to watch everyone. When interviewed on 7/12/19, at 11:18 a.m. DON stated, We've been staffing now the same for quite a while. One aide and one nurse on Rose Lane. Our census has been way down. We always staff the same way. Staffing numbers are consistent, nothing has really changed. Cares are not more. A new admit is challenging .It is busy. I had a resident say we were short. Even with the census being down, I think they want all the positions filled. DON indicated the facility has been accepting new admits, but we look at staffing. DON stated on Rose Lane, there's one resident that wanders, but she wanders fairly safely. DON stated they have put fall interventions in place, like alarms, and stated, We go running if there's an alarm. DON stated, one resident is the highest fall risk and he falls out of bed, but hopefully he does not get injured badly. DON stated, I can't say there would be less falls if there was another staff member down there. DON stated, (Staff) can call for assistance. They can call any other wing .It's not easy, we don't like it. During an interview on 7/15/19, at 10:08 p.m. NA-D indicated working over the weekend and stated she was crying by 10:00 a.m. on Saturday because several residents were on a roll. NA-D stated she called the charge nurse five times before she came and helped. NA-D stated, We couldn't keep up. It's just frustrating because these people deserve better than that. NA-D stated, I've had it down there, I can't keep up. If I can't do something right, I don't want to do it. NA-D added, This weekend was terrible. There's 60 clients here that deserve better. When interviewed on 7/15/19, at 10:50 a.m. NA-C stated, I asked to be on West today because sometimes you just need a break. It's hard to work alone all the time. It's very hard and stressful. I have to rush through everything. I don't even take a break. The residents come first. NA-C indicated she had gone to DON and talked for over a half hour one day, and stated DON promises they are working on the staffing but it's not getting better. NA-C stated residents are out there trying to stand up and there are falls. NA-C stated, It's little things, like putting on lotion, I don't have time. I forget to shave because I'm in a hurry. I'm lucky if I get them changed and lay them down. Sometimes I feel like I can't walk people. I'm charting at 3 and supposed to be done at 2:30. Policy was requested for staffing, but not provided.

Based on observation, interview and document review the facility failed to provide and maintain personal dignity for 3 of 3 residents (R35, R15, R52) reviewed for care provided in a dignified manner. Findings include: R35's Significant Change Minimum Data Set ((MDS) dated [DATE], indicated R35 cognition was moderately impaired. R35's [DIAGNOSES REDACTED]. R35's care plan dated 5/30/19, indicated R35 needed assistance with bed mobility, to get dressed, and personal hygiene. On 7/9/19, at 3:50 p.m. R35 was observed in bed with eyes closed and covered up from the neck down to the feet with a blanket. On 7/10/19, at 9:14 a.m. R35 was observed in bed having a dressing changed by licensed practical nurse (LPN)-B. R35 had a night shirt and an undershirt on and was covered with a blanket. A progress note dated 7/5/19, at 2:47 p.m. indicated R35 had a clinic appointment at 1:00 p.m. During an interview on 7/12/19, at 9:50 a.m. family member (FM)-A stated R35 was sent to a recent clinic visit without pants on and FM-A was very upset about R35 not wearing pants to the clinic. FM-A stated there was no office staff available when we got back to the facility from the clinic visit to talk with regarding the concern. During an interview on 7/12/19, at 1:16 p.m. the director of nursing (DON) stated she was not aware of an incident regarding a resident sent to the clinic with no pants on. During an interview on 7/12/19, at 1:42 p.m. social service (SS)-A stated FM-A called on 7/8/19, in the morning and was upset because FM-A had met R35 at the clinic and R35 had been sent to the clinic appointment with no pants on. SS-A further stated R35 was covered with a blanket only. FM-A was upset that no office staff were available to talk with on 7/5/19, regarding R35's clothing. SS-A stated it was disrespectful to send anyone anywhere with no pants on. SS-A stated it was a dignity issue for R35 to not have pants on and go to the clinic. A review of an email from SS-A to the DON dated 7/8/19, at 3:03 p.m. indicated FM-A had met R35 at the clinic. When R35 arrived via transportation, R35 did not have any pants on only a blanket covering R35's legs. FM-A felt it was inappropriate on many levels. SS-A indicated FM-A should continue to report this type of concern because it was not appropriate for R35 to go to the clinic without pants on. R15's admission record, dated 1/20/17, indicated [DIAGNOSES REDACTED]. R15's quarterly Minimum Data Set (MDS), dated [DATE], identified R15 had severe cognitive impairment, required extensive assistance with transfers, personal hygiene, and toilet use, and was frequently incontinent of urine and bowel. R15's bowel and bladder quarterly review, dated 4/17/19, indicated R15 required staff assistance with toileting, was occasionally incontinent of bowel, and generally incontinent of urine. R15's care plan, revised on 4/29/19, included R15's bladder record, indicated voiding every two hours and directed staff to assist with urinal as close to every two hours as possible, keep call light within reach, and anticipate and meet needs. The care plan further included R15 had alteration in elimination related to constipation, incontinence of bowel and bladder, and had an inability to self toilet related to impaired mobility. During an interview on 7/9/19, at 8:40 a.m. family member (FM)-B stated, Sometimes it's discouraging for (R15) because they're short staffed, you know. Sometimes (R15) has to wait a half hour to get someone in the room to help him. (R15) knows when he has to go to the bathroom. When you gotta go, you gotta go. He doesn't understand that they are short staffed. (R15) has an accident a couple times a week, that I'm aware of. That bothers him. During an interview on 7/11/19, at 1:15 p.m. R15 indicated he has had times when his call light doesn't get me the help I need. I sit and wait, having to go to the bathroom. Sometimes it's a half hour. Nobody comes. Yes, it bothers me, I'm humiliated when I have an accident. Review of R15's Device Activity Report, from 6/10/19 through 7/10/19, revealed that R15 on several occasions had to wait 20 minutes up to 100 minutes for assitance after putting on his call light. On 7/12/19, at 11:18 a.m. director of nursing (DON) stated, I don't think the 60 minute waits on the logs are true. Typically when there's a complaint from a resident, I look at it. The residents are good at that. I go to the staff and find out what was going on that (the call light) was on that long. I encourage staff to go in and answer the light .reeducating them (staff) so they understand that. DON further stated, Something could have been done differently. (Staff) have phones, they (staff) can call for assistance. They can call any other wing, or any of us. R52's Admission Record with an admission date of [DATE], indicated R52 had [DIAGNOSES REDACTED]. R52's care plan indicates R52 had potential for impaired thought process related to impaired decision making and [DIAGNOSES REDACTED]. Additionally, R52 was dependant on staff meeting emotional, intellectual, physical and social needs related to medical conditions. R52 had difficulty expressing preferences at times due to cognitive issues and would holler out when R52 wanted help and does not know what she wanted help with which was disruptive to groups. R52's interventions indicated staff were to request R52 wait until the end of the activity when she hollered out and was unable to identify her need. If R52 continued, remind R52 of the disruption to the group, and if the behavior continued, removed R52 from the group. During an observation on 7/8/2019, at 5:12 p.m. R52 was in the dining room in a wheelchair (WC) at the table with other residents. R52 was observed to be hollering out help on several occasions. Nursing assistant (NA)-F was observed to be walking away from R52's table while R52 was hollering help. NA-F was approximately five feet away from R52's table. NA-F turned her head backwards and looked toward R52's table while putting up a finger to NA-F's lips and with raised eyebrows loudly shushed R52. This could be heard 6-10 feet away from NA-F's location in dining room. R52 continued to holler help multiple times. During an interview with NA-F on 7/10/2019, at 1:49 p.m. NA-F stated the aides from the west neighborhood instructed NA-F to shush R52 when hollering help. Further, NA-F stated the facility staff informed NA-F to see if R52 needs anything and tell R52 to settle down. NA-F also stated the staff did not want to remove R52 from the dining room. During an interview with director of nursing (DON) on 7/12/2019, at 1:30 p.m. DON stated cognitively impaired residents demonstrating behaviors were to be redirected, check to see if the resident was in pain, and offer an activity as a possible intervention. Further, DON stated interventions utilized would depend on the resident and the situation. DON was informed of dining room observations involving R52 and NA-F. The DON stated her expectation would be the staff not be so blatant and she would not expect the staff to act in this manner. DON further stated all facility staff received dementia training during new hire orientation and annually. Review of the facility's policy, Dignity Policy-Long Term Care, last revised 1/18, included, Each resident shall receive hospitable care and services in a manner and in an environment that maintains or enhances dignity and respect in full recognition of his or her individuality.

Based on observation, interview, and document review the facility failed to ensure 2 of 5 residents (R27, R32) were assessed to safely self-administer medication (SAM) through use of a nebulizer machine (inhalation of medication treatment). Finding include: R27's [DIAGNOSES REDACTED]. R27's physician orders [REDACTED]. R27's annual Minimum Data Set ((MDS) dated [DATE], indicated a brief interview for mental status (BIMS) was 7, which identified severe cognitive impairment. R27's last SAM assessment was started on 5/8/19, which indicated R27 did not wish to self-administer medications while at the facility. Further, it indicated that R27 had not been deemed appropriate for self-administration of medication and R27 wanted staff to administer medications. The SAM dated 2/13/19, indicated the same as the 5/8/19 assessment. R27's care plan last revised on 5/20/19, identified a quarterly and as needed review to assess R27's ability to self-administer medications. During an observation on 7/10/18, at 8:22 a.m. licensed practical nurse (LPN)-C started the nebulizer machine for R27 and left the room. LPN-C set a timer and stated it reminded her to come back and check on R27. At 8:25 a.m. LPN-C checked on R27 and moved the medication cart down the hallway to room [ROOM NUMBER]. LPN-C was assisting a resident in room [ROOM NUMBER] when R27's timer went off at 8:33 a.m. on the medication cart. At 8:33 a.m. R27 unplugged the nebulizer machine from the wall and put the hand held nebulizer in a plastic storage bin. At 8:38 a.m. LPN-C returned to R27's room and cleaned the hand held nebulizer and placed on paper towels back in plastic bin. During an interview on 7/10/19, at 8:43 a.m. LPN-C stated she was unable to find an order for [REDACTED]. During an interview on 7/11/19, at 3:09 p.m. the director of nursing (DON) stated R27's assessment was started on 5/8/19, by registered nurse (RN)-C. The DON stated the SAM indicated R27 did not want to self-administer medications. During an interview on 7/11/19, at 3:15 a.m. RN-C stated staff should follow the most recent SAM. RN-C stated the physician orders [REDACTED]. RN-C stated staff should sit in the room with R27 until the nebulizer was completed. R32's Admission Record indicated R32 was admitted on [DATE], with [DIAGNOSES REDACTED]. An order dated 11/20/2018, indicated [MEDICATION NAME]-[MEDICATION NAME] solution 0.5-2.5 (3) mg/3 ml vial inhale orally via nebulizer every 4 hours as needed for shortness of breath, cough, [MEDICAL CONDITIONS]- R32 must have staff hold in place. R32's quarterly minimum data set ((MDS) dated [DATE], indicated R32 was severely cognitively impaired and required extensive assistance of two staff for bed mobility, transfers, dressing and toileting. Additionally R32 required extensive assistance of one staff member for eating and personal hygiene. R32's self administration of medication assessment dated [DATE], indicates R32 did not wish to self administer medications while in the facility. The interdisciplinary team (IDT) review further indicated R32 shook too much to hold nebulization and did not like the mask for delivery, staff must hold for R32. R32's care plan last review completed on 5/30/2019, indicated R32 had an alteration in respiratory status related to [DIAGNOSES REDACTED]. R32's care plan indicated interventions regarding medication via nebulization, and must be assisted by nursing staff- R32 no longer desired to hold neb device. Further, R32 did not like the mask on if left alone. Additionally R32 is willing to use the mask if staff hold up in front of R32's face. During an observation on 7/08/19, at 6:56 p.m. R32 received a neb via mask, licensed practical nurse (LPN-D) set up a nebulization treatment and exited R32's room stating ok we'll see you in about 10 minutes. R32 was observed to remove mask approximately five minutes after the administration was initiated. During an observation on 7/8/2019, at 7:07 p.m. LPN-D entered R32's room and stated ok, it's all done. R32 was sitting in a wheelchair (WC) holding nebulization device. LPN-D then asked this writer when R32 removed the nebulization mask. During an interview on 7/10/2019, at 2:04 p.m. LPN-D stated the process for R32 to self administer medications was to complete a self administration of medication assessment. LPN-D further stated the assessment was reviewed by the IDT for final approval. LPN-D also stated the physician would write an order for [REDACTED]. Additionally, LPN-D was not able to find a second assessment in the medical record. A facility policy, Medication Self Administration by Residents, Long Term Care, indicated residents shall be permitted to self-administer medications. The resident shall be informed of his/her right to self-administer medication subject to the approval of the interdisciplinary team. Further, the resident will need to complete an assessment and demonstrate competency to a member of the licensed staff by return demonstration. Additionally, there shall be a written order from the attending physician for medication(s) which can be self-administered by the resident.

Based on observation, interview and document review, the facility failed to ensure residents were free of physical restraints for 1 of 2 residents (R25) reviewed for restraints. Findings include: R25's quarterly Minimum Data Set (MDS), dated [DATE], indicated R25 was cognitively intact. R25 was extensive assist for bed mobility, transfers, dressing and personal hygiene. R25 was independent with locomotion on and off the unit. R25 had [DIAGNOSES REDACTED]. R25's Physical Device Assessment 2, dated 5/8/19, under other applicable devices being assessed, was check marked by k. Other (specify below) which indicated the use of a tray table on wheelchair. R25's care plan, dated 5/23/19, indicated R25 had mobility deficit related to MS. The care plan instructed staff to enc (encourage) R25 to push off the tray table when wanting to have it removed to ensure maintenance of strength and ability to do so. Further instruction included, report to the nurse if R25 was not able to remove the tray table by self. Also included was an explanation that it would be a physical restraint if no longer able to remove per self. R25's kardex, printed 7/12/19, indicated tray table on wheelchair, enc (encourage) to push off when wishes to have it removed to ensure maintenance of strength and ability to do so. Report to nurse if not able to remove per self. During an observation on 7/9/19, at 3:20 p.m. R25 was seated in her wheelchair with a tray table attached. On 7/10/19, at 8:11 a.m. R25 was seen in her wheelchair, eating toast and drinking coffee, tray table attached. During an interview on 7/12/19, at 8:21 a.m. licensed practical nurse (LPN)-A stated that R25 was suppose to be able to push off the tray table completely. LPN-A requested R25 demonstrate removal of the tray table. R25 attempted to push the tray and was only able to move it part ways. LPN-A stated if R25 cannot remove it, it was a restraint. During an interview on 7/12/19, at 9:42 a.m. nursing assistant (NA)-B stated that R25 had never been able to remove the tray table. During an interview on 7/12/19, at 9:55 a.m. NA-A stated R25 had never been able to remove the tray table. During an interview on 7/12/19, at 9:14 a.m. RN-B stated R25's kardex indicated a tray table, when staff noted inability to remove per self, it should have been reported so it could be re-evaluated. During an interview on 7/12/19, at 9:31 a.m. the director of nursing (DON) stated the kardex was the guide for care, if something was indicated on it, the staff should be doing it. The aides should have let us know that there was a change in R25's ability to remove the tray table per self.

Based on interview and document review, the facility failed to ensure allegations of abuse were immediately reported to the administrator and State Agency (SA) within two hours, for 1 of 3 residents (R205) reviewed for abuse. Findings include: R205's admission record, dated 5/2/16, indicated R205 had [DIAGNOSES REDACTED]. R205's significant change Minimum Data Set (MDS), dated [DATE], indicated R205 had severe cognitive impairment, had a condition or chronic disease that may result in life expectancy of less than six months and was on hospice, required extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene, and was totally dependent for transfers. MDS further identified R205's mood involved moving or speaking slowly. R205's care plan, last revised 6/26/19, indicated R205 was on hospice with goals for comfort cares, and control of pain and anxiety. R205's care plan further indicated R205 had potential for alteration in behavior related to anger, depression, striking out at staff with arm/hand, rejection of cares (refusal to take medications/eat at meals), and yelling at peers and staff when agitated. During an interview on 7/12/19, at 3:10 p.m. family member (FM)-C stated R205 passed away on 6/26/19. FM-C stated she had gone to the administrator and the president of CentraCare due to concerns about the care R205 received from a certain nurse, and stated she didn't feel things had gotten better. FM-C stated R205 would call FM-C, or FM-C would witness things during visits to the facility, that were upsetting. FM-C reported R205 was terrified of licensed practical nurse (LPN)-A. FM-C stated LPN-A was pushy and rough and aggressive with R205, and R205 would just shake when (LPN-A) was around. FM-C stated R205 had [MEDICAL CONDITION] and couldn't swallow well, and LPN-A would force him to take his medications and would make R205 sit in the dining room until he ate. FM-C stated, As (R205) got sicker, he would call me crying. He was terrified of her. FM-C stated she observed R205 get anxious and tremble even when he saw LPN-A pass by his room in the hallway, and FM-C witnessed LPN-A get in fights with the nursing assistants. FM-C stated she had reported her concerns to the director of nursing (DON) many times, and sent emails with no responses, and nothing got better. FM-C stated she even asked DON to move LPN-A to another lane in the facility, to which DON responded, they would just be moving the problem to another lane. FM-C stated she just wanted R205's end of life to be without the fear and anxiety that LPN-A caused R205. FM-C stated LPN-A was eventually moved to a different lane in the facility, and once she was gone, (R205) calmed down. During an interview on 7/12/19, at 3:45 p.m. the facility administrator and DON stated they were aware of the concerns regarding the rough and aggressive treatment by LPN-A, that was alleged by FM-C. DON stated, I'm aware of it. (LPN-A) was never rough with (R205). He would say that he didn't like her. We had many meetings. When (LPN-A) walked by he would get agitated. DON stated R205 was cognitive at times and was very anxious around LPN-A. DON stated she counseled LPN-A, although stated, There was nothing she had done. The administrator stated he was aware that R205 was just scared of (LPN-A), and stated, Why he was, I have no idea. (R205) would tell his family. They would tell us. It was all hearsay. Perception is not reality. When asked if a report was made to the state agency or if an investigation was ever completed, DON stated, No, we didn't file a VA (vulnerable adult) for that. (R205) never said he was afraid of (LPN-A). The family did. During an interview on 7/15/19, at 10:08 a.m. nursing assistant (NA)-D stated, (LPN-A) is a grouch, the Grinch. She's very rude with residents .she got moved to a different wing because a family complained about her being mean .There's been a few residents. Most of the residents on West complain about her. NA-D stated she had not personally gone to the DON to report this, however, she was aware that several other staff, had. During an interview on 7/15/19, at 11:05 a.m. NA-B stated LPN-A was rude to some of the families and residents, and stated she was aware of an issue involving R205. NA-B stated, (R205) had a problem with (LPN-A). NA-B indicated R205 was fidgety all the time, but he was more upset and anxious after cares from LPN-A. NA-B stated, He would make comments, and she could tell by his facial expressions that LPN-A upset him. NA-B stated R205 was more calm when LPN-A wasn't around, and when LPN-A was moved to a different wing for about a two week period, R205 was less upset and anxious. NA-B indicated she knew R205's family had talked to DON and the administrator about concerns of R205's reaction to LPN-A, but, I never went to anyone though. Review of the facility's policy, Vulnerable Adults-Abuse Prevention Policy-Long Term Care, last revised 4/19, indicated all employees, contracted employees, students, and volunteers of CentraCare Health-Long Term Care Facilities must report any suspected or known maltreatment immediately to Minnesota Department of Health (MDH)/Office of Health Facility Complaints (OHFC) .Instances of abuse of all resident, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Also included, The verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering.

Based on interview and document review, the facility failed to conduct a thorough and timely investigation, of an allegation of abuse for 1 of 3 residents (R205) reviewed for abuse. In addition, the facility failed to protect residents who resided in the facility on the West wing and Rose Lane, after an allegation was reported. Findings include: R205's admission record, dated 5/2/16, indicated R205 had [DIAGNOSES REDACTED]. R205's significant change Minimum Data Set (MDS), dated [DATE], indicated R205 had severe cognitive impairment, had a condition or chronic disease that may result in life expectancy of less than six months and was on hospice, required extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene, and was totally dependent for transfers. MDS further identified R205's mood involved moving or speaking slowly. R205's care plan, last revised 6/26/19, indicated R205 was on hospice with goals for comfort cares, and control of pain and anxiety. R205's care plan further indicated R205 had potential for alteration in behavior related to anger, depression, striking out at staff with arm/hand, rejection of cares (refusal to take medications/eat at meals), and yelling at peers and staff when agitated. During an interview on 7/12/19, at 3:10 p.m. family member (FM)-C stated R205 passed away on 6/26/19. FM-C stated she had gone to the administrator and the president of CentraCare due to concerns about the care R205 received from a certain nurse, and stated she didn't feel things had gotten better. FM-C stated R205 would call FM-C, or FM-C would witness things during visits to the facility, that were upsetting. FM-C reported R205 was terrified of licensed practical nurse (LPN)-A. FM-C stated LPN-A was rough and aggressive with R205, and R205 would just shake when (LPN-A) was around. FM-C stated R205 had [MEDICAL CONDITION] and couldn't swallow well, and LPN-A would force him to take his medications and would make R205 sit in the dining room until he ate. FM-C stated, As (R205) got sicker, he would call me crying. He was terrified of her. FM-C stated she observed R205 get anxious and tremble even when he saw LPN-A pass by his room in the hallway, and FM-C witnessed LPN-A get in fights with the nursing assistants. FM-C stated she had reported her concerns with the director of nursing (DON) many times, and sent emails with no responses, and nothing got better. FM-C stated she even asked DON to move LPN-A to another lane in the facility, to which DON responded, they would just be moving the problem to another lane. FM-C stated she just wanted R205's end of life to be without the fear and anxiety that LPN-A caused R205. FM-C stated LPN-A was eventually moved to a different lane in the facility, and once she was gone, (R205) calmed down. During an interview on 7/12/19, at 3:45 p.m. the facility administrator and DON stated they were aware of the concerns regarding the rough and aggressive treatment by LPN-A, alleged by FM-C. DON stated, I'm aware of it. (LPN-A) was never rough with (R205). He would say that he didn't like her. We had many meetings. When (LPN-A) walked by he would get agitated. DON stated R205 was cognitive at times and was very anxious around LPN-A. DON stated she counseled LPN-A, although stated, There was nothing she had done. The administrator stated he was aware that R205 was just scared of (LPN-A), and stated, Why he was, I have no idea. (R205) would tell his family. They would tell us. It was all hearsay. Perception is not reality. When asked if a report was made to the state agency or if an investigation was ever completed, DON stated, No, we didn't file a VA (vulnerable adult) for that. (R205) never said he was afraid of (LPN-A). The family did. During an interview on 7/15/19, at 10:08 a.m. nursing assistant (NA)-D stated, (LPN-A) is a grouch, the Grinch. She's very rude with residents .she got moved to a different wing because a family complained about her being mean .There's been a few residents. Most of the residents on West complain about her. NA-D stated she had not personally gone to the DON to report this, however, she was aware that several other staff had. When interviewed on 7/15/19, at 10:50 a.m. NA-C stated, In my opinion, (LPN-A) is horrible to work with, because of her attitude and rudeness toward staff and residents. During an interview on 7/15/19, at 11:05 a.m. NA-B stated LPN-A was rude to some of the families and residents, and stated she was aware of an issue involving R205. NA-B stated, (R205) had a problem with (LPN-A). NA-B indicated R205 was fidgety all the time, but he was more upset and anxious after cares from LPN-A. NA-B stated, He would make comments, and she could tell by his facial expressions that LPN-A upset him. NA-B stated R205 was more calm when LPN-A wasn't around, and when LPN-A was moved to a different wing for about a two week period, R205 was less upset and anxious. NA-B indicated she knew R205's family had talked to DON and the administrator about the concerns of R205's anxiety and anxiousness when LPN-A was present, however, she added, I never went to anyone though. When interviewed on 7/15/19, at 11:27 a.m. NA-A stated, There's one nurse in particular. She's rude. She was moved to another wing for a while because a resident and his family didn't like her. (R205) complained about her everytime she went in the room. He had colorful language about her. She's kind of abrupt. She wants to get her job done and she's not very gentle. NA-G also stated, She's just a crabby lady. It's no different with any other resident. Review of the facility's policy, Vulnerable Adults-Abuse Prevention Policy-Long Term Care, revised 4/19, included, an internal investigation will be completed. The policy further included, Immediately remove any alleged perpetrator(s) from their duties and place on administrative leave until the completion of the facility investigation. Further, the resident/residents involved, staff involved, staff witnesses, and other witnesses, will be interviewed.

Based on observation, interview and document review, the facility failed to provide assistance with bathing, per residents' preference, for 2 of 2 residents (R5, R9) reviewed for activities of daily living (ADL's) and who were dependent upon staff for care. Findings include: R5's admission record, dated 1/16/14, included [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set (MDS), dated [DATE], indicated R5 was cognitively intact, had no rejection of care, was frequently incontinent of bladder and occasionally incontinent of bowel, and required extensive assistance for ADLs (activities of daily living) with physical help in part of bathing activity. R5's care plan, revised 7/12/19, included R5 preferred whirlpool tub bath with assistance of one. R5's care plan also directed, See Bathing preference Sheet in tub rooms for specific client preferences. Review of the Facility Bath Schedule, updated 5/7/19, indicated R5 was scheduled for a bath on Tuesdays and Fridays. During an interview on 7/8/19, at 2:10 p.m. R5 stated she gets a bath on Tuesdays, and is supposed to get a bath on Friday, however, stated, Sometimes it's two to three times a month that I don't get my Friday bath. R5 indicated that the bath aide or the restorative aide get pulled when staffing is short, therefore, residents that are scheduled for their bath that day, miss their bath. R5 stated, It's frustrating to go a whole week without a bath. Review of the Point of Care, Follow Up Question Report, from 5/10/19 through 7/12/19, indicated R5 received a bath on Tuesday, 6/18/19, Tuesday, 6/25/19, and Tuesday, 7/2/19, not twice weekly as R5 prefers and as scheduled. Review of R5's progress notes, included documentation on 7/9/19, at 3:33 p.m. that included, (R5) denied having any concerns with the type of bathing, day of week or time of day in which she is getting her bathing-but did mention she does not always get 2 baths as sometimes the bath aide is pulled to the floor. R9's admission record, dated 4/18/17, included [DIAGNOSES REDACTED]. R9's quarterly Minimum Data Set (MDS), dated [DATE], indicated R9 was cognitively intact, had no rejection of care, and was independent for most ADLs but did require physical help in part of bathing activity. R9's care plan, revised 7/12/19, included R9 preferred whirlpool tub bath with assistance of one. R9's care plan also directed, See Bathing preference Sheet in tub rooms for specific client preferences. Review of the Facility Bath Schedule, updated 5/7/19, indicated R9 was scheduled for a bath on Tuesdays and Fridays. During an interview on 7/9/19, at 9:11 a.m. R9 stated, Staffing is a problem. I don't always get my Friday bath. The bath aide is pulled often off of the unit. You have to wait again until the next bath day. It's frustrating. They need somebody to help. Review of the Point of Care, Follow Up Question Report, from 5/10/19 through 7/12/19, indicated R9 received a bath on Tuesday, 6/18/19, Tuesday, 6/25/19, and Tuesday, 7/2/19, not twice weekly as R9 prefers and as is scheduled. Review of R9's progress note on 7/9/19, at 12:22 p.m. included, (R9) takes a whirlpool bath 2 times weekly and does not participate with washing and drying. Reported occasionally having bath aide pulled so doen't (sic) always get her second bath of the week (but she did this week). When interviewed on 7/11/19, at 10:18 a.m. registered nurse (RN)-A stated the bath aides and the restorative aide get pulled sometimes to help on the floor, as a last resort. During an interview on 7/11/19, at 10:55 a.m. nursing assistant (NA)-G stated residents were getting mad because they weren't getting their baths. NA-G stated, Now it's hit and miss, because when the bath aides get pulled, (residents) miss their second bath. NA-G stated, When we're short, it's not fair to the residents. We should have more staffing. NA-G added, Everyone feels the same way. We used to have plenty. When interviewed on 7/12/19, at 11:18 a.m. director of nursing (DON) stated, When the bath aide is pulled, we offer as many (baths) as the resident would like. We try to do it the day after to get them on track. That's what we do. We try to get at least one. We ask them. A policy for Activities of Daily Living was requested, but not provided.

Based on observation, interview and document review the facility failed to ensure a chair alarm, care planned as a fall intervention, was consistently attached for 1 of 4 residents (R40) reviewed for accidents. Findings include: R40's quarterly minimum data set (MDS), dated [DATE], indicated R40 had a BIM's (cognitive test) of 06, indicating impaired cognition. R40 required extensive assist with bed mobility, transfers, dressing, personal hygiene, and toileting. R40 had [DIAGNOSES REDACTED]. R40's care plan indicated potential for injury/falls related to impaired cognition, impaired mobility, incontinence, and history of falls. Resident had anxiety, and noted at times may not wait for help and attempt self transfers, self toileting. Further, the care plan indicated chair check alarm should be placed when R40 was in wheelchair or recliner. During an observation on 7/8/19, at 6:54 p.m. R40 was sitting in wheel chair. Chair check alarm was attached to the back of the wheelchair with clip hanging not attached to R40. During an observation on 7/9/19, at 3:07 p.m. R40 was resting in recliner, covered by a blanket, call light within reach and chair check alarm attached to her clothing. During an observation on 7/10/19, at 7:30 a.m. R40 was being assisted to the dining room while in her wheelchair. Chair check alarm was attached to her clothing. At 1:50 p.m. R40 was in her recliner, call light in reach, however the chair check alarm was not attached to her. During an interview on 7/10/19, at 2:00 p.m. nursing assistant (NA)-C stated the chair check was not attached and it should have been. During an interview on 7/10/19 at 2:01 p.m. licensed practical nurse (LPN)-A stated NA's were to check the kardex every morning and were expected to follow it and included placing the chair check alarm. During an interview on 7/12/19, at 9:14 a.m. registered nurse (RN)-C stated when chair check alarm was indicated for use on the Kardex, the expectation was staff made sure it was placed. During an interview on 7/12/19, at 9:30 a.m. director of nursing (DON) stated the kardex is the guide for care, when indicated on the kardex, staff should be doing it. Requested a device policy for the chair check alarm, none was provided.

Based on interview and document review, the facility failed to ensure the consultant pharmacist's recommendations were addressed for 1 of 5 residents (R14) reviewed for unnecessary medications. Findings include: R14's quarterly minimum data set (MDS), dated [DATE], identified R14's cognition was intact and was independent with all activities of daily living (ADL's) except dressing. R14's face sheet indicated [DIAGNOSES REDACTED]. R14's care plan, last reviewed/revised 4/29/19, identified other medical conditions: [MEDICAL CONDITIONS], diabetes, hypertension, [MEDICAL CONDITION], heart failure, [DIAGNOSES REDACTED] risks, sleep apnea, depression, and [MEDICAL CONDITION]. Interventions included: administer medications as ordered. observe for effectiveness and adverse side effects, update MD PRN (as needed); obtain labs as ordered. Update MD with results. Further, the care plan indicated a potential for alteration in mood related to: dx of depression. Intervention indicated monthly medication regime review by pharmacy consultant and forward recommendations to MD for review. R14's current physician orders [REDACTED]. -[MEDICATION NAME] (water pill) 2.5 milligrams (mg) one time a day every Tuesday, Thursday, Saturday with [MEDICATION NAME]. -potassium chloride extended release (ER), 40 miliequivalents (mEq) one time a day every Tues, Sat. -potassium chloride ER, 20 mEq one time a day every Monday, Wednesday, Thursday, Friday, Sunday. -[MEDICATION NAME] (calcium channel blocker) ER, 90 mg daily. -[MEDICATION NAME] ([MEDICATION NAME]) (anti-depressant) 15 mg at bedtime. R14's monthly pharmacy reviews included: -1/17/19: R14's was hospitalized . -2/15/19: No recommendations at this time. Will allow time to acclimate before attempting [MEDICATION NAME] GDR. Insulin was decreased 1/28/19 but still some [DIAGNOSES REDACTED]-will monitor. Due to [MEDICAL CONDITION] daily use of aspirin and [MEDICATION NAME], PPI (medications used to treat GERD) appears appropriate at this time. -3/20/19: Please document non-pharmacological interventions re: [MEDICAL CONDITION] (uses prn [MEDICATION NAME]). please add APAP (Tylenol) maximum to eMAR (electronic medication administration record). -4/18/19: Please check BMP (basic metabolic panel) per provider order 4/4/19. -5/23/19: Potassium supplement increased for 5 day course 5/15/19 with serum K+(potassium) = 3.4. History of [DIAGNOSES REDACTED] (low potassium) secondary to diuretic adjustments. (MONTH) consider rechecking serum K+ for medication monitoring to verify remains within desired range. -6/20/19: no recommendations from this visit. Although consultant pharmacist (CP) recommended documentation for non-pharmacological interventions for the use of [MEDICATION NAME], R14's medical record lacked documentation or a response from the physician to the request. Despite CP's recommendation to increase potassium for 5 days and recheck potassium level, R14's medical record lacked evidence of labs or a response from the physician to the request. During an interview on 7/11/19, at 12:23 p.m. registered nurse (RN)-A stated pharmacy reviews are cross-referenced with physician orders. RN-A stated R14's last potassium was drawn on 5/15/19 which was prior to CP's recommendation. Further, RN-A stated there is an order to re-check potassium and it had not been done. A facility policy, Medication Regimen Review, last approved 12/2018, indicated CP performs medication regimen reviews for each resident at least monthly. All irregularities requiring physician attention were intended to be addressed prior to or at the time of the next scheduled physician visit. Irregularities requiring nursing attention should be addressed prior to the pharmacist's next monthly visit. Further, the policy indicated the attending physician must document in the resident's medical record that the identified irregularity had been reviewed and what , if any action had been taken to address it.

Based on observation, interview and document review, the facility failed to conduct a comprehensive assessment and implement interventions to prevent further development of contractures for 1 of 1 residents (R1) with a [DIAGNOSES REDACTED]. Findings include: R1's Resident Face Sheet dated 2/9/16, indicated R1 was admitted to the facility with a [DIAGNOSES REDACTED]. R1's 5 day Minimums Data Set ((MDS) dated [DATE], indicated R1 had impairment with range of motion to upper extremities and R1's quarterly MDS dated [DATE], indicated impairment with range of motion to upper extremities. R1's annual MDS dated [DATE], identified R1 had no cognitive impairment and good communication skills, that R1 was non ambulatory, dependent on staff for most of his cares and had functional limitation in range of motion of upper extremities. The Care Area Assessment (CAA) dated 5/29/18, indicated R1 had some increase in contractures of his fingers in his right hand but is able to manually straighten them with his other hand and has weak grasp bilaterally. The CAA dated 8/28/18, indicated R1 is able able to use his call light despite contractures of his fingers of his bilateral hands (right hand is worse than left). He had weak grasp bilaterally today, but reports he has not dropped his cell phone and is still able to feed self, so his hands are working well enough for him. R1's Care Plan dated 3/1/18, indicated self care deficit related to weakness, atrophy in the muscles of the hands, with flexor deformities of his right hand. Care plan goal was to keep the ability to feed himself with use of adaptive equipment, wash his face and raise his arms for dressing, and to wheel self part way or all the way to a destination. R1's record did not contain any documentation of any current range of motion exercises or that R1 was treated by physical or occupational therapy for his diagnosed contractures either upon admission nor following R1's noted increase in contractures during R1's annual assessment on 5/29/18. During interview and observation on 9/10/18, at 5:29 p.m. R1 stated he believes all five fingers on right hand have been contracted for about [AGE] years. R1 states no therapy has been done for his right hand since his admission. R1 stated he has a little gray foam sponge that was given to him in [MEDICAL TREATMENT] to be used for stress. R1 stated a physical therapist (PT)-C came to his room a few months back to help him with standing. R1 stated PT-C observed his little gray foam sponge on his night stand and told R1 to pry his right hand open and squeeze the gray foam sponge and massage it across the top of his hand. R1 took PT-C's suggestion but felt his hand was getting worse and discontinued the suggestion after a few weeks due to his pain in right hand Physical Therapy treatment note dated 6/28/18, indicated PT-C instructed R1 to stretch right hand/fingers into flexion supporting ability to open right hand enough to put a foam exerciser in it as a home exercise. PT-C indicated R1 had a concern with his right hand, however, R1's record showed no indication that PT made a referral to occupational therapy for evaluation and treatment of [REDACTED]. During interview and observation on 9/11/18, at 1:39 p.m. R1 was observed to have significant deformities of the joints, all fingers of right hand are contracted including thumb. R1 stated right hand does not work, and unable to grasp anything. Stated all grasping is done with left hand and fingers. R1 stated it is frustrating because he is a right handed person. R1 indicated he does not write much due to the contractures and deformities of the right hand. During interview on 9/13/18, at 9:57 a.m. occupational therapist (OT)-A stated she first saw R1 in (YEAR), prior to admission, on a out patient basis. OT-A further indicated R1's right hand deformity was mild at that time and he could open his hand to grip. OT-A stated she saw R1 today and his right hand has worsened and progressed, he can not straighten ring finger, and is uncomfortable for him to try and straighten. OT-A stated his right fingers are not fixed but could become fixed if not treated. OT-A stated his right hand and fingers have worsened and progressed and believes he needs intervention. OT-A further stated she would have liked this to be reported sooner than today and that she tries to educate staff on the importance of contacting therapy when there is a need. In addition, OT-A stated a splint, range of motion and stretching is needed for R1. OT-A stated she believes she should have received an order to screen R1 when annual MDS assessment indicated R1 had an increase in the contractures of his fingers and when PT-C noted there was a concern with R's contractures. During interview on 9/13/18, at 10:25 a.m. nursing assistant (NA)-F stated R1 does not use right his hand much, and is not sure why he doesn't use it. NA-F stated R1's right hand is cramped up, his fingers are pulled into his palm and and it has looked like that ever since she was hired. NA-F stated the nursing assistants do not do anything with R1's hand or fingers and the nursing care sheets do not say to do anything with his hands. During interview on 9/13/18, at 10:32 a.m. NA-G stated she has worked there for seven years. R1's right hand is crippled, and his hands have been crippled since R1 was admitted . NA-G stated R1's right hand is bent inward toward palm and he uses built up silverware to eat. NA-G stated the nursing assistants do not do any range of motion with his hand and he does not have a splint to wear. NA-G stated R1 can write, hold his phone, and eat with that hand but R1 can not open a can of pop. NA-B stated the nursing assistants do not encourage R1 to do any exercises with the right hand but thinks [MEDICAL TREATMENT] helps R1 with his right hand. During interview on 9/13/18 at 10:53 a.m. licensed practical nurse (LPN)-D stated R1's right hand has been crippled for a while and it swells up. LPN-D stated R1 uses his right hand very little, but can hold his phone. LPN-D stated R1 does not have therapy for his right hand, has no range of motion exercises, no braces, splints or hand rolls are used. R1's fingers are curled into his palm and his hands are tightly curled inward. During interview on 9/13/18, at 11:43 a.m. director of nursing (DON) stated an increase in contractures of fingers was noted in an assessment and therapy should have been put into place for R1. The DON stated occupational therapy should have been involved and a referral should have been in initiated. A copy of the facility police was requested and was not received