Every finding on record at Cura of Onamia

Based on observation, interview, and record review the facility failed to ensure medication injectable supplies were removed from active stock once expired. In addition, the facility failed to ensure medications were properly labeled with either an expiration date or beyond use date. These deficient practices had the potential to impact all residents who received medications at the facility.Findings include:During a medication pass observation on 4/21/26 at 10:30 a.m., R17's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication pass observation on 4/21/26 at 11:58 a.m., R7's medication label was reviewed. The label did not include an expiration or beyond use date.During a medication pass observation on 4/22/26 at 10:22 a.m., R1's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication observation on 4/23/26 at 7:19 a.m., R7's medication labels were reviewed. Labels did not include an expiration or beyond use date.Two medication carts were reviewed on 4/22/26 at 1:15 p.m., with the assistant director of nursing (ADON). After reviewing medication labels filled by both the Mille Lacs pharmacy and the Onamia Drug store the ADON confirmed the labels from both pharmacies did not include an expiration or beyond use date.During a review of the medication room on 4/22/26 at 1:55 p.m., the ADON confirmed that the following supply items were stored in current stock and expired: 3 boxes of various needle sizes used for injection, a box of safety syringes with a 25-gauge needle, and a bundle of chlamydia swabs. The ADON pulled the supplies from stock and stated they should have been discarded when they expired to prevent accident use on a resident.During an interview on 4/22/26 at 2:01 p.m., while spot checking medication labels from their medication cart licensed practical nurse (LPN-B) confirmed none of the medication labels contained an expiration date. LPN-B stated they went by the fill date. If it was a year past the filled date, they would not use the medication.During an interview on 4/22/26 at 3:03 p.m., LPN-A pulled medication cards from the medication cart filled by Mille Lacs pharmacy and confirmed the medication cards did not list an expiration or beyond use date.During an interview and medication pass on 4/23/26 at 7:36 a.m., registered nurse (RN-A) confirmed medication labels from both pharmacies did not include expiration or beyond use dates. During morning huddle, they had been told PRN medications expired a year from fill date and scheduled medication should not be expired because the fill cycled every 28 days.During a follow-up interview on 4/23/26 at 11:18 a.m., the ADON stated they had been working on the medication label concern and stated they had reached out to the Mille Lacs Health System pharmacy. The ADON was not aware of either pharmacy policies or if the facility had copies or access to each pharmacy's policies. From a nursing perspective, they expected medications to be checked for expiration prior to administration to residents. The ADON confirmed the current labels printed by both pharmacies did not have clear expiration or beyond use dates for nurses to be able to check for expired medications prior to administration.During an interview on 4/23/26 at 12:36 p.m., the Onamia Drug Pharmacist (PHARM-D-B) confirmed they supplied medications for residents at the facility. Their cards did have a place to document the expiration date of the medication, but they did not do that at present but could if it was needed. Their process was to use the last refill date on the label as the use by or discard date for medications they filled. The pharmacist pulled up a medication label and confirmed nursing staff would not be able to determine if the medication was expired or should be discarded based on the dates that were listed on the label. They were uncertain if the pharmacy process for knowing when to discard medications had been communicated to the facility or provided in a policy. The date used worked well for scheduled medications, but it was possible that a PRN medication could remain in stock beyond the prescription refill date. PHARM-D-B stated it made sense to include an expiration date and indicated that was something they could change so nurses could verify if a medication could be used or should be discarded.During an interview on 4/24/26 at 11:09 a.m., consultant pharmacist (PHARMD-A) confirmed their medication labels did not include a medication expiration or beyond use date. Their repackaged medications expired a year from the date they were repackaged and if the medication expired before that date, the date would be added to the medication label. [NAME] had been supplied with access to Mille Lacs pharmacy polices when they acquired the facility. PHARMD-C stated prior to medication administration nurses should verify the medication has not expired or reached the beyond use date. At the time of the interview the PC was not able to access pharmacy policies.During an interview on 4/24/26 at 11:45 a.m., Mille Lacs PHARMD-C stated their pharmacy had always used the one year from filled to determine when a medication was expired unless they labeled otherwise. PHARMD-C had not reviewed the policy but confirmed [NAME] had received access to the polices when they took over the facility. Their label company did have the capacity to reconfigure their labels to include expiration dates if needed. PHARMD-C stated it would be important for nurses to be able to determine if a medication was expired before they administered it. They were not certain if the policy clearly defined when a medication was expired based on the label, but they were looking into it. They would either clearly define it in the policy or change the label as they wanted to make sure they were doing what was required. A follow-up e-mail and policy was received on 4/4/26 at 3:55 p.m., from Mille Lacs Health System PHARMD-A: Upon review, it appears that the long-term care (LTC) facility is not explicitly referenced in the current policy language. We will revise the policy to incorporate the long-term care facility accordingly to ensure clarity and alignment with our operations. Additionally, our pharmacist-in-charge for the retail pharmacy has confirmed that our pharmacy system is capable of automatically including expiration dates on prescription labels. We will work toward implementing this functionality moving forward.The undated policy Dispill Enrollment/Dispensing provided by Mille Lacs Health System pharmacy indicated state statute Rule 6800.3400 and 6800.3200 would be followed and included the following: packaging of single dose medication maybe be accomplished by a manufacturer or pharmacy. Unit dose packaging shall be properly labeled from the manufacturer with the name of the drug, dosage form and strength, manufacturer's name and lot number, and expiration date of all time dated drugs, or labeled in accordance with part 6800.3200 if prepackaged by the pharmacy.The facility policy Medication Guidelines - Long Term Care dated 7/2025, instructed medication for specific residents should be labeled with the following: medication name, prescribed strength, expiration date of medication when applicable, resident name, and route of administration. Step 14 under medication administration guidelines instructed check expiration date/beyond use date on package/container.

Based on interview and record review, the facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. This had the ability to affect all 35 residents who resided in the facility.Findings include:A facility-submitted document, received 4/21/26, identified breakfast began at 8:00 a.m., lunch began at 12:00 p.m., and dinner began at 5:00 p.m.During an interview on 4/20/26 at 2:15 p.m., the manager of nutrition services confirmed the mealtimes at the facility were 8:00 a.m., 12:00 p.m., and 5:00 p.m. The facility contracted food services through the kitchen of the attached hospital.During an interview on 4/23/2026 8:43 a.m., nursing assistant (NA)-A indicated the evening snacks were sent from the kitchen for specific residents between 6:30 p.m. and 7:00 p.m. These snacks were labeled with resident names, not all residents received them, but snacks were available to all residents upon request.During an interview on 4/23/26 at 8:47 a.m., licensed practical nurse (LPN)-A indicated dietary brought a tray for scheduled snacks to some residents and stated staff were always asking residents if they wanted something to eat.During an interview on 4/23/26 at 9:10 a.m., the assistant director of nursing (ADON) stated snacks are available in the evening if a resident asked for one but there was no routine evening snack offering. They indicated dietary provided a snack tray with individually labeled snacks for a few residents that had orders for an evening snack.During an interview on 4/23/26 at 10:35 a.m., R31 stated they were never offered snacks in the evening, but they were pretty sure staff would give them one if asked.During an interview on 4/23/2026 at 11:14 a.m., R36 stated staff did not offer snacks most evenings.Facility policy Frequency of Meals dated 4/2026, identified the facility would serve at least three meals daily at scheduled times and there would not be more than a 14-hour span between the substantial evening meal and breakfast; however, dining times could extend up to 16 hours between the evening meal and breakfast as long as resident council approved and a nourishing snack was provided before bed. Nourishing snacks were defined as items from the basic food groups, offered either separately or with each other.

Based on interview and document review the facility failed to track and monitor residents and staff with symptoms of possible illness to prevent a possible outbreak. This could affect all residents and visitors in the facility.Findings include:During a review of the facilities infection control program paper on 4/23/26 at 8:12 a.m., the paperwork lacked any information related to staff and resident illness symptoms reported to the facility. There was no documentation of symptoms, trends in the facility or indications the facility was monitoring to prevent a potential outbreak.During an interview on 4/23/26 at 8:38 a.m., the assistant director of nursing/infection preventionist (IP) stated there had been no tracking and trending of resident or staff symptoms since she had taken over the IP program on 1/26. The IP was not aware tracking and trending of symptoms needed to be done.During an interview on 4/23/26 at 9:18 a.m., the regional clinical director (RCD) stated the facility should have a way to keep track of resident and staff symptoms. The IP should monitor that system frequently to know when residents and staff have symptoms that could be contagious to try to prevent an outbreak.During an interview on 4/23/26 at 9:27 a.m., the IP stated the facility should do any monitoring needed to prevent outbreaks from occurring in the facility and keep residents, visitors, and staff safe.Facility policy Infection Control last reviewed 1/26, indicated the objective of the infection control policies was to prevent, detect, investigate, and control infections in the facility. This was done to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public.Facility policy Surveillance for Infections last reviewed 1/26, indicated surveillance of infections was done to identify both individual cases and trends of or epidemiologically significant organisms to guide appropriate interventions and to prevent future infections.

Based on observation, interview, and record review the facility failed to ensure resident medications were properly labeled with either an expiration date or beyond use date to ensure expired medications were not administered to residents. This deficient practice had the potential to impact all residents who received medications at the facility.Findings include:During a medication pass observation on 4/21/26 at 10:30 a.m., R17's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication pass observation on 4/21/26 at 11:58 a.m., R7's medication label was reviewed. The label did not include an expiration or beyond use date.During a medication pass observation on 4/22/26 at 10:22 a.m., R1's medication labels were reviewed. Labels did not include an expiration or beyond use date.During a medication observation on 4/23/26 at 7:19 a.m., R7's medication labels were reviewed. Labels did not include an expiration or beyond use date.Two medication carts were reviewed on 4/22/26 at 1:15 p.m., with the assistant director of nursing (ADON). After reviewing medication labels filled by both the Mille Lacs pharmacy and the Onamia Drug store the ADON confirmed the labels from both pharmacies did not include an expiration or beyond use date.During an interview on 4/22/26 at 2:01 p.m., while spot checking medication labels from their medication cart licensed practical nurse (LPN-B) confirmed none of the medication labels contained an expiration date. LPN-B stated they went by the fill date. If it was a year past the filled date, they would not use the medication.During an interview on 4/22/26 at 3:03 p.m., licensed practical nurse (LPN-A) pulled medication cards from the medication cart filled by Mille Lacs pharmacy and confirmed the medication cards did not list an expiration or beyond use date.During an interview and medication pass on 4/23/26 at 7:36 a.m., registered nurse (RN-A) confirmed medication labels from both pharmacies did not include expiration or beyond use dates. During morning huddle, they had been told PRN medications expired a year from fill date and scheduled medication should not be expired because the fill cycled every 28 days.During a follow-up interview on 4/23/26 at 11:18 a.m., the ADON stated they had been working on the medication label concern and stated they had reached out to the Mille Lacs Health System pharmacy. The ADON was not aware of either pharmacy policies or if the facility had copies or access to each pharmacy's policies. From a nursing perspective, they expected medications to be checked for expiration prior to administration to residents. The ADON confirmed the current labels printed by both pharmacies did not have clear expiration or beyond use dates for nurses to be able to check for expired medications prior to administration.During an interview on 4/23/26 at 12:36 p.m., the Onamia Drug pharmacist (PHARM-D-B) confirmed they supplied medications for residents at the facility. Their cards did have a place to document the expiration date of the medication, but they did not do that at present but could if it was needed. Their process was to use the last refill date on the label as the use by or discard date for medications they filled. The pharmacist pulled up a medication label and confirmed nursing staff would not be able to determine if the medication was expired or should be discarded based on the dates that were listed on the label. They were uncertain if the pharmacy process for knowing when to discard medications had been communicated to the facility or provided in a policy. The date used worked well for scheduled medications, but it was possible that a PRN medication could remain in stock beyond the prescription refill date. PHARM-D-B stated it made sense to include an expiration date and indicated that was something they could change so nurses could verify if a medication could be used or should be discarded.During an interview on 4/24/26 at 11:09 a.m., consultant pharmacist (PHARMD-A) confirmed their medication labels did not include a medication expiration or beyond use date. Their repackaged medications expired a year from the date they were repackaged and if the medication expired before that date, the date would be added to the medication label. [NAME] had been supplied with access to Mille Lacs pharmacy polices when they acquired the facility. PHARMD-C stated prior to medication administration nurses should verify the medication has not expired or reached the beyond use date. At the time of the interview the PC was not able to access pharmacy policies.During an interview on 4/24/26 at 11:45 a.m., Mille Lacs PHARMD-C stated their pharmacy had always used the one year from filled to determine when a medication was expired unless they labeled otherwise. PHARMD-C had not reviewed the policy but confirmed [NAME] had received access to the polices when they took over the facility. Their label company did have the capacity to reconfigure their labels to include expiration dates if needed. PHARMD-C stated it would be important for nurses to be able to determine if a medication was expired before they administered it. They were not certain if the policy clearly defined when a medication was expired based on the label, but they were looking into it. They would either clearly define it in the policy or change the label as they wanted to make sure they were doing what was required. A follow-up e-mail and policy was received on 4/4/26 at 3:55 p.m., from Mille Lacs Health System PHARMD-A read: Upon review, it appears that the long-term care (LTC) facility is not explicitly referenced in the current policy language. We will revise the policy to incorporate the long-term care facility accordingly to ensure clarity and alignment with our operations. Additionally, our Pharmacist-in-Charge for the retail pharmacy has confirmed that our pharmacy system is capable of automatically including expiration dates on prescription labels. We will work toward implementing this functionality moving forward.The undated policy Dispill Enrollment/Dispensing provided by Mille Lacs Health System pharmacy indicated state statute Rule 6800.3400 and 6800.3200 would be followed and included the following: packaging of single dose medication maybe be accomplished by a manufacturer or pharmacy. Unit dose packaging shall be properly labeled from the manufacturer with the name of the drug, dosage form and strength, manufacturer's name and lot number, and expiration date of all time dated drugs, or labeled in accordance with part 6800.3200 if prepackaged by the pharmacy.The facility policy Medication Guidelines - Long Term Care dated 7/2025, instructed medication for specific residents should be labeled with the following: medication name, prescribed strength, expiration date of medication when applicable, resident name, and route of administration. Step 14 under medication administration guidelines instructed check expiration date/beyond use date on package/container.

Based on interview and document review, the facility failed to ensure resident personal fund accounts were insured with adequate surety bond coverage to cover the total account balance. This had the potential to affect all 34 residents who had personal funds in the facility's trust account. Findings include: On 4/21/26 at 1:18 p.m., the residents' personal funds accounts were reviewed with the business office manager. The business office manager confirmed the total amount of the residents' accounts was in the amount of 40,688.56 dollars.On 4/22/26 at 10:02 a.m., the chief financial officer (CFO) confirmed the facility's surety bond for the residents' personal funds identified a penalty amount of 10,000 dollars. The CFO stated the bond should cover 100,000 dollars and stated they needed to reach out to their insurance [NAME] for clarification.Review of surety bond number 2653018 document dated 7/17/25, identified a surety bond for ten thousand dollars was in effect 7/23/25 and ended on 7/23/26. This document was signed by the current CFO.Review of the rider document associated with surety bond number 2653018 dated 4/23/26, identified an increase in the surety bond from ten thousand dollars to one hundred thousand dollars effective 4/23/26.Facility policy Resident Trust Account - Skilled Nursing Facility dated 4/2026, identified the facility would maintain a surety bond to assure the security of all resident personal funds deposited with the facility.

Based of observation, interview and document review, the facility failed to ensure physician prescribed medications are reviewed and monitored, for interactions between other prescribed medications, for 1 of 12 residents (R9) in the resident sample reviewed. Findings include: R9's annual Minimum Data Set (MDS) assessment of 11/11/24, identified R9 had brief interview for mental status (BIMS) score of 9, classified as moderate cognitive impairment. R9's medical diagnoses included unspecified dementia - unspecified severity without behavioral disturbance, psychotic disturbances, mood disturbance, anxiety, major depression, Gasto-esophageal reflux disease (GERD) without esophagitis and hyperuricemia (increased uric acid levels) without signs of inflammatory arthritis or tophaceous disease (monosodium urate crystals build up in the body). In review of R9's physician orders, the following medications were noted to have been ordered: Allopurinol 50 milligrams (mg) - give 1 tablet every day for hyperuricemia Diltiazem HCL 15 mg - give 1 tab three times a day for hypertension Carafate 1 gram (gm) - give 1 tablet by mouth two times a day for Gastric reflux melt 1 tablet in scant amount of water prior to administering to make a slurry. In review of R9's History and Physical (dated 10/20/23) documented R9 has the diagnosis of: Hyperuricemia, documenting: [R9] generalized aching could be hyperuricemia exacerbated by dehydration or if she has worsening chronic kidney disease. Likely, her generalized aching could be polymyaligia rheumatic, autoimmune disorder, fibromyalgia. We will evaluate these with laboratory testing. She stopped allopurinol. During medication observation on 2/4/25 at 6:16 p.m., trained medication assistant (TMA)-A began setting up R9's 7:00 p.m. medications, placing resident's allopurinol 50 mg tablet and diltiazem 15 mg tab in a medication cup. Then pouring a small amount of water in a plastic medication cup, TMA-A placed the Carafate 1 gm tablet into the water, stirring until dissolved. TMA-A then approached R9 and resident drank the Carafate slurry, then took the other two medications with a glass of plain water. When asked about the other medications being given with the dose of Carafate, TMA-A stated she would have to ask a nurse, while she doesn't know medication interactions. TMA-A assumed when the medications are scheduled on the electronic medication record, that is when they are to be given. In review of the pharmaceutical reference site, Drugs.com, the reference indicted the following: Using sucralfate [Carafate] together with allopurinol may decrease the effects of allopurinol. Allopurinol should be administered at least 3 hours before or after sucralfate. If your doctor does prescribe these medications together, you may need a dose adjustment or special test to safely use both medications. In review of R9's lab testing the following was noted: Uric Acid Levels: 1/1/14 - 6.4 milligrams / deciliter (mg/dl) (rang for Females: 2.4 - 8.0 mg/dl) 3/19/24 - 5.3 mg/dl 12/30/24 - 5.4 mg/dl 1/7/25 - 4.7 mg/dl During telephone interview on 2/5/25 at 8:40 a.m., pharmacy consultant (PharmD) stated any medication should be separated from the Carafate by 3 hours, so not to bind to and prevent absorption of any medication, according to the reference materials her organization utilized. PharmD stated this must have been missed in review of R9's medications. During telephone interview on 2/5/25 at 8:56 a.m., primary physician (MD)-A stated according to her references, Carafate should be given 2 hours before or 2 hours after all medication and/or meals. MD-A stated Carafate can affect the absorption of other medications, and with R9 taking water with her other medications, potentially washed the Carafate coating to the espohagus that the Carafate was ment for. During interview on 2/5/25 at 9:17 a.m., registered nurse / care manager (CM)-A stated she knew Carafate should be given 1 hour before or after meals, but was not aware of the medication interaction with R9's other medications. In an interview on 2/5/25 an 10:37 a.m., the director or nursing (DON) stated they were unaware of this concern and they are currently looking to see if there are any other residents were receiving Carafate and had it scheduled in this manner. In review of the facility's policy, entitled: Documentation and Communication of Consultant Pharmacist (last reviewed 03/08/2022) indicated the following: PURPOSE: The facility supports pharmacy services that promote quality care including drug regimen review (DRR). DRR is defined as the systematic evaluation of drug therapy viewed within the context of resident-specific data. The consultant pharmacist reviews the drug regimen of each resident at least monthly and more frequently if deemed necessary. Irregularities are reported to the director of nursing, RN Care Coordinators, the attending physician, and the medical director for irregularities to be addressed by the attending physician. PROCEDURE: A. The facility assures that the consultant pharmacist has access to residents and the residents' medical records; the provider pharmacy's resident medication profiles, if requested; the facility's records of medication receipt and disposition; medication storage areas; and controlled substances records and supplies. Section 1. - ix. The administration schedule is appropriate for the resident, considering side effects and compatibility with other medications and diet.

Based on observation, interview and document review, the facility failed to assess and monitor bruising for 1 of 1 residents (R9) reviewed for impaired skin integrity. Findings include: R9's annual Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and diagnoses of dementia, benign paroxysmal vertigo (a sensation of spinning or moving), inflammatory arthritis (pain, swelling and warmth in the joints) and pruritus (itchy skin). R9's care plan dated 11/21/23, identified the potential for alteration in skin integrity and directed staff to complete skin audits with showers or baths weekly. During observation on 2/3/25 at 11:52 a.m., was seated in the memory care unit dayroom area and was noted to have what appeared to be a dark purple irregular shaped bruise on the top of her left hand between the thumb and index finger approximately five centimeters (CM) in diameter. When interviewed on 2/3/25 at 11:53 a.m., R9 stated she did not remember how she obtained the bruise, denied pain and denied deliberate harm by other residents and staff. R9 stated she bruised easily and could have bumped her hand on something but didn't remember. When interviewed on 2/4/25 at 6:14 p.m., R9 stated staff assist her with showers and believed she had received a shower that morning. R9's bathing and skin report task documentation dated 2/4/25 at 1:59 p.m., identified she received physical assist by one person on the bathing report and not applicable on her skin report. R9's bath checklist dated 2/4/25 at 9:45 a.m., identified she had a shower, and no skin issues were found. When interviewed on 2/5/24 at 8:01 a.m., registered nurse (RN)-B, stated the facility process for checking resident skin was done on each resident's bath or shower day. If skin issues were found, the staff member completing the bath or shower was to report to the charge nurse. The charge nurse would then assess the skin, measure or provide first aide, investigate cause and make appropriate notifications to the resident's provider, family and director of nursing (DON). When interviewed on 2/5/25 at 8:37 a.m., nursing assistant (NA)-A stated she thought the discoloration on R9's left hand was not new and not a bruise otherwise she would have reported it to the charge nurse. When interviewed on 2/5/25 at 9:36 a.m., clinical manager (CM)-A stated she had assisted R9 with a shower on 2/4/25 in the morning and did not notice any bruising on R9's left hand. CM-A stated she assisted R9 with washing and drying her back and feet and R9 was able to wash and dry the rest of her body independently with supervision. CM-A stated R9 had a habit of rubbing and scratching her own skin and this was the most logical explanation for the bruising. CM-A stated the facility process for checking resident skin was done on their bath or shower day. If a staff member noticed any impaired skin integrity, they were to report this to the charge nurse. The charge nurse should then assess the resident's skin and initiate any needed first aide and monitoring and make notifications to the provider and families. On 2/5/25 at 9:47 a.m., CM-A measured the discolored area on R9's left hand at 3.5 CM x 4.3 CM in diameter with light purple edges and dark purple covering the rest of the area and agreed it appeared to be a bruise. CM-A again stated she did not notice the bruise when providing R9 her shower the previous day and stated the facility impaired skin integrity process had now been initiated for R9 including notifications to her provider and family. On 2/5/25 at 10:36 a.m., the director of nursing stated her expectation was that staff report any skin impairment to the charge nurse immediately who should then assess, make notifications and monitor healing per facility policy and procedure. The DON acknowledged this process was missed for R9. The facility policy Skin injury (non-pressure) Prevention and Management dated1/9/25, identified all new skin injuries would be documented and would include a description of the injury with measurements, the potential or actual cause of the skin injury, the intervention or treatment implemented, and the resident representative notification of injury.

Based on interview and document review, the facility failed to ensure a thorough investigation was completed for an injury of unknown to ensure abuse had not occurred for 1 of 1 residents (R1) reviewed. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, aphasia (language disorder that makes it difficult to understand, speak, read, or write), dementia, and hemiplegia. Further, MDS indicated R1 had severely impaired cognition and exhibited physical, verbal, and other behavioral symptoms. Review of facility report number 358743 to the SA, submitted at 11:48 a.m. on 11/24/24, by director of nursing (DON) indicated R1 had unexplained bruising to left arm. Nursing assistant (NA)-A reported R1 had bruising to left forearm, left posterior hand, and some purple coloring on the inside of left fingers, and the bruising was tender to the touch to licensed practical nurse (LPN)-A in the morning after a.m. cares on 11/23/24. Further, report indicated DON attempted to interview R1 however R1 could not speak due to aphasia other than single unclear words and sounds. R1 did not appear fearful or scared. DON asked if someone had hurt her, but she could not clearly answer. DON wrote down yes and no and asked resident to point, but R1 did not follow direction. On 11/27/24 at 2:01 p.m., DON stated she was completing the investigation related to R1's bruising. DON stated she had interviewed R1 in attempt to figure out the cause of the bruising however R1 did not respond appropriately to questions asked. DON stated she interviewed staff but that was it for interviews and DON confirmed she did not interview any other residents on R1's unit. DON stated she reviewed R1's behavior charting which revealed R1 had minimal behaviors and R1 was taking medications that would cause her to bruise easily. When asked how she ruled out abuse, DON stated she was not sure, but typically she would interview other residents but there were no other residents with any injuries that had been reported. Review of facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property/Vulnerable Adult Policy, undated, indicated investigations of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse and injuries include but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. Further, the policy indicated when an incident or suspected incident of abuse was reported, the administrator or designee would investigate the incident and the investigation would include: interview the protected adult, and for non-verbal, cognitively impaired or those who refuse to be interviewed, the interviewer should: observe the protected adult, complete an evaluation of protected adult behavior, affect and response to interaction, and document findings, and obtain statements from the roommate or other residents located in the same area of the protected adult. In addition, procedures must be in place to provide the protected adult with a safe, protected environment during the investigation and staff were directed to examine, assess and interview the protected adult and others potentially affected immediately to determine any injury and identify any immediate clinic interventions necessary.

Based on interview and document review, the facility failed to ensure an injury of unknown origin was reported immediately and/or within 2 hours, to the State Agency (SA) and administrator for 1 of 1 residents (R1). Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, aphasia, dementia, and hemiplegia. Further, MDS indicated R1 had severely impaired cognition and exhibited physical, verbal, and other behavioral symptoms. Review of facility report to the SA, submitted at 11:48 a.m. on 11/24/24, by director of nursing (DON) indicated R1 had unexplained bruising to left arm. Nursing assistant (NA)-A reported R1 had bruising to left forearm, left posterior hand, and some purple coloring on the inside of left fingers, and the bruising was tender to the touch to licensed practical nurse (LPN)-A in the morning after a.m. cares on 11/23/24. LPN-A reported to registered nurse (RN)-A around 2:00 p.m. on 11/23/24, and RN-A filed a MAARC (Minnesota Adult Abuse Reporting Center) report for injury of unknown source. Further, report indicated the administrator was notified at 9:46 a.m. on 11/24/24, by DON. On 11/27/24 at 10:21 a.m., LPN-A stated staff were expected to notify the floor nurse if a new bruise had been identified and the nurse would complete a skin assessment and document the findings in the resident's record as well as notify the charge nurse or care coordinator immediately. LPN-A stated she was notified by NA-A on 11/23/24 in the morning of R1's new bruising to her left arm and LPN-A then reported to RN-A. On 11/27/24 at 10:48 a.m., NA-A stated staff were expected to report to the nurse when a new skin impairment had been identified and attempt to determine if the skin concern is explainable or unexplainable. Further, NA-A stated on 11/23/24, she was assisting R1 with morning cares when NA-A noted new bruising on her left forearm which was raised, on her left hand and under her fingers. NA-A stated the bruising appeared to be fresh and R1 was unable to communicate what had happened and previous shift did not report any incidents that had occurred. NA-A stated she reported the bruising to LPN-A immediately. On 11/27/24 at 12:36 p.m., interview was attempted with RN-A but was unsuccessful. On 11/27/24 at 2:01 p.m., DON stated once an injury of unknown was discovered the staff were expected to report the injury to the charge nurse and if the injury was reportable then notify the DON and administrator immediately. DON stated reporting an injury of unknown to the SA depended on the severity of the injury if the injury was severe immediately or no later than 2 hours and if the injury was not severe then 24 hours or less. Further, DON stated R1's bruising was discovered by NA-A who reported to LPN-A; however, LPN-A did not report the bruising to the charge nurse RN-A until 2:00 p.m. on 11/23/24. RN-A then submitted a MAARC report on 11/23/24 at 2:23 p.m. and printed the report and put it on DON's desk. DON stated she was made aware of R1's bruising on 11/24/24, in the morning and she called the administrator at that time. DON confirmed reeducation had not been provided to LPN-A or RN-A regarding reporting injuries of unknown to the SA, DON and administrator timely following this incident. Review of facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property/Vulnerable Adult Policy , undated, indicated an injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the protected adult; and the injury was suspicious because of the extent of the injury or the location of the injury (the injury was located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Further, policy indicated abuse allegations (abuse, neglect, exploitation, or mistreatment including injuries of known source and misappropriation of protected adult property) are reported per Federal and State law. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation if made, if the events involves abuse or result in serious bodily injury, or not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury, to the administrator, the director/manager or their designee, and to the department designated Common Entry Point (CEP).

Based on observation, interview and document review, the facility failed to ensure bruising was monitored for changes until resolved for 1 of 3 residents (R1) reviewed. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, aphasia (language disorder that makes it difficult to understand, speak, read, or write), dementia, and hemiplegia. Further, MDS indicated R1 had severely impaired cognition and exhibited physical, verbal, and other behavioral symptoms. R1's Progress Notes revealed: -On 11/23/24 at 2:35 p.m., large amount of bruising was reported by nursing assistant. R1 was unable to state what happened. -On 11/24/24 at 11:48 a.m., resident had a 7-centimeter (cm) x 7 cm bruise to proximal and posterior left forearm, bruise was purple in the center with green around the edges, bruise was slightly raised and tender to the touch. Bruise 2 cm x 1.8 cm to distal posterior forearm dark purple in color. 3 cm x 4 cm bruise to posterior (back) of left hand by the thumb and index finger and going up onto the posterior middle finger, bruise was purple in color. 1 cm x 1 cm purple bruise to posterior left and near the ring finger. There was a slight purple coloring to the inside of fingers 2-5. R1's progress notes lacked any additional monitoring of the bruise. R1's care plan revised on 6/16/22, indicated R1 had the potential for alteration in skin integrity related to impaired mobility with right sided hemiparesis, and incontinence of bowel and bladder. Further, R1's care plan directed staff to inspect skin daily with cares. However, care plan lacked evidence of notification for staff to monitor for bruising on R1's arm and appropriate interventions. R1's treatment administration record for November 2024, printed 11/27/24, lacked evidence of monitoring for R1's bruising until resolved. On 11/27/24 at 10:21 a.m., licensed practical nurse (LPN)-A stated if bruising was identified, the floor nurse would enter a treatment order into the resident's record to monitor at least daily, for changes until resolved. LPN-A stated she was made are of R1's bruising by a nursing assistant on 11/23/24, and LPN-A confirmed she did not put in an order to monitor the bruising. On 11/27/24 at 12:27 p.m., registered nurse (RN)-A stated if a new skin impairment had been identified staff would document in the resident's record but was unaware of facility procedure for additional monitoring. On 11/27/24 at 1:25 p.m. RN-B stated when a bruise was identified staff would be expected to measure the bruising and the bruising was extensive staff would enter a treatment order into the resident's record to monitor the bruising daily for changes until the bruise was resolved. RN-B stated she observed R1's bruising on 11/25/24, and the bruising appeared to be healing and R1 had no pain. RN-B confirmed there was not an order in R1's treatment record for staff to monitor her bruising but staff should be assessing the bruise, but they are not. RN-B stated monitoring the bruise would be important to ensure the bruising does not worsen and there are no complications. On 11/27/24 at 2:01 p.m., director of nursing stated when a new skin impairment was identified the licensed nurse should implement an order to monitor every shift or twice a day for changes until resolved. DON confirmed R1's record lacked evidence of a treatment order for licensed nursing staff to monitor. DON stated she was at fault for the error of the missed treatment. DON stated monitoring the bruise for any changes or worsening would be important. Review of facility policy titled Treatment and Prevention of Skin Breakdown and Ulcers, undated, indicated nurse aides (NA) would inspect the skin every shift with cares for signs and symptoms of breakdown, and report issues to the team leader. Further, policy indicated a licensed nurse weekly skin assessment was to be performed by the licensed nurse on shower day or other designated day and the care plan was to be evaluated and revised based on response, outcomes, and needs of the resident.

Based on observation, interview and document review the facility failed to ensure process's were followed for safe lift transfers for 1 of 6 residents (R1) reviewed for safety with mechanical stand transfers. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, and was dependant on staff for transfers. R1 had a height of 60 and weighed 198 pounds (lbs) diagnoses included stroke, hemiparesis or hemiplegia, and seizure disorder, R1's care plan dated 11/5/23, directed staff to transfer R1 with EZ-stand (sit to stand lift). R1's undated, Care Sheet directed staff to transfer R1 with EZ-stand and large sling. A Facility Reported Incident (FRI) dated 1/29/24, identified R1 had a fall during a transfer to the bathroom. R1 was being transferred from the EZ-stand when the left side of the sling slipped off. R1 was lowered from the EZ-stand and assisted to the floor. It was a witnessed fall and no injuries. The facility investigation dated 1/29/24, indicated R1 had hemiplegia and hemiparesis following cerebral infarction affecting right dominate side. Nursing assistant (NA)-A felt the sling may have been too large for the resident, as they were using an XL sling and it was switched out for a large size. On 2/6/24 at 1:05 p.m., NA-A was obsered transferring R1 from R1's wheelchair using the EZ-stand. NA-A was working the day R1 had slid to the floor when the left side of the strap came undone from the EZ- stand. NA-A was using the XL sling and thought it was too big fro R1 as R1's left arm was raised in the air. During interview on 2/6/24 at 2:16 p.m., NA-B stated she transferred R1 with the EZ-stand with the large sling, but sometimes was unable to find the large sling and would have to use the XL sling, which was too big for R1. During interview on 2/6/24, at 1:34 p.m., NA-C stated he worked with R1 and they used a EZ-stand and was working the day R1 slipped from sling during a the lift transfer. NA-C stated R1 had a XL sling that was too large for her and felt that was why she slid out. During interview on 2/7/24 at 10:03 a.m., physical therapy assistant (PT)-A stated R1 used to use a stand aide, and now was using a EZ-stand, and suspected the reason R1 slid out from her sling was due to her not providing enough upper and lower assistance. During interview on 2/7/24, at 11:28 a.m. director of nursing (DON) stated R1 was transfered with a XL sling, after the incident R1's sling was switched to a large sling. It sounds like from what I gathered the loop came off on the left side and maybe was not connected properly. The staff had training on using the EZ-stand and are having company come out to the facility and do refresher training on the lifts/stands on February 19th this year. On 2/7/24 at 3:35 p.m., NA-D while orientating NA-E stated she was told to use the large sling with R1 since she started in September 2023, but did not feel it was safe and prefers to use the XL sling. NA-D stated the large sling was too small for R1. NA-D and NA-E were observed to transfer R1 from her chair into the bathroom on to the toilet with the XL sling and not the L sling as care planned.There were no observed concerns with the transfer. During interview on 2/7/24, at 4:45 p.m. the DON stated immediately after the incident occurred with R1 sliding out of her sling she had changed the nursing assistance care sheets to make sure they use the large sling instead of the XL sling. During interview on 2/8/24 at 11:58 a.m. the DON stated she informed NA-D she needed to use the large sling and not the XL sling. The DON stated NA-D was not happy since she felt the XL sling was safer. An EZ Way Harness (sling) sizing chart indicated the large sling to be used on 190-320 lbs, the XL sling to be used on 280-450 lbs., and The size/weight designations are merely estimates that have basic guidelines.

Based on interview and document review, the facility failed to ensure a physician ordered medication was acquired timely from the pharmacy to prevent delay in administration and reduce the risk of complications for 1 of 1 residents (R1). This resulted in R1's anticoagulant (blood clot prevention) medication being omitted for six consecutive days. In addition, the facility failed to ensure procedures were implemented and followed to ensure sufficient medication supplies, timely medication re-ordering, after hours on-call pharmacy use, and appropriate action(s) taken when a medication was not available for administration. Findings include: A Facility Reported Incident (FRI) report was submitted to the State Agency (SA) on 1/19/24 at 9:45 a.m. and identified R1's ordered Xarelto (anticoagulant) medication was reordered on 1/5/24 from the pharmacy; however, the medication was not delivered and thus, R1's Xarelto was omitted on 1/6/24 through 1/11/24. In addition, the report indicated her medical record lacked evidence staff followed-up with the pharmacy or that her provider was notified timely. Staff contacted the pharmacy on 1/12/24 after the omissions were discovered and pharmacy supplied the medication that day. R1's signification change Minimum Data Set (MDS), dated [DATE], identified R1 was severely cognitively impaired with diagnoses of atrial fibrillation (irregular heartbeat) and dementia. The MDS indicated R1 received anticoagulant medication daily. R1's care plan identified R1 experienced an alteration in cardiovascular status related to atrial fibrillation, history of hyperlipidemia (elevated fat in blood) and peripheral vascular disease (impaired blood circulation), episodes of lower extremity edema (fluid buildup), hypertension (elevated blood pressure), and use of pacemaker (implanted device assists to control heartbeat). The care plan directed medication was to be administered as ordered. A PointClickCare (PCC - electronic medical record) Electronic [medication reorder] Transmission Report identified R1's Xarelto was reordered on 1/5/24 at 7:14 p.m. Reorder status indicated it was Processed on 1/5/24 at 7:15 p.m. R1's January 2024 MAR directed staff to administer R1 Xarelto 20 mg (milligrams) at bedtime related to paroxysmal (comes and goes) atrial fibrillation. The MAR identified from 1/6/24 through 1/11/24 a recorded entry of 9 (Other / See Nurse Notes). R1's nursing progress notes identified the following Xarelto information: -1/6/24 6:11 p.m.: none in stock -1/7/24 6:18 p.m.: none in stock -1/8/24 6:20 p.m.: none in stock -1/9/24 7:28 p.m.: waiting on pharm[[NAME]] -1/10/24 9:47 p.m.: supply not available from pharmacy -1/11/24 7:43 p.m.: no supply -1/12/24 9:21 a.m.: [R1] has not had xarelto [sic] [for] 6 days, called pharmacy and they will send it up today. -1/19/24 3:36 p.m.: Family notified R1's Xarelto was omitted from 1/6/24 through 1/11/24. -1/19/24 4:32 p.m.: R1's provider was emailed and updated about the missed Xarelto doses. R1's medical record lacked evidence staff followed-up with pharmacy on the lack of Xarelto supply, or contacted/updated R1's provider, from 1/6/24 through 1/11/24. In addition, the medical record lacked evidence staff followed-up or investigated the medication error, nor contacted the provider, when the omission was first identified on 1/12/24. R1's provider response related to the email sent on 1/19/24 was requested; however, none was provided. A Medication Event report, dated 1/19/24 at 4:44 p.m., identified the information reported in the FRI. Questions labeled Check the causes of the error and Contributing Factors indicated an answer of NO ANSWER. An additional question labeled, What changes to our system/process could be helpful to prevent this event from happening again? indicated the response, There seems to be an issue with the electronic ordering communication between [PCC] and pharmacy. Claim submitted to [PCC] to resolve. The event report Follow up section remained blank. A 5 Day FRI follow-up report submitted to the SA on 1/23/24, identified similar re-ordering incidents in the past six months where meds were not received from the pharmacy before a supply lack. Pharmacist (P)-A was interviewed and was unable to confirm the reorder request was received on 1/5/24 and thus the facility filed a claim with PCC. PCC confirmed the request was successfully transmitted. R1's insurance follow-up determined the prescription drug information was different as of 12/28/23. Two licensed practical nurses (LPNs - one no longer worked at the facility and LPN-C) related to the 1/6/24 through 1/8/24, and 1/9/24 incidents were interviewed, and both stated they were unaware they should have contacted the provider to hold the medication. Both were educated on ways to notify the pharmacy when a medication was unavailable. [The report lacked information related to the third nurse involved.] The report identified an LPN-B emailed registered nurse (RN)-B (RN Care Coordinator) on 1/11/24 the Xarelto was unavailable which prompted RN-B's 1/12/24 follow-up. The report identified R1's progress notes were reviewed and lacked evidence the provider was undated and/or the pharmacy was contacted. Facility policy review determined the current med administration policy's directed follow-up to med errors required revamping and a separate specific medication error policy that included protocols to prevent future incidents and omissions. Once completed, staff education would be performed. An email, sent to LTC (long term care) Nurses on 1/24/24 at 4:35 p.m., indicated frequent issues lately with reordering medications and not receiving from pharmacy, in which a resident recently did not receive a 'significant' med for a period of six days despite it being reordered from pharmacy. Multiple factors felt were involved in the incident, but ultimately the resident went without the med putting her health at risk. The email updated more information would be forthcoming and staff were asked to be more diligent in following up on medication issues/concerns. Going forward, staff were to send an email to the Pharmacy Distribution Group and LTC Nurses when meds were out of stock and reordered. In addition, the email identified omitted meds due to no supply were med errors unless the provider was contacted and an order to hold was obtained. Furthermore, the email identified the current policy that included med errors was found to be not helpful, and thus the director of nursing (DON) would be working on a separate policy related to med errors and would send out when completed. When interviewed on 1/25/24 at 1:50 p.m., trained medication aide (TMA)-A stated she re-ordered meds when needed and explained she had experienced distant history of episodes where after she reordered medications there were glitches and when she called pharmacy to follow-up, pharmacy indicated lack of reorder receival. She explained if a resident missed anticoagulant med, the resident would be at increased risk for stroke and blood clots. If she were unable to find a medication, she updated a nurse to assist. TMA-A was unaware of any recent anticoagulant omission concerns and denied any recent emails from the DON related to such concerns. TMA-A checked her email and confirmed her email lacked the 1/24/24 email. During an interview on 1/25/24 at 2:40 p.m., LPN-B stated when a medication was unfound, she was expected to utilize the emergency kit and if not, the attached hospital charge nurse was contacted as that nurse was able to access the hospital pharmacy. If a med error was identified, she was expected to either contact or email the resident's care coordinator, contact the provider, and complete a med error incident report. She denied she had yet to complete such a report since her December hire. LPN-B stated if a resident's anticoagulant was omitted, they were at risk for blood clots, and this would be considered a med error. LPN-B explained she emailed RN-B on the evening of 1/11/24 when R1's Xarelto was not found after she investigated the missing medication and noted R1 missed the previous evening's dose also. She questioned RN-B via email, after review of R1's chart orders, if this was a pharmacy issue or if the medication was discontinued based on an antibiotic order back in December. She stated she only emailed RN-B related to her concerns and did not contact the pharmacy, the hospital charge nurse, or the provider as she felt the medication needed to be investigated more if it was supposed to be given or not, and thus awaited RN-B's response. When interviewed on 1/25/24 at 3:03 p.m., LPN-C stated when a med was not found, she was expected to utilize the emergency kit, and if not there, the provider was to be updated. If the provider continued to order the administration, the hospital on-call pharmacy process was to be utilized. If the rights of med administration, which included omitted meds, were not followed, a med error incident report was to be completed. This process required contacting the provider, the family, charge nurse, DON, and care coordinator. LPN-C identified she passed on the missing Xarelto on the 24-hour report sheet and reported it to the charge nurse and the oncoming nurse. She did not fill out a med error report or contact the provider or the care coordinator. As the on-call hospital pharmacy process was a last resort, she did not contact the pharmacy. She thought, based on her passing on the information, staff would contact pharmacy in the a.m. and the medication would be sent. During interview on 1/25/24 at 3:22 p.m., RN-B stated when a med was not found, she expected staff to call the pharmacy, call or leave her a message so she could follow up, and to call the provider or on-call provider to get orders either to give or to hold. She stated she would not expect staff to contact the provider for one missed dose of Xarelto; however, once at least three doses were missed, then the provider should be updated. She explained she reviewed an email on 1/12/24 that identified R1's omitted Xarelto doses. She reviewed the MAR and contacted the pharmacy; however, she did not perform any further actions as R1 had past episodes of held Xarelto without any adverse impacts and thus she was not concerned. It was not until a few days later that the omissions were followed up on and the provider contacted. RN-B stated a missed medication was considered a medication error and explained she was expected to complete a med error incident report in such situations. She stated she did not complete one for R1 due to having a lot of other things on her mind at that time. In addition, she stated she was not sure if R1's missed Xarelto would be considered a significant medication error or not. When interviewed on 1/25/24 at 3:45 p.m. the DON explained the facility transitioned to pharmacy integration with PCC around July of 2023 and expected staff to re-order meds when the medication card indicated a reorder status. She was unsure her expectation was in a policy but stated it should be. She stated staff ordered R1's Xarelto late on the day of the last dose. The DON stated if staff were unable to find a medication, she expected them to contact the pharmacy, the provider, and the on-call hospital pharmacy if required. An omitted med was considered a medication error and she expected staff to complete an incident report. Once received, this gave her the opportunity to investigate the error. She stated R1's omitted Xarelto was a significant medication error, thus the reason she filed the incident with the SA. The DON identified she sent out an email on 1/24/24 to the LTC group updating them on her concerns; however, she determined this group did not include the TMA's after TMA-A approached her after being interviewed. She identified the facility employed three TMA's. The DON stated she continued to work on updating the policies surrounding the identified medication administration and reordering concerns and thus these had yet to be developed and implemented. When interviewed via telephone on 1/26/24 at 10:43 a.m., R1's provider, who identified himself as the medical director (MD)-A, initially stated he expected staff to follow facility polices related to medication administration, pharmacy services, and medication errors. He identified he was aware of the Xarelto omission and stated this was an outlier based on the quarterly medication error reports he reviewed. He was not concerned R1 missed six doses; however, he was concerned that the incident happened, and medications were not administered as ordered. He stated if a person experienced atrial fibrillation they were at a double rate of stroke; however, R1's rate of stroke was low. He indicated R1 experienced history of Xarelto holding in prep for a dental procedure in the past and remained stable. Later in the interview, he stated when a medication was omitted, he expected an update based on what the medication was and if a medication was significant: something dangerous, he expected an update right away. He identified he was always updated on errors as he was there so often. He indicated the facility continued to investigate the omission and thus he was unsure as to what went wrong with the processes. Due to this, he could not explain what his expectations were that centered around this incident. However, he stated this incident should not have gone to the provider as it should have been fixed by the nursing staff, unless the pharmacy was unable to provide the medication. He continued medication errors usually occurred when one missed dose occurred. During conversations with the care coordinator, the DON, and the administrator, they realized how concerning this situation was. During interview on 1/26/24 at 1:17 p.m., P-A stated pharmacy services were available seven days a week with weekdays until 5:30 p.m. and weekends until 2:30 p.m. If a medication was needed after those hours, he expected facility staff to utilize their emergency kit otherwise the policy in place was for them to contact the hospital charge nurse as that nurse had access to the hospital pharmacy. He confirmed staff were expected to reorder Xarelto as it could only be filled for a 14-day supply because of its brand name status. He explained meds requiring reorder processes were marked with a red sticker that identified when the meds should be reordered. This allowed the pharmacy adequate time to process and dispense the medication. P-A stated R1's Xarelto order was reviewed on 1/6/24 at 9:04 a.m. When ran through insurance verification/authorization, coverage was denied and thus the med was not filled. He stated in R1's situation, pharmacy staff should have called the facility. He was unaware of what led to the possible lack of communication and confirmed there was not a glitch in the communication between PCC and the pharmacy. On 1/12/24, the facility contacted the pharmacy and when the insurance claim was re-ran, the claim went through, and the med was dispensed. When interviewed via telephone on 1/29/24 at 8:24 a.m., R1's family member (FM)-A denied concerns with R1's stay; however, she was concerned staff did not catch the Xarelto omissions sooner. She was unsure how such a thing was allowed to occur when staff were expected to write down when residents received their meds. She denied she received a call from pharmacy about insurance and was concerned the pharmacy failed to contact the facility so the facility could contact her. FM-A stated staff informed her they would investigate the incident; however, she had yet to hear back from them related to any outcomes. A Medication and Treatments policy, dated 4/17/23, identified med refills provided by the hospital pharmacy were requested as needed in a 'drug Order' book, and for those residents who received meds elsewhere and the med was not delivered on time, the med was then to be obtained from the hospital pharmacy. The policy identified a section for medication error direction that included omission as an error. When an error was realized, the responsible nurse was to complete the appropriate form which must then be signed by the attending provider, LTC manager, and forwarded to the Pharmacy and Therapeutics Committee for review. The policy lacked direction(s) related to the PCC integrated pharmacy reordering and/or adequate med supply processes, process(ies) for staff to follow when a med was unfound, and/or the process(ies) for on-call pharmacy utilization. A Charting and Transcription Procedures policy, dated 7/24/23, identified the Mille Lacs Health System pharmacy was integrated with PCC and all new and updated non-controlled med orders were to be electronically submitted/communicated to the pharmacy via PCC. The policy lacked direction processes for reordering meds. A Medication Administration Times policy, undated, directed if a med was not administered within the time frame noted on the MAR, a progress note was to be entered indicating the reason. The policy lacked additional direction(s)/follow-up if such an event occurred. A LTC-Pharmaceutical Services policy, undated, directed in the absence of a pharmacist, meds a provider felt must be started immediately, should be sought first from the Emergency Drug Kit. Oral solid meds were dispensed by a punch card unit dose system on a 30-day exchange basis and all other meds were filled on a regular prescription basis. Prescriptions were filled Monday through Saturday. The policy lacked processes related to the PCC/pharmacy integration, process(ies) for reordering of meds, and process(ies) for Sunday and/or after hour med ordering. A Significant Change in Resident Condition policy, undated, directed the provider was to be updated in the event of any significant error in med administration when the error presents a risk to the health, safety or security of the resident and when there was an inability to obtain or administer on a prompt, timely basis, medications as prescribed under conditions that present risk to the health, safety or security of the resident. The provider and the representative were to be notified immediately or as soon as possible. A medication error policy was requested; however, none was provided.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Payroll Based Journal (PBJ) [NAME] Report 1705D identified the following dates triggered: 7/2/23, 8/20/23, 8/26/23, 8/27/23, and 9/4/23 for failure to have licensed nurse coverage 24 hours per day. Daily staff schedules on the above-mentioned dates identified licensed nursing staff including registered nurses had worked and therefore the data submitted in the PBJ to CMS was inaccurate. During interview on 1/8/24 at 8:41 a.m., administrator stated the reporting was the facility's error as the agency staff are not reflected in the report. During interview on 1/9/24 at 12:10 p.m., administrator stated the payroll coordinator generates a report from the payroll system, with information on report that is uploaded in the PBJ portal. Administrator stated it was realized the agency staff are not reflected on that report, so their hours were not getting uploaded into the PBJ portal. Administrator stated the human resource staff who was responsible for submitting data is not available for interview. Administrator confirmed the information that was submitted for fiscal year Quarter 4 2023 was inaccurate. A facility payroll-based journal policy was requested and was not received.

Based on interview and document review, the facility failed to routinely provide and document range of motion (ROM) exercises to maintain and prevent decline in current physical functioning for 1 of 1 resident (R18) reviewed for restorative therapies. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had moderately impaired cognition and diagnoses of multiple sclerosis (a chronic disease that affects the central nervous system but attacking myelin, a substance that protects nerve cells) and paraplegia (paralysis of the legs and lower body). R18 needed extensive assistance with activities of daily living (ADL's). R18 had impairments to both sides of upper and lower extremities and no rejection of cares. R18's care plan printed 1/9/24, indicated that R18 would participate in maintenance nursing range of motion (ROM) exercises to bilateral (both sides of body) upper and lower extremities daily. R18's physician orders printed 1/9/24, indicated maintenance nursing: ROM exercises on bilateral lower and upper extremities 7x/week. During record review, task documentation indicated that R18 had received PROM exercises on upper and lower extremities four out of the last 30 days. During interview on 1/9/24 at 10:30 a.m., nursing assistant (NA)-A stated NAs did not complete exercises with R18 and was not sure if R18 had a range of motion program. During interview on 1/9/24 at 12:18 p.m., registered nurse clinical manager (RN)-A stated the nursing assistants performed the ROM exercises for R18. During interview on 1/9/24 at 12:33 p.m., NA-B stated she assisted R18 with cares and did not complete range of motion exercises with R18. During interview on 1/9/24 at 12:55 p.m., RN-B stated the nursing assistants are expected to complete the ROM exercises with the residents. RN-B stated the restorative nursing tasks have fallen by the wayside since the facility currently does not have any restorative nursing assistants. RN-B stated physical therapy was coming to reassess the therapy plans to see if ordered programs were appropriate for residents. RN-B was not able to provide specific dates when reassessment when this was to occur. RN-B confirmed that ROM exercises were not being done as ordered for R18. During interview on 1/9/24 at 1:42 p.m., director or nursing (DON) stated ROM exercises were previously being done by the maintenance nursing assistants and that due to staffing the facility had to eliminate that position. DON stated ROM exercises are assigned on the nursing assistants' tasks to complete and are expected to complete them. DON confirmed that R18 had not had ROM exercises completed as ordered. DON stated that it was important for R18 to have ROM exercise completed to maintain his highest level of functioning, especially since R18 was a paraplegic. DON stated R18 had not had any decrease in his ROM currently due to exercises not being completed. The facility policy Nursing Maintenance Program dated 6/21, indicated the facility to ensure that a Nursing Maintenance Program is an integral part of nursing care, and that nursing care strives to prevent deterioration and maintain optimal level of functioning and independence. Active and passive Range of Motion plans are directed per nursing recommendation. Residents may receive the appropriate treatment by a Rehab Aide or by a member of the nursing staff.

Based on interview and document review, the facility failed to assess for and identify past trauma (PTSD) for 1 of 1 resident (R8) who had a history of multiple past traumatic experiences. Findings include: R8 was readmitted the the facility from Senior Services (geriatric-psych services - SCS) on 11/14/23 where he had been admitted due to behaviors of striking out, yelling, biting and other threatening behaviors. R8's admission Minimum Data Set (MDS) dated [DATE], identified resident as being severely cognitively impaired, Alzheimer's type dementia, and behaviors were noted in the look back period. R8's Behavior Care Area Assessment (CAA) worksheet (dated 11/20/23) documented the following: Resident's behavior symptoms not currently directed at other residents. Behaviors occur most with staff and with cares. He will swear, verbally and physically threaten, hit or kick out, grab on to things and not let go. At this point, cares have been able to be competed. The CAA went on to document: Resident has some trauma in his history, it is not totally clear due to his inability to fully state and his ex-wife not knowing details but does appear to be afraid and is resistive with personal cares. R8's Vulnerable Adult Assessment (dated 11/14/23) documented the following trauma history: Family shared that he was sexually assaulted as a child. Yes, hitting his ex-wife. Was in prison for vehicular homicide. Was stabbed in the right wrist and shot in the left leg in two different instances. Resident also has a long [history] of alcohol abuse. In review of R8's behavior care plan concern (last revised 1/24/23) identified: Alteration in Mood/Behavior [related to] dementia Mood/Behavior [with history of] wandering, [history of] verbally and physically abusive behavior [examples given] yelling, hitting out, biting. Date Initiated: 01/24/23. R8's care plan had no mention of his history of multiple traumatic experiences. During a telephone interview on 1/8/24 at 12:08 p.m., Family member (FM)-A stated she only knew of R8 being the outcome of his mother being raped. FM-A stated FM-B would know more of R8's life history. During a telephone interview on 1/8/24 at 12:14 p.m., FM-B stated she did not get to know her father until in her 20s but was aware her father was the outcome of his mother being raped by a white man. FM-B stated in those times, Native American children were taken from their families and placed in boarding schools. FM-B stated R8 had expressed to her and other family members, he had been sexually abused by 1-2 males during his boarding school years. FM-B further stated, throughout his life, R8 had been harassed and physically beaten while he was of mixed ethnicity. During observation of R8's morning cares on 1/9/24 at 6:49 a.m., the home health aid / hospice aid (NA)-M entered resident's room to perform cares. NA-M stated she was here to provide R8's morning shower and any other cares needed. NA-M stated R8 will grab out at the Hoyer lift bar (mechanical lift) and at his sheets and lift straps but had never struck out at her. A facility nursing assistant (NA-A) then entered the room to assist NA-M. As R8 was being cleaned and prepared for Hoyer lift transfer to the shower chair, R8 was grabbing out at staff and the Hoyer lift sling bar. NA-A placed one of the sling straps in R8's hand, so the NAs could continue positioning R8 for the transfer. Once in the shower chair, NA-M placed a shower drape and took resident down the hall to the enclosed shower room. NA-M could be heard through the shower room door, talking with R8, explaining what she was doing. No resident behavior was overheard during the showering process. During interview on 1/9/24 at 11:33 a.m., NA-A stated R8's behaviors have improved since he returned for SCS back in November 2023. NA-A stated R8 used to get angry, grabbing a hold of staff arms, swinging out at staff and pulling on the curtains. NA-A state occasionally they would place the lift she straps in his hands to calm R8, however that did not always work. NA-A stated R8 would occasionally have an angered look, with other times a look of fear. Staff would try to talk R8 through cares, and reapproach at a later time if needed. NA-A stated since R8 had returned from SCS, R8 still occasionally has the look of anger or fear, but does not grab out / swing out as frequently. In an interview on 1/9/24 at 1:15 p.m., the facility's licensed social worker (LSW) and R8's nursing care manager (RN)-A stated they were aware of the documentation in R8's Vulnerable Adult Assessment when he returned from SCS. LSW stated the information has been included in R8's discharge summary from SCS and family mentioned R8's trauma during the care conference after R8's readmission. LSW stated she reached out to FM-A, who only knew of R8's mother's rape. Both LSW and RN-A stated they did not investigate R8's trauma history further, neither with SCS or other family members. LSW stated she only performed the Trauma Risk Assessment upon any resident's initial admission to the facility, when R8 was admitted on [DATE]. LSW stated upon re-admission from SCS, only the Vulnerable Adult section of the assessment had been completed. A facility policy in regards to the assessment of trauma informed care and the care planning of was request, but not provided. The LSW and director of nursing (DON) stated the facility lack a policy for this process.

Based on interview and document review, the facility failed to comprehensively assess fall risk and implement individualized interventions to reduce the risk of falls for 1 of 3 residents (R3) reviewed for accidents. This resulted in R3 falling 18 times since his January 2023 admission. Findings include: R3's admission Minimum Data Set (MDS), dated [DATE], identified R3 admitted to the facility on [DATE]. He was moderately cognitively impaired and received limited physical assist with ambulation, transfers, and toileting. He was frequently incontinence of bladder. Diagnoses included dementia with behavioral disturbances, benign prostatic hypertrophy (BPH - enlarged prostate), and macular degeneration (eye condition impacting central vision). In addition, the MDS identified R3 fell prior to admission and utilized bed and chair alarms daily. R3's quarterly MDS, dated [DATE], identified R3 was severely cognitively impaired and received supervision with ambulation, transfers, and toileting. He was occasionally incontinent of bladder. Diagnosis included dementia with behavioral disturbances. In addition, the MDS identified R3 fell two or more times with no injury and two or more times with non-major injury and utilized bed and chair alarms daily. R3's Fall Risk Assessment, dated 1/5/23, identified a score of 14 (moderate risk). The assessment indicated R3 was free of falls prior to admission; however, at risk due to medication usage, occasional bladder incontinence, poorly fitted shoes, exhibited short discontinuous steps and/or shuffled steps and instability during turns, and the required need for assistive device to walk. R3 was free of systolic blood pressure drops of 20mmHG or more between lying and standing (orthostatic hypotension). The assessment lacked a comprehensive fall risk analysis based on the identified information. R3's admission MDS driven Fall Care Area Assessment (CAA), dated 1/17/23, identified R3 fell on [DATE] while at the hospital. He was unsteady on his feet and declined to use the PT recommended walker and thus utilized a wheelchair (w/c) for locomotion and to transfer. Upon admission, therapy recommended he required stand by assist (SBA) for mobility. R3 was diagnosed with dementia with behaviors and currently utilized antipsychotic medications. Additional diagnoses included cardiac condition, anemia, and BPH. He maintained bowel control; however, was incontinent of bladder and was found to have an enlarged prostate and started on medication while in the hospital. He was offered toileting every two hours and upon his request. Hearing loss was present, and he did not wear hearing aids. Pain management was in place due to history of headaches and back pain. Due to edema (swelling) he wore a slip-on shoe. Adequate vision was assessed; however, vision loss reported in right eye. R3 required a motion sensor pad on bed, w/c, and recliner and he was free of significant drops in orthostatic blood pressure. The fall risk assessment indicated a moderate fall risk. The CAA indicated staff would proceed to care plan for interventions to minimize risk factors. The CAA lacked evidence staff completed a comprehensive fall assessment analysis or individualized intervention(s) identification based on R3's fall risk. R3's care plan identified the following information: -On 1/19/23, a Vulnerable Adult Focus was initiated with a goal he would remain safe while he lived at the facility. -On 1/23/23, a Potential for Falls Focus was initiated related to altered mobility, vision, medication, edema, past history of falls, incontinence with a revised goal on 2/6/23 to remain free of fall related injury. The following interventions were implemented: medication monitoring for adverse reactions and continued need, encouragement of feet elevation and appropriate footwear use, follow mobility, vision, and toileting care plans, keep frequently used items within reach and room free of clutter, motion sensor pad on bed, w/c, and in recliner. -On 1/23/23, an Alteration in Toileting/Elimination Focus was initiated and directed staff to offer R3 the toilet every two hours and upon request. -On 1/24/23, an Alteration in Mobility Focus was initiated related to weakness and dementia and identified R3 required 1 staff for ambulation and transfers. -On 4/26/23, the Potential for Falls Focus was revised to include anti-rollback brakes on w/c. -On 7/14/23, the Alteration in Cognition Focus, was revised and identified R3 had dementia with behaviors and displayed impaired safety awareness and decision making, along with short- and long-term memory changes. R3's subsequent progress notes and facility provided Fall Scene Investigation Reports (FSI) identified the following information: -On 1/8/23, R3 self-transferred repeatedly and required reminders to use the call light, frequent safety checks, redirection, and assist with toileting needs. -On 1/9/23, R3 removed the alarm sensor pad out of his w/c on two separate occasions, self-transferred and required one-on-one supervision. -On 1/13/23, R3 self-transferred to the toilet and stated he had to go, or he was going to have an accident. -On 1/18/23, R3 attended a care conference with his family. Due to his self-transfers, bed and chair alarms were used. The note lacked information related to any additional fall intervention discussion. -On 1/19/23, R3 lost his balance and slowly lowered himself to the floor next to his bed. A FSI was not provided. -On 1/21/23 and 1/22/32, R3 constantly self-transferred/toileted. -On 1/24/23 at 7:20 p.m., R3 was seated on his buttocks in front of the bed. The alarm failed to sound. He stated he forgot to lock his w/c breaks. His conversation was confused but at baseline. Neurological (neuro) assessment was within normal limits (WNL). The FSI indicated the alarm failed as R3 turned it off. The Falls Team Meeting Notes embedded within the FSI identified the fall was reviewed on 1/25/23 in which a maintenance request was submitted for anti-rollback brakes on 1/24/23, prior to the fall, which had yet to be completed. -On 1/25/23, R3 complained of upper neck and bilateral shoulder pain which he stated, happened awhile back when he fell in the bathroom. -On 1/26/23, R3 removed his alarms and turned them off on numerous occasions. Staff intercepted R3 when he self-transferred. He nearly missed the w/c and landed on the arm rest. A FSI was not provided. -On 2/2/23, R3 was seated on the bathroom floor next to the toilet. He sustained a moderate sized abrasion to his right hip and complained of right sided temple tenderness. Neuro assessment was WNL. -On 2/3/23, neuros were performed on R3 in which his right pupil was a 2 in size and had no reaction to light and his left pupil was a 3 in size and reacted briskly to light. R3 received a right eye injection that morning during an appointment. A FSI report was not provided. -On 2/5/23, R3 was found lying on his bedroom floor. The alarm sounded. He stated he was reaching under the bed for his remote. He denied falling. A FSI was not provided. -On 2/11/23 at 6:55 a.m., R3 was seated on the floor with his head on the bed. The alarm sounded. He stated he was unsure where he was or what he tried to do. His w/c was pointed to the door and unlocked. Pupils were 2mm (millimeters) sluggish. A follow-up note on 2/11/23, indicated right pupil was 2mm sluggish and left pupil was 3mm reactive. A FSI report identified R3 wore flip flops, the w/c was unlocked, and he stated his eyes were not working. In addition, the rear w/c wheel anti-lock brake failed to work. The team meeting note, dated by the director of nursing (DON) on 3/29/23, identified the w/c was repaired. -On 2/13/23, R3 walked in his room without walker or chair. The alarm sounded. When staff grabbed at his pants to help him, he attempted to hit staff and almost fell . -On 3/26/23 at 11:30 p.m., R3 eloped from the facility and ran down a sidewalk away from staff who chased him. He stepped off a sidewalk curb. The momentum lunged him forward onto the pavement. R3 exhibited hallucinations when staff reached him. He sustained abrasions to his right 5th finger, right knee, right elbow, left calf, left palm, and required added support for transfers for the hours that proceeded the fall. The FSI's team meeting notes, undated, indicated a medication (unidentified) was increased. -On 4/6/23 at 6:30 p.m., R3 was seated on his bedroom floor. Socks and sandals were on. He stated he hit his head and neuros were at his baseline. The alarm sensor pad sat on his bedside table. Staff replaced the sensor pad back in w/c. The FSI indicated R3 was slightly more confused than baseline. The teams meeting note, undated, remained blank; however, team member signatures were present. R3's Fall Risk Assessment, dated 4/11/23, identified a score of 23 (high risk) related to multiple falls over the last six months, medication usage, occasional bladder incontinence, experienced orthostatic hypotension, poorly fitted shoes, exhibited short discontinuous steps and/or shuffled steps instability during turns, and the required need for assistive device to walk. The assessment lacked a comprehensive fall risk analysis based on the identified information. R3's care plan lacked revision(s) based on the fall risk assessment and R3's increased fall risk score. R3's subsequent progress notes and facility provided FSI reports identified the following information: -On 4/24/23 at 8:30 p.m., R3 was seated on the television room floor in front of his w/c. Alarm functioned; however, it failed to sound. R3 stated he stretched and slid to his butt. The FSI's teams meeting note, undated, remained blank; however, team member signatures were present. -On 4/25/23, R3 informed staff he fell in his room that afternoon around 1:00 p.m. He stated he lost his balance when he attempted to get his dirty laundry together. He wore his usual sandals. The alarm sensor was in the w/c; however, when staff tested it, it failed to function properly, and the low battery light flashed. Battery and sensor pad were changed and functioned after. The note indicated R3 was a fall risk and required SBA of one staff for transfers and frequently self-transferred. The FSI report indicated R3 wore sandals and time last toileted was unknown as R3 toileted himself. Root cause of the fall was identified as R3 should be SBA, the alarm had a low battery, and R3 preferred sandals. The teams meeting note, undated, indicated an occupational therapist (OT) walked by R3's room around that time and he was seated in his w/c, the bed alarm sounded, and R3 talked about his laundry. -On 4/26/23 at 7:30 a.m., R3 was witnessed to slide out of his w/c. He stated he attempted to get an eye drop that fell under the bed. The FSI indicated R3 wore slippers at that time and the team meeting note, undated, remained blank: however, team member signatures were present. -On 4/26/23, R3 attended a care conference. His daughter joined by phone. The note identified R3 requested to have the toilet riser removed from this toilet. The note lacked additional related information. R3 required SBA for transfers but R3 failed to call staff or wait for assist which resulted in frequent falls. Bed and chair alarms were in place; however, he turned them off despite reminders to use his call light and wait for assist. R3 tended to decline activity invites. And thus, activity staff provided R3 with one-to-one visits. The note lacked information related to any additional fall intervention discussion. -On 4/26/23, R3 self-transferred multiple times that shift. His alarm functioned; however, he usually self-transferred before staff could respond. Reminders to use call light and to make sure his brakes were on were provided. -On 4/28/23, R3 was assessed to toilet without the commode over the toilet and did well. Signs were placed next to the toilet and by his bed to remind him to lock his w/c breaks. He does have the anti-rollback brakes, but they will loosen over time and need to be tightened, so signs were placed as a precaution. -On 4/30/23 at 10:20 a.m., R3 was seated on the floor with his feet in the w/c. Prior to this, he was observed to fall asleep across his bed with his feet in the w/c. This was quite common for him. The FSI report identified a team meeting note, undated, which indicated a work order was submitted to adjust the anti-rollback brakes. -On 5/10/23, R3 was found on the toilet after alarm sounded. -On 5/11/23, R3 was found getting out of bed after alarm sounded in which he stated he needed to use the bathroom. -On 5/17/23, R3 updated staff he 'just blacked out. Blood pressure at that time was 95/70 and heart rate was 99. He was encouraged to drink more water and avoid coffee. Follow-up vitals two hours later identified his blood pressure and heart rate were WNL and no further concerns were identified. -On 5/17/23 at 8:00 p.m., R3 was seated on the television room floor in front of his w/c. He stated he reached for something which took the best of him, and he tipped over. The FSI's team meeting note, undated, remained blank: however, team member signatures were present. -On 5/22/23, at 7:40 p.m., R3 was on his knee in front of his recliner. The FSI report identified R3 attempted to sit in the recliner and the team meeting note, undated, remained blank: however, team member signatures were present. -On 5/28/23, R3 was seated in his w/c at the lunch table without the alarm pad under him. He disassembled it and removed it. Staff assembled the alarm and replaced in the chair. -On 5/30/23 at 7:00 p.m., R3 was on his right side on the hallway floor near the memory care unit. The alarm sounded. He stated he thought he could walk but he went down. The FSI identified physical therapy (PT) walked with him that afternoon and thus he thought he could walk. The teams meeting note, undated, remained blank; however, team member signatures were present. -On 6/3/23, R3 set off the bed or chair alarms over 15 times this shift . -On 6/5/23, R3 sat on a roller chair behind the desk and he was redirected back to his own w/c. -On 6/18/23, R3 self-transferred to parked wheelchairs in the hallway in which he was very hard to redirect. -On 6/23/23, R3 was found in the therapy room where he attempted to climb onto one of the therapy beds. -On 6/29/23, R3 attempted to self-transfer in the common area. -On 7/1/23 at 9:30 a.m., R3 was seated on the floor with crossed legs next to his w/c. He stated he went to pick a battery up from the floor and fell when he slide out of his chair. The FSI's team meeting note, undated, identified R3 utilized a sensor pad alarm and anti-roll back brakes on w/c already as fall prevention interventions. R3's Fall Risk Assessment, dated 7/7/23, identified a score of 24 (high risk) related to multiple falls over the last six months, medication usage, occasional bladder incontinence, orthostatic hypotension, poorly fitted shoes, exhibited short discontinuous steps and/or shuffled steps and required hands-on assistance to move from place to place with an assistive device. The assessment lacked a comprehensive fall risk analysis based on the identified information. R3's care plan lacked revision(s) based on the fall risk assessment and R3's increased fall risk score. R3's subsequent progress notes and facility provided FSI reports identified the following information: -On 7/12/23 at 7:00 p.m., R3 was seated on the floor parallel to his bed. The alarm sounded. An FSI was not provided. -On 7/13/23, an MDS note identified R3 was gradually became more confused and was severely cognitively impaired. His transfer ability varied day to day from SBA to hands on and needed assist of one staff for ambulation due to unsteadiness. R3 was manipulative and demonstrated impaired safety awareness with attempted self-transfers and ambulation in his room. A significant change MDS was initiated. -On 7/13/23 at 6:30 p.m., R3 was on the floor on his back and side. He confirmed he hit his head and was unable to explain the reason for the fall. His speech was noticeable more slurred. Neuros assessed in which left eye reacted WNL for him; however, the right eye which at baseline was a 3mm and sluggish to light was assessed at a 2 and non-reactive to light. The on-call provider was updated and R3 was brought to the emergency department for observation. The FSI indicated the fall occurred by the television lounge; however, the report lacked information related to post fall huddle information, root cause of the fall, or the completing nurse information. In addition, the team meeting notes also remained blank with no team member signatures. -An ED provider progress note, dated 7/13/23, indicated facility staff reported R3's speech seemed more garbled, he was more confused, and he was more incontinent that day which was unlike [R3]. The note indicated R3's pupils were not equal; however, it appeared as if R3 had cataract surgery on the left eye and there were no acute findings identified on the head and cervical spine CT scans. Plan was for R3 to follow-up on an outpatient basis for a repeat CT scan as R3 took aspirin and Plavix. Discharge orders identified diagnoses of unspecified head injury, fall on same level, and repeated falls. -On 7/13/23 at 10:43 p.m., R3 returned to the facility. Neuros were performed and R3's right pupil reacted per prior baseline. -On 7/16/23 at 3:10 a.m., R3 was seated on the bathroom floor. The alarm sounded. The w/c was next to the toilet and the breaks were locked and his pants were wet apparently from urine incontinence. R3 stated he fell against the wall and then to the floor. He confirmed he hit his head and that his hand was hurt in the fall. The note identified an intervention: Recommendation for a toileting schedule. The FSI identified R3 remained in bed for about six hours prior to the fall and indicated due to R3's instability and impulsivity when he needed to void the nurse recommended a toileting plan on night shift. The team meeting note, dated 7/17/23, indicated R3's care plan identified, Toilet Q (every) 2 hrs (hours) and PRN (as needed) and this was added to the POC (plan of care) task list. In addition, a PT evaluation/screen was requested. Nursing assistant (NA) care/group sheets indicated R3 required SBA with ambulation and transfers, Q two hour and PRN toileting, and a motion sensor pad on bed, w/c, and recliner, along with a wanderguard (device that alarms when leaves facility) on his w/c. The sheet lacked information related to R3's fall risk factors and/or any other fall mitigation interventions. R3's medical provider dictated progress notes identified the following information: -1/19/23: R3 required a lot of redirection and he did not like a lot of assistance. He self-transferred in which bed and chair alarms were used to keep him safer. -3/16/23: R3 was extremely impulsive and will get up and move when he is recommended not to in which alarm on bed and w/c utilized. During the visit, the provided observed R3's transfer multiple times in his room in which R3 moved quite well today. After the visit, R3 wheeled throughout the nursing home; intermittently getting up and setting off his alarms. Plan to continue current therapies and follow-up in one month. -4/20/23: R3 was assisted with all ADLs, but self-transfers. R3 had not left the building again after last month's episode where he ran and fell in the parking lot. Assessment and plan were for continued behavioral monitoring to assist in potential behavioral medication adjustments. -5/25/23: No identification of fall history since last visit. Assessment and plan were to continue him with behavioral medications in setting of his dementia with impulsivity and labile emotional status which has been very helpful in managing . -6/8/23: R3 complained he felt like the vision out of his right eye was not very good. It appeared to him to be 'wobbly or wavy' which had gotten steadily worse over the last few weeks. An ophthalmologic evaluation was indicated as this could be a retinal injury. -7/7/23: R3 was started on an antidepressant medication to improve his appetite and decrease some of his abusive language toward staff. Pain medications were also adjusted due to complaints of back pain. R3's medical provider notes lacked documentation R3's provider was involved in a comprehensive fall risk assessment/analysis process related to R3's numerous falls. R3's medical record identified R3's fall risk was assessed on 1/5/23, 4/11/23, and 7/7/23 based on the MDS process; however, the record lacked comprehensive fall risk assessment analysis' were completed after R3's multiple falls to develop, adjust, and/or monitor for effectiveness of individualized care plan interventions, to mitigate R3's fall and/or fall injury risk, which were based on his high fall risk factors identified in the fall risk assessments and in the progress notes. During interview on 7/14/23 at 11:59 a.m., licensed practical nurse (LPN)-A stated when a resident fell the resident was to be assessed, a fall huddle conducted to review the fall and determine if there was anything that could have been done differently, and to implement any new interventions if applicable to prevent further falls; however, she explained usually after a couple falls interventions would be implemented within a week and if the resident fell too many times or if there was an imminent need the provider would be called right away to get an order for something. She stated any fall intervention was expected to be place on the care plan. LPN-A stated R3 was a major fall risk due to continued unsteady self-transfers with too many falls, significant impulsivity, and fluctuations in his cognitive status where he lacked cognition to understand his fall risk. She identified R3's fall interventions were as follows: alarms, anti-roll back breaks, pain management, keep him busy, alarm checks each shift to ensure function, and attempts to keep him closer to her with extra rounds to check on him which she completed per her own choice. She explained R3 enjoyed staying busy, liked social interaction, and occasionally placed his feet on his w/c when he laid across the bed. She denied R3 utilized a toileting plan and was unsure as to why; however, she explained he has always been pretty good about asking [to go to the bathroom]. She denied any recent changes to R3's fall interventions and was unsure of any interventions she would implement that potentially would decrease R3's fall risk. During observation on 7/14/23 at 2:09 p.m., R3 laid in bed appropriately with his eyes open. His room was situated directly across from one side of the nurse's station. When approached he quickly uncovered himself and sat up at the edge of the bed. Staff seated at nurses' station were alerted by surveyor as he appeared as if he was going to self-transfer to the w/c situated right next to the edge of his bed. The w/c breaks were engaged, and he utilized gripper socks. As he stood up and staff situated themselves next to him the bed alarm engaged. He demonstrated an unsteady transfer to the w/c in which staff provided contact guard (hands on) assist. A standard call-light was located at the head of the bed, anti-roll breaks were in place on the w/c, a standard mattress was in place and the bed was positioned at a standard height, a commode frame was over his toilet, and signs on the wall next to the bed and in the bathroom on the wall across from the toilet encouraged him to lock his breaks. The signs did not direct him to wait and call for help. Once in w/c, staff placed shoes with Velcro closures on him. R3 was free of pain indicators; however, he displayed cognitive impairments and asked surveyor if she was going to go babysitting. When interviewed on 7/14/23 at 2:14 p.m., NA-C stated she utilized the NA group sheets, kept at the nurse's station, for resident need(s) information and fall risk interventions; however, she just kind of knows what the resident needs are and what the fall interventions were. She explained she was expected to follow the plan of care/NA group sheets and the managers were very good at emailing updates to staff. She considered R3 to be a fall risk as he was constantly up and down in which he was very busy and was known to take off the alarms and/or unplug them. He preferred staff not watch him, or help him, while he toileted and his cognitive status fluctuated. If staff heard the alarms, they knew he was in the bathroom, and they would then stand close and provide any assist he allowed or he pretty much informed them when he needed the bathroom. She denied R3 utilized a toileting plan; however, at the end of the interview when she was asked to show where the group sheets were kept, she reviewed R3's group sheet information and confirmed he had a toileting plan in place. NA-C stated she attempted to keep R3 closer to the nurse's station, attempted to keep his door open when he was in there, and always looked in his room when she walked by to help mitigate falls. She explained the only intervention that would stop his falls would be 1:1 supervision and was unsure of any other interventions to help mitigate R3's falls and/or fall risk. She denied management staff involved her in any fall analysis and/or intervention conversations. During interview on 7/14/23 at 2:39 p.m., LPN-B stated staff were not provided a lot of specific details about the residents; however, they were expected to follow the NA group sheet in which staff are supposed to review the sheets before starting their shift. LPN-B considered R3 to be a fall risk in which it was hard to know when R3 was going to fall. LPN-B stated R3 utilized alarms; however, the alarms agitated R3 when he moved back and forth. Despite this, the alarms were required to help alert staff when he transferred, or moved around, so they could assist as soon as possible with whatever R3 needed. LPN-B explained communication amongst the nurses had occurred related to the alarm agitation; however, he denied he relayed this information to management. LPN-B denied management asked for his input into R3's falls or thoughts on fall interventions. He explained keeping R3 from falling could not be avoided as things just happen but he stated a comprehensive group discussion would be required to come up with interventions and build a solid frame to address R3's fall risk and his status fluctuations. When interviewed on 7/14/23 at 3:10 p.m., NA-D stated she was expected to follow the NA group sheet for fall interventions and care needs. She explained R3 was a fall risk and already that shift he had been up and down from bed five to six times as R3 was a very confused busy guy. She explained she attempted to keep him busy, such as rummaging through his drawers or listening to music which he seemed to enjoy, while also trying to keep him located nearby with more 1:1 supervision. R3 required toileting every two hours and was not very good at alerting staff of his needs. In addition, he liked to lay in bed with his legs up on the w/c seat. Anti-roll breaks were utilized, along with alarms which did not appear to bother him. NA-D identified R3's fall risk may be decreased if he was involved in more 1:1 activity, assisted to listen to his preferred music, or engaged in conversation about his native American heritage as he liked when staff provided him with attention. She confirmed she did not communicate these suggestions with activity or any other staff and denied management staff involved her in any fall analysis and/or intervention conversations. During interview on 7/14/23 at 3:25 p.m. activity aide (AA)-A stated she was not aware of details surrounding any of R3's falls or the extent of how often R3 fell . She stated R3 was not provided 1:1 sessions with activity staff and overall, they just invited him to activities; however, he was not one to typically stick around. If they had spare time and encountered him in the hallway or in his room, they would interact with him. She denied staff had approached her to update her about potential activity involvement to decrease his fall risk nor involved her in any fall analysis and/or intervention conversations. On 7/17/23 at 10:50 a.m., during a telephone interview, R3's family member (FM)-A stated she was invited to two care conference to talk about R3. She was able to attend one and another family member attended the other. No additional conferences have occurred. She denied being involved in any discussion related to R3's falls or to get her intake on possible interventions. She was aware R3 frequently fell , and she indicated R3 required alarms to alert staff when he self-transferred. She believed R3's falls were related to his dementia process. She explained staff adjusted his medications related to his behaviors and performed lab work, but otherwise she was unsure what interventions were in place to mitigate falls. She stated she expected R3 would be on a toileting plan as he had a history of frequency and she further expected staff kept him busy and distracted as he always liked to play with, fiddle with, or straighten things up in his garage. He enjoyed smoking and talking on the phone, he also found comfort with animals, and always kept himself busy. FM-A stated R3 had a longer standing history of vertigo which may also be a factor which increased his fall risk. She stated she had a phone call from staff on 7/14/23 and she expressed her concern related to that; however, she was unsure what the staff did with that information. On 7/17/23 at 10:56 a.m. the clinic for R3's medical provider was called. Receptionist staff stated the provider was out of clinic until 7/19/23; however, a message would be relayed to him that day to return a call. At the time of the exit conference, the provider had yet to response to the message and thus was not interviewed. When interviewed on 7/17/23 at 12:04 p.m. activity aide (AA)-B stated she was currently the acting interim activity director. She stated she was not aware of the extent of R3's falls or details surrounding his falls as she did not attend the morning's interdisciplinary team (IDT) meetings. She identified currently no one was represented from activities in this meeting. She denied anyone from nursing approached her to involve her in any fall analysis and/or intervention conversations; however, after she talked with AA-A following her interview on 7/14/23, they talked about setting R3 up to participate in a smaller men's sensory group that met once a week and some other potential interventions as R3 was a very busy man in which he liked to stand up and go through his pockets. During interview on 7/17/23 at 12:33 p.m. the DON stated fall assessments were completed with the MDS process i.e., on admission, quarterly, annually, significant change in status and denied they were completed at any other times. Once completed, the care plan was to be updated with information based on the assessment. If a resident fell , she expected staff to follow the fall protocols which included a fall huddle and fall intervention(s) implementation. The IDT then meet three times a week and discussed the falls that occurred, reviewed the incident reports, ensured they were completed as expected, and revised and/or implemented additional fall interventions. She explained this process would be documented either in the progress notes and/or on the incident report (FSI). If documentation was not found in either of these two areas, she would assume this expectation was not followed. The DON explained intervention revision and/or initiation was important to prevent continued falls, injury, or death. She stated R3 had numerous falls in which he initially had anti-roll breaks on his wheelchair, along with alarms in bed and w/c. Initially, R3 would unhook these and remove them from the bed or w/c; however, he currently left them alone. In addition, initially the anti-roll brakes malfunctioned, and he was provided a new w/c and brakes; however, they were not a success as he continued to have more falls. R3 initially worked with PT but his dementia and follow through was not good. Signs were[TRUNCATED]

Based on interview and document review, the facility failed to monitor antibiotic effectiveness for an upper respiratory infection (URI) for 1 of 4 residents (R4) reviewed for antibiotic use. Findings include: R4's annual Minimal Data Set (MDS) dated [DATE], indicated R4 had diagnoses which included shortness of breath, dementia and severely impaired cognition. R4's Progress Notes indicated: -On 4/24/24 at 2:21 a.m., Resident continued with antibiotics for URI with no adverse effects observed, occasionally productive cough, swallowed sputum, oxygen level was 93% on room air, and respirations regular and unlabored. In addition, no other shifts on 4/24/23 documented R4's condition. -On 4/25/23 at 3:12 a.m., resident has been resting with eyes closed, no complaints of pain, no behaviors noted this shift. At 2:20 p.m., resident was alert and awake, no complaints of pain or discomfort noted. No new concerns noted and will continue to monitor. Further, progress note lacked evidence of vitals such as oxygen lever, temperature, pulse, respirations, or lung sounds being obtained. -On 4/26/23 at 1:03 a.m., resident remains on antibiotics for URI with no adverse reactions observed or reported, occasional loose cough observed, and denied shortness of breath. Further, progress note lacked evidence of vitals such as oxygen level, temperature, pulse, respirations, or lung sounds being obtained. In addition, no other shifts on 4/26/23, documented R4's condition. -On 4/27/23 at 3:35 a.m., resident completed day four of Zithromax last evening. There have been no adverse reactions observed or reported. Resident was resting in bed with eyes closed and showed no indicators of acute distress at this time. Respirations were regular and unlabored on room air. Further, progress note lacked evidence of vitals such as oxygen level, temperature, pulse, respirations, and lung sounds being obtained. Review of Progress Notes revealed a lack of evidence vitals such as temperature, pulse, respirations, and lung sounds were obtained to determine effectiveness of antibiotic use. Progress notes were also only documented once daily on resident's condition versus every shift. During an interview on 6/27/23 at 11:14 a.m., licensed practical nurse (LPN)-D indicated staff were expected to document on resident's overall condition every shift if resident had an infection and was receiving antibiotics. Further, LPN-D indicated staff were expected to obtain a vital sign every shift which included oxygen level, respirations, pulse, temperature, and lung sounds and document the vitals in the resident's record. During an interview on 6/27/23 at 11:53 a.m., registered nurse (RN)-D indicated staff were expected to monitor respiratory infections every shift by charting on the resident's condition and obtaining vitals that included temperature, respirations, blood pressure, and oxygen level and document in the resident's record. During an interview on 6/27/23 at 12:21 p.m., LPN-C indicated staff were expected to monitor respiratory infections and antibiotic effectiveness every shift by charting in the resident's record on resident's condition, symptoms displayed, any reactions, and vital signs were to be obtained. During an interview on 6/27/23 at 2:18 p.m., RN-B indicated staff were expected to monitor respiratory infections by charting in the resident's record every shift on resident's condition and obtain vital signs. RN-B confirmed R4's record lacked evidence staff were monitoring R4's respiratory infection every shift and obtaining vital signs. In addition, RN-B stated monitoring respiratory infection per facility policy would be important to determine if the resident was improving or declining. During an interview on 6/27/23 at 2:49 p.m., director of nursing (DON) stated staff were expected to monitor respiratory infections and antibiotic effectiveness every shift by completing Acute Care Charting on the resident's condition and obtain vital signs such as temperature, respiratory status, lung sounds, and oxygen level as well as any adverse reactions of the antibiotic. DON stated the importance of monitoring would be to ensure the resident was receiving the correct antibiotic and determining if the antibiotic was effective or if symptoms have worsened and being able to address the concerns with the physician. Review of facility procedure titled Charting Guidelines, not dated, directed staff for acute charting, vitals signs were to be obtained every shift, document reason they are on charting (cold symptoms), any assessments or actions taken (lung sounds, etc.), document any actions taken and document effectiveness.

The facility failed to ensure residents received medications as ordered and as needed (PRN) medications were utilized as prescribed for 1 of 4 residents (R4) who were reviewed for pharmacy services. Findings include: R4's annual Minimal Data Set (MDS) dated [DATE], indicated R4 had diagnoses which included shortness of breath and dementia and R4 had severely impaired cognition. R4's Long Term Care Note dated 4/23/23, Doctor of Medicine (MD)-A's assessment was as follows: right lower lobe pneumonia and continue with Rocephin plus a total of 10 days of Zithromax (nine more days of 250 mg daily), to help with expectoration (cough or spit out phlegm from the throat or lungs) we will try acapella valve, order a BNP (brain natriuretic peptide test that measures levels of a protein called BNP that is made by the heart and blood vessels which is useful to diagnose heart failure), and start on Spiriva 18 mcg inhalation once daily to see if it helps to decrease the secretions. Review of R4's Doctor's Orders dated 4/23/23, revealed orders from MD-A listed above were signed by two licensed nurses, LPN-A and LPN-B, which would indicate the facility procedure for transcribing medications was followed and orders were active and in R4's record. Review of R4's April Medication Administration Record (MAR) revealed MD-A's orders written on 4/23/23, were not processed until 4/29/23 and 4/30/23. During an interview on 6/23/23 at 10:01 a.m., RN-C indicated licensed nurse who received a new order from a physician would be expected to review orders with the physician prior to adding the orders in the resident's electronic record and then order new medications through the pharmacy and sign the order in the resident's paper chart that those steps were completed. Further, RN-C indicated licensed nursing staff would then ensure the yellow tab in the resident's paper record was revealed and the record was left at the nurses' station. Another licensed nurse would then see the yellow tab and know there was a new order that required a second nurse to verify the new physician's order matched the orders that were placed in the resident's electronic record, and if completed the second nurse would also sign the physician's order in the resident's paper record. During an interview on 6/23/23 at 11:17 a.m., LPN-A stated MD-A came to the facility approximately 9:00 p.m. on 4/23/23, to assess R4 and wrote new orders. LPN-A indicated she was directed by MD-A to wait to put the new orders into pharmacy until the morning since they were closed for the evening already. Further, LPN-A indicated she signed off on the orders that evening after confirming orders with MD-A and then another nurse had signed off on those orders indicating that they checked the orders, and the orders were in the system and sent to pharmacy. Further, LPN-A indicated she was re-educated on transcribing orders process and should have completed the orders and sent to pharmacy when they were received from MD-A on 4/23/23. Interview with LPN-B was attempted but unsuccessful. During an interview on 6/23/23 at 2:15 p.m., RN-B confirmed physician's orders that were received on 4/23/23, for R4 were not processed despite there being two nurses' signatures. RN-B was not aware R4's orders were missed and was unsure if there was a medication error completed. Further, RN-B stated when a licensed nurse would receive a new physician's order, they would be expected to process the order right away following the facility procedure. During an interview on 6/23/23 at 3:40 p.m., DON stated MD-A wrote new orders for R4 on 4/23/23 at approximately 8:00 p.m. and LPN-A had signed the written orders which indicated the orders were processed and ordered through pharmacy, and LPN-B was the second nurse who signed the written order indicating they verified the order was processed and correct, however neither of these were actually completed and DON stated which is concerning. Further, DON indicated this medication order was brought to LPN-A's attention remembering she never processed the orders when R4 had a decline in condition later that week and was sent to the hospital. DON stated LPN-A completed a medication error form and education was provided to LPN-A by DON regarding processing orders and the expectation, however DON confirmed the medication error was not addressed with LPN-B who had signed the written order but did not verify the order was processed. In addition, DON stated she would expect the licensed nurse who received the new physician's order would transcribe the order and send to pharmacy right away, then a second licensed nurse would verify these were completed and sign the written order. Review of R4's April MAR printed 6/23/23, revealed R4 had an order for ProAir Aerosol Solution 108 mcg/act inhale 2 puffs orally every 4 hours PRN for shortness of breath or wheezing. MAR revealed this inhaler was not utilized in April. Review of R4's May MAR printed 6/23/23, indicated ProAir inhaler was not utilized in May. Further, MAR revealed R4 had an order for Ipratropium-Albuterol Solution 1.5-2.5 mg/3ml inhale 1 vial orally every 8 hours PRN for cough or shortness of breath with a start date of 5/2/23, which was utilized one time on 5/17/23. MAR revealed on 5/17/23, the order was changed to every 4 hours PRN which was utilized two times on 5/17/23 and once on 5/19/23. In addition, MAR revealed crackling lung sounds were documented, and PRN medications were not utilized, as well as wheezing was noted on 5/16 through 5/22/23, and PRN medications were not utilized. During an interview on 6/27/23 at 11:53 a.m., RN-D indicated R4 had PRN medications staff were expected to utilize if resident appeared uncomfortable or had respiratory distress which included any wheezing or crackling observed. During an interview on 6/27/23 at 12:21 p.m., LPN-C indicated R4 had PRN medication staff would be expected to utilize upon completing an assessment and determining if there was any shortness of breath, wheezing, or crackling noted. During an interview on 6/27/23 at 2:18 p.m., RN-B stated she was aware R4's PRN medication were not being utilized when she reviewed R4's MAR and updated the physician to change the frequency of the nebulizer to every 4 hours on 5/17/23. Further, RN-B stated staff would be expected to utilize and administer the PRN medications if there were any symptoms of shortness of breath, wheezing or crackling noted. In addition, RN-B stated PRN medications are ordered and are available for a reason anticipating the resident has the symptoms and to alleviate the symptoms would be to administer the PRN medications. RN-B stated nebulizer's go hand-in hand with an upper respiratory infection to help improve the resident's status in that moment. During an interview on 6/27/23 at 2:49 p.m., DON indicated staff would be expected to administer PRN medications as ordered based on physical appearance of the resident, any shortness of breath noted, rapid breathing, decreased oxygen levels, or if any wheezing or crackles were noted to help with the resident's respiratory status and open the airway. During an interview on 6/28/23 at 12:19 p.m., MD-B stated he was R4's primary physician and involved in R4's care. MD-B stated he was aware of R4's orders that were not processed on 4/23/23, however MD-B stated the missed orders would not have impacted R4's condition or prevented R4 from being hospitalized . Further, MD-B stated he assessed R4 on 4/24/23, and R4 was noted to be improving and MD-B did not observe any concerns at that time. In addition, MD-B stated he would expect staff to administer PRN nebulizer's if the resident was observed to be struggling, short of breath, or wheezing was noted then a PRN would be beneficial. Review of facility policy titled Charting and Transcription Procedures, not dated, directed staff the procedure for signing off on an order was as follows: when an entire order is completed place brackets around entire order and place signature and title to the left of bracket, orders to be check and signed by another nurse. Review of facility policy titled Medications and Treatments, not dated, directed staff when a medication error has occurred and the error was realized, the responsible nurse will complete the appropriate form which must then be signed by the attending physician, long term care manager, and forward to the Pharmacy and Therapeutics Committee for review. Requested policy related to PRN medications, however policy was not provided.

Based on interview and document review, the facility failed to notify residents, representatives and families timely of confirmed cases of Coronavirus Disease 2019 (COVID-19) per Center for Medicare & Medicaid Services (CMS) requirements, when five residents tested positive for COVID-19. This deficient practice had the potential to affect all 40 residents, families and representatives at the facility. Findings include: Center for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group (CMS QSO) memo 20-29 NH dated 5/6/20, required nursing homes to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Review of facility's notification record, indicated the last notification to residents, representatives and families was dated 12/14/20. This notification identified number of new cases in residents and staff, and also indicated mitigation methods taken by the facility to prevent further spread of the COVID-19 virus. Further review of notification, indicated updates within the facility related to indoor visits, essential care visits and vaccinations. On 12/28/20, at 12:46 p.m. family member (FM)-A indicated the facility has notified FM-A previously regarding if there was a new case of COVID-19 in either a resident or staff. However, FM-A indicated that she had not received a notification regarding any new positive cases after the most recent routine weekly testing that was completed on 12/21/20. On 12/28/20, at 2:25 p.m. director of nursing (DON) indicated most recent notification to residents, representatives and families was on 12/14/20. DON indicated the medical director will always call the positive family members and update them on the positive test results, and will at times call all family members in the facility regarding the new positive cases. Further, DON indicated a discussion is usually had with the administrator; infection preventionist (IP) and herself if a notification needs to go out to residents, representatives and families regarding the change in cases. DON also indicated care coordinator (CC)-A and CC-B will divide all residents and call their family members to notify them of new positive cases in the facility. Further, DON indicated activities department continues to call family members to update them regarding the outbreak status and activities and visitor restrictions in place at that time. In addition, DON confirmed five new positive cases of COVID-19 should prompt a phone call and if you can't reach a bunch of people then a letter will go out too. DON also confirmed only families that were affected by a positive loved one were updated regarding their test results, and there were no other phone calls made or letters sent to residents, representatives or families after the most recent routine testing that occurred on 12/21/20, which resulted in five new positive residents. On 12/28/20, at 4:24 pm administrator indicated the facility was still considered to be in a COVID-19 outbreak status therefore did not warrant a call to update residents, representative and families. Administrator also indicated that families know the facility is in an outbreak and the families speak with the care coordinators on the units and also speak with the medical director daily, but the facility is not documenting that information in the resident records or keeping a log. Further, administrator confirmed residents, representatives and families were not informed after the most recent routine testing that was completed on 12/21/20, which resulted in five new positive residents and the facility does not have a policy regarding notifying residents, representatives and families. Facility policy titled Outbreak Investigation, revised 9/3/20, indicated appropriate notifications to the Medical Director, Administrator, all departments, attending physicians, state and local agencies, and resident representatives will take place as soon as possible after the outbreak has been identified. Further review of policy, indicated outbreak monitoring and reporting will continue until the outbreak has resolved. Control measure may include on confirmed resident, unit isolation or quarantine measure for the entire facility. Facility lacked information regarding informing residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other, per guidance by CMS.

Based on observation, interview, and document review, the facility failed to ensure proper personal protective equipment (PPE) was utilized while collecting COVID-19 specimens from staff for routine testing, in accordance with Centers for Medicare & Medicaid Services (CMS) requirements and failed to provide an environment for testing away from others including a resident (R1), other residents, staff and visitors. This practice had the potential to spread COVID-19 in the facility, with the potential to affect all 41 residents in the facility. Findings include: During observation on 12/8/20, at 8:40 a.m. staff member checked in at the front desk before sitting in a chair next to the front desk, to be swabbed for COVID-19. RN-A wore a facemask, eye protection, and gloves when collecting the staff's specimen, but did not wear a gown. During interview on 12/8/20, at approximately 8:40 a.m. RN-A confirmed that all staff and residents were being tested on [DATE]. During interview on 12/8/20, at 10:29 a.m. RN-A confirmed while collecting COVID-19 specimen she wears a facemask, eye protection and gloves, but does not wear a gown. RN-A indicated RN-A had swabbed 20 staff already on the morning of 12/8/20. RN-A indicated if a staff member were symptomatic she would wear a facemask, eye protection, gown and gloves while collecting that staff's COVID-19 specimen. RN-A confirmed staff can be asymptomatic and test positive for COVID-19. During interview on 12/8/20, at 10:42 a.m. Director of Nursing (DON) confirmed when staff collect the COVID-19 specimen staff are wearing facemask, eye protection, and gloves, but are not wearing a gown. DON stated staff are not wearing a gown due to staff being swabbed are not suspected of COVID-19. Further, DON stated if staff display symptoms of COVID-19, DON would change the process and implement the use of a gown in addition to facemask, eye protection and gloves to collect the specimen from that staff member. During interview on 12/8/20, at 11:25 a.m. Administrator confirmed the staff collecting the COVID-19 specimen was wearing facemask, eye protection, and gloves, but was not wearing a gown. Further, Administrator stated a gown was not being used due to not worried about the staff that are getting tested because we (Mille Lacs Health System) are only testing due to the county positivity rate, not because we (Mille Lacs Health System) are worried about these staff (being positive for COVID-19) since staff are screened before their shift. Administrator confirmed staff could be asymptomatic and test positive, but continued to state was not worried due to staff wear a facemask and eye protection when they are working. During interview on 12/8/20, at 2:09 p.m. Infection Control Preventionist (ICP) stated that during COVID-19 specimen collection staff were expected to wear a facemask, eye protection, gloves, but no gown was needed. Further, ICP stated no gown was needed due to the collection being just a nasal swab and facility was doing community based testing, not due to suspected cases. Review of staff list provided by facility, dated 12/8/20, indicated a total of 106 staff were tested on [DATE]. Review of facility policy, COVID-19 Community Testing Plan: MLHA (Mille Lacs Health System)/LTC (long-term care), dated 9/1/20, indicated during surveillance testing specimen collection staff will wear a surgical face mask, eye protection, gloves, and a gown. The Minnesota Department of Health (MDH) website page titled PPE (Personal Protective Equipment) and Hand Hygiene for Point Prevalence Survey (PPS), updated 6/24/20, indicated the swabber involved in the specimen collection should wear a N95 respirator or medical-grade face mask (if respirator not available), face shield, gown, and gloves during specimen collection. CMS memorandum QSO-20-38, dated 8/26/20, indicated During specimen collection, facilities must maintain proper infection control, and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if respirator is not available), eye protection, gloves, and a gown, when collecting specimens. Location of testing During observation on 12/8/20, at 8:40 a.m. a COVID-19 specimen collection station was located in the front entrance of the long-term care facility. The designated station was placed next to the reception desk, which did not contain a barrier for the staff member behind the desk. The designated collection station consisted of a round table with two chairs, one on each side of the table, and no barriers to provide privacy to the staff being swabbed or prevent staff or residents from entering the designated collection area. Further, the Director of Nursing and Administrator walked through the COVID-19 specimen collection area to meet with surveyor in the activities room. During observation on 12/8/20, at 11:14 a.m. staff member was screened at the front desk and seated in a chair, at the specimen collection station. Staff member was wearing eye protection and facemask was pulled down under staff's chin in preparation to be swabbed. RN-A had gloves on and nasal swab opened about to conduct COVID-19 specimen collection when a R1 walked up to the specimen collection station. R-1's annual Minimal Data Set ((MDS) dated [DATE], indicated R-1 had a [DIAGNOSES REDACTED]. R-1's care plan dated 12/8/20, indicated R-1 was independent with mobility, ambulates around facility and has a history of wandering. R-1 was tested for COVID-19 on 9/1/20, 9/10/20, 9/17/20, 11/20/20, 11/24/20, and 12/1/20 all of which resulted negative for COVID-19. During interview on 12/8/20, at 10:29 a.m. RN-A confirmed the specimen collection area was set up in that location every staff testing day. During interview on 12/8/20, at 10:42 a.m. DON stated the specimen collection area was set up by the entrance of the facility to prevent staff from walking through the building. During interview on 12/8/20, at 11:25 am Administrator stated the designated specimen collection station was set up in the entrance so staff could enter and exit without walking through the facility. Further, Administrator confirmed R-1 does wander and will walk to the area and is redirected. Administrator also confirmed that staff need to walk through that area to get to their office and stated there is probably a better way we could do it. During interview on 12/8/20, at 1:56 p.m. Activities (A)-A stated I do walk through that area (designated COVID-19 specimen collection station) often when they (staff) are doing the testing and didn't even think of it. When testing was completed in the activities room we were not allowed to walk into our office while testing was being conducted. During interview on 12/8/20, at 2:09 p.m. ICP stated designated COVID-19 specimen collection station was proper technique related to no visitors at this time and no residents are supposed to be over there, a few do wander that we redirect usually they (staff) put up a table so that the resident's don't go through and activities staff were going the other way to their office. Review of facility policy, COVID-19 Community Testing Plan: MLHA (Mille Lacs Health System)/LTC (long-term care), dated 9/1/20, indicated specimen collection will be performed in a resident's room or other designated space with the door closed, for surveillance and symptomatic testing. Further review of facility policy, indicated only staff who are essential to collect the specimen will be present. The CDC website page titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 11/4/20, indicated when collecting diagnostic respiratory specimens (e.g. nasopharyngeal or nasal swab) from a patient with possible [DIAGNOSES REDACTED]-CoV-2 infection, the following should occur: specimen collection should be performed in a normal examination room with the door closed. The MDH website page titled Road Map for Conducting a COVID-19 Point Prevalence Survey (PPS), updated 8/3/30, indicated when multiple staff are to be tested , this can be done outside (e.g. drive through or parking lot set up) or in a room large enough to ensure spacing.

Based on observation, interview and document review, the facility failed to ensure all staff entering the facility were being actively screened (other facility staff performing the screening process) for the prevention and potential transmission of COVID-19. This had the potential to affect all 47 residents currently residing in the facility, at the time of the COVID-19 focused survey. Findings include: On 4/23/20, at 10:05 a.m. the survey team entered the facility via the building's main unlocked entrance. A small table was observed with a temporal thermometer and alcohol wipes, along with a binder for staff to enter their temperature for that day. A separate folder had printed directions alerting nurses to fill out the screening sheet for each employee coming on a new shift. One screening sheet was in the folder. A facility employee took the temperature and asked COVID-19 screening questions before allowing surveyors entrance to the facility; however, temperatures and screening questions were not recorded at time of entrance to facility. During the entrance conference on 4/23/20, at 10:11 a.m. registered nurse/clinical care coordinator (RN)-A stated the facility did not have any presumptive or confirmed cases of COVID-19. During interview on 4/23/20, at 10:49 a.m. activity aide (AA)-A stated the administrative assistant (ADM)-A took her temperature upon coming to work through the designated employee entrance, however, AA-A did not fill out any screening questions. The ADM-A did not ask her any screening questions before beginning her shift. During interview on 4/23/20, at 10:50 a.m. nursing assistant (NA)-A stated all LTC (long term care) employees entered the facility through the front door. When they started their shift no one was present and screening staff for COVID-19 signs and symptoms. NA-A took their own temp and recorded it then placed a color coded sticker on their name badge identifying they had been screened and were okay to work. On 4/23/20, at 10:57 a.m. housekeeper (H)-A stated LTC staff entered through the front door. There was not anyone stationed at the front door to screen employees as they came to work. Lately staff had been taking their own temperatures, prior to their shift starting. During interview on 4/23/20, at 11:01 a.m. trained medication assistant (TMA)-A stated all LTC employees entered the facility through the front doors. The take their own temperature and document it. There used to be a questionnaire completed regarding potential symptoms of COVID-19, but that stopped about a week prior. When the facility changed doors to separate hospital and LTC employees, there was no one directed to screen staff when they entered the LTC door. When interviewed on 4/23/20, at 11:12 a.m. (RN)-B stated she took her own temperature prior to starting her shift on 4/23/20. When interviewed on 4/23/20, at 11:23 a.m. licensed practical nurse (LPN)-A stated she took her own temperature prior to starting her shift on 4/23/20, and recorded it in the designated book located in the front entrance. LPN-A did not fill out a screening questionnaire nor was asked screening questions by another staff member. LPN-A explained they used to fill out a questionnaire but currently the sheet has gone missing and she had not seen it in a while. During interview on 4/23/20, at 11:36 a.m. ADM-A stated all LTC employees came in the front door only and had their temperature taken. ADM-A further stated staff took their own temperature at times and they no longer filled out a screening questionnaire, as they had been doing initially. ADM-A did not know why the facility employees no longer filled out the questionnaire. ADM-A had taken their own temperature and did not answer any screening questions prior to their shift on 4/23/20. On 4/23/20, at 12:01 p.m. the facility infection control preventionist/registered nurse (RN)-C stated when LTC staff entered through the designated North door entrance before their shift, they were to have their temperature checked and logged, and asked screening questions. RN-C stated she was not aware staff were taking their own temperatures and not being asked screening questions. Staff should not be taking their own temperatures as part of the facility active screening process. The facility HICS Incident Action Plan (IAP) Quick Start, dated 4/20/20, identified staff will be stationed at entrances in Onamia (8-9pm) to identify those who may require additional assessment or testing. The Quick Start action plan did not direct the stationing of staff from 9:00 p.m. to 8:00 a.m. An undated COVID-19 Action Plan for Health Care Facilities further identified implementation of active screening of staff when reporting to duty for fever (>100.0), acute respiratory symptoms (e.g. cough, SOB, sore throat). Staff should be asked to leave work if ill. Use line list.

Based on observation, interview and document review, the facility failed to follow the plan of care and neglected to provide meal-time supervision for 1 of 1 residents (R29) who spilled a hot beverage on herself. This resulted in actual harm for R29 who suffered a 2nd degree burn and [DIAGNOSES REDACTED] (redness) on her right side and arm. The facility took immediate corrective actions to ensure the safety of R29 and other residents, re-educated staff, then reviewed and revised their process to ensure staff had available current dietary and feeding assistance needs for residents. The actual harm was past non-compliance which was corrected prior to the start of the standard, re-certification survey. Findings include: R29's annual Minimum Data Set (MDS) completed 3/14/19, indicated R29's [DIAGNOSES REDACTED]. R29's care plan revised 3/14/19, identified an alteration in eating, and directed staff to set up meal tray and provide supervision as needed; dine with assistance; set up meal tray and assist resident/supervision to hands-on-assist, as resident allows; a lipped (adaptive) plate and coffee served served in lidded cup. During observation on 5/14/19 at 5:10 p.m. R29 was seated in a Broda-style wheel chair (specialized wheel chair to aide in positioning) in the dining room for the evening meal and R29's chair was located at a table where residents received more assistance. At 5:10 p.m. R29's food tray arrived and a lipped plate with serving of chopped fish, vegetables and potatoes was placed in front of R29. In front of the plate of food were two beverages: orange juice in a plastic cup with a lid on, and a plastic coffee mug. which contained mocha, also with a lid on; both beverages had straws coming out of the lid. Licensed practical nurse (LPN)-B sat in front of and to the right of R29 and fed R29, who looked tired and uninterested in eating. R29 did not participate to feed herself. LPN-B fed R29, and when R29 wanted a drink, LPN-B lifted the orange juice and lidded mocha cups to R29, who drank through the straws. R29 was assisted throughout the entire meal. When interviewed on 5/14/19 at 5:23 p.m., LPN-B stated during dining tonight, R29 did not want to eat any bite of food I gave her. LPN-B stated R29 had to be supervised during meals, and that was why R29 was seated in the area where she was in the dining room. LPN-B stated R29's abilities to feed herself vary, and at times, like during breakfast, R29 can feed herself, but still supervised here in the dining room, or in her room. LPN-B stated R29 required a lipped plate and beverages had to be lidded. Other times, R29 had to be fed. LPN-B stated the plan for R29 was to get her out of her room and provide assistance to eat in the dining room. Review of a facility document, MLHS Vulnerable Adult Incident Referral Form, indicated on 5/6/19 at 1300 (1 p.m.) R29 was set up for lunch in her room. Nursing assistant (NA)-G left R29's room, and R29 picked up her mocha cup (1/2 coffee, 1/2 hot chocolate) to attempt to drink on her own and dropped it. The cup did have a cover on it, that come off when dropped, causing the liquid to spill on R29's chest and run down her ride side under her arm. The Initial Evaluation section indicated Resident (R29) was to have supervision during meals and assist as she allows, and this was stated in R29's care plan and (nursing assistant) assignment sheet. The form also indicated R29 sustained 2nd degree burn on chest and immediate [DIAGNOSES REDACTED] (redness) on other areas the liquid came in contact with R29's skin. R29's clothing was removed to get heat off skin, cold compress applied, and doctor notified and examined resident. A Kerofoam dressing (a kind of foam dressing) was applied. Physician's progress noted dated 5/6/19, indicated: R29 spilled a cup of hot coffee onto her right upper chest. This was promptly attended to by nursing staff and cold compresses were applied. R29 has had some discomfort in his area. The note indicated there was a vague area of [DIAGNOSES REDACTED] about 8 x (by) 8 cm (centimeters) or perhaps a bit smaller and there is two or three small areas of very superficial blistering. The area is mildly tender. The assessment identified first and second degree burn. The physician applied Xeroform gauze (kind of dressing), noted R29 used [MEDICATION NAME] (an [MEDICATION NAME]) for pain, and ordered daily dressing changes. When interviewed on 5/15/19 at 8:40 a.m. family member (FM)-A talked about R29's incident when she spilled mocha on herself. FM-A stated R29 drank out of a lidded coffee mug, which likely slipped out of her hand. FM-A stated there should have been a staff person there to supervise, but conceded that R29 could have spilled coffee, even with a staff present, I think it was an accident. FM-A stated and emphasized R29 was often not accepting of assistance to eat or be fed, and still wanted to be independent. FM-A stated R29's ability to manipulate and hold onto the mug has diminished, and that it was due to her progressing MS ([MEDICAL CONDITION]), thought and R29's dementia also played a role. FM-A stated he'd prefer is R29 be given only warm mocha to drink but questioned how good would that taste? for R29. FM-A stated R29 really likes the mocha and I really can't take that away from her. FM-A stated when the talked to the facility after the incident, he agreed with facility that it would be best for R29 for staff to encourage and have R29 get up, be out of bed, and eat in the dining room. When interviewed on 5/14/19 at 5:37 p.m. NA-E stated there were days when R29 could feed herself, including being able to drink by herself after you set up her food tray. NA-E stated on other days, R29 required total assistance and had to be fed. NA-E stated when she needed most help, R29 could not bring food up to her mouth and you had to hold the glass up to her mouth so R29 could take a drink through a straw. NA-E stated she had worked at the facility several months ago, and when she returned in (MONTH) of 2019, R29 really had a decline in her abilities. NA-E stated someone has to be there to supervise when she eats, for all meals, whether R29 eats in her room or the dining area. NA-E stated she gets new information and updates about resident care via email, and email is required to be read. NA-E stated we learn about updated for residents during the shift change reports, too. During interview at 6:14 p.m. on 5/14/19, NA-F stated R29 needed supervision during meals because she is on dining with assistance and supervision. NA-F stated R29 recently spilled her mocha, and they made changes to her care plan. NA-F stated she found out about this in shift report, and our emails. NA-F stated we have to read the emails. NA-F stated R29 had lidded beverages, and needed to be supervised in the dining room or if she refused to come to the meal and wanted to eat in her room, where she needs to be supervised while eating. During interview at 12:51 p.m. on 5/15/19, NA-B stated there was a specific inservice for R29, and the care coordinator sent out an email regarding the new instructions for R29. NA-B stated R29 was not to be left unsupervised, and cannot have hot liquids alone staff need to be in her room at all times or in the dining room. NA-B stated the facility gets updates and education for resident cares with emails that's how we communicate and they are required reading. NA-B stated there were also an email regarding the importance of reading the emails containing the updates for resident cares. During interview on 5/15/19 at 2:30 p.m. registered nurse (RN)-A stated although R29 can and does feed herself at time, R29 required assistance with eating, and at a minimum was care planned to have supervision during dining, whether R29 ate in her room or in the dining room. RN-A stated R29 needed a lipped plate, and her coffee, and she likes half coffee and half hot chocolate needed to be in a lidded mug. RN-A stated she was on duty when R29 spilled the mocha on herself and ended up with a 2nd degree burn on her chest area. RN-A stated the nursing assistant left R29 alone with her meal tray in her room, and did not follow the care plan. RN-A stated following the incident and providing R29 with first aid, we took immediate action to prevent this from happening again, and also began the investigation. RN-A stated she first identified to see if there were other resident who fell into this category, being at risk to harm themselves, and looked especially at the residents on the Dine with Assist/supervision list. RN-A stated the charge nurse on duty re-educated NA-G right after the incident, and there was a meeting with the other aides that shift, as well as during the change of shifts. RN-A stated she sent out communication via the email, which staff are required to open and read about what happened and reminded of what R29's dining needs are, and how R29's dining is care planned. RN-A stated that communication was sent out the same day as the incident, Monday, (MONTH) 6th. RN-A stated the next day she talked with R29's family to solicit ideas regarding R29's dining needs, and changes were made to R29's care plan. RN-A stated R29's updated plan was send out to staff on may 7th, and R29's updated care plan was presented shift to shift. RN-A stated the social worker sent out an email on Tuesday, (MONTH) 7th. emphasizing the need for staff read the emails, and review resident's updated care plans and needs. RN-A also mentioned R29 was part of the Dine with Assist, which means just that resident needs assistance to dine, and the level of assistance can vary, and also the residents are seated in an area of the dining room and will be provided the level of assistance they need. RN-A also stated the dining area was always supervised by licensed nursing staff. When interviewed at 2:55 p.m. on 5/15/19, RN-D stated on the day R29 spilled on herself, she was charge nurses and supervising in the dining room. RN-D stated she noted NA-G was getting room trays from the dining area, and asked NA-G if she was helping R29. RN-D stated she told NA-G that R29 required assistance, and it was when NA-G returned to R29's room when R29 spilled the hot coffee. RN-D stated when she assisted R29 who had mocha covered on her shirt, and I could see reddened area on her chest and down her right breast, and there were three, dime-sized blisters forming. RN-D stated after providing R29 cold packs, and her clothing changed, the doctor came down to examine her and ordered a dressing. RN-D stated R29 suffered a minor burn. RN-D stated shortly after the incident she spoke with NA-G, and she was devastated and re-educated and reminded her R29's and all residents' dining needs, allergies [REDACTED]. RN-D stated the other aides were also provided education that shift, and additional education at the change of shift. RN-D also stated the care manager (RN-A) sent out the training reminder that same day in the required reading emails. When interviewed at 3:33 p.m. on 5/15/19, the director of nursing (DON) stated she reported this incident because there was potential for abuse and neglect to a resident. The DON stated in this case, there was an injury for R29, resulting when we did not follow the care plan and so we re-acted to this like we did with our deficiencies from the last survey. The DON stated we corrected the problem for R29, looked to see who else could be affected, and we reviewed our systems and I have audit forms ready to go. The DON stated we reviewed our process the day following the incident, especially focusing on having the most current dining assistance needs spelled out and available to staff. The DON stated we identified one of the reasons why R29 had this accident was that the nurse aide did not know what R29's expectations and needs were, and one of the things we reviewed was our process to ensure we have the most current, updated feeding assistance information available to staff. The DON stated we were cited last year because of our paid feeding assistants, and this incident forced us to again review our dining with assistance program. The DON stated had the survey not begun this week, the facility would have proceeded to begin their audit of cares and systems in preparation of the next inspection but I had to put that on hold, as the State is already here. During observation on 5/16/19 at 7:07 a.m., NA-B and NA-A were assisting R29 with morning cares, when RN-D entered the room and asked R29 is she could check your skin on your chest. Present on R29's chest were three slightly reddened circular areas, each approximately quarter-inch in size with scabbing areas present in the center of each area. There was no swelling, odor or other sign of infection on R29's chest. During the observation, R29 denied any current pain, but stated there was pain when it happened. A review of R29's progress notes from 5/6/19 to 5/16/19 indicated R29's skin burn was monitored daily, that there was a daily dressing change, and also R29's skin was healing, without sign of infection. Facility incident reports were reviewed from 8/9/2018 to 5/15/19. There were no similar hot beverage of food burn incidents for R29 or any other residents. The past non-compliance that began on (MONTH) 6, 2019, was verified during the current re-certification survey from 5/14/19 to 5/17/19, and was found to have been corrected by (MONTH) 10, 2019. Verification of corrective action was confirmed by observation, interview with a variety of nursing staff, and document review. Observations during meal times on 5/14/19, 5/15/19 and 5/16/19 indicated R29 was fed or encouraged to eat, with staff always present with R29 in the dining room. During the survey, R29 was not observed eating in her room. Nursing assistants and licensed nursing staff, who regularly assist residents at mealtime, including R29, and dietary staff were interviewed and observed at meal times. The interviews indicated staff were aware of R29's care-planned interventions to assist her at meals, as well as knowing how and where to find the most current dietary wants and requirements for R29 and all other residents in the facility. R29's assessments were reviewed, and indicated R29 had been re-assessed since the incident following the interdisciplinary team's (IDT) review and investigation. With input from the resident, the family and the IDT team, R29's care plan was revised, and, through observation, was implemented. The facility's Dine with Assistance guides were reviewed. The guides were located in each of the facility's two main dining areas (including on the locked unit) and contained the most up-to-date dining information available for staff. The director of nursing had already created audit forms that were going to be used to test on-going compliance.

Based on observation, interview and document review, the facility failed to comprehensively assess behavioral changes for 1 of 1 residents (R46) observed to become upset and anxious during activities of daily living (ADL)'s while staff were providing care. This resulted in actual psycho-social harm (mental health state which occurs because of a severely distressing event) for R46. Findings include: R46's annual Minimum Data Set ((MDS) dated [DATE], indicated severe cognitive impairment with a [DIAGNOSES REDACTED]. R46's annual MDS dated [DATE], did not identify any behavioral symptoms or mood assessments and were left blank. On R46's annual MDS dated [DATE], R46 had a PHQ-9 (tool used to identify depression levels) identified a score of 28 which indicated severe depression. Review of quarterly MDS dated [DATE], indicated R46's PHQ-9 score was a 0, identifying minimal depression. R46's Cognitive Loss/ Dementia Care Area Assessment (CAA) dated 5/11/16, indicated R46 had [MEDICAL CONDITION], was receiving end of life care and had a decreased ability to make self understood. The CAA indicated R46 needed frequent re-orientation to her environment. Although Cognitive Loss/Dementia and Mood State Care Area Assessments (CAAs) were completed at this time, there was no analysis/assessment of R46's behavioral disturbances, or patterns to assist with developing appropriate interventions to help reduce or remove R46's behaviors. The Mood State CAA, dated 5/11/16, indicated R46 had communication problems and dementia. The CAA indicated R46 was receiving antipsychotics and identified a goal of minimizing risks and managing mood symptoms. R46's care plan, dated 5/23/16, identified, potential for alteration in mood which is manifested by crying, tearfulness, physically and verbally abusive behavior during baths. Behaviors can occur unprovoked. R46's care-planned interventions included: target behavior monitoring every shift; monitor for side effects from medications; attempting diversion with game shows; give small doll named 'Pete'; offer snacks-likes. Additional care planned interventions were added during the survey on 8/24/16, that identified to offer candy to suck which was soothing and decreased behaviors; pre-treat with [MEDICATION NAME] (generic name for [MEDICATION NAME] to treat nerve pain, help with anxiety) before bath weekly, residents enjoys talking about pets, and when resident agitated she strikes out. Review of R46's undated Nursing Assistant Aid Care sheet, indicated R46 was to receive baths every Tuesday evening. There was no mention of R46 resisting her baths. During observation on 8/23/16, at 8:10 p.m. R46 was heard screaming and hollering from outside a room labeled, Bathing Room next to the entry doors to the locked memory care unit. The surveyor knocked on the door and it was opened by nursing assistant (NA)-G. R46 was visible inside a second shower room seated in a shower chair with her hands over her ears, visible water dripping from her and the chair as she continued to scream nonsensical speech which continued to be audible from the hallway. Trained Medication Aide (TMA)-A was standing in the shower room holding a towel, however, R46 was totally exposed seated on the shower chair facing the wall. At 8:15 p.m. R46 was brought out of the shower room by TMA-A. R46 had her hands over her ears and was crying while stating, Mother help me. R46's face was red in color and flushed, and she had visible tears in her eyes and on her cheeks. R46 had furrowed eyebrows with a puckered lower lip as she was wheeled in her chair past the nursing station to her room on the opposite side of the unit. TMA-A turned R46's television on for her and left the room the assist another resident. R46 remained seated in her chair with her face in her hands crying and rocking back and forth stating, Help me, Help me, and, Mother several times aloud. At 8:21 p.m. R46 remained in her chair in her room crying and screaming and at times, could be heard from the nursing station. At 8:29 p.m. R46 was no longer crying or screaming, and was watching television quietly in her room. During interview at the nursing station on 8/23/16, at 8:14 p.m. NA-G stated R46's screaming and crying during her showers was, Just a behavior for her. R46 often cries out, screams and hits at staff during her shower, Usually she will just scream and cry, and this had been occurring for the past several months. NA-G stated R46 will, Usually cry for a little while after her shower is completed adding she had observed R46 to continue to cry and scream, For a good hour, after her shower. NA-G stated staff had never tried a different kind of bathing for R46 because she, Heard the bath leaks, however, added the facility had multiple bathing rooms available to use. NA-G stated she sometimes will give R46 a piece of candy which, Will help quite a bit, however, nobody had presented her any other interventions to attempt with R46 and her behaviors, What else can I do? During an interview on 8/23/16, at 8:23 p.m. TMA-A stated it was typical for R46 to scream and cry with personal cares. TMA-A stated R46 received her scheduled 3:00 p.m. [MEDICATION NAME] (a medication used for anxiety) on time that evening, but R36's shower was delayed several hours later and was given at 8:00 p.m. that evening. As a result of the late shower, TMA-A stated R46 had increased anxiety/stress throughout personal cares. Further, TMA-A stated R46 was having a hard time with her shower as she was observed screaming, crying and hitting out at staff and NA-G should have notified him sooner of the situation. During observation on 8/24/16, at 7:50 a.m. NA-E entered R46's room, turned on her bedroom light and left R46's room. Licensed practical nurse (LPN)-B entered R46's room and pulled back the covers on her (R46)'s bed while she (R46) appeared to be sleeping. As a result, R46 woke up and stated, don't do that as LPN-B started providing personal cares. LPN-B then placed (R46)'s Ted stockings on, R46 started to cry and stated, Please don't hurt me and that hurts! ouch, ouch as she (R46) attempted to hit LPN-B's hands. NA-E then entered R46's room to assist with R46's personal cares. As LPN-B placed R46's pants on R46 repeated, please don't hurt me. LPN-B continued to provide cares and told R46 it would be okay several times throughout the process while providing personal cares. NA-E then began washing R46's face, she (R46) started to hit LPN-B's hands and stated, no, no don't do that and sobbed intermittently making convulsant gasps in between her cries. As LPN-B and NA-E attempted to place on her (R46)'s shirt she stated, I am sad and began to cry, with visible tears coming down her cheeks. When LPN-B turned R46 to her side, R46 gave a loud piercing cry and yelled, Help me! and You are hurting me! as she (R46) attempted to hit and pinch LPN-B. LPN-B and NA-E continued to provide personal cares and again told R46 it would, be okay, as they continued to dress R46. R46 continued to cry and stated, don't do that, stop it as LPN-B and NA-E transferred R46 into her wheelchair. At 8:07 a.m. NA-E wheeled R46 into the dining room and gave her a cup of coffee, where R46 continued to intermittently cry until 8:29 a.m.,nearly 20 minutes after morning cares were completed. No staff attempted to intervene and provide comfort to R46 as she was sitting in the dining room. During interview on 8/24/16, at 11:18 a.m. NA-E stated R46 always screamed and cried during personal cares or showers. NA-E stated she was not aware of nursing staff trying different interventions with R46 and stated it was a very frustrating situation. Further, NA-E stated it typically took on average ten to fifteen minutes for R46 to calm down after receiving personal cares. During interview on 8/24/16, at 11:33 a.m. LPN-B stated R46 would normally become upset with any type of personal cares. Further, LPN-B stated R46 had been like this since admission and other than adjusting her (R46)'s medications nothing has seemed to help much. During interview with R46's family member on 8/25/16, at 1:53 p.m., R46's family member stated R46 enjoyed taking whirlpool baths because it helped to ease her arthritic pain. Further, R46's family member stated she felt it would cause less anxiety if R46 received a bath because of her (R46) fear of getting hurt during personal cares. Review of R46's physician progress notes [REDACTED]. 5/3/16- Discharge physician progress notes [REDACTED]. R46 is often anxious, agitated and very difficult to redirect. She is very uncooperative with cares, and suspicious of staff. Lately she had become physically threatening and agitated. 5/17/16- Resident is a new resident from geriatric psych who was admitted with hospice and advanced dementia with behavioral issues. R46 is currently restless/anxious and has already been physically/verbally abusive towards staff within the facility. They have seen increased irritability if she is pushed beyond her comfort zone. 8/23/16- The majority of R46's behaviors include crying, yelling, screaming related to cares and when her family leaves following visitation. During the worst times, R46 scratches, kicks and hits at staff. These episodes typically occur two to three times a shift in the mornings/evenings. R46 has also had three episodes of paranoia during July. In review of R46's behavior logs, it is obvious there are times where she is visibly distraught. R46's behaviors can persist for an hour up to an hour and a half at times after personal cares/shower are given. Nursing assistants at the facility explain they keep her nails clipped to decrease injury inflicted to staff by scratching. Review of R46's Target Behavior Monitoring in the month of June 2016, identified approximately 20 episodes of crying/tearfulness which interfered with R46's ADL's. There were no target behaviors identified for physically/verbally abusive behavior in June 2016 behavioral monitoring sheet and no non-pharmalogical interventions were identified to reduce R46's anxiety. In July 2016, R46 had 26 episodes of crying/tearfulness of which 11 of these episodes interfered with R46's ADL's and 5 of these episodes were identified as disturbing and difficult to ignore. In addition, R46 also had target behavior monitoring for physically/verbally abusive behavior which identified R46 had approximately 20 episodes during the month. Of these incidences,17 of them were identified as interfering with R46 ADL's and 16 of these occupancies were considered disturbing and difficult to ignore. July's target behavior monitoring sheet did not identify any specific non-pharmalogical interventions staff could use to help reduce or prevent R46's target behaviors of anxiety, crying and physically/verbally abusive behavior. From 7/26/16 through 8/17/16, a facility daily behavioral log was identified several disruptive behaviors of yelling, crying, physically and verbally abusive behaviors. There was no indication what specific non-pharmalogical interventions were completed or if they were effective in decreasing R46's physical/behavior symptoms during personal cares. Review of R46's 24 Hour Assessment dated 5/10/16, identified R46 was resistive to cares and required a behavioral management program. After review of R46's medical record, there was no indication a behavioral management program, besides what was identified on the care plan since her (R46)'s admission. There was no indication R46's care plan interventions (offer doll,, diversion and snacks) were implemented or if they decreased her anxiety during personal cares after review of R46's medical record. Review of nursing notes from May 2016 identified at the end of the month R46 began becoming resistive towards personal cares and identified behaviors of increased anxiety and verbal/physical aggression towards facility staff which lasted anywhere from 30 to 60 minutes in duration. There was no indication of what intervention were implemented and if they were effective. After review of June 2016 nursing notes, it was identified R46 began having increased anxiety and tearfulness after her (R46) family left after visits. R46 continued to express verbal and physical behaviors during personal cares. 1:1 monitoring, comforting R46 and distraction was found not be be beneficial interventions. Review of July's 2016 nursing noted identified R46 began refusing prescribed medications. R46 continued to have verbal/physical abusive behaviors towards facility staff during personal cares and showers. No successful non-pharmalogical interventions were identified. In August 2016, R46 began having an increase in paranoid behaviors towards facility staff (i.e. accusations of facility staff feeding her 'old food' and were talking negatively about her). Licensed social worker (SW) identified nursing needed to assess R46's target behaviors as she (R46) continued to be verbally/physically abusive towards facility staff. During interview on 8/25/16, at 8:54 a.m. LSW-A stated approximately one week after being admitted to the facility R46 started becoming anxious with cares, and was physical/verbally abusive towards facility staff. These behaviors for R46 have continued since her admission to the facility. LSW-A stated the facility was completing daily target behavior monitoring, but no analysis of trends or new care plan interventions had been attempted since her (R46)'s admission. The Mood State CAA, dated 5/11/16, indicated R46 had communication problems and dementia. The CAA indicated R46 was receiving antipsychotics and identified a goal of minimizing risks and managing mood symptoms. LSW-A stated the purpose of the Care Area Assessments (CAA)s is to, drive the care plan. LSW-A stated a psychology consult should have been recommended with R46 to help address R46's increase in anxiety and verbal/physical symptoms with personal cares. Further, LSW-A stated R46 was not as secure and comfortable as she should have been at the facility and acknowledged her role was to work with staff to address R46's behaviors When interviewed on 8/25/16, at 9:38 a.m. registered nurse (RN)- B stated she had not coordinated with the social worker in the past in regards to CAA assessments and the development of the resident's care plan. RN-B stated R46's behavior began in May 2016 and became worse near the end of July/beginning of August 2016. Further, RN-B stated she should have communicated more with floor staff about R46's behaviors during personal cares and her (R46)'s care plan should have been modified accordingly. During interview on 8/25/16, at 10:13 a.m. director of nursing (DON) stated there should have been more coordination of care for R46 between the social worker and interdisciplinary team in regards to R46's ongoing anxiety with personal cares. Further, DON stated it was the responsibility of the care coordinator to monitor R46's ongoing behaviors and to modify the interventions/care plan accordingly which had not occurred in this situation. DON acknowledged R46 had very few interventions added to her care plan and stated the social worker/care coordinator should have been monitoring personal cares to get a better idea of R46's anxiety with cares. Although R46 was distraught with personal cares in which she screamed, cried and becomes inconsolable even after cares were completed for approximately 1 to 1.5 hours. The facility had not comprehensively reassessed R46's increased behaviors of physical aggression, crying, and screaming during personal cares. The facility had not changed or modified interventions to help decrease or removed R46's ongoing anxiety/behaviors which resulted in actual psychosocial harm for R46. Review of facility policy titled, Target Behavior Monitoring, dated 03/2014, indicated it was the responsibility of the care coordinator for reviewing target behaviors, and providing a summary to the physician during rounds. Target behavior monitoring should examine a review of the residents diagnosis, psychotherapeutic medications, target behaviors, potential casual factor and interventions.