Every finding on record at Cura of Paynesville

Based on observation, interview, and document review, the facility failed to properly store and label individual portions of food to reduce the risk of foodborne illness. This had the potential to affect all 48 residents who resided at the facility. Findings include: During initial kitchen tour on 4/6/26, at 10:19 a.m., with dietary manager (DM): in the freezer part of walk-in cooler there was a gray plastic bin located on the second shelf on the left were multiple individual portions of meals in round cardboard containers with plastic covers. The tub contained: 3 bowls chicken broccoli soup - dated 1/13/261 bowl chicken broccoli soup - dated 12/31/252 bowls potato soup - undated1 bowl chicken pot pie soup - dated 11/15/251 bowl chicken dumpling soup - dated 11/2/252 bowls egg bake - dated 11/18/251 bowl chicken salad - dated 5/2/251 bowl marinara sauce - dated 11/28/25 On the shelf below the bin were two opened bags containing 4 chicken drummies; one with an opened date of 11/4/25 and a full bag dated 10/18/25. Additionally, there was an opened bag of bacon bits dated 11/2/25.Second kitchen tour 04/08/2026 at 10:38 a.m., DM stated above listed items were past expiration and had been removed from freezer. DM stated the bowls were good for 2-3 months once placed in the freezer. DM stated she used an app to determine expiration dates and only one dietary staff had access to use the same app. Bowls were labeled with opened on date but should also have a use by date. DM stated staff defaulted to 3 months if they were unsure of the use by date. DM agreed the current method put the residents at risk of being served expired food. During interview on 4/08/26, at 2:30 p.m., Administrator (Admin) stated he was unaware of the dating process for leftovers in the kitchen. Admin agreed if an app was being used to identify expired foods, it would be necessary for all staff to have access to the app to avoid serving outdated food and prevent a potential food borne illness outbreak.A policy was requested for food storage, however lacked specific instructions on the labeling and storing leftovers and identifying expired foods.

Based on interview and document review, the facility failed to ensure a Level II pre-admission screen (PASARR) had been completed prior to admission for 1 of 5 residents (R7) reviewed for Level II PASARR screening for mental illness. Findings include: R7's comprehensive Minimum Data Set (MDS) dated [DATE] Indicated R7 was severely cognitively challenged, and had the following diagnoses: Anxiety, Bi-Polar disorder, Post Traumatic Stress Disorder, Unspecified Dementia and Unspecified mental disorder. R7's Minnesota Senior Linkage line pre-admission screening results dated 7/1/24, indicated R7 met the requirements for a mental illness OBRA Level II assessment and was required to have an OBRA Level II assessment prior to being admitted to any nursing facility. R7's complete medical record was reviewed on 4/7/26 and lacked documentation of results of a Level II assessment. During interview on 4/8/26 at 8:46 a.m., Director of Nursing (DON) provided copy of the completed Level II assessment and stated the facility had received it on 4/7/26 after state agency surveyors had requested a copy. DON stated the facility did not have the completed Level II assessment at the time of R7's admission and therefore did not include the findings when creating an initial plan of care. DON expected staff to obtain all required Level II assessments prior to a resident's admission and stated it was important to have the information at the time of admission to best meet the needs of residents with mental health issues. A policy was requested but not provided.

Based on observation and interview, the facility failed to submit complete and/or accurate data for staffing information based on payroll and other verifiable data during 1 of 1 quarter (Quarter 2) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include:Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D identified the facility had one star staff rating and four or more days within the quarter with no Registered Nurse (RN) hours during the first quarter of fiscal year 2026, which included dates between October 1, 2025, through December 31, 2025.Review of daily staff schedules and facility staffing report during quarter 1 indicated adequate levels of RN coverage throughout the first quarter of fiscal year 2026. Therefore, the data submitted in the payroll-based journal (PBJ) report to the Center for Medicare and Medicaid Services (CMS) was inaccurate. During interview on 04/08/2026 at 1:47 p.m., Director of Nursing (DON) stated corporate staff was responsible for submitting PBJ report to CMS, and until recently had been completed and submitted by the previous owner. DON stated both she and the Administrator (Admin) had made multiple attempts to assist in fixing the error, however, they had been unsuccessful. During interview on 04/08/2026 at 2:30 p.m., Admin stated he had been trying to get someone in the corporate offices to address this for months to correct the issue, but it remained a problem. Admin provided copies of email exchanges with corporate offices indicating an awareness of the issue and attempts to correct. A policy was requested but not provided

Based on observation, interview, and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 1 of 2 residents (R249) during high contact cares. In addition, the facility failed to ensure PPE use while providing wound care for 1 of 2 residents (R249) reviewed for enhanced barrier precautions (EBP). Findings include: R249's quarterly Minimum Data Set (MDS) dated [DATE], indicated R249 was cognitively intact and had acute osteomyelitis (bone infection) on the right ankle and foot and had recently undergone orthopedic surgery for right below the knee amputation, phantom limb syndrome with pain (real pain in a missing limb after amputation), peripheral vascular disease (PVD) (narrowed arteries reduce blood flow to the arms and/or legs), type II diabetes mellitus (DM), hypertension (elevated blood pressure), hyperlipidemia (high cholesterol), neuropathy (nerve pain, tingling, or numbness), and was a carrier or suspected carrier of Methicillin-susceptible Staphylococcus aureus (MSSA) (type of staph bacteria that can cause infections on the skin or other parts of the body). R249's care plan dated 2/26/25, indicated R249 was on EBP due to MSSA, PICC line with six weeks of antibiotics, and chemotherapy medication. Interventions included posting clear signage on the exterior of resident's door with the required PPE, provide education to residents and visitors, PPE available outside of the room, use gown and gloves with high-contact resident care activities. During observation on 3/17/25 at 3:26 p.m., registered nurse (RN)-A along with an unidentified nursing assistant (NA) assisted R249 from his manual wheelchair into his recliner to perform wound care. Neither NA or RN-A wore gown or gloves while assisting R249 with transfer. NA exited the room after assisting with the transfer. R249's legs were elevated using the recliner. RN-A gather the supplies to complete dressing changes then sat in R249's wheelchair to perform R249's wound care. RN-A donned gloves to both hands, but failed to don a gown prior to procedure. RN-A then removed Prevalon boot (heel protectant boot) from R249's left heel wound. RN-A noted there was no dressing in place, she then lifted R249's left leg and foot and placed R249's ankle on her right leg above the knee to provide support while painting the wound with betadine per the provider order. After bandaging the left heel RN-A removed her gloves and discarded the used supplies. RN-A returned to sit in the wheelchair and applied a glove to her right hand. She removed the dressing from R249's right below the knee surgical wound with gloved hand, noted there was no drainage and was seen painting the site with a betadine swab. RN-A redressed, dated and initialed the tape used to secure the gauze wrap, and applied the limb protector with gloved hand. RN-A removed her glove and discarded the used supplies. Signage, PPE supply cart and disposal bin were observed on resident's door and just inside of the door. RN-A was not wearing a gown to protect R249 nor herself from pathogens during this procedure. Interview on 3/17/25 at 3:46 p.m., RN-A stated that she had worn gloves. RN-A confirmed she had not worn a gown during resident high contact cares, she stated I forgot. Unable to complete interview at this time. Interview on 3/17/25 at 3:48 p.m., R249 stated she [RN-A] never wears a gown. Interview on 3/19/25 at 3:02 p.m., RN-A stated when a resident required EBP there should be a sign on the resident's door to alert them. In the resident's plan of care there is a stop sign that indicated the precaution, and if hovered over, it showed the type of precaution specifically. RN-A confirmed R249 did have EBP signage posted on exterior of his door and that there was a PPE cart and disposal bin located inside his doorway. RN-A did not recall receiving any specific EBP training, and stated she may not have been there for it. RN-A stated gown and gloves should be worn for, anything up close and personal where concerns for infection are possible, like peri cares, all personal cares and wound care. RN-A was not aware high contact care included transfers. RN-A stated PPE use was important to prevent infection for the resident with whatever I could be carrying, to keep as clean as possible and not introduce anything new to him. Interview on 3/19/25 at 3:20 p.m., with case manager (CM) and director of nursing (DON). DON stated staff were able to tell which residents were on EBP in the residents EHR, it was flagged on their face page, on the care plan, signage on their door, as well as on the huddle board (white board) in the breakroom that lists all residents on precautions. CM stated they also had supply bins and disposal containers in the residents' rooms. CM also stated they go through the residents on EBP in their morning huddle daily, during shift reports and pass on. DON stated precautions were put into PCC like a medication order, when it was time for wound care to be completed, it alerted the nurse. CM stated training on EBP was provided to care staff at their annual skills fair. DON stated many different audits had been completed, and gown and gloves were expected for all wound care. Both CM and DON agreed they would expect orders to be followed, infection control practices followed, and if there was a question, staff would ask for clarification as they had many tools and resources available to them. DON and CM were not specific on the expectation of staff to wear PPE during high contact cares, including transfers. A policy effective 3/2025, titled Enhanced Barrier Precautions indicated the policy is in place to reduce the transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions is defined as an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. PPE used for these high-contact resident care activities as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care of any skin opening requiring a dressing.

Based on interview and document review, the facility failed to ensure Physicians Orders for Life Sustaining Treatment (POLST - Code Status) were clarified for 1 of 1 residents (R34), who was readmitted from the hospital with orders in conflict with their signed POLST and Advance Directives. Findings include: R34's significant change Minimum Data Set (MDS) dated [DATE], indicated cognitively intact and required partial to moderate assistance for activities of daily living (ADLs). R34's Face Page printed [DATE], indicated resident's code status as DNR-intubation on case-by-case basis but no chest compressions. R34's Health Care Directive (HCD) signed [DATE], indicated I do not want CPR attempted if my heart or breathing stops. I want to allow a natural death. R34's HCD further directed: Keep me comfortable. No extraordinary measures. R34's most recent POLST (signed [DATE] upon admission to the facility), directed if R34 was not breathing or had no pulse as, DNR/DO NOT ATTEMPT RESUSCITATION (Allow Natural Death). R34's POLST further documented resident wished not be intubated (insertion of a tube into a patient's body, especially that of an artificial ventilation tube into the trachea), no artificial nutrition by tube. However indicated the use if antibiotics, IV fluids and cardiac monitor as indicated. R34 was admitted to the hospital, from [DATE] through [DATE], where resident was treated for pneumonia. R34's hospital discharge orders documented R34's Code Status as: Intubation on case-by-case basis but no chest compressions. Limited code - no cardiac resuscitation. During interview on [DATE] at 8:20 a.m., R34 stated if she was found not breathing and heart had stopped, I don't want anything done. When clarified with R34, this included no breathing or feeding tubes. However she was open to having comfort measures such as antibiotics and IV fluids. In and interview on [DATE] at 9:30 a.m., registered nurse (CM)-B verified R34's HCD and POLST both indicated resident's expressed decision was to be DNR and did not wish to have extraordinary means to be implemented. In review of R34's Point Click Care records (electronic medical records), where it documented Intubation on case-by-case basis but no chest compressions. Limited code - no cardiac resuscitation, and the [DATE] hospital discharge orders, CM-B stated R34's orders should have been clarified with the physician before being transcribed. In review of the facility's policy, entitled: No Not Resuscitate Order (effective date ,d+[DATE]), indicated the following: 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provide the facility with a signed and dated request to end the DNR order. a. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. b. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet. In review of the facility's policy, entitled: Transcription Processing Provider Orders - Long Term Care (effective ,d+[DATE]), lacked evidence of what the facility staff person who transcribed orders should do when they have received conflicting orders. In this case, changing R23's end of life choices without consent.

Based on interview and document review, the facility failed to ensure 2 of the 5 residents (R9 and R23) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R9's face sheet, dated 2/8/24, indicated she was [AGE] years old. The immunization record, undated, indicated she received a PPSV23 on 4/29/08 followed by the PCV13 on 11/2/16. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R9 was offered or received PCV20. R23's face sheet, dated 2/8/24, indicated she was [AGE] years old. The immunization record, undated, indicated she received a PPSV23 on 7/18/15 followed by the PCV13 on 6/23/17. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R23 was offered or received PCV20. During an interview with care manager (CM)-A on 2/7/24 at 7:50 a.m., the CM indicated immunizations were verified upon admission through MIIC (Minnesota Immunization Information Connection). IP stated IP would ask residents and/or their families and consents were obtained if immunizations were needed. CM verified R9 and R23's pneumococcal immunizations as listed above. CM verified they had not been offered or provided education on PCV20. During interview with director of nursing (DON) on 2/8/24 at 11:25 a.m., DON stated immunization reports through MIIC, recommended immunizations were discussed during the admission process but R9 and R23 were missed. A facility policy titled Pneumococcal Immunization, Long Term Care with an effective date of 6/2023 was provided. Policy indicated: Residents will be offered the pneumococcal vaccinations and administered, according to the MDH and CDC recommended interval for the vaccines, unless contraindicated, already immunized, or the resident and/or the resident representative declines the vaccine.

Based on interview and document review, the facility lacked evidence the facility provided the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN/CMS-10055) to 3 of 3 residents reviewed (R17, R36, and R38,) whose Medicare Part A coverage ended and the residents remained in the facility. Findings include: R17 Medicare A coverage documentation, provided by the facility, the records lacked evidence R17 nor their family were provided the SNFABN; CMS-10055. In review of the survey worksheet provided to the facility (SNF Beneficiary Protection Notification Review CMS-20052) indicated R17's Medicare A stay started on 1/26/23, and last coverage date was 2/24/23, and R17 remained in the facility. R36 Medicare A coverage documentation, provided by the facility, the records lacked evidence R36 nor their family were provided the SNFABN/CMS-10055. In review of the survey worksheet provided to the facility (SNF Beneficiary Protection Notification Review CMS-20052) indicated R36's Medicare A stay started on 12/14/22, and last coverage date was 1/19/23, and R36 remained in the facility. R38 Medicare A coverage documentation, provided by the facility, the records lacked evidence R38 nor their family were provided the SNFABN/CMS-10055. In review of the survey worksheet provided to the facility (SNF Beneficiary Protection Notification Review CMS-20052) indicated R38's Medicare A stay started on 2/9/23, and last coverage date was 2/22/23, and R38 remained in the facility. On 4/18/23, at 12:57 p.m. the director of nursing (DON) said that the facility could not produce the SNFABN/CMS-10055) records for the residents R17, R36, and R38. The DON continued the SNFABN/CMS-10055 had not been done correctly since the previous Social Worker had left, and after reviewing with the administrator and social worker, they were actively reviewing and correcting the situation. On 4/20/23, at 11:24 a.m. social worker (SW)-C stated the Notice of Medicare NonCoverage (NOMNC's) were being done, but not the ABN's. SW-C continued, I do see it as an issue, especially if residents do not know their remaining days, or if they are unaware of the appeals process, which is why we are working to correct it. The facility's policy, titled, Advanced Beneficiary Notice - ABN (effective 04/2023) indicted the following: CMS recommends facilities issue a voluntary ABN or a similar notice as a courtesy to alert the beneficiary about their financial liability. The policy continues that an ABN is valid if using the most recent version approved by the office of Management and Budget (OMB), complete the entire form, and ensure the beneficiary understands the notice.

Based on observation, interview and document review, the facility failed to protect 1 of 1 residents (R1) from alleged resident to resident sexual abuse when R2, who has a history of wandering into other resident rooms and a history of sexual behavior, entered R1's room unsupervised and was found in bed with her. Further, the facility failed to assess R1 for signs of injury/abuse after the incident and failed to immediately implement safety interventions for either R1 or R2 to help mitigate the likelihood abuse would occur again. These findings resulted in an immediate jeopardy (IJ) situation for R1 when she was allegedly sexually abused by R2. The IJ began on 4/21/22, when staff observed R2 lying in R1's bed with her and R1's nightgown was observed to be pulled up to her midsection with her incontinence brief exposed. Although R2 was immediately removed from R1's room, R1 was not assessed for signs of injury/abuse, despite confirming by interview she was touched by R2, and immediate interventions were not put into place for R1 and R2 to prevent future incidences of sexual abuse. The executive administrator (EA) and two corporate nurse consultants (RN-A, RN-B) were notified of the IJ for R1 on 4/28/22, at 8:00 p.m. The IJ was removed on 4/29/22, at 5:00 p.m. when the facility successfully implemented a removal plan; however, a non-compliance remained at an isolated scope with no actual harm with potential for more than minimal harm (Level D). Findings Include: A facility submitted SA Incident Report, dated 4/21/22, identified a facility's reported allegation of sexual abuse involved R1 and R2. The report outlined on 4/21/22, at 10:27 p.m. R2 was witnessed lying in R2's bed and that R2's nightgown was pulled up with the bottom half of [R1's] body exposed. The report identified staff asked R1 if R2 touched her and R1 replied in a clear yes. On 4/28/22, at 10:15 a.m. it was observed R1 and R2 shared adjacent rooms along the West hallway in the facility. Attached to the right side of R1's doorway frame with velcro adhesive were three white cloth mesh pieces of material which hung down alongside the doorframe. A stop sign was present in the middle of each mesh piece. One mesh piece was centered in the door frame with one above and one below by approximately five to seven inches. On 4/28/22, at 10:40 a.m. West hallway video surveillance footage was reviewed and displayed the following: On 4/21/22, at 10:21 p.m. an unidentified staff was seen; however, the footage failed to identify their exact location down the hallway due to the distance from the camera. At that same time, R2 exited his room self propelling his wheelchair. He turned to his right and approached the hospital double doors. At 10:22 p.m. R2 headed back toward his room and entered it at 10:23 p.m. Soon after, he again exited his room, turned to his left, and at 10:24 p.m. entered R2's room which was adjacent to his. At that same time, unidentified staff continued to be seen down the hallway. At 10:27 p.m. staff walked towards R2's room and entered. At 10:28 p.m. another staff entered R1's room. At 10:29 p.m. R2 was brought out of R1's room and escorted to his room. For approximately three minutes, R2 was unsupervised in R1's room. R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 was severely cognitively impaired with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She required extensive physical assist for cares. R1's progress note (PN), dated 4/21/22, at 10:35 p.m. identified at approximately 10:27 p.m. resident had a situation involving another resident found lying in her bed. Other resident was immediately directed out of the bed and room. Staff provided comfort and when attempting to cover back up with blankets, noted to have night gown pulled up exposing bottom half of body. When asked if R1 was o.k., resident mumbled the word yes. Asked resident again if o.k. and replied with only mumbling. Asked R1 did he touch you? and R1 replied very clear yes. PN additionally indicated at approximately 10:31 p.m. report was provided for oncoming RN (registered nurse), filing VA (vulnerable adult) report, Approximately 10:33 p.m. updated DON (director of nursing) and Administrator. An Alleged Abuse incident report, undated, identified R1's 4/21/22, 10:35 p.m. PN information, along with a witness statement which identified a nursing assistant (NA) found R2 cuddling with R1, her shirt was up by her stomach, and the NA and the evening RN assisted R2 back to his room. In addition, the report identified the following individuals were notified of the event: 4/22/22, at 9:23 a.m. R2's wife; 4/22/22, at 9:30 a.m. R1's representative (guardian); 4/22/22, at 9:33 a.m. the nurse practitioner (NP). The report lacked documented evidence of any interventions implemented to mitigate the risk of R2 returning to R1's room. A PN, dated 4/25/22, at 11:38 a.m. identified R1 was observed to have purple bruising to her left upper forearm that measured 5 centimeters (cm) by 3.5 cm and another bruise to the top of her right hand that measured 2 cm by 2 cm. R1 denied anyone had harmed her. A NP dictated progress note, dated 4/27/22, indicated R1 was seen and has been relatively stable. A review of systems was unobtainable due to the patient's advanced dementia and nonverbal state. Physical exam indicated psychological status as She does appear to be happy and there were no changes to her plan of care. The progress note does not reference the 4/21/22 alleged allegation. R1's medical record was reviewed and lacked documented evidence R1 was assessed for any physical injuries or sign of abuse on 4/21/22, or until her 4/25/22 weekly skin evaluation. In addition, the medical record lacked evidence her mood or psychological status was assessed for any potential adverse impacts related to the alleged allegation. R1's care plan, dated 4/25/22, identified R1 was considered vulnerable due to compromised medical health as evidenced by her need for nursing home care. R2's quarterly MDS, dated [DATE], identified R2 was moderately cognitively impaired with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 exhibited the following behaviors: physical abuse directed towards others (1 to 3 days), other behaviors not directed towards others (1-3 days). The MDS identified R2 was free of wandering behavior; however, he utilized a WanderGuard (device to alert staff of facility exit) daily. R2 was independent with transfers and with walking to and from locations on and off his unit; however, he required limited to extensive physical assist with other activities of daily living (ADLs). R2's progress note, dated 4/21/22, at 11:04 p.m. identified the entry: Resident found lying in another resident's bed. Other resident reported was touched. This resident was easily re-directed out of bed and out of other resident's room. Report filed accordingly. A progress note, dated 4/24/22, at 4:27 a.m. indicated R2 continued on 15 minute [location] checks. He slept quietly and was free of wandering behavior. R2's Behavior - Target Symptom Follow Up Question Report, dated 4/1/22 - 4/29/22, identified staff monitored the behaviors of severe restlessness and hallucinations. R2's sexually aggressive behaviors and wandering into others rooms was not identified as a target symptom being monitored. R2's care plan, dated 4/14/22, identified R2 was diagnosed with [CONDITION(S)] (difficulty sleeping), he wandered into others rooms and there was a potential for resident to resident conflict related to his impaired cognition and perception and listed a goal R2 would be free of conflicts with other residents. Interventions directed staff to administer his medications, monitor his behavior(s), remove him and/or other residents from conflict situations, report assaultive/aggressive behavior to the nurse, and observe R1 and other residents for signs and symptoms of agitation/irritation. These were the only interventions listed prior to 4/26/22 to help ensure R1 remained free of abuse. On 4/26/22, R2's resident to resident conflict care plan was updated to include a long standing history of sexual advances towards others and his mood and behavior care plan was updated to include sexually inappropriate towards staff grabbing and comments. R2's care plan lacked documented interventions in relation to the incident that occurred on 4/21/22. R2's medical record was reviewed and lacked evidence R2 was comprehensively assessed by facility staff to help determine contributing factors and subsequent interventions to help reduce and/or eliminate R2's wandering into other residents rooms and sexually aggressive behaviors directed at others. When interviewed on 4/28/22, at 9:50 a.m. the DON stated during their investigation R1's single mesh stop sign was not engaged across the entire width of her door when R2 entered R1's room. She denied she followed-up with staff or that audits were initiated to ensure the mesh signs were placed as care planned for resident after the incident. She explained R1 was not sent to the emergency room for assessment following the incident as there was lack of suspicion by staff that anything happened that warranted such an examination. We went by the time on the video. [R2] was in there for only about three minutes before staff entered the room and she had no injuries. [R1] had a body assessment and her nightgown was flipped up but her pad was still up. She indicated she was aware R2 went into other resident rooms, which included R1's room, That is why the [one] sign was put up in the first place. Further, she indicated, per staff reports, R2 was witnessed to take mesh sign(s) down or has gone under them to enter other resident rooms. The DON acknowledged R2 has a history of sexual behaviors, Just the other day he tried to grab staff; however, she lacked knowledge if sexual behaviors were directed at other residents. She identified R1's two additional mesh signs were added on 4/22/22, along with R2's 15 minute location checks. She denied knowledge of any interventions implemented immediately after the incident on 4/21/22. During telephone interview on 4/28/22, at 1:48 p.m. R1's guardian stated she was updated on 4/22/22. She indicated she was available by phone 24 hours a day and, They could have attempted to contact me that night. She acknowledged the alleged allegation was a pretty serious situation. She explained she was actually quite shocked that they got a reply from her when they asked her a direct question .when asked other questions typically she just mumbles. When interviewed on 4/28/22, at 2:42 p.m. RN-B stated on 4/21/22, around 10:30 p.m. during shift change, she witnessed R2 pushing his wheelchair wandering down the hallway and she had a close eye on him as she provided the night nurse with report. Shortly after that, she was called into R1's room in which she observed R2 being escorted out of R2's room. RN-B indicated her only questioning to R2 was when she jokingly asked him if he was getting cuddle time? She indicated he responded with something that sounded like ohhhh. When she reentered R1's room, R1's pajamas were perfectly folded up .not ruffled or anything .that did not look right. RN-B pulled down R1's pajamas and covered her back up with the blankets. She explained she questioned R1 if she was okay and R1 first mumbled a yes. R1 was questioned again if she was okay and R1's response was completely mumbled. She then questioned R1 if R2 touched her and R1 responded as clear as day yes, which seemed serious. She denied any follow-up questions to R1 and verbalized, Of course he touched her, he was lying in bed with her. But, that did not mean he did not grab her somewhere. When she was questioned on her incident follow-up, RN-B stated, Nope, I did not do any. After the fact, I was hoping they would have done something. She confirmed she did not perform a skin check on R1 for potential injury and only visualized R1's exposed stomach area, did not engage with any other residents in the vicinity of R2's room to ensure they were safe, did not set up any interventions to ensure R2 did not reenter R1 or other residents rooms, did not call any resident representative(s) or medical provider(s), and did not call the police. Further, she did not follow-up with staff to investigate the situation further to ensure care plans were followed at the time. She did identify she contacted the DON and administrator and spoke with the night nurse: however, she denies they discussed interventions for either R1 or R2. Once she filled out a written statement for the night nurse to use to fill out the SA report, she ended her shift. I just assumed they would ensure it would not happen again. She acknowledged the incident was very serious and stated, I should have just did the 15 minute checks. She stated R1 used one stop sign on her door prior to the incident; however, she commented, We did not always put it up . and she was unsure if the stop sign was part of R1's care plan. She explained, We did not think it was much of a threat for somebody going in her room. She confirmed she had witnessed R2 enter other residents rooms, which included R1's, and commented, He is everywhere. During interview on 4/28/22, at 2:11 p.m. licensed practical nurse (LPN-A) stated she did not witness the incident between R1 and R2; however, RN-B updated her after. She confirmed she was the only nurse on that night shift. She explained she submitted the SA report after RN-B provided her with the incident information and she spoke to the DON about contacting R1 and R2's representatives that night. She stated the DON instructed her to wait until the morning. LPN-A confirmed she did not perform an overall skin assessment on R1 during her shift, did not contact anyone else, did not engage with other residents in the vicinity of R2's room to ensure they were safe, did not assess R1's mood and/or psychological status during the night, and did not put any interventions into place to protect residents from R2. She identified she and the other night staff only performed prior interventions of checking on both R1 and R2 during routine rounds and if they passed R2's room to make sure he was in there. She stated she had witnessed R2 enter other residents rooms at night prior to this incident and she thought R1's care plan reflected she was to use the mesh stop sign; however, she was not absolutely sure. She confirmed that on 4/25/22, her next scheduled shift, the three mesh slings were in place for R1 and R2 was on routine location checks. When interviewed on 4/28/22, at 6:00 p.m. RN Nurse Consultant (RN)-A, stated she would expect as part of an abuse allegation investigation the following processes to occur: immediate separation of the individuals involved, observation of the entire situation and gather as much information about the incident as best able, report the incident to the appropriate representatives and medical providers for each resident involved, and file the report with the SA. Further, RN-A indicated she expected staff to perform a basic skin assessment on the victim to identify any potential concerns that may direct the need for a more comprehensive assessment of injuries, based on the allegation, along with implementing interventions right away, or at least something in the interim to make sure it does not happen again until the interdisciplinary team was able to review the incident fully. She provided examples of someone to keep an eye on him, 15 minute location checks, and one on one supervision if staff availability allowed. During interview on 4/28/22, at 6:35 p.m. the executive administrator (EA) stated knowledge of the incident. He identified he expected in an alleged abuse situation the victim was to be assessed for any signs of injury and interventions initiated to make sure the resident does not come back into the room. He explained he would have closed R1's door and kept R2's open for ease of observing R2. He would expect that the nurses do not leave the area. EA denied knowledge R2 removed or went under the cloth mesh stop signs and explained if this happened staff should implement another stop sign or discuss the possibility of a room change. He denied involvement in conversation(s) related to a room change for R2. He stated he expected the administrator, DON, and social services to investigate abuse allegations thoroughly and follow-up immediately with any concerns identified. Further, he indicated formal staff education related to abuse and the expectation staff follow their abuse policy should have occurred. When interviewed via telephone on 4/29/22, at 11:16 a.m. NA-A acknowledged she witnessed R2 initially in R2's bed. She explained the evening of 4/21/22 she observed R1's call light to be engaged which she thought was weird .as she does not use it. She explained she knew R2 was lying down while in R1's bed as he leaned forward in the bed and then moved his body forward .he appeared shocked and he had his hand on [R1]'s hip. NA-A provided the following further details: R1 laid slightly on her right side facing the middle of the room and R2 was on his left side and faced her; R2's clothing was on and his genital area was not exposed; R1's sheets were located down to her knees; her gown was on and it was rose up about to her stomach, by her ribs; her incontinence brief was exposed which was secured and in place; R2's full right hand was directly placed on R1's right hip below her brief between her hip and her thigh region and was not actively moving when NA-A observed it on R1's hip. R1 was wide awake at the time and when RN-B initially asked R1 questions, we could not understand what she was saying; however, when RN-B asked her if R2 had touched her, R1's responded with a yes and not her typically mumbled word(s). She indicated she comforted R1 and provided her with her doll after the incident and R1 appeared the same as she typically does when they provide cares to her at night. NA-A denied they performed any new interventions that night for either R1 or R2. NA-A stated she has witnessed R2 enter other resident rooms during day and night hours and has witnessed him enter other residents rooms after he removed their mesh sign. He also can be more touchier sometimes during cares. She identified interventions utilized for R2 included closing [resident] doors and currently checking on him every 15 to 30 minutes. She explained she did not formally document any location checks for R2 and further explained, Nights is a little hard, especially when me and my co-worker are helping another resident then it is hard to see what R2 is going to do next. During interview on 4/29/22, at 3:00 p.m. R2's family member (FM)-A stated she is unaware of R2's facility reported history of sexual behaviors: however, she indicated at times He will tickle one of the nurses on the back of the next . She stated R2 had wandered into other resident rooms and she had witnessed him attempting to go underneath the door mesh stop signs to enter another residents room. She explained, due to R2's past profession and history of fixing things, It [the sign] attracts his attention more than keeping him out. It does slow him down, but I do not think it would stop him. When interviewed via telephone on 5/2/22, at 12:05 p.m. R1's NP stated she, was notified the next morning. She verbalized the only interventions discussed for R1 were the stop signs. For R2, they discussed 15 minute checks and inpatient mental health placement; however, they [staff] did not think it [placement] was needed. She denied conversation occurred related to an sort of assessment of injury for R1. NP explained her expectation for provider notification centered around the parameters .based on their procedures. She identified R2 is going to wander until he cannot and typically his behaviors were hit and miss, waxes and wanes, and were directed more toward staff. She was unsure of his sexual behavior history or his past relationship with his wife. The immediate jeopardy that began on 4/21/22 was removed on 4/29/22, when the facility assessed R2 and implemented strategies to address target behaviors, assessed and implemented strategies to protect R1 from abuse, reviewed and revised incident/abuse policies, retrained staff on new care plan interventions and policies and procedures. A Vulnerable Adult Policy, dated 2/2022, identified residents were to be protected against abuse and did not condone resident abuse by anyone. The policy's abuse definition included sexual abuse. The policy directed staff to complete an internal investigation which included interviews and review of the circumstances and resident records, and victim protection and supportive services as necessary. The policy also directed staff upon identification of suspected abuse, immediate safety was to be provided to the resident with some examples listed as: resident room change; 1:1 monitoring as necessary.

Based on interview and document review, the facility failed to develop a policy and procedure defining the responsibilities of the Medical Director (MD) and ensure the MD assisted in the implementation and guidance of resident care policies, and coordination of resident medical care in the facility. This had the potential to impact all 37 residents who resided in the nursing home at the time of the survey. Findings Include: During an extended survey, on 5/2/22, a Medical Director (MD) policy and the MD's job description and/or contract was requested; however, these items were not provided. Due to lack of requested information, the following interviews were conducted: During interview on 5/2/22, at 2:18 p.m. a facility nurse consultant (RN)-C stated the MD was not updated R2 was alleged to have sexually abused R1. Further, RN-C confirmed the MD was not updated on the IJ related to the allegation. She verbalized she did not know why he was not contacted for either concern. When interviewed on 5/2/22, at 2:46 p.m. executive co-owner stated the facility had a contract with the MD for providing services to the facility. He expected the MD to understand the contract and to follow what the contract laid out in terms of what his responsibilities to the facility were. During interview on 5/2/22, at 2:58 p.m. the administrator stated he was not aware if the MD had been updated R2 was alleged to have sexually abused R1 or that the MD was updated on the IJ related to the allegation. The administrator indicated the facility and the MD had a contract for services; however, he lacked knowledge of the contract specifics. He explained the MD participated in their quarterly Quality Assurance and Performance Improvement (QAPI) program and he has communicated with the MD at times on certain policies; however, overall any facility policies were developed within the corporation without MD participation. When interviewed on 5/2/22, at 3:20 p.m. the MD stated he lacked knowledge R2 was alleged to have sexually abused R1 or that the facility was determined to be in an IJ status related to the allegation. He indicated he expected such allegations and an IJ status were to be reported to him. He explained he started his involvement with the facility, about May or June of last year, in which he was on medical leave shortly after for approximately six weeks. When he was questioned on the process for medical director coverage when he was unable to fulfill his duties, or who covered for him on his medical leave, he stated, I do not know to be honest with you probably one of the partners that rounds there now. He lacked knowledge of a formal process for coverage in his absence. In addition, he stated he did not participate a lot in policy development or adjustments as, Their process for polices is a well-established process .they would know more about nursing home related processes than me. He explained, They do not tend to contact me; but, there is a quarterly meeting I attend, in which his role is limited. Further, he identified he reviewed the facility consulting pharmacy reviews; however, has not been required to follow up with any facility practicing providers related to any identified concerns and denied overall communication with these providers since he started his role. The MD stated he lacked knowledge he signed a MD contract with the facility and identified he has basic knowledge of his responsibilities as a MD; however, nothing laid out in depth. He stated he has only walked through the facility once briefly since he became the MD and explained this was due to COVID-19 regulations. On 5/3/22, at 11:18 a.m. RN-C sent an email to the surveyor which included an attached email sent to the MD on 11/23/21, which identified a written response he would take over as MD after the first of the year. RN-C wrote she heard back from the executive administrator (EA) and they were unable to locate a contract for the MD which pertained to Paynesville Health Care Center.

Based on interview and document review, the facility failed to ensure the care plan for transfers was followed for 1 of 7 residents (R1) reviewed for mechanical stand lift use. This resulted in R1 falling from the mechanical stand lift during a transfer. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated, severe cognitive impairment with delusions (fixed, false beliefs), along with verbally abusive behaviors directed towards others. He required extensive physical assist of 2 staff for transfers and had arm and leg range of motion limitations to one side of his body with four or more falls reported since May 2021. The MDS further indicated R1 had diagnoses including, [CONDITION(S)]/[CONDITION(S)] (weakness on one side of the body) related to a stroke, along with dementia, anxiety, depression, [CONDITION(S)], chronic pain and arthritis. R1's self-care deficit care plan interventions revised on 6/7/21, directed R1 to be transferred with a mechanical standing lift and two staff, along with two staff to be used for toileting. R1's Witnessed Fall incident report dated 8/17/21, identified nursing assistant (NA)-A transferred and provided pericares to R1 with a standing lift and assist of one, in which R1 lifted his arms up over the lift, was verbally aggressive, and sustained a fall as a result. The report identified R1 was free of injury at the time of the incident. The facility incident report dated 8/17/21, identified NA-A had transferred R1 with a mechanical standing lift and one staff, despite R1 having been care planned to require two staff. Further, the report identified during the transfer, R1 was provided pericare and lifted his arms from the lift handles and fell . A follow up incident report dated 8/23/21, identified R1's care plan was not followed during a mechanical stand lift transfer and he fell . The report indicated NA-A acknowledged she was aware R1 required two staff to transfer and she initially used a Walkie to call for transfer assist. Further, NA-A reported that everyone was busy and there was no response to her requested assist, with an additional statement she and others had used one assist with R1 in the past. She informed the facility R1 had a bowel movement during the transfer and during the process of providing pericare she had moved the wheelchair off to the side, at which time R1 started yelling and swearing. R1 instructed NA-A to hurry up, proceeded to lift his arms up and over, and slipped from the lift. When interviewed on 8/30/21, at 2:05 p.m. NA-B stated she was expected to follow resident care plans to avoid potential resident falls and/or injury. She explained R1 required two staff and a mechanical stand lift for all his transfers as, he is a hard one. He sometimes tries to not stand up tall and sometimes his arms will get a little tired. She further explained he required, a lot of coaching, to stand up tall as he will, slouch. NA-B stated, R1 had memory loss, behavior issues, and, He has done the arm movements, as long as she has worked with him. She stated she performed tasks, quicker for R1 [when he was in the lift] to reduce R1's risk of becoming too weak during transfers. When interviewed on 8/30/21, at 4:13 p.m. NA-C stated she was expected to follow resident care plans, to make sure they [the residents] get the best care as possible; otherwise, It would make them a lot less safe and at risk for injuries. NA-C explained at times R1 lifted and/or flailed his arms from the lift and hit out at staff during lift transfers. Due to this, staff observed him closely and assisted him to place his hands back on the lift or cued him to stand up straight. When interviewed on 8/30/21, at 4:32 p.m. licensed practical nurse (LPN)-A stated she was expected to follow resident care plans which helped to ensure resident safety and, quality of life. LPN-A further explained R1 was very impatient, very rude, refused to place his hands on the lift at times and he swung out at staff, quite a bit. He really needs two staff for lift transfers. When interviewed on 8/31/21, at 9:38 a.m. NA-D stated she was, very much expected to follow the care plans, and if she failed to follow the care plan, they [residents] could be getting hurt. She explained all residents were different and did not respond the same way so she needed to follow the care plan to ensure the residents required care was provided. NA-D denied facility staff audited her for her use of the mechanical lift after R1's fall or that she was provided re-education on the facility's expectation she follow resident care plans. When interviewed on 8/31/21, at 10:40 a.m. NA-E stated one staff was able to be used for resident mechanical standing lift transfers. However, if the resident did not hold onto the lift properly or had behaviors when transferred, then two staff were care planned to be used for lift transfers. She explained she was expected to follow the care plans, as it is a safety factor for the residents. NA-E stated R1's transfers depended on the day and, depending on the mood he is in he can get pretty aggressive and will act out and let go of the lift. She explained, When I change him, I always have him over a surface just in case he were to lift his arms up. NA-E denied facility staff audited her for use of the mechanical lift after R1's fall or that she was provided re-education on the facility's expectation she followed resident care plans. When interviewed on 8/31/21, at 11:22 a.m. case manager, registered nurse (RN)-A stated, she expected staff to follow resident care plans, because they have been assessed by personnel who can make the [care planned] decisions, and when staff failed to follow the care plans they risked injury to themselves and/or the residents. She denied staff had brought information to her that R1's transfers were not safe. However, she commented, Nobody likes being stood up on a lift for an extended period of time with their pants around their ankles. RN-A further explained, R1 had chronic pain and he required things to be explained to him step by step in which staff tried to perform tasks quicker so that R1 stood for the shortest possible time when in the lift. RN-A denied facility staff audited her for use of the mechanical lift after R1's fall or that she herself had audited other staff. When interviewed on 8/31/21, at 12:09 p.m. the director of nursing (DON) stated she expected staff to follow resident care plans, so they [staff] know how to care for the residents, and when staff failed to follow the care plans the residents were at risk for falls, injury, or declined mobility. She explained R1 was known for periods of, horrible transfers, and, He is a two person [transfer] for a reason. The DON denied she or other designated staff performed standing lift transfer audits on staff after R1's fall. She acknowledged audits after R1's fall would have helped to verify staff followed resident care plans and to ensure staff were competent to use the lifts. She commented she had placed a note in the nursing communication book on 8/20/21 (three days after R1's fall) that reminded staff to follow resident care plans; however, she denied staff acknowledged the communication book entry and further denied she tracked or audited their review of this education. The DON explained because there was one staff who failed to provide resident cares as care planned, there was a risk of other staff who performed the same way; thus, all staff should be retrained. A facility policy titled, Using the Care Plan dated 6/7/21, indicated, The care plan shall be used in developing the resident's daily care routines. A facility policy Lifting Machine, Using a Mechanical dated 5/21/21, indicated the policy's purpose was to establish general principles of safe lifting using a mechanical lifting device and directed, Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. One staff was indicated for use of the mechanical standing lifts. However, the policy failed to identify two staff may be required for lift use based on the residents medical condition and care planned needs, in which staff were then expected to follow the residents care plan for mechanical standing lift use.

Based on observation, interview and document review, the facility failed to ensure insulin from a [MEDICATION NAME] (single dosing system which uses a new needle attached each time) was administered in accordance with manufacturer directions to ensure proper dosing for 1 of 2 residents (R6) observed during medication of insulin via an insulin pen. Findings include: R6's quarterly minimum data set ((MDS) dated [DATE], identified R6 was cognitively intact, was independent with activities of daily living (ADLs) with [DIAGNOSES REDACTED]. R6's current physician orders [REDACTED]. Give with sliding scale insulin dose to give one injection. On 6/10/19, at 5:52 p.m. registered nurse (RN)-A was observed as she set up R6's Humalog. R6's blood sugar was 400 with 3 carbohydrates consumed at meal. R6 was to receive Humalog 18 units, RN-A turned the dial of the pen to 20 units then turned the dial back to 18 units. RN-A did not prime (the process of removing the air from the needle and cartridge which may have collected during normal use) the pen per manufacturers instruction to ensure an accurate dose would be delivered. RN-A entered R6's room, to deliver the medication and was stopped by the surveyor prior to administering the dose. RN-A stated she had been taught to dial 2 units past the desired dose then turn back to desired dose before administering insulin with a flex-pen. RN-A then turned the dial to 2 units primed the needle, then turned dial to desired dose of 18 units before administering dose to R6. An undated, Humalog KwikPen user's manual identified a procedure to administer the insulin while using the pen. The instructions identified to avoid getting too much or too little insulin to attach the needle to the KwikPen, turn the dose knob to 2 units, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob until it stops and 0 is seen in the dose window, insulin should be seen at the tip of the needle. When interviewed on 6/12/19, at 8:43 a.m. the director of nursing (DON) stated the facility policy was to prime the pen before each use with 2 units of insulin unless the manufacture specifies a different amount of insulin to prime with. The pen was to be primed to ensure the pen and needle was worked and ensured the proper dose of insulin was administered. The facility policy Insulin Administration-Long Term Care dated 4/19, identified staff were to prime the pen with 2 units of insulin if the dose increments of the pen were single units, if the dose increments of the pen was 5 units, then dial to 5 units. Staff were directed to press the injector button down to 0. The policy then directed staff to dial pen to the ordered dosage for injection and proceed with administration.

Based on interview and document review, the facility failed to follow-up and implement treatment for [REDACTED]. Findings include: R38's quarterly Minimum Data Set ((MDS) dated [DATE], identified R38 had moderate cognitive impairment, however, displayed no delusional behavior. Further, R38 had minimal difficulty with hearing and did not wear hearing aids. During interview on 4/16/18, at 1:10 p.m. R38 stated her hearing was not good at all, and she was unable to hear like she used to. R38 explained her left ear was bothering her for quite a few months with abruptly poor hearing, and staff had checked her left ear for wax build-up, however, none was found. R38 stated she was not aware of anything else being done or looked at to help diagnose or potentially restore her hearing in her left ear, nor if her physician had even been notified of her concern. R38 expressed frustration with her hearing stating, (I) feel foolish that I can't hear, but what can I do about it? R38's progress note(s) identified the following entries: On 2/27/18, (R38) has (complaints of) ear pain in her left ear . noted a layer of creamy looking exudate on the bottom of her ear canal but her ear did not appear to have wax build up. Resident winced in pain when attempting to look in her ear which is not normal for her. Placed a hot compress on her ear and told her to let us know if her ear continued to hurt in the AM. On 2/28/18, . (left ear) looks good, no extra wax present, no redness noted. (R38) states her left ear hurts when she touches it and she can't hear out of it . Did notify charge nurse. On 3/1/18, Followed up with resident's (complaints of) left ear pain . states that she cannot hear 'as well' out of it. No wax visible in ear canal by otoscope. Discussed option of administering mineral oil to try and soften any unnoticeable wax. Resident agreed to try mineral oil for 3 days. Task initiated to start 3/2/18. R38's medical record lacked any evidence R38's physician had been notified of her complaints with hearing loss or ear pain, nor was there evidence to identify R38's ears had been irrigated after the treatment of [REDACTED]. Further, the record lacked any evidence audiology was contacted to help address the hearing concerns voiced by R38. When interviewed on 4/18/18, at 1:53 p.m. registered nurse (RN)-A stated R38 had made no further complaints of hearing loss since staff used mineral oil in (MONTH) (YEAR), so she thought it had been resolved, however, added she had not specifically followed up with her about the concern(s). RN-A explained R38 had just been seen by the nurse practitioner in the recent past, and if she had unresolved complaints about her hearing, she would voice it to the physician. RN-A reviewed R38's medical record and acknowledged it lacked evidence R38's ears were irrigated after having the mineral oil instilled, nor any consultation with audiology or R38's physician regarding her complaints of ear pain and hearing loss. Further, RN-A explained it was important to follow up on concerns like these so residents don't have complications related to their care or any unanswered questions. A facility provided Care of Hearing Impaired Resident policy dated 06/2017, identified several guidelines for care of a hearing impaired person including administer hearing test(s) as ordered by the physician, and arranging for consultation with an otologist if needed.

Based on observation, interview and document review, the facility failed to coordinate care with an outside health agency for the use of hand splint(s) to prevent possible contracture for 1 of 2 residents (R2) reviewed for range of motion (ROM) and who had limited functional movement of their hands. Findings include: R2's admission Minimum Data Set ((MDS) dated [DATE], identified R2 had intact cognition and displayed no delusional thinking or rejection of care behaviors. Further, R2 had functional limitations in range of motion (ROM) on both sides of his upper and lower extremities, and was quadriplegic (a paralysis of all four limbs). When interviewed on 4/16/18, at 4:20 p.m. R2 stated he was unable to scratch his nose or head due to very limited range of motion from his hands. R2 explained he resided at the nursing home, however, went out to the VA (Veteran's Administration) for a lot of his health care and rehab needs. R2 directed the surveyor to a box on the floor next to his dresser which had two separate static positioning splints (one for each hand) still in their packaging and sealed. R2 stated he was supposed to be using them according to the VA, however, nobody was applying them and the nursing home therapy had not worked with me yet about them. R2 expressed frustration with not using the splints, and the lack of explanation about their lack of use, from the nursing home staff. During observation on 4/17/18, at 8:56 a.m. R2 was seated in an electric wheelchair in the dining room being assisted with eating by staff. R2's hands were supported on a rolled piece of foam, and his fingers were all extended outwards from his hand with no visible contracture(s) present. There were no splints or devices on his hands. During subsequent observation on 4/18/18, at 8:44 a.m. R2's hands were down on his lap, and he continued to have no visible splints or devices used on his hands. R2's care plan dated 1/3/18, identified R2 was independent with decision making and demonstrated good cognitive abilities. R2 had a self care deficit and was unable to perform activities of daily living (ADLs) on his own. Further, the care plan directed staff to complete passive ROM with R2's upper extremities twice a day, however, lacked any information on using splints or devices on his hands to prevent contracture. R2's progress note(s) identified the following entries: On 2/15/18, .called (family) and she will inquire with the VA regarding getting (R2) resting hand splints and a commode chair . On 2/23/18, OT (occupational therapy) to see for 6 visits over 12 week period for maintenance therapy for UE (upper extremity) ROM, [MEDICAL CONDITION] and splinting UE. R2's medical record was reviewed, and lacked any evidence these splints had been assessed, or coordinated with the VA to develop and implement a treatment plan for their use. When interviewed on 4/18/18, at 8:52 a.m. nursing assistant (NA)-A stated R2 had ROM and hand exercises completed daily by staff. NA-A explained R2's fingers typically were straight out from his palm in a sprawled out manner, however, his movement of them had not changed since he admitted in January. R2 did not wear any splints or devices on his hands, however, NA-A acknowledged R2 had resting hand splints in his room. When questioned about them, NA-A stated R2 had told her about them a couple weeks ago, however, staff had not been instructed or given direction on how to use them for R2. During interview on 4/18/18, at 11:59 a.m. registered nurse (RN)-A stated R2's family member had brought the splints in and staff did not have any real instructions on using them. They had been at the facility for about a week and a half, and RN-A stated she requested physical therapy (PT) to review them and thought they did. RN-A reviewed R2's medical record, including EPIC (hospital record system), and stated there were no entries or directions identified from nursing or therapy for their use. When interviewed on 4/18/18, at 12:40 p.m. physical therapist (PT)-A stated staff were still waiting for clarification from the VA on the resting splints and how to use them. PT-A explained she thought RN-A was following up on their use with the VA. During follow-up interview on 4/18/18, at 2:07 p.m. RN-A stated the VA needed to give us direction on how to use those for R2. RN-A expressed the coordination of care was not that great with the VA sometimes though, and staff were now trying to get clarification on how to implement the resting hand splints. Further, RN-A stated it was important to coordinate care with the VA to provide continuity of care. A facility Restorative Nursing Programs - ROM and Ambulation Guidelines for ROM Exercises policy dated 06/2017, identified a procedure to complete ROM exercises, however, lacked any direction or guidance on splint and/or device use within the facility. A facility policy on coordination of care with outside resources was not provided.

Based on interview and documentation review, the facility failed to seek clarification for physical therapy orders for 1 of 1 residents (R39) who had had orders to continue physical therapy. Findings include: During interview on 4/17/18, at 10:03 a.m. R39 stated he had been informed by the orthopedist specialist at his last appointement he was to receive therapy but was unsure as to when this would start or why it had not begun. R39's admission Minimum Data Set (MDS) of 3/26/18 identified R39 had intact cognition and received extensive with mobility. R39's [DIAGNOSES REDACTED]. R39's care area assessment (CAA) dated 4/2/18 identified need for assist with two staff and four wheeled walking for ambulation. R39's care plan with last review completed 4/4/18 identified an alteration in comfort level and mobility related to a history of fractured femur. The care plan interventions included physical and occupational therapy as directed. R39's Consult Form dated 4/10/18, indicated under new orders to continue with physical therapy (PT), pain control per primary physician, and encourage ambulation. A review of the record lacked documentation of any follow up with physical therapy after the physician's appointment. On 4/18/18, at 1:45 p.m. registered nurse (RN)-A stated R39 was seen in clinic on 4/10/18 and an order was received for continuation of PT, however, R39 was not currently receiving any PT. RN-A stated a fax was sent to clarify the order, however, the fax had not been returned and further follow up had not been completed. During interview on 4/19/18, at 11:10 a.m. RN-B stated a call had been placed earlier to the geriatric nurse practitioner (GNP) to follow up on this request for initial therapy orders. On 4/19/18, at 2:25 p.m. the director of nursing stated since R39 had no current orders for PT, the order received on 4/10/18 required follow up for clarification. The DON stated as the order was processed late in the day as noted in the electronic record (5:32 p.m.) it would be her expectation clarification would be sought on the following day (4/11/18). A review of electronic narrative notes was completed with DON did not identify follow up calls were placed or faxes were sent to the physician/orthopedist for clarification. The DON stated if orders were received from the orthopedist for the resident to receive ongoing therapy to progress, it was important to follow through with these orders in a timely fashion. A facility policy was requested for process of transcribing orders after physician or specialist consults but was not received.

Based on interview and document review, the facility failed to ensure 1 of 9 residents, R1, reviewed for abuse, was free from abuse when R1 was resistive to cares when staff was assisting him with cares. The staff member, nursing assistant (NA)-H, grabbed R1's hands and forced them on the mechanical standing lift which resulted in multiple bruising and discolored areas on both of R1's hands. Findings include: R1's significant change Minimum Data Set ((MDS) dated [DATE], indicated the resident had severe cognitive impairment, had behaviors of rejection of care, and required extensive staff assistance with transfers, toileting, and dressing. R1's care plan dated 1/12/18, indicated the resident had a history of [REDACTED]. R1's care plan directed staff to approach the resident warm and positively, attempt to determine the underlying cause of the behavior, and if the resident developed a behavior while staff was providing cares they should ensure the resident is safe and reapproach the resident at a later time. R1's care plan also indicated the resident was at risk for unreported pain due to dementia and directed staff to observe for non verbal signs of pain. R1's Progress Note dated 1/25/18, at 7:55 p.m. indicated the resident had petechiae on both the posterior right and left hands including: Left Hand: Between thumb and forefinger; 2.2 cm (centimeter) x 2 cm yellowish colored area with (2) 0.2 cm in diameter red petechiae that were 0.7 cm apart and 4 pinpoint red petechiae superior to the (2) 0.2 red petechiae. Right Hand: 4 cm superior to the metacarpophalangeal joint of forefinger and 3.5 cm lateral to the metacarpophalangeal joint of the thumb. 0.8 cm x 0.4 cm area with (2) 0.1 cm red petechiae 0.5 cm apart. A facility investigation dated 1/31/18, indicated on 1/25/18, at approximately 2:00 p.m. NA-F approached social worker (SW)-C and stated she had concerns about an interaction she had just witnessed with R1 and NA-H. NA-F stated NA-H requested assistance to change R1's pants. NA-F stated when she entered the bathroom R1 was yelling and swinging out refusing assistance from NA-H. NA-H demanded R1 hang on to the mechanical standing lift and grabbed R1's hands forcefully and placed them on the bars of the mechanical standing lift. NA-F suggested to NA-H they reapproach R1 at a later time but NA-H stated, I am changing his pants! NA-F stated she felt R1 was physically and emotionally abused by NA-H during the interaction. As part of the facility investigation, 5 cognitively intact residents were interviewed by SW-C on 1/25/18, and 1/26/18. R5 indicated NA-H did not explain cares and always rushed. R6 indicated NA-H did not explain cares and she, Slams doors. R7 had no concerns with NA-H. R8 stated NA-H rushed through cares and would rather not have her provide cares to him. R9 stated NA-H went fast with cares and can be, Crabby and sassy, she makes you feel stupid and abrupt. During interview on 3/22/18, at 9:45 a.m. NA-F stated on 1/25/18, she assisted NA-H with cares for R1. NA-F stated when she walked into the bathroom R1 was yelling, swinging his arms at NA-H, was attempting to push the mechanical standing lift away, and was yelling, No! NA-F stated she told NA-H they should stop attempting to assist R1 and attempt to assist R1 at a later time. NA-F stated NA-H grabbed R1's hand(s) and, slammed, them onto the bars of the mechanical standing lift and started to raise the lift. NA-F stated R1 was still swinging his arms around and yelling when NA-H continued to raise the mechanical lift. NA-F stated she felt NA-H was abusive to R1 and went immediately to the charge nurse and SW-C after witnessing the interaction between NA-H and R1. During interview on 3/22/18, at 11:50 a.m. NA-D stated she was aware some residents had requested in the past they did not want NA-H to provide cares to them. NA-D stated she never heard NA-H was abusive, however, she was task orientated and did not take the resident's preferences into account. NA-D stated she had seen NA-H force a resident's hand on the mechanical lift and on a grab bar in the past, however, she did not feel it was abusive and did not believe she had bruised or left any marks on residents. During interview on 3/22/18, at 12:15 p.m. NA-E stated she had no concerns regarding resident mistreatment with NA-H. NA-E stated there had been several resident's in the past who requested NA-H not provide cares to them, however, that was due to the resident's feeling NA-H was rushed. No resident's had reported to NA-E they had been mistreated or abused by NA-H. During interview on 3/22/18, at 1:05 p.m. licensed practical nurse (LPN)-G stated both resident's and staff had reported to her NA-H did not put resident needs first, and she was very focused on getting tasks complete without taking the resident preferences into account. During interview on 3/22/18, at 12:30 p.m. SW-C stated when notified about the incident on 1/25/18, between R1 and NA-H she immediately called NA-H into the conference room for an interview. SW-C stated NA-H explained R1's pants were wet and he needed to be changed. SW-C stated she and the director of nursing proceeded to interview staff and resident's regarding NA-H. SW-C stated when the investigation was complete it was determined to terminate NA-H's employment with the facility related to the interviews with staff and resident's, the current allegation regarding R1, the bruising on R1's hands, and previous coaching sessions done in the past related to resident interactions with NA-H. During interview on 3/26/18, at 9:25 a.m. NA-H stated on 1/25/18, R1's pants were wet and she took him to the bathroom to get him changed. NA-H stated R1 was swinging his arms and was resisting getting hooked up to the standing mechanical lift so she called NA-F for assistance. NA-H stated R1 kept refusing assistance with cares, however, she felt she needed to get R1 out of the wet pants. NA-H stated she had provided cares for R1 in the past and he had a history of [REDACTED]. NA-H stated she put R1's hand's on the bars of the standing mechanical standing lift but did not think she had forced his hands. NA-H stated it could have been perceived that her interaction with R1 was inappropriate. NA-H stated she may have raised her voice to R1 and looking back she knows she should have just, Walked away. During interview on 3/26/18, at 10:05 a.m. registered nurse (RN)-I stated she assessed R1's hands on 1/25/18, after the reported incident with NA-H. RN-I stated she was directed to monitor the resident for bruising related to allegations of NA-H grabbing R1's hands with force. RN-I stated when assessing R1's hands she noted multiple discolorations and petechiae spots. RN-I stated according to her assessment of R1's hands, the bruising on R1's hands appeared like fingerprint marks and did not seem to be bruising the resident could have obtained from being combative or striking his hand(s) on something. RN-I stated she could not remember the specific time she did the skin assessment on 1/25/18, however, the resident had no behaviors after the incident with NA-H until the skin assessment was completed. Review of NA-H's employee record indicated on 1/30/17, NA-H transferred a resident without the use of a transfer belt. When transferring the resident the resident told NA-H that it hurt. NA-H responded to the resident by saying, No, it didn't hurt. The DON re-educated NA-H and reviewed the facility abuse and prevention policy with NA-H. On 2/16/17, a resident reported NA-H was rough with her when assisting her with changing her shirt. The resident asked for NA-H to no longer provide cares to her. The DON re-educated NA-H, reviewed the facility abuse prevention plan, and was required to complete effective customer service videos #1, #2, #3, and #4. An Employee Corrective Action form dated 1/31/18, indicated NA-H was discharged from employment with the facility effective 1/31/18. The Corrective action form indicated the detailed explanation of the offense: - Resident's had continually reported a pattern of roughness, demeaning, and reports of pain when assisting them with transfers. - Being disrespectful to resident's feelings. On 1/25/18, harsh handling of a resident which caused petechiae to bilateral hands. - Resident's continue to report on how rough NA-H handles them, how rushed their cares are, and the disrespect by not explaining their cares to them. - The Corrective action form included description of previous related consultations, including disciplinary actions which included: - Counseling conference 1/30/17, for inappropriately transferring a resident without use of a transfer belt and belittling the resident's feelings. - Counseling conference on 2/16/17, for roughness with a resident when assisting the resident in getting dressed. - Performance appraisal on 11/30/16, which indicated resident centered care needed improvement, needs improvement in the areas of listening, teamwork, serving as a positive role model, and resident care competency. - Performance appraisal 10/3/17, noted a need in improvement in the areas of improving communication with resident's, listening, being open to ideas, and being aware of the shadow you cast related to being negative and short. - The Employee Corrective Action form was signed by NA-H on 1/31/18. The facility policy titled Vulnerable Adults- Abuse Prevention Policy- Long Term Care, dated 11/2017, indicated the definition of physical abuse as the use of physical force that may result in bodily injury, physical pain, or impairment. This includes, but is not limited to hitting, slapping, pinching, and kicking.

Based on interview and document review, the facility failed to implement a comprehensive infection control program to include analysis of collected data to prevent potential spread of infection in the facility. This had potential to affect all 46 residents, staff and visitors in the facility. Findings include: The facility collected infection control data for each month was provided by registered nurse (RN)-A on 2/13/17, and identified the following information: NOVEMBER 2016: A Monthly Report of Resident Infections in Facility listing dated 11/2016, identified five different residents had infections, with two urinary tract infections (UTI), three lower respiratory (LR) and one ophthalmic infection being identified. The flowsheet identified each infection' date of start, site, antibiotic treatment, and corresponding cultures (if obtained). Further, the listing identified four of the infections were facility acquired, and two were community acquired. An undated Koronis Manor Care Center Resident Infections 2016 graph was provided. The graph was color coded with several categories of infections including upper respiratory, lower respiratory, skin/wound, gastrointestinal (GI) and ear. The graph listed October 2016 and November 2016 data, however lacked any documented analysis of the collected data to determine if infections were spreading, or if any action plans needed to be developed to address the identified infections. No further information was provided to demonstrate any analysis of the collected data had been completed to determine if the identified infections were related and/or spreading; or if any action plans had been identified or implemented to address them. DECEMBER 2016: A Monthly Report of Resident Infections in Facility listing dated 12/2016, identified nine different residents had infections, with six UTI, one LR, one cellulitis and one being listed, Unknown. The flowsheet identified each infection' date of start, site, antibiotic treatment, and corresponding cultures (if obtained) along with six of the infections being facility acquired, and two being community acquired. Further, the listing identified two of the UTIs were resulted from the same organism, Proteus Mirabilis (bacteria commonly seen in UTI's), between two different residents on the same unit (North). An undated Koronis Manor Care Center Resident Infections 2016 graph was provided. The graph was color coded with several categories of infections including upper respiratory, lower respiratory, skin/wound, GI and ear. The graph listed October 2016, November 2016 and December 2016 data, however lacked any documented analysis of the collected data to determine if infections were spreading, or if any action plans needed to be developed to address the identified infections. A Infection Control Report dated 12/2016, identified the facility had six, Facility acquired, infections with five being UTI related, and one cellulitis. The report listed two community acquired infections including one UTI and one LR. Further, the report identified 16 episodes of employee illnesses and added, Employee illnesses and resident illnesses are not found to be in correlation with each other. No further information was provided to demonstrate any analysis of the collected data had been completed to determine if the identified infections were related and/or spreading, or if any action plans had been identified or implemented to address them. JANUARY 2017: A Monthly Report of Resident Infections in Facility listing dated 1/2017, identified 15 different residents had infections, with one UTI, five LR, two fungal, two ophthalmic, and one cellulitis. The flowsheet identified each infection' date of start, site, antibiotic treatment, and corresponding cultures (if obtained) along with 13 of the infections being facility acquired, and three being community acquired. Further, the listing identified one resident had tested positive for Influenza B. An undated Koronis Manor Care Center Resident Infections 2017 graph was provided. The graph was color coded with several categories of infections including upper respiratory, lower respiratory, skin/wound, GI and ear. The graph listed October 2016, November 2016, December 2016 and January 2017 data, however lacked any documented analysis of the collected data to determine if infections were spreading, or if any action plans needed to be developed to address the identified infections. A Infection Control Report dated 1/2017, identified the facility had 13, Facility acquired, infections with five being LR, one UTI, three skin/wound, one ophthalmic, one vaginal and two being classified as, Other. The report listed three community acquired infections including one ophthalmic and two LR. Further, the report identified 28 episodes of employee illnesses and added, Employee illnesses and resident illnesses are not found to be in correlation with each other. A Koronis Manor Care Center Resident Infection Report 2017 dated 10/2016 to 1/2017, identified four columns with each month being listed. The infection, Incidence Rate(s), were identified as follows: October 2016 - 2.67% (percent), November 2016 - 2.82% and, December 2016 - 4.32% and, January 2017 - 9.33%. No further information was provided to demonstrate any analysis of the collected data had been completed to determine if the identified infections were related and/or spreading, or if any action plans had been identified or implemented to address the increasing infection incidence rate for the facility. When interviewed on 2/15/17, at 10:01 a.m. RN-A stated she was in charge of the infection control program and had been overseeing it for the past, Year and a half approximately. RN-A stated she gathered infection data by reviewing progress notes and consulting with the floor staff, then tracked them on the provided listings. At months end, RN-A then enters the collected data onto a spreadsheet and creates the provided reports containing the data. RN-A stated these reports are then presented at the infection control and quality assurance meetings. RN-A stated there had been no documented analysis of the collected data to determine in the identified infections were related or spreading, nor had any action plans been developed to address the increasing infection incidence rate identified on the reports. A facility Infection Prevention and Control Program policy dated 2/2017, identified the infection control program was used to, Decrease the risk of infection to residents and personnel, monitor for occurrence of infection, implement appropriate control measures, identify and correct problems relating to infection prevention practices, and maintain compliance with state and federal regulations relating to infection prevention. Further, the policy directed staff to complete on-going monitoring of infections amongst residents and employees and document record of community acquired and health-care associated infections. The policy did not identify any steps to ensure the collected data was routinely reviewed and analyzed to determine if infections were spreading, or if any action plans needed to be developed to address the identified infections.

Based on interview and document review, the facility failed to ensure the supplemental nursing service agency (SNSA) being used to provide care to residents was registered with the Minnesota Department of Health (MDH). This had the potential to affect all 49 residents residing in the facility. Findings include: During interview on 4/7/16, at 11:30 a.m. the administrator stated the facility used 3 SNSA agencies for staffing, one of which was Cariant Health Partners agency. However, the administrator stated Cariant Health Partners agency was not listed in the Directory of Registered Supplemental Nursing Services Agencies (SNSA's) online with MDH dated 4/1/16. During phone interview on 4/7/16, at 2:47 p.m. MDH SNSA representative stated they had no record Cariant Health Partners agency was registered as a SNSA with MDH. During interview on 4/7/16, at 3:00 p.m. the administrator and director of nursing stated the facility routinely used Cariant Health Partners agency for supplemental nursing staff and had used them in the last 3 months, and they were not aware the agency was not registered in the state of Minnesota as an SNSA according to SNSA statute 144A.71. 144A.71 Subdivision 1. Duty to register. A person who operates a supplemental nursing services agency shall register the agency with the commissioner. Each separate location of the business of a supplemental nursing services agency shall register the agency with the commissioner. Each separate location of the business of a supplemental nursing services agency shall have a separate registration. Subd. 2. Application information and fee. The commissioner shall establish forms and procedures for processing each supplemental nursing services agency registration application. An application for a supplemental nursing services agency registration must include at least the following: (1) the names and addresses of the owner or owners of the supplemental nursing services agency; (2) if the owner is a corporation, copies of its articles of incorporation and current bylaws, together with the names and addresses of its officers and directors; (3) satisfactory proof of compliance with section 144A.72, subdivision 1 </statutes/?id=144A.72>, clauses (5) to (7); (4) any other relevant information that the commissioner determines is necessary to properly evaluate an application for registration; and (5) the annual registration fee for a supplemental nursing services agency, which is $891. Subd. 3. Registration not transferable. A registration issued by the commissioner according to this section is effective for a period of one year from the date of its issuance unless the registration is revoked or suspended under section 144A.72, subdivision 2 </statutes/?id=144A.72>, or unless the supplemental nursing services agency is sold or ownership or management is transferred. When a supplemental nursing services agency is sold or ownership or management is transferred, the registration of the agency must be voided and the new owner or operator may apply for a new registration.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R31) observed during transfers was comprehensively assessed for safe transfers using the MedCare brand stand (mechanical device that uses a harness to stand someone) with an EZ Way harness, which the EZ Way manufacturer had not recommended to use with other mechanical stand brands. This had the potential to affect an additional 4 residents (R28, R10, R44, and R68) residing on the North Unit who used MedCare and EZ Way stands/harnesses interchangeably for resident transfers. Findings include: R31's quarterly Minimum Data Set (MDS), dated [DATE], identified R31 had intact cognition, and required extensive assistance of two staff to complete transfers. R31's care plan, dated 4/16/14, identified R31 was at risk for falls, and required, "Transfer: Ext (extensive) Assist of 1-2 and EZ Stand." During observation of care on 3/4/15, at 7:06 a.m. nursing assistant (NA)-A entered R31's room with a MedCare mechanical stand which had two different colored harnesses (A blue harness, developed by MedCare along with a green harness, developed by EZ Way, Inc.) on top of the device, placing it in front of R31 who was seated in her wheelchair. NA-A removed the EZ Way brand harness from the top of the MedCare stand, placed it behind R31 and secured the it to the stand using two cloth loops on the harness. R31 was stood up from her wheelchair and assisted into the restroom with the mechanical stand. At 7:09 a.m. R31 was assisted to stand, using the same stand and harness, and seated back in her wheelchair. NA-A detached the EZ Way harness from the MedCare stand, placed it back on top of the device, and placed it back in the hallway for further use with other residents at 7:14 a.m.. During review of R31's medical record, indicated there was no assessment to determine if R31 was safe to transfer with a MedCare mechanical stand and EZ Way harness. When interviewed on 3/4/15, at 12:59 p.m. registered nurse (RN)-A stated the residents are not assessed for safety when interchanging the mechanical stands and harnesses. Further RN-A stated, "I don't see a problem." Review of the EZ Way Stand Operator's Instruction manual, dated 3/11/09, identified, "EZ Way harnesses are made specifically for EZ Way stands. For the safety of the patient and caregiver, only EZ Way harnesses should be used with EZ Way stands." Review of the MedCare Products Operation Manual, dated 2014, identified, "MedCare slings and belts have been specifically designed and tested for use with lifts and stands manufactured by MedCare Products, Inc. and any other lift with a 4 point hanger bar loop system." There was no indication if another manufacturer's harnesses could safely be used with their mechanical stands. During interview on 3/4/15, at 9:06 a.m. licensed practical nurse (LPN)-A stated some residents have a preference for a certain harness because of comfort, however EZ Way harnesses should only be used with EZ Way mechanical stands, "I believe so." When interviewed on 3/4/15, at 9:14 a.m. NA-C held up both harnesses side by side, and stated the EZ Way harness had two attachment points, while the MedCare harness had three attachment points. Further, the staff had been told all harnesses are interchangeable, and could be used with either brand of mechanical stand. During interview on 3/4/15, at 7:26 a.m. nursing assistant (NA)-A stated she had been told the harnesses could be used interchangeably, and were not specific to each manufacturers product. She further stated the North Unit had four residents (R28, R10, R44 and R68) who used MedCare and EZ Way stands/harnesses for resident transfers. R28's quarterly MDS, dated [DATE], identified R28 had short and long term memory problems, and required extensive assistance from two staff to complete transfers. R28's care plan, dated 4/17/14, identified she was at risk for falls, needed assistance with activities of daily living (ADLs) and required, "Transfer: EZ Stand and assist of 1-2." During review of R28's medical record, no assessment was located to determine if R28 was safe to transfer with a MedCare mechanical stand and EZ Way harness, which the EZ Way manufacturer had not recommended for safety. R10's quarterly MDS, dated [DATE], identified R10 had moderate cognitive impairment, and required extensive assistance of one staff to complete transfers. R10's care plan, dated 2/2/15, identified she was at risk for falls, needed extensive assistance from staff for ADLs, and required, "Transfer: EZ-Stand with 1 assist." During review of R10's medical record, no assessment was located to determine if R10 was safe to transfer with a MedCare mechanical stand and EZ Way harness, which the EZ Way manufacturer had not recommended for safety. R44's annual MDS, dated [DATE], identified R44 had short and long term memory problems, and required extensive assistance of two staff to complete transfers. R44's care plan, dated 4/30/14, identified she was at risk for falls, and required, "Transfer: EZ Stand with 1, or 2 person stand pivot, Extensive Assist of 1-2." During review of R44's medical record, no assessment was located to determine if R44 was safe to transfer with a MedCare mechanical stand and EZ Way harness, which the EZ Way manufacturer had not recommended for safety. R68's initial care plan, dated 2/28/15, identified R68 was "forgetful", at risk for falls, and required assistance to transfer using the EZ Stand and assistance of one staff. During review of R68's medical record, no assessment was located to determine if R68 was safe to transfer with a MedCare mechanical stand and EZ Way harness, which the EZ Way manufacturer had not recommended for safety. During a subsequent observation on 3/5/15, at 8:48 a.m. three EZ Way mechanical stands, and a single MedCare mechanical stand were in the hallway of the North Unit and available for use to transfer residents. The MedCare stand had two harnesses sitting on top for use, a MedCare harness and a EZ Way harness. In addition, a EZ Way lift had two harnesses sitting on top for use, a MedCare harness and a EZ Way harness. During interview on 3/4/15, at 9:21 a.m. an EZ Way representative stated the MedCare company often tells people the harnesses are universal, however EZ Way does not agree. The EZ Way harnesses are tested with EZ Way mechanical stands, and the products are not able to be used on other manufacturer's mechanical stands, "We tell people, use our slings (harnesses) on our lift." When interviewed on 3/5/15, at 2:06 p.m. the director of nursing (DON) stated the MedCare mechanical stands were purchased in early 2014, and MedCare indicated the stands and harnesses were universal and interchangeable. Further, no residents had been assessed for safety with using the equipment against EZ Way manufacturer guidelines, but that manufacturer guidelines should be followed. During interview on 3/6/15, at 11:07 a.m. a MedCare representative stated he was unsure why EZ Way would say their products are not able to be used with MedCare stands, but felt the products were universal, "I have no idea why they would say that." Further, the facility was still responsible to ensure the resident was safe during the transfer, "They should be assessing if the transfer is done safe." A facility supplied memo from MedCare, dated 1/1/14, identified, "MedCare's patient lift slings are manufactured as "universal slings." Further, "It is imperative that caregivers operating patient lifts receive proper training for the application of each sling with each type of lift it is used." The memo lacked any indication if it was safe to use a EZ Way sling with a MedCare lift. A facility E/Z Stand policy, dated 12/2014, identified a purpose of, "Provide staff with procedural guidelines for the safe use and care of the E/Z stand." However, the policy lacked any direction for assessment of resident safety using the mechanical stands and harnesses, nor if the different manufacturer's products were interchangeable. There was no indication that facility had comprehensively assessed the use of an MedCare brand stand (mechanical device that uses a harness to stand someone) with an EZ Way harness, eventhough on 3/6/15, at 11:07 a.m. a MedCare representative stated, "They (the facility) should be assessing if the transfer is done safe," eventhough the EZ Way manufacturer had not recommended to use their harnesses with any other mechanical stand brands.

Based on interview, and document review, the facility failed to notify the family regarding a roommate change for 1 of 1 residents (R56) reviewed with cognitive impairment, and whom had a new roommate. Findings include: R56's significant change Minimum Data Set (MDS), dated [DATE], identified R56 had severe cognitive impairment, and it was "very important" to have her family involved in her care. During interview on 3/3/15, at 1:00 p.m. family member (FM)-A stated he was the person who was typically notified of changes in R56's care. Further, R56 had several roommate changes in the past couple months, and staff did not update him with those changes stating, "It would be nice to know that." When interviewed on 3/5/15, at 12:29 p.m. licensed practical nurse (LPN)-A stated R56 has had two different roommates, with the current roommate admitting just a few days prior. Further, the facility's licensed social worker (LSW) was responsible for notifying residents and families regarding room and roommate changes. During interview on 3/5/15, at 1:06 p.m. LSW-A stated she was responsible for notifying residents and families about room and roommate changes, and her typical practice was to notify the resident just prior to the roommates admission. R56 had been told on Friday (2/27/15) that she (R56) would be getting a new roommate over the weekend. Further, LSW-A stated she did not notify any family members, despite R56's severe cognitive impairment, regarding a roommate change, "I always knew I had to tell the residents, and that's what I did." A facility LTC (Long Term Care) Interdisciplinary Care Team policy, dated 6/2014, identified a procedure which included, "The Social Worker will serve as the coordinator of any admissions, transfers/room changes, or discharges...", in which the LSW would, "Notify the resident, their roommate, and any responsible party of the decision."

Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 4 residents (R44) observed who required staff assistance for eating. Findings include: R44's diagnoses, as indicated in the annual Minimum Data Set ((MDS) dated [DATE], identified R44 had dementia and [MEDICAL CONDITION], had severe cognitive impairment, and required extensive assistance of 1-2 persons for all activities of daily living (ADLs), including eating. During observation on 3/4/2015, at 12:03 p.m. nursing assistant (NA)-D was pushing R44 into the dining room in her wheelchair, while R44 was dozing off for the noon meal. NA-D told R44 about the noon menu, placed a clothing protector around R44's chest, and then exited the room to assist other residents into the dining area. At 12:13 p.m., R44, was asleep with her chin on her chest. At 12:23 p.m., three other residents who were seated at the table with R44 were served their meals. NA-C, who was seated opposite R44 at the same table, began assisting the residents nearest her. At 12:26 p.m., R44's meal tray was brought to the table, and NA-D sat down to the right of R44, who was asleep. NA-D began to talk and gently massaged her arm to attempt to wake her. NA-D continued to talk to R44, whose eyes were closed and chin still touching her chest, placed a spoon in her hand, and encouraged her to begin eating. R44 nodded to NA-D's words with her eyes closed. NA-D offered R44 a bite of food from another spoon, and R44 took a small bite with her eyes closed. At 12:27 p.m., NA-D suddenly stood up and left the dining room. R44 continued to doze off with her spoon in her hand, and did not attempt to feed herself, nor was provided assistance from staff to eat from 12:28 p.m. until 12:37 p.m. (9 minutes). NA-C, who was seated at the same table, neither provided R44 assistance nor offered encouragement to eat, but rather continued to assist the two residents nearest her. At 12:37 p.m., NA-D returned to the dining room and began feeding R44 her meal. NA-D remained with R44 in the dining room, assisting her to eat, until 1:00 p.m. In an interview on 3/4/2015, at 1:07 p.m. nursing assistant (NA)-D stated she left the table because she had been "called to help with a transfer", and left R44 unattended. During an interview on 3/5/2015, at 10:33 a.m. registered nurse (RN)-A stated NA's should not leave the resident while helping them to eat, and they should be able to finish their meals "without interruption." In an interview on 3/5/2015 at 1:27 p.m., the director of nursing (DON) stated she "fully agreed with the charge nurse", that it was not dignified for any residents meal time to be interrupted. A facility policy entitled "Resident Bill of Rights," undated, in the "Quality of Life" section, under dignity, indicated the following: "The facility must, with courtesy, promote and care for you in a manner and environment that maintains or enhances your dignity and respect, in full recognition of your individuality."