Every finding on record at Cura of Watkins

Based on observation, interview and document the review the facility failed to ensure the dishwashing machine temperatures reached adequate washing temperatures to clean and sanitize ddishware. This deficient practice had the potential to affect all 46 residents who received meals from the facility's kitchen. Findings include: On 3/20/24 at 8:22 a.m., while observing the dishwasher, the wash cycle was observed 4 times and the temperatures were as follows: Wash cycle #1 at 8:22 a.m. =147 degrees Fahrenheit ( F) Wash cycle #1 at 8:23 a.m. =148 F Wash cycle #1 at 8:25 a.m. =149 F Wash cycle #1 at 8:27 a.m. =152 F On 3/20/24 at 8:27 a.m., the dietary dishwasher (DD)-A stated it was a common occurrence for the dishwasher wash cycle to not reach the required temperature of 150 F, since date of hire (November 2023). The log for the dishwasher temperatures was reviewed and indicated wash cycle temperatures greater than 150 F. DD-A stated the machine had to run a few times before it got to the required temperature that morning. However, DD-A stated when/if the wash cycle did not reach the required temperature the dishes were put out for use and not rewashed. On 3/20/24 at 9:23 a.m., the dietary manager (DM)-A stated they had not been notified the dishwasher was not meeting required wash cycle temperature. DM-A confirmed the dishwasher used high heat and chemical to sanitize and the required temperatures were 150 F for wash cycle and 180 F for rinse cycle. The DM-A expected staff to rewash dishes if the dishwasher did not get to the required washing temperature and report occurrence to DM-A. On 3/21/24 at 4:15 p.m., the maintenance staff (MA)-A confirmed the required temperatures for the dishwasher was a wash cycle at 150 F or higher, and sanitize cycle at 180 F. Additionally, MA-A confirmed issues in the past with dishwasher temperatures had been addressed. On 3/21/24 at 4:22 p.m., the Ecolab technician who maintained the machine for the facility confirmed the wash cycle needed to reach 150 F and the rinse cycle 180 F. If the temperature did not reach 150 F, staff should have run a test strip to ensure the machine reached the required temperatures. Prior to washing dishes, approximately 20-30 cycles could be necessary to reach the required 150 F. The facility policy Operation of the Dish Machine dated 03/2024, indicated the required ranges was >150 F for the wash cycle and >180 F for rinse cycle.

Based on interview and document review, the facility failed to notify the physician and/or nurse practitioner (NP) for 1 of 3 residents (R34) reviewed for change of condition. Findings include: R34's quarterly minimum data set (MDS) dated [DATE], identified R34 had severe cognitive impairment and diagnoses which included dementia, Alzheimers, chronic kidney disease, edema and constipation. A review of R34's medical record revealed on 3/16/2024, at 4:41 a.m. a nursing progress note indicated Resident had small blood clots in her incontinent product. Further progress note on 3/16/2024 2:22 p.m. indicated resident had an emesis during lunch. After lunch, resident also had blood clots in her stool noted. Progress note on 3/18/2024, at 2:26 a.m. indicated R34 had a large blood clot and blood coming from her rectum that filled her incontinent pad. Further review of R34's medical record revealed the medical record lacked evidence R34's physician and/or NP had been notified. During interview on 3/21/24, at 11:07 a.m. registered nurse (RN)-B stated R34 had not had blood clots coming from the rectum prior to this and was not sure if the physician and/or NP were notified. On 3/21/24, at 11:13 a.m. RN-C stated it was not ordinary for R34 to have blood clots or blood coming from the rectum. RN-C stated the provider would be informed of a change in condition if there was a concern with R34's comfort or if there was something out of the ordinary. On 3/21/24, at 12:15 p.m. director of nursing (DON) reviewed the medical record and verified the record lacked evidence the provider had been notified of clots and blood coming from the rectum. The DON stated the provider should have been updated blood and clots from the rectum are definitely not ordinary. Facility policy Change in a Resident's Condition or Status dated 1/2024 identified our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and /or status.

Based on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 2 of 2 residents (R19, R32), reviewed for hospitalization . This had the potential to affect all residents transferred to hospital. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], indicated R19's diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure, and R19 was cognitively intact. R19's progress notes indicated R19 was hospitalized from 6/3/23 through 6/8/23. R19's medical record lacked evidence the Ombudsman for LTC was notified of R19's transfer to the hospital. R32's face sheet, undated, indicated the following diagnoses hemiplegia and hemiparesis of the right side (weakness and paralysis on the right side), osteoarthritis, right femur fracture, and cerebral vascular infarction (CVA-stroke). Progress notes indicated R32 was hospitalized from 9/10/23 until 9/20/23 and 10/22/23 until 10/24/23. R32's medical record lacked evidence a written notification of transfer was sent to the Ombudsman for long term care. The facility's Admission/Discharge To/From Report for 6/1/23 to 6/30/23, listed resident names, dates, and location for seven residents discharged to home or other facilities from 6/1/23 through 6/30/23. However, the report did not include the names and dates of residents transferred to the hospital. On 3/21/24 at 1:03 p.m., social services director (SSD) stated the ombudsman of LTC was not notified of transfers to the hospital and was only notified of discharges to home or other facilities. SSD acknowledged the ombudsman should have been notified of all discharges, including residents transferred to the hospital. On 3/21/24 at 1:11 p.m., administrator acknowledged the ombudsman of LTC had not been notified of resident transfers to hospital. Administrator stated the ombudsman of LTC should have been notified of all resident hospital transfers. The facility's Transfer or Discharge, Emergency policy, last approved 3/2024, indicated the procedures that would be implemented for emergency transfer or discharge to a hospital. However, the policy lacked information regarding notification to the ombudsman of LTC. 49657

Based on observation, interview and document review the facility failed to ensure the required nurse staffing information was posted daily. This had the potential to affect all 46 residents residing in the facility and visitors who may have wished to view this information. Findings include: On 3/18/24 until 3/21/24 the staff posting was posted at the door. However, upon review of the weekend postings the facility only indicated licensed staff in the facility but did not differentiate between registered nurses (RN) and licensed practical nurses (LPN). The Staff Posting Report [NAME] dated 2/17/24, listed out 3 licensed staff working a total of 24 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 2/18/24, listed out 3 licensed staff working a total of 24 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 2/24/24, listed out 2 licensed staff working a total of 16 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 2/25/24, listed out 2 licensed staff working a total of 16 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 3/2/24, listed out 3 licensed staff working a total of 24 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 3/3/24, listed out 3 licensed staff working a total of 24 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 3/9/24, listed out 2 licensed staff working a total of 16 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 3/10/24, listed out 2 licensed staff working a total of 16 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 3/16/24, listed out 3 licensed staff working a total of 24 hours but no designation of their license being RN or LPN. The Staff Posting Report [NAME] dated 3/17/24, listed out 3 licensed staff working a total of 24 hours but no designation of their license being RN or LPN. On 3/21/24 at 9:00 a.m., the business office manager (BOM) stated the staff posting was auto populated by a computer program, printed daily and was not broken down to indicate RN or LPN and only listed them as licensed staff. The BOM confirmed the staff posing lacked information on the weekends. It was important to include so anyone who wanted to know the staffing, could view the information. On 3/21/24 at 2:00 p.m., the director of nursing (DON) confirmed on the weekends the RN's and LPNs were only listed out as licensed staff with no designation between RN and LPN. The DON stated it was important to include the information to show how many RNs were in the building and they have enough staffing coverage. The facility policy Posting of Nursing Hours-Long term care last approved 12/2022, indicated the total number of actual hours worked by the following categories of hours worked was to be listed on the posting: RNs, LPNs, certified nurse aides, and resident census.

Based on observation, interview, and document review, the facility failed to ensure an eternal (feeding) tube was consistently checked for placement prior to the administration of medications through for 1 of 1 residents (R1) whose medication administration was offered through a stomach tube. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had unspecified intracranial injury with loss of consciousness for unknown period of time (injury to the brain without being awake for an unknown length of time) with related diagnosis of dysphagia (difficulty swallowing), and use of an abdominal feeding tube (a type of tube going straight into the stomach). R1's current orders, dated 2/2/23, identified a G-tube (gastrostomy tube) (a type of tube going straight into the stomach) and received medications given directly into stomach. On 1/31/23 at 2:12 p.m. registered nurse (RN)-A was observed by 2 surveyors, performing medication administration in R1's room following medication review, gathering a marked syringe, and beaker with water. RN-A raised the head of the bed, donned clean gloves, connected syringe onto G-tube and using gravity flow method, poured 30 ml of water through the syringe. RN-A did not check the placement of the tube prior to the 30 ml pour of water, RN-A continued to administer crushed medications through G-tube, and then flushing again with a 30 ml pour of water before disconnecting, and capping G-tube line. On 1/31/23 immediately after exiting R1's room from completion of medication administration, RN-A was unable to explain the facilities policy for checking G-tube placement prior to giving medications. RN-A stated, I'm not sure, I would have to ask, I don't know how we check placement. On 1/31/23 at 3:27 p.m. licensed practical nurse (LPN)-A said her process for performing medication administration for R1 would be to review the rights of medication administration, crush medications, use proper hygiene, and PPE (personal protective equipment) with syringe, and check placement through auscultation. LPN-A said she generally does not check residual volume for R1 (pulling back with a syringe for gastric contents) but does do auscultation (using a stethoscope. placed over the stomach to listen for rushing air through a G-tube from a syringe). On 1/31/23 at 3:32 p.m. clinical manager (CM)-A Identified R1 as the only resident with a G-tube in the facility. CM-A explained her expectation of skilled nursing staff, before administering a medication for any resident through a G-tube was to perform the rights of medication administration, use proper hand hygiene with PPE, have necessary equipment, and to check placement by both auscultation, and residual volume prior to medication administration. On 1/31/23 at 4:13 p.m. director of nursing (DON) said her expectations of skilled nursing staff administering medications through a G-tube, review the MAR with rights of medication administration, do appropriate water flushes, have proper hand hygiene with PPE, having an awareness of infection control, and to check tube placement. The DON stated, I would expect placement be checked through a residual volume check. The DON continued, staff should be checking placement prior to putting any medications or flushes through a G-tube and should not rely on auscultation. I have been reviewing the facility policy for G-tube medication, and it does identify checking placement prior to administration. The DON continued, if the placement was incorrect, it could result in potential infection, respiratory issues, and failure of medication absorption. Facility policy titled Administering Medications through an Enteral Tube obtained on 1/31/23, with upcoming review of 11/23 identified purpose, preparation, general guideline, equipment and supplies, steps in the procedure, and documentation. Under steps in the procedure on step 18, the policy identified confirm placement of feeding tube. Step 25 stated administer medication by gravity flow.

Based on interview and document review the facility failed to report allegations of abuse to the administrator and the State Agency (SA) immediately, not to exceed two hours, for 1 of 1 residents (R1) alleged to have been verbally abused by nursing assistant (NA)-A. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and required extensive assist with all activities of daily living (ADL). On 2/8/22, at 3:08 p.m. NA-B stated on 1/19/22, she was still in training and had been assigned to work with NA-A. NA-B stated she was asked by NA-A to check on another resident while NA-A continued to assist R1 with toileting. NA-B stated when she returned to R1's bathroom, NA-A was bent down, with her back to the bathroom doorway, changing R1's brief when R1 said, shut up and NA-A replied, No, you shut up. If you're going to throw an attitude at me, I'm going to throw one back at you. NA-B further stated, At that point, it was the end of my shift, and I was new, so I went home. NA-B stated when she worked the next day, 1/20/22, she informed NA-C what she heard the previous day and was directed by NA-C to notify the director of nursing (DON). NA-B stated, I didn't know to report it immediately after, so I reported it the next day. On 2/9/22, at 12:49 p.m. NA-C stated on 1/20/22, NA-B informed her about the alleged verbal abuse. NA-C indicated she told NA-B she should have reported her concern to the supervisor immediately and directed NA-B to notify the DON. On 2/9/22, at 3:22 p.m. DON stated NA-B should have notified her immediately on 1/19/22, instead of waiting until 1/20/22. DON stated she met with NA-B on 1/20/22, to discuss the expectations and the importance of reporting all suspected abuse/neglect immediately to a supervisor. Review of My Transcript, undated, indicated NA-B completed Dementia Management and Abuse Prevention course on 12/24/21, Elder Justice Act course on 12/24/21, and Vulnerable Adult - SNF - MN course on 12/22/21. A Vulnerable Adult Acknowledgment Form, dated 12/16/21, and signed by NA-B, indicated NA-B read and understood the facility's Abuse Prevention and Vulnerable Adult Reporting Plan. The facility Abuse Prevention and Vulnerable Adult Reporting Plan policy, dated 3/1/21, indicated staff were responsible for reporting all alleged violations of maltreatment, neglect, or abuse immediately.

Based on interview and document review, the facility failed to identify corrective action following a drug diversion to develop a systematized oversight process to better identify discrepancies and unusual patterns related to narcotic and controlled medication administration, reconciliation and documentation practices for 4 of 4 residents (R1, R2 ,R3 and R4) who received controlled substance. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 had intact cognition, [CONDITION(S)] and received opiod medication with pain rated at a 10 (severe). R1's physician order dated 7/21/21, indicated an order for [MEDICATION(S)] 5 mg give orally as needed every 4 hours for pain rated 3-6 and give 10 mg for pain rated 7-10 using a scale of 1-10. An initial facility report was submitted to the State Agency (SA) on 9/11/21, indicated R1's narcotic ledger and electronic medical record (EMAR) had multiple discrepancies and timecard report had discrepancies with documentation. The report indicated the facility policy or procedure was followed at the time of the incident. Following the initial investigation into suspected medication diversion ; the nurse licensed practical nurse (LPN)-A did admit to steeling approximately 5-10 milligram (mg) tablets of PRN (as needed) [MEDICATION(S)] (controlled substance to treat moderate to severe pain) from R1 and discovered diversion began upon nurse date of hire in July 2021. The facility investigation report identified the discovery of an excessive amount of PRN medications administered that did not coincide with the EMAR over a four month period and multiple dates and times had been falsified. Further the report indicated that LPN-A was not in the building on multiple days the medication was documented as administered and medications were given in excess of the physician order. The report indicated LPN-A was terminated, a complaint was filed to the Board of Nursing and staff education paper content and video and in-services hosted by pharmacy consultant regarding medication diversion was scheduled for a future date. During interview on 9/20/21, at 9:30 a.m. the director of nursing (DON) stated the charge nurse called on 9/11/21, to inform her there was a discrepancy with R1's [MEDICATION(S)]. It appeared R1 had been taking the medication when his plan was to taper off. When the nurse asked R1 about this, he informed the nurse that he had not taken the medication for a week, which was not consistent with the record. That was when the charge nurse knew something was wrong. We as a team met with LPN-A and she admitted to taking 5-10 tablets of R1's [MEDICATION(S)] and we terminated her and began our internal investigation and found out she had been diverting medications with three additional residents and all of them were receiving [MEDICATION(S)] as needed for pain. The DON stated the Board of Nursing was notified and a police report was filed with [NAME] County. The following reports were filed to the SA in regards to there investigation: R2 admission MDS dated [DATE], indicated R1 was cognitively intact, had medically complex condition and frequent very severe pain and receive PRN opiod's. R2's physician orders dated 7/28/21, indicated she received [MEDICATION(S)] 5 mg tablets every 6 hours as needed for moderate to severe pain. A facility reported incident dated 9/16/21, indicated R2 had multiple ledger discrepancies and time card discrepancies. The report investigation indicated it was found LPN-A on multiple occasions was documenting administration of medication in the Narcotic ledger and not entering in the EMAR. There was a total of 21 tablets that had not been documented in the EMAR and there was a few pages in the ledger with the dates and times duplicated for the scheduled PRN doses. It was found difficult to determine if the diversion caused harm to the resident and all the doses taken were PRN. R3's admission MDS dated [DATE], indicated R3 was cognitively intact had non-traumatic spinal cord dysfunction, had pain rated at 5 with occasional pain and received as needed opiod's. R3's physician orders dated 7/26/21, indicated R3 received [MEDICATION(S)] 5 mg every 3 hours for for severe pain rated from 7-10. A facility reported incident dated 9/16/21, indicated R3 had narcotic ledger/ EMAR and time card with multiple discrepancies. The report further indicated from looking at the ledger it appeared LPN-A administered the medication on average twice on her shift and received multiple doses on her shift. In addition the report indicated it was difficult to determine if it caused harm to R3. R4's quarterly MDS dated [DATE], indicated R4 had non-traumatic brain dysfunction, severely cognitively impaired, vocalized pain and had facial expressions of pain. In addition the MDS indicated she received opiod's for pain. R4's physician orders dated 3/21/21, indicated R4 received [MEDICATION(S)] 5 mg as needed twice daily for moderate to severe pain. R4's facility reported incident dated 9/16/21, indicated had narcotic ledger/ EMAR and time card with multiple discrepancies. The report further indicated for R4 the documentation of excessive PRN administration in the narcotic paper ledger when LPN-A was working as well as falsification of dates and times, multiple paper documentation entries do not coincide with the EMAR. In addition to R4's cognitive impairment it was difficult to determine the effect on the resident. It was identified 24 tablets of [MEDICATION(S)] that were documented as administered in the narcotic ledger but not entered into the EMAR system. During interview on 9/20/21, at 10:00 a.m. the DON stated after they terminated LPN-A when she admitted to taking 5-10 tablets from R1 they completed a internal investigation on all residents receiving controlled substances/narcotics, reviewing the narcotic ledgers, EMARs, time cards and they found LPN-A diverted 122 tablets of [MEDICATION(S)] from R1,R2,R3 and R4. The DON stated the staff followed there policies and procedures but after the findings she was planning to complete a 11 minute training with the nursing staff which included a video and paperwork for the nurses. The DON stated she had been working on the training but has not yet started the training for the staff. The DON did state she does have a training set up with the pharmacy to help identify diversion in October. Although it had been 9 days since the first incident identified diversion and the DON was aware of the discrepancy of narcotic ledger, EMAR and time card the staff had not yet been trained to identifiy diversion. During interview on 9/21/21, at 10:41 a.m. registered nurse (RN)-A stated she was the nurse who identified the discrepancy of the diversion with LPN-A. RN-A stated she was giving [MEDICATION(S)] more than it was scheduled on a shift and that is what made her look at the times and when RN-A noticed this on 9/11/21 she contacted the DON and a meeting was made. RN-A stated LPN-A would make it so the narcotic record did not match the EMAR and she would empty the card and put them in random times in the narcotic ledger and in fact even spilled water on the narcotic ledger so we could not read it. During interview on 9/20/21, at 11:00 a.m. lead detective from [NAME] County indicated he was assigned to the case with LPN-A and stated when interviewed LPN-A admitted to taking 5-10 tablets of [MEDICATION(S)] from the facility. Although the facility had policy and procedures in place to prevent narcotic diversion, once they did identify a diversion they failed to assess how the diversion occurred and put measures in place to prevent additional diversion practices. Facility policy Controlled Substances dated 1/30/20, indicated The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parities, and shall give the Administrator a report of such findings.

Based on observation, interview and document review, the facility failed to screen a food service delivery person (FSD)-A upon entry to the building and failed to ensure the FSD-A wore a source protection mask. This had the potential to affect all 45 residents who resident in the facility. Findings include: On 4/23/20, at 9:15 a.m. a food service delivery person (FSD)-A was observed as they exited the supply truck with a delivery cart stacked with boxes, and proceeded into the facility through the door leading directly into the kitchen door which was propped open. FSD-A was observed without a source protection mask in place, as they entered into a narrow entry way (approximately four feet in width), past a aluminum rack which was observed to have an uncovered chocolate cake and plate of buns. FSD-A was observed as they walked through the kitchen, past three unidentified dietary staff who were working on meal prep. During interview upon their return to the truck, FSD-A stated they had not been screened at this facility, nor had they been instructed on the use of mask when making deliveries. On 4/23/20, at 9:25 a.m. the director of nursing (DON) stated it was her expectation all individuals entering the facility, including delivery staff, would be screened and instructed to wear a mask while in the facility. DON stated the delivery people generally present to the front door where the screening is initiated. On 4/23/20, at 11:00 a.m. the certified dietary manager (CDM)-A stated she had screened FSD-A during their delivery today, and had entered the results of screening on the tracking form at the front of the facility. CDM-A stated the facility staff are to complete screening for FSD-A upon their arrival to the facility and, if symptom free, provide them with a mask. CDM-A stated when initial screening was implemented, a mask was not indicated, however, now a mask is required for all entering the facility. CDM-A stated FSD-A was routinely screened with deliveries. On 4/23/20, at 11:26, the DON reviewed the facility tracking sheets for 4/2/20, 4/9/20, and 4/16/20 (dates in which FSD-A had made deliveries) and identified FSD-A was not listed on the tracking form. DON stated she had spoken with CDM-A and screening had not been consistently completed. A facility policy, Coronavirus Disease 2019 (COVID-19): Preventing and Controlling the Transmission of COVID-19, Long Term Care, undated, identified the facility actively screened visitors based on the current CDC (Centers for Disease Control) recommendations. This screening included monitoring for symptoms of a respiratory infection, such as fever, cough, shortness of breath, or a sore throat.

Based on observation, interview and document review, the facility failed to implement the plan of care for safe assistance with toileting for 1 of 1 resident (R13) who fell while standing to use a urinal. This resulted in actual harm for R13 who suffered a subdural hematoma, [MEDICAL CONDITION] and required hospitalization . Findings include: R13's Admission Record, printed 7/11/19, identified [DIAGNOSES REDACTED]. R13's admission Minimum Data Set ((MDS) dated [DATE], indicated R13 required extensive assistance with transferring and toilet use. The MDS indicated with transfers, R13 was not steady, and only to stabilize with human assistance. The MDS indicated R13 had a functional limitation with range of motion to upper extremities (shoulder, elbow, wrist hand) and lower extremities (hip knee, ankle, foot), and had this impairment on one side, and indicated R13 did not walk. The MDS also identified R13 was cognitively impaired. R13's care plan, dated 4/1/19, identified Bowel and Bladder as a focus area, and indicated R13 used a urinal, and was not safe to use a toilet or commode at this time, and that R13 needed staff assistance. R13's care plan identified mobility as a focus area, and indicated R13 has impaired mobility related [MEDICAL CONDITION](cardio-vascular accident or stroke), and had as goal to wait for help and have no falls. The care plan directed staff, among other interventions, that R13 needed assist of one with slide board with transfers to and from bed and wheel chair. R13's care plan also identified impaired cognitive function, related to a history of stroke, had difficulty with long and short term memory, and needed time to process conversation and time to respond. R13's Kardex report, printed 7/11/19, indicated the following: For mobility R13 used a wheel chair to get to all destinations; for transfers, R13 needed assist of one staff with a slide board to and from bed and wheel chair; and for bladder and bowel, R13 used a urinal, as he was not safe to use toilet or commode at this time. During observation on 7/8/19, at 5:25 p.m. R13 was seated in a wheel chair, with his right leg positioned on a foot pedal, and right arm and hand resting in an arm trough, and propelling himself slowly and steadily down the hallway from the chapel toward the dining area. R13 used his left hand and arm to move the left wheel of his wheel chair to propel forward. A white, rectangular-shaped dressing, approximately three by four inches, was visible and taped on upper, right side of R13's head. R13's nursing progress note, dated 6/27/19, at 5:56 p.m. indicated: Writer and other nurses called to resident bathroom at 4:55 p.m. Resident was face down on floor, laying more on right side, with right arm awkwardly under body. Feet were near toilet, head was near south wall of bathroom. Resident was not responding to questions at first, but after a minute he was able to deny pain. Blood was noted to be coming from under resident head, therefore we assisted resident onto backside after his arm was pushed further under his body. Pressure was applied to right side of forehead with ice pack and ABD (kind of dressing). About 30 ml (millimeters) of blood noted, most was clotting and stuck to right side of face. Left medial wrist also noted to have laceration, no draining noted, ABD pad applied with pressure. Right hip noted to have abrasions lengthwise about 5 inches, though resident cannot feel due to H/[MEDICAL CONDITION](history of cardio vascular accident or stroke). When interviewed at 11:25 a.m. on 7/9/19, R13 stated what he remembered on the day he fell is only I blacked out and then had an ambulance ride. R13 stated he does not remember going to the bathroom or why he wanted to go to the bathroom, nor recalled how he fell . R13 said he was in St. Cloud hospital for a couple of days, I wound up with a concussion and was woozy for the next few weeks. R13 stated I just blacked out and ended up with four stitches. R13 said he was told at the hospital to expect he may not feel very good right away, but since the fall had been feeling better. When interviewed on 7/11/19, at 10:41 a.m. registered nurse (RN)-D stated she was on duty when R13 fell in his bathroom. RN-D recalled she was working in the office, and with the floor nurse, licensed practical nurse (LPN)-A, responded to nursing assistant (NA)-A's call for help. When she came to the bathroom RN-A stated R13 was lying face down on the bathroom floor, with some blood on the floor, but unsure of its source. RN-D stated after she initially assessed R13 it would be best to roll him over to further assess him. RN-D stated she remembered having placed an ice pack on R13's head and applied pressure to a cut on his head. RN-D stated she then called for an ambulance and notified R13's family. RN-D stated R13 was sent to the emergency room and was admitted to the hospital for a couple days. RN-D further indicated in the days following his return to the nursing home, R13 had experienced nausea and dizziness. RN-D stated NA-A took R13 into the bathroom to assist him with toileting. RN-D stated R13's wheel chair in the bathroom, and also noted R13 had a gait belt around him. When asked what lead to R13's fall, and RN-D stated his legs gave out when he was standing in the bathroom, using a urinal. RN-D stated typically you would not have the resident use a urinal while standing. RN-D stated R13 used the urinal in bed. RN-D stated while R13's care plan does not specifically say to use the urinal in bed and R13 should not have to use a urinal standing up. RN-D stated therapy had been working with R13 on standing and transferring, but there were issues with consistency and the only safe way to transfer R13 was use of the sliding board. RN-D stated presently, including at the time of the fall, R13 was not safe to use the toilet or commode. RN-D stated NA-A was a pretty new aide, and at the time must not have been aware of his care plan. During interview at 10:19 a.m. on 7/11/19, nursing assistant (NA)-A stated she was the person who assisted R13 when he had the fall. NA-A stated R13 put on his call light and said he wanted to use the bathroom. NA-A stated R13 had a male guest in his room, and because of that, I assumed R13 wanted privacy and requested to go in the bathroom. NA-A stated she wheeled R13 into the bathroom, and then told R13 I had not ever done this. Once in the bathroom R13 assured NA-A that he had done this all the time and wanted to use his urinal while standing up. NA-A stated R13 stood up out of his chair, and NA-A stated she put the gait belt around R13. NA-A explained R13 had limited use of his right hand, and when he stood up, R13 grabbed onto the bar in the bathroom, and NA-A stated I held the urinal. NA-A said things happened quickly and R13 fell down. NA-A stated when R13 fell I called his name and right away tried to get a response and then asked for help over the walkies ( in-house two way radios) NA-A stated LPN-A and RN-D came quickly to help out. NA-A stated she was aware R13 had injured himself, and was sent to the hospital. Following R13's fall, NA-A stated she spoke with the director of nursing (DON) and we went over skills, and what went wrong, and what I should to to change so it would not happen again. NA-A stated the DON emphasized it was not in R13's care plan to use the bathroom, as R13 required a sliding board for transfers. NA-A stated she was not hurt by this, I was a new employee and still learning. When asked why she assisted R13 with the urinal in the bathroom, standing, NA-A stated I guess I did not know any better. NA-A stated she knows where and how to find residents' care plans, and with respect to R13 I know now not to take him in the bathroom. When interviewed at 11:01 a.m. on 7/11/19, NA-B stated R13 did not use the bathroom or commode now. NA-B stated R13 was not able to stand or safely transfer onto the toilet in the bathroom because R13 could not do a pivot transfer (while standing to turn or pivot one's body) to move from one position to another due to his stroke which affected his right side. NA-B stated R13 used a urinal, and we assisted R13 to use the urinal typically when in bed. NA-B added R13 would not be able to use the urinal independently. Review of R13's Physical Therapy (PT) discharge summary, dated 6/27/19, indicated R13: could stand upright with upper extremity support for two minutes without a rest break; was a high fall risk; needed substantial assistance to hold or support when going form sitting to standing; and that R13 did not walk. Physical Therapy progress notes indicated R13 had therapy from 5/1/19 until he was discharged from PT following the fall on 6/27/19. A hospital Orders Discharge Report ,dated 6/29/19, indicated R13 had been hospitalized due to a small amount of bleeding on the brain. R13's discharge [DIAGNOSES REDACTED]. Review of facility personnel training records indicated NA-A completed orientation on 6/6/19. The record review indicated NA-A demonstrated skill competencies on 6/28/19, which included: including: how to access electronic care access, Kardex, and resident care plan; and resident care skills, including: toileting plan, transfers and walking. During interview with the facility administrator and director of nursing (DON) at 2:12 p.m. on 7/11/19, R13's fall was discussed. The DON stated NA-A reported R13 had requested to use the urinal, and because he had a male visitor, wanted to go into the bathroom. NA-A took R13 into the bathroom, assisted with the urinal and R13 fell . The DON stated she felt NA-A did what she could to stop R13, acknowledging NA-A had placed a transfer belt around R13, but could not stop him. The DON stated after R13 fell , NA-A immediately summoned the charge nurse who assessed R13; and then R13 was sent to the hospital for evaluation and remained for a couple of day because he had subdural hematoma. The DON stated NA-A was a pretty new aide, who had recently completed clinical's to become a nursing assistant. The DON stated direct floor orientation is usually five shifts with another staff, one-to-one, in addition to general orientation and other computer-based training and as part of facility orientation, was assigned a more seasoned staff member to train NA-A on the unit. The DON stated new staff are offered additional training or shifts if they want, and wean off of other staff as they gain confidence, and are always told to ask, no question is a dumb question, and if unsure of anything, then ask. The DON stated following the incident, she retrained NA-A on skills, and made sure NA-A knew how to access the Kardex and resident care plan. The DON also discussed with NA-A what alternatives she had if this situation occurred again, if the resident was not following the care plan. The DON stated she emphasized to NA-A, she could have told the resident please wait, I need to check with the nurses, or could have called out for help right away. Although R13 was assessed and care planned accurately, when staff failed to implement the care plan, or intercede and take action when R13 required toileting assistance, R13 had a fall and was harmed. A facility policy, Using the Care Plan, dated 1/30/18, indicated the the care plan shall be used in developing the resident's daily care routines and be available to staff personal who have the responsibility for providing care or services to the resident. The policy indicated nursing assistants were responsible for following all resident's plan of care. A facility policy, Abuse Prevention and Vulnerable Adult Reporting Plan, dated 6/10/19, indicated as its purpose, to prevent residents patients from abuse. The policy identified abuse to include neglect, which the policy defines occurs when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress. Based on observation, interview and document review, the facility failed to follow the care plan to provide appropriate toileting assistance resulting in neglect for 1 of 1 residents (R13) who fell using a urinal. This resulted in actual harm for R13 who was hospitalized and had a subdural hematoma and [MEDICAL CONDITION]. Findings include: R13's Admission Record, printed 7/11/19, identified [DIAGNOSES REDACTED]. R13's admission Minimum Data Set ((MDS) dated [DATE], indicated R13 required extensive assistance with transferring and toilet use. The MDS indicated with transfers, R13 was not steady, and only to stabilize with human assistance. The MDS indicated R13 had a functional limitation with range of motion to upper extremities (shoulder, elbow, wrist hand) and lower extremities (hip knee, ankle, foot), and had this impairment on one side, and indicated R13 did not walk. The MDS also identified R13 was cognitively impaired. R13's care plan, dated 4/1/19, identified Bowel and Bladder as a focus area, and indicated R13 used a urinal, and was not safe to use a toilet or commode at this time, and that R13 needed staff assistance. R13's care plan identified mobility as a focus area, and indicated R13 has impaired mobility related [MEDICAL CONDITION](cardio-vascular accident or stroke), and had as goal to wait for help and have no falls. The care plan directed staff, among other interventions, that R13 needed assist of one with slide board with transfers to and from bed and wheel chair. R13's care plan also identified impaired cognitive function, related to a history of stroke, had difficulty with long and short term memory, and needed time to process conversation and time to respond. R13's Kardex report, printed 7/11/19, indicated the following: For mobility R13 used a wheel chair to get to all destinations; for transfers, R13 needed assist of one staff with a slide board to and from bed and wheel chair; and for bladder and bowel, R13 used a urinal, as he was not safe to use toilet or commode at this time. During observation on 7/8/19, at 5:25 p.m. R13 was seated in a wheel chair, with his right leg positioned on a foot pedal, and right arm and hand resting in an arm trough, and propelling himself slowly and steadily down the hallway from the chapel toward the dining area. R13 used his left hand and arm to move the left wheel of his wheel chair to propel forward. A white, rectangular-shaped dressing, approximately three by four inches, was visible and taped on upper, right side of R13's head. R13's nursing progress note, dated 6/27/19, at 5:56 p.m. indicated: Writer and other nurses called to resident bathroom at 4:55 p.m. Resident was face down on floor, laying more on right side, with right arm awkwardly under body. Feet were near toilet, head was near south wall of bathroom. Resident was not responding to questions at first, but after a minute he was able to deny pain. Blood was noted to be coming from under resident head, therefore we assisted resident onto backside after his arm was pushed further under his body. Pressure was applied to right side of forehead with ice pack and ABD (kind of dressing). About 30 ml (millimeters) of blood noted, most was clotting and stuck to right side of face. Left medial wrist also noted to have laceration, no draining noted, ABD pad applied with pressure. Right hip noted to have abrasions lengthwise about 5 inches, though resident cannot feel due to H/[MEDICAL CONDITION](history of cardio vascular accident or stroke). When interviewed at 11:25 a.m. on 7/9/19, R13 stated what he remembered on the day he fell is only I blacked out and then had an ambulance ride. R13 stated he does not remember going to the bathroom or why he wanted to go to the bathroom, nor recalled how he fell . R13 said he was in St. Cloud hospital for a couple of days, I wound up with a concussion and was woozy for the next few weeks. R13 stated I just blacked out and ended up with four stitches. R13 said he was told at the hospital to expect he may not feel very good right away, but since the fall had been feeling better. When interviewed on 7/11/19, at 10:41 a.m. registered nurse (RN)-D stated she was on duty when R13 fell in his bathroom. RN-D recalled she was working in the office, and with the floor nurse, licensed practical nurse (LPN)-A, responded to nursing assistant (NA)-A's call for help. When she came to the bathroom RN-A stated R13 was lying face down on the bathroom floor, with some blood on the floor, but unsure of its source. RN-D stated after she initially assessed R13 it would be best to roll him over to further assess him. RN-D stated she remembered having placed an ice pack on R13's head and applied pressure to a cut on his head. RN-D stated she then called for an ambulance and notified R13's family. RN-D stated R13 was sent to the emergency room and was admitted to the hospital for a couple days. RN-D further indicated in the days following his return to the nursing home, R13 had experienced nausea and dizziness. RN-D stated NA-A took R13 into the bathroom to assist him with toileting. RN-D stated R13's wheel chair in the bathroom, and also noted R13 had a gait belt around him. When asked what lead to R13's fall, and RN-D stated his legs gave out when he was standing in the bathroom, using a urinal. RN-D stated typically you would not have the resident use a urinal while standing. RN-D stated R13 used the urinal in bed. RN-D stated while R13's care plan does not specifically say to use the urinal in bed and R13 should not have to use a urinal standing up. RN-D stated therapy had been working with R13 on standing and transferring, but there were issues with consistency and the only safe way to transfer R13 was use of the sliding board. RN-D stated presently, including at the time of the fall, R13 was not safe to use the toilet or commode. RN-D stated NA-A was a pretty new aide, and at the time must not have been aware of his care plan. During interview at 10:19 a.m. on 7/11/19, nursing assistant (NA)-A stated she was the person who assisted R13 when he had the fall. NA-A stated R13 put on his call light and said he wanted to use the bathroom. NA-A stated R13 had a male guest in his room, and because of that, I assumed R13 wanted privacy and requested to go in the bathroom. NA-A stated she wheeled R13 into the bathroom, and then told R13 I had not ever done this. Once in the bathroom R13 assured NA-A that he had done this all the time and wanted to use his urinal while standing up. NA-A stated R13 stood up out of his chair, and NA-A stated she put the gait belt around R13. NA-A explained R13 had limited use of his right hand, and when he stood up, R13 grabbed onto the bar in the bathroom, and NA-A stated I held the urinal. NA-A said things happened quickly and R13 fell down. NA-A stated when R13 fell I called his name and right away tried to get a response and then asked for help over the walkies ( in-house two way radios) NA-A stated LPN-A and RN-D came quickly to help out. NA-A stated she was aware R13 had injured himself, and was sent to the hospital. Following R13's fall, NA-A stated she spoke with the director of nursing (DON) and we went over skills, and what went wrong, and what I should to to change so it would not happen again. NA-A stated the DON emphasized it was not in R13's care plan to use the bathroom, as R13 required a sliding board for transfers. NA-A stated she was not hurt by this, I was a new employee and still learning. When asked why she assisted R13 with the urinal in the bathroom, standing, NA-A stated I guess I did not know any better. NA-A stated she knows where and how to find residents' care plans, and with respect to R13 I know now not to take him in the bathroom. When interviewed at 11:01 a.m. on 7/11/19, NA-B stated R13 did not use the bathroom or commode now. NA-B stated R13 was not able to stand or safely transfer onto the toilet in the bathroom because R13 could not do a pivot transfer (while standing to turn or pivot one's body) to move from one position to another due to his stroke which affected his right side. NA-B stated R13 used a urinal, and we assisted R13 to use the urinal typically when in bed. NA-B added R13 would not be able to use the urinal independently. Review of R13's Physical Therapy (PT) discharge summary, dated 6/27/19, indicated R13: could stand upright with upper extremity support for two minutes without a rest break; was a high fall risk; needed substantial assistance to hold or support when going form sitting to standing; and that R13 did not walk. Physical Therapy progress notes indicated R13 had therapy from 5/1/19 until he was discharged from PT following the fall on 6/27/19. A hospital Orders Discharge Report ,dated 6/29/19, indicated R13 had been hospitalized due to a small amount of bleeding on the brain. R13's discharge [DIAGNOSES REDACTED]. Review of facility personnel training records indicated NA-A completed orientation on 6/6/19. The record review indicated NA-A demonstrated skill competencies on 6/28/19, which included: including: how to access electronic care access, Kardex, and resident care plan; and resident care skills, including: toileting plan, transfers and walking. During interview with the facility administrator and director of nursing (DON) at 2:12 p.m. on 7/11/19, R13's fall was discussed. The DON stated NA-A reported R13 had requested to use the urinal, and because he had a male visitor, wanted to go into the bathroom. NA-A took R13 into the bathroom, assisted with the urinal and R13 fell . The DON stated she felt NA-A did what she could to stop R13, acknowledging NA-A had placed a transfer belt around R13, but could not stop him. The DON stated after R13 fell , NA-A immediately summoned the charge nurse who assessed R13; and then R13 was sent to the hospital for evaluation and remained for a couple of day because he had subdural hematoma. The DON stated NA-A was a pretty new aide, who had recently completed clinical's to become a nursing assistant. The DON stated direct floor orientation is usually five shifts with another staff, one-to-one, in addition to general orientation and other computer-based training and as part of facility orientation, was assigned a more seasoned staff member to train NA-A on the unit. The DON stated new staff are offered additional training or shifts if they want, and wean off of other staff as they gain confidence, and are always told to ask, no question is a dumb question, and if unsure of anything, then ask. The DON stated following the incident, she retrained NA-A on skills, and made sure NA-A knew how to access the Kardex and resident care plan. The DON also discussed with NA-A what alternatives she had if this situation occurred again, if the resident was not following the care plan. The DON stated she emphasized to NA-A, she could have told the resident please wait, I need to check with the nurses, or could have called out for help right away. Although R13 was assessed and care planned accurately, when staff failed to implement the care plan, or intercede and take action when R13 required toileting assistance, R13 had a fall and was harmed. A facility policy, Using the Care Plan, dated 1/30/18, indicated the the care plan shall be used in developing the resident's daily care routines and be available to staff personal who have the responsibility for providing care or services to the resident. The policy indicated nursing assistants were responsible for following all resident's plan of care. A facility policy, Abuse Prevention and Vulnerable Adult Reporting Plan, dated 6/10/19, indicated as its purpose, to prevent residents patients from abuse. The policy identified abuse to include neglect, which the policy defines occurs when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress.

Based on observation and interview facility failed to implement proper storage procedure for liquid controlled medications (medications that have a potential for abuse) which required refrigeration. This has the potential to affect all 49 residents who resided in the facility. Findings include: On 7/9/19, at 12:59 p.m. The medication room was reviewed with licensed practical nurse (LPN)-A there was a black refrigerator (fridge) sitting on the counter, there was no lock attached to the fridge. On the shelves of the fridge were insulin pens and [MEDICATION(S)] solution. Located in bottom drawer of the fridge was two prescription labeled boxes of [MEDICATION(S)] concentrate (a medication used to manage anxiety) and a small tackle box approximately 5 inches x 8 inches emergency kit (e-kit) with 2 numbered zip ties attached which contained 5 vials of [MEDICATION(S)]. When interviewed LPN-A stated the medication fridge had never had a lock on it to secure the medications. The other narcotic e-kit is secured in a locked cupboard in the medication room. When interviewed on 7/10/19, at 11:18 a.m. LPN-B stated liquid [MEDICATION(S)] for residents and the refrigerated e-kit was stored in the refrigerator in the medication room, the [MEDICATION(S)] was counted at each shift change. The medication room was locked but the medication fridge was not secured. When interviewed on 7/10/19, at 2:01 p.m. RN-A stated controlled medications in the medication cart were in a secured drawer in the locked cart. The regular e-kit was secured in a locked cupboard inside locked medication room with the liquid [MEDICATION(S)] and refrigerated e-kit in the medication room fridge. The fridge was not secured. When interviewed on 7/10/19, at 2:22 p.m. director of nursing (DON) stated [MEDICATION(S)] was a controlled medication and should be secured in the fridge in the medication room to prevent diversion. Although a facility Controlled Substance policy dated 1/30/18 identified controlled substances must be stored in the medication cart in a double locked drawer, separate from containers for any non-controlled medications the policy failed to address controlled medications which required refrigeration.

Based on observation and interview, the facility failed to ensure expired products and supplies were removed from the medication room following the manufacture expiration dates. This had the potential to affect all 35 residents in the facility. Findings include: During observation on [DATE], at 12:22 p.m. the facility medication storage room cupboard had the following items available for resident use: Dressings: Iodoflex (contains cadexomer iodine) - 4 centimeters (cm) by 6 cm, two boxes (10 total) with manufacture expiration dates of ,[DATE]. Acticoat (contains silver coated antimicrobial barrier) flex- 3 2 inch by 2 inch, two left in the box, manufacture expiration ,[DATE]. Medihoney (contains medical grade honey)- 5 cm by 4 cm box of 9 dressings manufacture expiration ,[DATE]. Mepilix (dressing for wound absorption) sacrum border -18 cm by 18 cm, 8 in the pack with manufacture expiration date ,[DATE]. Intravenous supplies (IV) supplies: IV dressing change tray (2) manufacture expiration ,[DATE]. Lab draw sample vial collection tubes BactT/alert (1) which expired on [DATE] (aerobic tube) and BactT/alert (2) on [DATE] (Anaerobic tube). In an interview on [DATE], at 12:22 p.m. registered nurse (RN)-B, stated he was not sure who was responsible for checking for expiration dates on items in the medication storage room. During an interview [DATE], at 1:09 p.m RN-A, stated she was not aware of any process where a staff person goes in and evaluates the expiration dates of the medication room supplies. In an interview on [DATE] at 1:58 p.m. the director of nursing (DON) stated the lab supplies came from a local hospital and staff should be checking for expiration dates on the supplies they bring and use. The DON stated the IV supplies came from the pharmacy. A facility policy and procedure related to the checking of expiration dates for the medication storage area was request. The facility provided a document, Checklist for Nights, which identified once a week staff will, Check for expired meds (medications) in refrigerator, stock meds in cupboard and med cart every Sat. (Saturday).

Based on observation, interview and document review the facility failed to immediately notify the physician of the open wounds located on the bony prominence's of the spine 1 of 1 resident (R18) reviewed who developed pressure ulcers. Findings include: R18's annual Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment, extensive assistance of 2 staff with transfers/bed mobility and does not walk. The Care Area Assessment (CAA) dated 7/25/16, identified R18 as being at risk for pressure ulcers (PU) and no pressure ulcer present. Progress notes dated 8/16/16, identified 3 skin/problem areas located on the spine for R18 and were described as noted: (#1) Top area red and measured 1.5 centimeter (cm) by 2 cm; (#2) middle area open measured 0.8 cm by 0.7 cm and (#3) bottom area scabbed and measured 1.5 cm by 1 cm. The area was cleansed and left open to the air. A progress noted dated 8/22/16, identified adhesive foam dressing was applied to the lower spine; three bony prominence's with skin breakdown were: (#1) upper wound on spine has pinkness that is resolving, (#2) middle wound located on the spine measured 0.2 cm x 0.2 cm yellow scab and (#3) the lower wound located on the spine has 0.5 cm x 0.8 cm scab. Wounds occurred with longer period of sitting on toilet during sitz baths; Sitz baths were discontinued 8/15/16. Although documentation indicated the daughter was updated on wounds at this time, no physician notice was evident. The wound observation tool dated 8/22/16, described the problem areas on the spine of R18 as noted: upper wound-(#1) a suspected deep tissue injury (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and the lower wound (#3) an Unstageable PU (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Documentation indicated the physician was notified of the identified PU on 9/6/16 even though it was first identified on 8/16/16 and documentation dated 8/22/16, indicated the wound located on the upper part of the spine was due to deep tissue injury and the lower wound was documented as unstageable PU. Review of the care plan revised 8/26/16, identified R18 at risk for skin breakdown and open area present to bony prominence's to back. Interventions included: air mattress on bed, treatment per nursing order, turn and reposition at least every 6 hours when sitting and every 2 hour repositioning at night due to skin breakdown to spine. A review of the nursing home rounds note dated 9/6/16, identified 2 closed areas and one open area of skin breakdown on R18's spinal column. R18 was identified as quite resistant to being repositioned during the night; however, nursing staff encouraged her to allow repositioning to aid in healing the spine. During interview on 9/22/16, at 11:46 a.m. registered nurse (RN)-D stated she thought the sores started as a result of R18 sitting on the toilet for longer periods of time due to sitz baths. RN-D confirmed the sitz baths were discontinued on 8/15/16; however, the PU's were first identified on 8/16/16, and the physician was not notified until 9/6/16. RN-D verified the physician should have been notified sooner.

Based on observation, interview and document review the facility failed to assess and monitor significant bruising for 3 of 3 residents (R15, R41, R60) reviewed for non- pressure related skin problems and failed to assess, revise and implement timely interventions to promote healing for 1 of 1 resident (R24) reviewed who had a bunion wound. Findings include: R15 Current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated R15's Brief Interview of Mental Status (BIMS) score was 15, indicating no cognitive impairment. On 9/19/16, at 3:53 p.m. R15 was observed to have large bruises on both forearms, hands and knees. R15 had arm protectors donned and indicated she has a skin tear located on the left elbow. It was noted that a dressing covered a part of the wound. When interviewed at this time, R15 explained, those are all from the hospital, they just roll you over, they don't care. During further observation of R15's arms, the following was noted: The left arm had a Vaseline dressing over a skin tear located at the left elbow area, which was wrapped with a soft gauze. The arm had bruising which appeared dark maroon to dark purple in color. This bruising extended around the circumference of the arm from the fingers extending to the area above the elbow, 4.5 inches. The backside (posterior) of the upper arm had a rectangle shaped bruise which measures 3.5 x 5 inches. Bruising was noted on the tops of both hands, covering the entire surface. The right arm had bruising which started at the top of the hand, circumferences the arm at the wrist and extended to above the elbow approx. 2 inches. The outer forearm revealed an uncovered open wound, measuring 1.5 x 2 inches. The wound bed appeared to be open and a ½ inch opening with a weepy base was evident through the dermis. The surrounding tissue was very dry and the skin was peeling. Review of the current care plan dated 7/12/16, identified R15 at risk for skin breakdown due to decreased mobility and incontinence; ulcer present to right forearm from a hematoma and skin tear to the left elbow. Interventions indicated R15 bruises easily, had been on [MEDICATION NAME] (blood thinner), only on aspirin now and to apply a protective sleeve daily. Documentation in the record revealed R15 was hospitalized from [DATE]-9/16/16 for treatment of [REDACTED]. Documentation indicated R15 had been on [MEDICATION NAME] and aspirin prior to hospitalization but was discharged on aspirin only. Review of the admission assessment dated [DATE], also identified that R15 had extensive bruising to both upper extremities, faded to right knee, bruising to dorsal hands and a large skin tear to the left elbow which was L shaped, measuring 7 centimeters and 3 centimeters in length. Steri-strips and a secondary dressing were applied. When interviewed on 9/22/16, at 12:03 p.m. registered nurse (RN)-A stated R15 returned from the hospital stay with bruising to bilateral (both) upper extremities, fading bruises on the right knee and bruising to dorsal (posterior) hands. She confirmed documentation was not available to review related to any ongoing assessment and/or status of the extensive bruising. R41 R41 had [DIAGNOSES REDACTED]. R41 returned from the hospital on [DATE] with bruising noted to bilateral upper and lower extremities; bruising faded to right knee, bruising to dorsal hands, purplish color from shins to toes. On 9/20/16, at 10:48 a.m. R41 was observed to have bruises on both elbows, top of both lower arms, both wrists and both hands. These bruises were dark purplish to maroon in color and varied in size. Interview with R41 at this time indicated he was unsure of when or how he obtained these bruises. The identified bruises varied in size on both arms, wrists and hands. The top of the right hand revealed one bruise 1.5 inches between the second and third finger. On the top surface of the right hand there was another 2 inch bruise. The top of the wrist had a 3 inch bruise, (involving the sides of the wrist). The forearm had 3 more bruises: 2 x 3 inches, 1 x 1 inch and 2 x 3 inches. Located above the elbow was a 3 x 4 inch dark purple bruise. On top of the left hand were two 1 inch bruises and the left forearm had 2 bruises measuring 3.5 x 4 inches. Review of the current care plan 9/4/16, identified R41 had experienced 12 falls in the last 3 months. The care plan intervention identified the spouse brought in long sleeve shirts for R41 to wear to reduce the risk of skin tears with falls. The care plan also revealed that arm protector sleeves have been attempted but R41 kept removing them so they were discontinued. When interviewed on 9/22/16, at 12:23 p.m. RN-B indicated she was aware of R41's bruises on the arms, wrists and hands. RN-B further indicated R41 always has some kind of bruising on his arms and confirmed these bruises had not been monitored on the treatment sheets nor in any other format. RN-B confirmed she had never seen any monitoring for bruises while working at the facility. Interview with RN-D on 9/21/16, at 12:27 p.m. confirmed R41 frequently has bruises on his arms and hands from falls. She further indicated that staff have attempted in the past to don sleeve protectors, but R41 removed them. RN-D confirmed staff had not had a system for monitoring any of R41's bruises for healing and/or deterioration. R60 It was observed on 9/19/16, at 11:49 a.m. that R60 had significant bruising on his arms. R60's hands and arms had dark purple to maroon color bruises. The top of his right hand revealed two 1.5 inch bruises. The forearm had 4 x 4 inch bruises which involved the circumference of the arm. Located above the elbow was a 3 x 4 inch bruise. The left arm revealed two 1 inch bruises and the forearm had one 3 x 4 inch bruise and two 1.5 inch bruises. The bruises were all dark purple to maroon in color. Interview with R60 at the time indicated he was unsure of how he got them but shared he has a history of easily bruising. The quarterly assessment dated [DATE], indicated R60 had a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the R60 current care plan dated 7/14/16, identified him as having a potential for skin alteration due to the dying process and end of life and decreased mobility. The care plan revealed [DIAGNOSES REDACTED]. Review of the bath audit skin observations for July, August, and September 2016 identified there was no documentation related to the significant bruising evident on R60's arms. During an interview on 9/22/16, at 10:17 a.m. RN-B stated that upon discovery of a new wound, a bruise and/or a skin tear, an alert is created by the nursing assistant in the software system. The alert is electronically sent to the charge nurse which subsequently triggers an assessment, treatment and/or monitoring program. RN-B confirmed that monitoring bruising to identify deterioration and/or healing would be a good idea. During an interview 9/22/16, at 10:10 a.m. RN-D confirmed there was no system to monitor the significant bruising on the arms of R60. RN-D stated that R60 has experienced bruising since admission on 3/16/16. When interviewed on 9/22/16, at 12:12 p.m. the director of Nursing (DON) confirmed there is not a system implemented to monitor skin bruising. DON stated that if there was a change in condition of a wound it would be documented in the progress notes but there was no current process for daily/weekly skin monitoring. She confirmed there is no policy to address monitoring of non-pressure related wounds or bruises. During a subsequent interview with the DON on 9/22/16, at 1:00 p.m. the DON presented a picture of a monitoring system to be set up in the facility software and indicated she would implement this system for monitoring and assessing resident bruises after staff were educated. Review of the facility skin care policy dated 5/2011, indicates skin problems are identified and treatments instituted promptly. A registered nurse oversees each residents skin care in accordance with the comprehensive assessment/care plan. The facility staff receive education on skin care and standard protocol to assure accurate documentation and timely interventions for skin care or problems. R24 Review of R24's admission assessment dated [DATE], identified that R24 had a 0.2 cm by 0.2 cm open area to callused area on left bunion; Scant weeping drainage and bilateral bunion with approximately 1 cm pinkness was present. Foam dressings were placed on both bunion for protection at the time of admission, (7/28/16). The admission MDS assessment dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14 (intact cognition), extensive assistance of two staff with bed mobility/transfers, at risk for PU and the presence of a lesion on the foot. The CAA dated 8/4/16, included: no pressure ulcers, a scab to hammer toe and bunion and the care plan indicated a turn/repositioning schedule every 2 hours and monitor skin. Review of the shower day worksheet audits for R24 were as noted: (1) 8/1/16-small area to left bunion, (2) 8/5/16- open left bunion, (3) 8/12/16-bunion pink, sore to left bunion and (4) 8/19/16-open left bunion. The nurse progress notes dated 8/19/16, included: open area to left bunion despite padding with foam dressing; red round with well-defined edges; no pressure noted from shoes; no infection symptoms; and foam dressing replaced with skin prep to wound edges. A get acquainted visit physician note dated 8/10/16, did not identify the presence of a bunion nor any open area. A fax sent to the physician dated 8/19/16, at 4:38 p.m. identified: small open area to left bunion despite adding foam padding to area; measured 0.5 cm by 0.5 cm.; and continue foam dressing. The fax was noted, signed by the physician and faxed back to the facility on [DATE], at 1:52 p.m. The 8/19/16, wound observation tool identified the open area as: measurement-0.5 cm by 0.5 cm moist area with 100% granulation tissue. The treatment was to continue adhesive foam dressing every 3 days. A nurses progress note dated 8/25/16, identified: foam dressing was replaced to left bunion; an additional sore was noted to the left bunion; and a total of two open areas were noted to bunion. No measurements were documented. The wound observation tool dated 8/25/16, identified: area worsening, measured 0.5 cm by 0.5 cm, and moist with 100% granulation. A nurses note dated 8/31/16, indicated R24 had an appointment scheduled with the podiatrist on 8/31/16, but the appointment was canceled and rescheduled for 9/8/16 due to R24 not feeling well. The wound observation tool dated 9/1/16, identified the area as worsening with 50% granulation tissue and 50% slough tissue and measuring 0.8 cm by 1.3 cm. The current treatment plan was to continue foam dressing changes 2 times per week. The evaluation identified worsened sore. Although the wound was noted to worsen according to the documentation dated 8/25/16 and 9/1/16, no revisions and/or reassessments occurred to ensure healing occurred. During interview on 9/21/16, at 8:03 a.m. R24 stated the bunion was not sore initially but the more she had therapy the more it started to hurt. She stated, you are working your shoe all the time and it hurt. R24 received physical therapy until 9/9/16. Documentation was lacking to indicate the plan of care was revised to address the offloading of the foot to remove pressure from R24's regular shoe. Review of a podiatry visit note dated 9/8/16, identified a full thickness ulceration over the left foot bunion, approximately 1 cm in diameter. The ulceration was debrided and a dressing and surgical shoe utilized. New orders were written for [MEDICATION NAME] ointment, gauze and kling wrap to foot, surgical shoe (open toe shoe) to offload ulcer and return in 4 weeks. The wound evaluation tool dated 9/9/16, identified: 75 % granulation tissue, 25 % slough tissue, measurement-0.8 cm by 1.2 cm and treatment of [REDACTED]. A physician visit note dated 9/14/16, identified the ulceration on the bunion as measuring 0.6 cm by 0.6 cm and pink around the edge. The wound observation tool dated 9/16/16, identified: area unchanged, 10 % granulation tissue and 90 % slough tissue and measurements-0.9 cm by 0.9 cm and 0.1 cm depth. Current treatment identified as [MEDICATION NAME] and gauze wrap daily. A nursing progress note dated 9/17/16, at 2:34 p.m. identified the area on R24's left foot ulcer as being red, warm to touch , macerated/non-blanch-able with R24 expressing pain to area with palpation. Nursing progress noted dated 9/17/16, at 9:50 a.m. identified increased drainage noted to left foot at bunion site. The dressing was saturated with drainage with soaked through R24's socks. The site was identified at red and warm to touch with purulent drainage. A nursing progress note dated 9/19/16, identified that R24 was receiving the antibiotic [MEDICATION NAME] a possible urinary tract infection (a urine culture was pending, but no growth after one day). A fax from the physician dated 9/19/16, indicated to [MEDICATION NAME] would cover the foot infection and a culture of the open area on bunion was ordered. Documentation on R24's wound evaluation tool dated 9/21/16, identified: area worsening, 100 % slough tissue, 0.7 cm by 0.8 cm by 0.9 cm depth, infection suspected and purulent drainage present. Treatment: [MEDICATION NAME], gauze and [MEDICATION NAME], started [MEDICATION NAME] mg (antibiotic) twice daily on 9/16/16; bunion became inflamed 9/17/16 and culture was obtained on 9/19/16. During interview on 9/22/16, at 12:21 p.m. registered nurse (RN)-D verified the left bunion of R24 had an open area when admitted (7/28/16) and the physician was notified of the open area by fax on 8/19/16. The physician responded to the fax on 8/22/16 with noted. RN-D verified the physician should have been notified of the open area when identified on admission. She stated we just covered it with a foam dressing; (R24's) shoes didn't seem tight like they were adding pressure or anything.

Based on observation, document review and interview the facility failed to provide the appropriate treatment to prevent further deterioration of pressure ulcers for 1 of 1 (R18) resident reviewed with facility acquired pressure ulcers. Findings include: R18's annual Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment, extensive assistance of 2 staff with transfers/bed mobility and does not walk. The Care Area Assessment (CAA) dated 7/25/16, identified R18 as being at risk for pressure ulcers, no pressure ulcer (PU) identified, is turned a minimum of every 6 hours and tolerates this per assessment. Progress notes dated 8/16/16, identified 3 skin/problem areas located on the spine of R18 and were described as noted: (#1) Top area red and measured 1.5 centimeter (cm) by 2 cm; (#2) middle area open measured 0.8 cm by 0.7 cm and (#3) bottom area scabbed and measured 1.5 cm by 1 cm. The area was cleansed and left open to the air. A progress noted dated 8/22/16, identified adhesive foam dressing applied to lower spine. Three bony prominence's were identified with skin breakdown: (#1) upper wound has pinkness that is resolving, (#2) middle wound has 0.2 cm x 0.2 cm yellow scab and (#3) the lower wound has 0.5 cm x 0.8 cm scab. Wounds occurred with longer period of sitting on toilet during Sitz baths; Sitz baths were discontinued 8/15/16. During observation on 9/20/16, at 2:07 p.m. R18 was lying supine (on back) in bed. At 2:37 p.m. R18 was resting in bed facing the window. R18 had a pillow positioned behind her back and a wedge under legs. At 3:31 p.m. she remained in the same position but lying more on her back than side. On 9/21/16, at 7:00 a.m. R18 was observed in the bathroom seated on the toilet with EZ stand hooked up. R18's back was resting/pressing against the toilet seat cover. R18's spine was curved and kyphotic. At approximately 7:15 a.m. R18 was assisted from the toilet and transferred into the wheel chair which had a thin piece of lambs wool over the back. At 9:30 a.m. R18 was observed seated in a recliner. At 10:20 a.m. registered nurse (RN) A was observed doing a wound treatment to R18's spine. The top wound (#1) was reddened and did not appear open, the middle area (#2) had an open area and the bottom (#3) open area was covered with slough. R18 had a rolled bath blanket behind her lower back. RN-A stated this was to relieve pressure from her back and had just (9/20/16) been implemented. At 1:26 p.m. R18 was observed on the toilet hooked up to EZ stand. R18's back/spine was again pressing up against the toilet seat cover until she was assisted back to bed at approximately 1:36 p.m. There was no padding/protection between the resident and the hard surface. On 9/22/16, at 12:43 p.m. R18 was seated on the toilet, hooked up to EZ stand. R18's kyphotic appearing back/spine remained pressed against the toilet seat cover. R18 was taken off the toilet and put to bed at approximately 12:55 p.m. The wound observation tool dated 8/22/16, described the problem areas on the spine of R18 as noted: upper wound (#1) as a suspected deep tissue injury (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and the lower spine wound (#3) as an Unstageable PU (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Review of the care plan revised 8/26/16, identified R18 at risk for skin breakdown and open areas present to bony prominence's to back. Interventions included: air mattress on bed, treatment per nursing order, turn and reposition at least every 6 hours when sitting and every 2 hour repositioning at night due to skin breakdown to spine. No reassessments were conducted and/or interventions revised after noted skin breakdown. A review of the nursing home rounds note dated 9/6/16, identified 2 closed areas and one open area of skin breakdown on R18's spine. R18 was identified as quite resistant to being repositioned during the night; however, nursing staff encouraged her to allow repositioning to aid in healing the spine. The wound observation tool for R18 dated 9/9/16, identified the spine wound located on the lower area (#3) as being a Stage III PU (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). Documentation indicated the physician was notified of the identified pressure ulcers on 9/6/16. The wound observation tool dated 9/21/16, identified the upper wound on the spine (#1) as being a Stage II PU and the lower spine (#3) wound as a Stage III PU. During interview on 9/22/16, at 12:43 p.m. nursing assistant (NA) A verified R18's back (bony prominence) does press against the toilet seat while seated on the toilet. She stated she routinely sits for 5-10 minutes at a time in this position. During interview on 9/22/16, at 11:46 a.m. registered nurse (RN)- D stated she thought the sores started from R18 sitting on the toilet for longer periods of time due to having sitz baths. She stated the sitz baths were discontinued on 8/15/16, but she could not identify when the sitz baths were started. She stated she thought they had been doing them maybe 2 weeks before they discontinued them. She verified the pressure areas were identified on 8/16/16, and stated she put a foam dressing on right away. She stated the lambs wool placed on the wheel chair was implemented this week and the rolled bath blanket behind back in recliner had been implemented on 9/19/16. RN-D further stated I didn't really think about them being from pressure and also confirmed that all three areas on the spine were open again. RN-D stated the top one (#1) was healed on Friday (9/16/16) but had re-opened. RN-D verified R18 still had pressure to the open areas/bony prominence when toileted and resting against the seat due to her kyphosis. She verified R18 would have pressure on her back from the toileting and sitting. She stated R18 had not been reassessed for positioning since the PU developed and repositioning every 6 hours would not be adequate as defined in the plan of care.

Based on observation, interview, and document review, the facility failed to ensure nail care was completed for 1 of 1 resident (R35) reviewed for activities of daily living (ADLs) who was dependent on staff for care. Findings include: R35's quarterly Minimum Data Set ((MDS) dated [DATE], identified R35 had no cognitive impairment, had [MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side of the body), and required extensive assistance to complete personal hygiene. During observation on 6/17/15, at 8:35 a.m. R35 was seated in a wheelchair in the hallway. R35 had long fingernails noted on his right hand, and short fingernails on his left hand. R35 stated the nails on his right hand were a little longer than he liked them to be, and they should be trimmed. Further, R35 stated he just had a bath earlier that morning. During subsequent observations, on 6/17/15 at 2:35 p.m. and 6/18/15 at 7:06 a.m., R35 continued to have long fingernails on his right hand. When interviewed on 6/18/15, at 7:21 a.m. nursing assistant (NA)-D stated R35 was dependant on staff for his personal hygiene, and his fingernails are trimmed by the nurse because he is diabetic. NA-D added she was unaware of any desire by R35 to have long fingernails, and stated they should have been kept trimmed, They are a little long. During interview on 6/18/15, at 7:53 a.m. NA-C stated she completed R35's bath the day prior (6/17/15) and did not trim his fingernails because he's diabetic, however she had forgotten to notify the nurse they were long and needed to be trimmed on his right hand, They need cutting. When interviewed on 6/18/15, at 8:18 a.m. registered nurse (RN)-B stated R35's fingernails are scheduled to be trimmed every 4 weeks, and they were last done on 5/27/15 (22 days prior) according to the Treatment Administration Record (TAR). RN-B viewed R35's long fingernails on his right hand. RN-B stated she spoke to R35, and R35 reported the staff often only trim the nails on his left hand. RN-B added R35's long fingernails should have been trimmed. During interview on 6/18/15, at 8:40 a.m. RN-A stated R35's nails should have been trimmed when they were noticed to be long. A facility Care of Fingernails/Toenails policy, dated 6/13, identified, Nail care includes daily cleaning and regular trimming. Further, the policy identified, Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on interview and document review the facility failed to respond to a resident's health care related request in a dignified and prompt manner for 1 of 1 resident (R11) who had requested her ears be irrigated. Findings include: R11's annual Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition. The MDS further indicated R11 could usually make herself understood to others, and that she had the ability to clearly understand what others were saying. During an interview on 6/17/2015 at 8:53 a.m., R11 stated that in March 2015, she had told registered nurse (RN)-A, My ears are full of wax. Would you cleanse my ears? R11 stated she had asked RN-A a number of times since to complete the irrigation. R11 said RN-A had responded to her unfulfilled requests with .I didn't forget you, or I don't have time right now. R11 stated she could not remember the exact date she requested to have her ears cleaned, but emphasized, It's June 16th, and still not done. A review of the Hilltop Care Center Standing Orders, revised 4/14/14, and signed by R11's provider 7/9/14, indicated the following: Ear Irrigation: Mineral Oil eardrops 5 drops BID (two times daily) to affected ear(s); for up to 4 days; follow with ear irrigation, may repeat. In an interview on 6/18/2015 at 1:18 p.m., RN-A was interviewed regarding R11's request for ear irrigation. RN-A stated, She did ask, and I have not done it. RN-A also stated, R11's ear irrigation had been a low priority, as far as the things I need to get done. RN-A could not recall exactly when R11 had first asked her to irrigate her ears. RN-A acknowledged, .it's been a while and I should have gotten to it by now but haven't. RN-A verified there was a current standing order for ear irrigation for R11. In an interview on 6/19/15 at 7:12 a.m., the director of nursing (DON) said she was unable to respond without talking to the nurse as to why R11's request had not yet been addressed. The DON said it was unusual for RN-A not to follow up on things and stated that ear irrigation could be completed by any nurse or could have been delegated. In a subsequent interview at 8:50 a.m., the DON said, Bottom line, the nurse should have jotted it down, and that the nurse honestly just forgot to do it. The facility policy, Resident Grievance Procedure undated, provided guidance to residents .when a patient/resident issue cannot be resolved promptly by staff present. The policy did not address timely response of resident to day-to-day concerns or requests.

Based on observation, interview, and document review, the facility failed to ensure all ventilation openings in the kitchen were clean of dust and debris. This had potential to affect all residents, staff and visitors who consumed food from the kitchen. Findings include: During the initial tour of the facility kitchen with cook (CK)-C on 6/16/15, at 6:04 p.m. a Maxum stainless steel range hood was in use above where food was prepared. On the range hood, two large vents were labeled, make-up air and were visibly coated in a dark brown substance with numerous areas of clumped dust and black debris. When interviewed on 6/16/15, at 6:25 p.m. CK-C stated she was unaware when the vents were last cleaned. Further, CK-C stated the facility maintenance crew was responsible for cleaning the range hood vents, and they should not be soiled and have clumping dust stuck to them. During a subsequent observation of the facility kitchen on 6/17/15, at 10:23 a.m. the range hood vents remained visibly coated in a dark brown substance with numerous areas of clumped dust and black debris. When interviewed on 6/17/15, at 10:56 a.m. CK-D stated the vents are cleaned by whoever has time. Further, CK-D stated the vents should be kept clean as air blows out of them, Their a little dusty. During interview on 6/17/15, at 1:58 p.m. the maintenance director (MD) stated the vents were cleaned the month prior, but they should not be allowed to collect excessive build up. Further, the MD stated air blows out from the vents into the kitchen and they should be cleaned adding, That is quite a bit of build up. A Preventive Maintenance: Exhaust Fans policy, dated 2015, directed staff to check for proper operation and included a procedure which included, Clean vents, using vacuum and air compressor to remove dust. Further, staff were directed to clean them on a monthly basis. The vents were last cleaned on 6-3-15 according to the schedule (13 days prior). A manufacturer's operation manual was requested from the facility, but none was provided.