Every finding on record at Ecumen Lakeshore

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident (R8) reviewed for MDS accuracy.Findings included:The CMSA Long-Term Care Facility Resident Assessment Instrument (RAI) 3. User Manual, dated 10/2023, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section F: Preferences for Customary Routine and Activities. This section had the intent to obtain information regarding the resident's preferences for her daily routines and activities.R (8)'s annual MDS dated [DATE] indicated, R8 had memory problems, had no delusions or hallucinations, and did not reject cares. The section F of the MDS was not completed.During the interview on 8/7/25 at 10:34 a.m., MDS coordinator stated the life enrichment coordinator needed to complete the R8's activity review and the activity preferences assessments to enter the information into the section F and made the necessary updates to the care plan. The MDS coordinator stated, she had sent a message to the life enrichment director to complete the assessments.Facility's policy titled MDS Assessment Coordinator dated 11/2019, indicated a registered nurse (RN) shall be designated the responsibility of conducting and coordinating each resident's MDS assessment. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of the portion of the assessment.

Based on observation, interview, and document review the facility failed to ensure dishwasher temperatures were maintained or implement other strategies to effectively sanitize dishware and utensils to reduce the risk of foodborne illness. This had potential to affect 56 residents residing in the nursing home along with staff and visitors who consume meals from the main production kitchen. Findings include: During observation on 6/13/24 at 8:43 a.m., culinary aide (CA)-A was washing morning dishes. The dishwasher monitoring system was flashing red and showed a low rinse temperature at 140 degrees Fahrenheit (F). The thermometer on the dishwasher also indicated 140 degrees. CA-A continued to insert dirty dishes in to the dishwasher. Review of the facilities dishwasher temperature log from 6/1/24 to 6/13/24, identified rinse temperatures that ranged from 145 to 155 degrees F. During an interview on 6/13/24 at 8:45 a.m., CA-A-stated the dishwasher temps had been below 180 degrees F since at least the beginning of June and Ecolab was aware and was going to fix the broken part. The food services director was aware. During an interview on 6/13/24 at 9:03 a.m., food services director (FSD) stated the dishwasher was a high temperature dishwasher which sanitized dishes with high heat and not chemicals. The FSD stated the rinse cycle temperatures had to be at least 180 degrees F to sanitize dishes appropriately. The booster was not working and to his knowledge, the booster had been broken for since at least the first of this month. FSD was unaware of any changes being made to the dishwashing process since the booster had broken stating, everything stayed the same regarding the process for cleaning and sanitizing the dishes used by the residents. FSD stated the dishes were still getting sanitized and safe to use even though the temperature was below 180 degrees. During an observation on 6/13/24 at 9:08 a.m., FSD performed a litmus test on the dishwasher which indicated the rinse cycle was not reaching160 degrees. He then utilized a thermometer and stated the core was only reading 155 degrees at that time. During an interview on 6/13/24 at 9:22 a.m. the infection preventionist (IP) stated if dishes are not washed and sanitized at the appropriate temperature there was an increased risk of contamination and an increased risk anybody eating out of the kitchen becoming ill. A facility policy for dish cleaning was requested but not provided.

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 2 residents (R14) reviewed whose Medicare A coverage ended and remained in the facility. Findings include: R14's Centers for Medicare and Medicaid Services (CMS)-10123 dated 5/1/23, identified a Medicare last covered day (LCD) of 5/3/23. R14's undated Census Records form identified on 5/4/23, R14's payer source changed from Medicare Part A to Private Pay, and R14 remained in the facility. R14's medical record lacked evidence a SNFABN was provided to explain the estimated cost per day or provide rationale of the extended care services or items to be furnished, reduced, or terminated. R14's progress note dated 5/1/23, identified the social worker (SW) had given R14 a Notice of Medicare Non-Coverage. The note identified R14 planned to discharge to home after her surgery. On 9/7/23 at 2:31 p.m., the SW reviewed R14's chart and identified R14 received the notice of non-coverage, and was planning to go home, but R14's surgery date was changed, therefore R14 remained in the facility. R14's status changed to private pay on of 5/4/23, and R14 did not receive a SNFABN, when they decided to remain in the facility. It was the facility process to make sure everyone received proper notice, to allow them to make an informed decision about discharging or remaining in the facility. On 9/8/23 at 8:40 a.m., the director of nursing (DON) stated it was her expectation that every resident received a SNFABN to notify them how much it would cost to stay in the facility as a private pay resident. The document allows residents and their families to make an informed decision. The facility policy Medicare Advanced Beneficiary and Medicare Non-Coverage, dated 9/22, identified the facility would issue a SNFABN to a resident or their representative in the event it was anticipated Medicare part A would not pay for an otherwise covered skilled service(s). The notification would inform residents that services may not be covered and of the resident's potential liability for payment of non-covered service(s).

Based on interview and document review, the facility failed for 1 of 5 residents (R159) reviewed for medications. Findings include: R159's admission Minimum Data Set (MDS) dated [DATE], identified memory problems and had no behaviors identified. R 159 utilized antipsychotic medications for seven days during the look back period. The antipsychotic identified it was used on a routine basis, there was no drug regimen review identified as completed and lacked and medication follow up. A diagnosis of insomnia was identified. R159's care plan revised on 9/6/23, identified R159 used Seroquel (an antipsychotic medication) and the facility would monitor for the inability to fall asleep/ stay asleep and for nocturnal restlessness. R159's Order Summary Reported dated 9/6/23, identified an order for Seroquel 50 milligrams (mg) via g-tube at bedtime for diagnosis pending. R159's Medication Administration Record (MAR) dated 9/7/23, identified the Seroquel was prescribed for insomnia. R159's pharmacy reviews from July 2023, through August 2023 identified the following: - 7/9/23 no irregularities - 8/12/23 no irregularities - 8/29/23 requested clarification of Amlodipine dose. Provider clarified dose. - 8/29/23 request to address PRN non-antipsychotic psychotropic medication Benadryl. A stop date was added for 9/11/23. During an interview on 9/8/23 at 8:38 a.m., director of nursing (DON) stated the medical providers prescribed medications so she could not say if it was appropriate for R159 to receive scheduled Seroquel for insomnia. During an interview on 9/8/23 at 10:01 a.m., consulting pharmacist (CP) stated Seroquel was an antipsychotic medication and insomnia was not an appropriate diagnosis for the use of Seroquel in the long-term setting. Indications for prescribing Seroquel included: as an adjunct to an antidepressant, bipolar, dementia with behaviors, or behaviors in conjunction with other diagnoses like a personality disorder. Seroquel was often used in the acute care setting to manage sleep but identified it was usually discontinued by the hospital provider at discharge or upon admission to a long-term facility. R159's Seroquel was not an appropriate dose for the treatment of insomnia. The CP stated their partner reviewed R159's admission orders not sure what happened. Typically the Seroquel would have been flagged to be discontinued and would flag the medication for review during the September reviews. R159 was at a greater risk for falls and Seroquel consumption by chemical design could result in changes to the brain and mood. The facility Medication Regimen Reviews policy dated May 2019, identified a medication review would be conducted by a pharmacist at the time of admit then monthly or as needed for all residents in the facility that received medication. The review included the identification of, notification to the provider, and resolution of medication irregularities. Actionable irregularities included but were not limited to: medication errors, excessive doses or doses without a clinical indication, inadequate monitoring for side effects, duplicative therapies, and potentially adverse consequences of medications.

Based on interview and document review, the facility failed to ensure an appropriate diagnosis to support ongoing use of an antipsychotic medication for 1 of 5 residents (R159) reviewed for medications. Findings include: R159's admission Minimum Data Set (MDS) dated [DATE], identified memory problems and had no behaviors identified. R 159 utilized antipsychotic medications for seven days during the look back period. The antipsychotic identified it was used on a routine basis, there was no drug regimen review identified as completed and lacked and medication follow up. A diagnosis of insomnia was identified. R159's care plan revised on 9/6/23, identified R159 used Seroquel (an antipsychotic medication) and the facility would monitor for the inability to fall asleep/ stay asleep and for nocturnal restlessness. R159's Order Summary Reported dated 9/6/23, identified an order for Seroquel 50 milligrams (mg) via g-tube at bedtime for diagnosis pending. R159's Medication Administration Record (MAR) dated 9/7/23, identified the Seroquel was prescribed for insomnia. R159's pharmacy reviews from July 2023, through August 2023, failed to identify a need to review an insomnia diagnosis for the use of antipsychotic medications. During an interview on 9/8/23 at 8:38 a.m., director of nursing (DON) stated the medical providers prescribed medications so she could not say if it was appropriate for R159 to receive scheduled Seroquel for insomnia. During an interview on 9/8/23 at 10:01 a.m., consulting pharmacist (CP) stated Seroquel was an antipsychotic medication and insomnia was not an appropriate diagnosis for the use of Seroquel in the long-term setting. Indications for prescribing Seroquel included: as an adjunct to an antidepressant, bipolar, dementia with behaviors, or behaviors in conjunction with other diagnoses like a personality disorder. Seroquel was often used in the acute care setting to manage sleep but identified it was usually discontinued by the hospital provider at discharge or upon admission to a long-term facility. R159's Seroquel was not an appropriate dose for the treatment of insomnia. During an interview on 9/8/23 at 11:55 a.m., nurse practitioner (NP)-A stated NP-A was responsible for the management of R159's medication while he resided at the facility. R159 received Seroquel in the hospital and the order continued at the facility. R159's indication for Seroquel was insomnia and explained Seroquel was used off label to treat insomnia. R159's medical record lacked a medical provider's assessment related to Seroquel used for insomnia following admission to the facility. The facility Antipsychotic Medication Use policy dated July 2022, indicated residents would not receive medications that were not clinically indicated to treat a specific condition. The policy included a list from the Diagnostic and Statistical manual of Mental Disorders which provided conditions and diagnoses for which antipsychotic medications would be prescribed to treat a resident. Insomnia was not a listed indication for Seroquel. Antipsychotic medications would not be used if the only symptoms are one or more of the following: a. wandering; b. poor self-care; c restlessness; d. impaired memory; e. mild anxiety; f. insomnia; g. inattention or indifference to surrounding; h. sadness or crying alone that is not related to depression or other psychiatric disorders; fidgeting; j. nervousness; or k. uncooperativeness. A physician would either change or stop problematic doses or medications or document why the benefit of continuing a medication outweighed the risk of suspected or confirmed adverse consequences.

Based on observation, interview and document review the facility failed to cut food in bite size pieces as directed for 1 of 1 resident (R2) reviewed nutrition. Findings include: R2's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was severely cognitively impaired and had difficulty with swallowing. R2's undated Admission Record, included diagnoses of dementia, hemiplegia, and hemiparesis (paralysis and/or weakness on one side of the body) following a stroke affecting the right dominant side. R2's care plan dated 7/13/23, identified R2 had a self-care deficit and required assistance with eating. The interventions indicated R2 required set up and assistance for meals and staff were directed to cut up food. R2 had a swallowing problem secondary to cerebral infarction. Interventions included upright at 90 degrees with food/fluids, cut up foods, monitor for shortness of breath, choking, labored respirations, and lung congestion. Staff were directed to monitor for pocketing of food, choking, coughing, drooling, or holding food in mouth. R2 would refuse to eat and appeared concerned during meals. R2's orders dated 9/5/23, identified swallow precautions and the need to be upright 90 degrees for meals with food cut up. Staff were directed to report signs and symptoms of dysphagia (difficulty swallowing foods or liquids) or respiratory distress immediately every shift. In addition, R2 had orders dated 7/13/23, for a regular diet level 7-regular texture (regular diet), level 0-thin liquids with half portions. During observation on 9/5/23 at 5:30 p.m., R2 was in her bed with her food in front of her, not eating anything. During observation on 9/5/23 at 5:55 p.m., R2 remained in bed with food in front of her, not cut into bite size pieces, with no staff assisting her with eating. R2 was not feeding themselves. During observation on 9/6/23 at 11:48 a.m., R2 was seated in her bed, her food was in front of her. R2 was served baby carrots (not cut up), beef stroganoff, ice cream, and juice. There was a paper napkin covering some of the food on her plate. During observation on 9/6/23 at 12:13 p.m., nursing assistant (NA)-B entered R2's room and asked R2 why R2 covered her food. NA-B removed the napkin, but did not cut the food. During observation on 9/7/23 at 7:53 a.m., R2 was seated in bed eating oatmeal. She also had juice, a quiche, a hash brown patty, of which were not cut up. During observation on 9/7/23 at 8:07 a.m., R2 was alone in her room and was heard coughing from the hallway. No staff were present in the area. During observation on 9/7/23 at 8:11 a.m., R2 remained alone in her room as she continued to cough. R2 had drank all of her juice and eaten everything on her tray with the exception of the crust from the quiche . During observation on 9/8/23 at 7:55 a.m., R2 was seated in her chair drinking her juice and had finished her oatmeal. There was an omelet on her plate not cut into bite size pieces. Registered nurse (RN)-C verified the omelet was not cut up. RN-C asked R2 if she ate the sausage and R2 shook her head yes. RN-C picked up the meal ticket and verified the instructions, 1/2 portions, cut food into bite sized pieces. R2's meal ticket dated 9/8/23, for the breakfast meal, identified R2 should receive half portions and was supposed to have her food cut into bite size pieces. During an interview on 9/7/23 at 8:59 a.m., NA-C stated R2 was supposed to have her food cut into bite size pieces. During an interview on 9/8/23 at 8:44 a.m., RN-C stated the kitchen staff was new and had been reminded to look at meal tickets and follow the instructions. Staff would not be able to monitor a resident for coughing, choking, or drooling if they were not present in the room while the resident was eating. R2 had a current order for swallow precautions and staff were expected to cut up R2's food to prevent possible choking. During an interview on 9/8/23 at 9:16 a.m., the director of nursing (DON) verified staff would need to be present with a resident to monitor for choking, coughing, and/or drooling. Staff were expected to follow orders for swallow precautions. The policy Dysphagia-Clinical Protocol dated 9/2017, identified the staff and the physician would identify individuals with a history of swallowing difficulties or related diagnoses such as dysphagia as well as individuals who had difficulty chewing or swallowing food.

Based on observation, interview and document review, the facility failed to ensure staff completed proper hand hygiene and glove use during personal cares for 1 of 4 residents (R159) reviewed for activities of daily living (ADL). Findings include: R159's admission Minimum Data Set (MDS) dated [DATE], identified memory problems, and required assist of two for transfers and ADL's. During an observation on 9/6/23 at 11:20 a.m., trained medication aide (TMA)-A and nursing assistant (NA)-A entered R159's room to perform cares. TMA-A moved R159's catheter drainage bag from the lift to the bed, then stopped and donned gloves and lowered R159's pants. NA-A with gloved hands cleansed R159's peri area, catheter insertion site. TMA-A and NA-A cleansed R159's buttocks area with the same gloves. NA-A with the contaminated gloves opened R159's bedside table to look for barrier cream. NA-A and TMA-A with the same contaminated gloves secured a clean brief on R159 and pulled up their pants. NA-A lowered the bed with a remote and boosted R159 up in bed, then positioned R159 with pillows under both feet and left hip and raised the head of the bed with the remote, with the same gloved hands. - NA-A then removed their gloves, did not perform hand hygiene and then arranged R159's bed covers. TMA-A grabbed the dignity bag from R159's recliner, secured it onto the bed, and then placed R159's drainage bag into the dignity bag. TMA-A removed her gloves, sanitized her hands and left the room. NA-A lowered R159's bed to the lowest position and clipped R159's call light within reach. NA-A gathered R159's garbage bag and tied it off and un-muted R159's tv with the remote and angled the tv so R159 could see it. NA-A arranged R159's glasses case and cell phone on the bed side table and moved the table bedside. NA-A then sanitized their hands, picked up the garbage and exited the room. During an interview on 9/6/23 at 11:35 a.m., NA-A confirmed they did not remove their gloves after performing peri care on R159. NA-A should have removed their gloves, sanitized hands, and then finished with cares. NA-A also should have sanitized their hands before they touched the resident or items in the room upon entrance. It was important to remove gloves and sanitize hands after touching something that was considered dirty because it prevented the spread of germs and cross contamination. NA-A planned to go back into R159's room and sanitize the items they touched. NA-A would have changed gloves and sanitized hands after touching something dirty, but they had been distracted when they could not find barrier cream, so it was missed. During an interview on 9/6/23 at 11:42 a.m., TMA-A verified TMA-A had not changed their gloves after touching the catheter drainage bag and before they assisted with cares for R159. The catheter drainage bag could have had urine on the outside so it would be considered dirty. It would have been best practice to remove their gloves and sanitize their hands after they touched the foley bag. During an interview on 9/8/23 at 9:54 a.m., director of nursing (DON) stated gloves should come off and hand hygiene should take place after performing peri care and before proceeding to clean cares and/or touching clean items. This practice was important to prevent the spread of infection and cross contamination of clean items. A catheter drainage bag would be considered a dirty item so staff should remove gloves and sanitize hands before touching clean surfaces or the resident. The facility Handwashing/Hand Hygiene policy dated August 2019, provided instruction on when staff should complete hand hygiene. The policy identified hand hygiene was to be completed before and after contact with residents, before and after handling medical devices or equipment, before moving from a contaminated body site to a clean body site during care, after contact with resident skin, and before and after glove use. The purpose of appropriate glove use and hand sanitization was to prevent the spread of infections.

Based on observation, interview, and document review, the facility failed to consistently post the nurse staff posting. This had the potential to effect all 45 residents residing in the facility and/or visitors who may wish to view the information. Findings include: On 11/7/22, at 10:48 a.m. the facility nurse staff posting was observed on the wall in a pocket near the backdoor entryway. The nurse staff posting dated 11/7/22, indicated a census of 45 and had categories for registered nurse (RN), licensed practical nurse (LPN), trained medication aide (TMA), and certified nursing assistant (CNA) for 6:00 a.m. to 2:30 p.m., 2:00 p.m. to 10:30 p.m. and 10:00 p.m. to 6:30 a.m. There were no hours filled in for RN, LPN, TMA, or CNA. The nurse staff postings from 10/19/22, through 11/7/22, were reviewed. The facility census was recorded for each day, but there were no nursing hours indicated on the following dates: 11/6/22, 11/5/22, 11/4/22, 11/3/22, 11/2/22, 11/1/22, 10/31/22, 10/28/22, 10/27/22, 10/26/22, 10/25/22, 10/24/22, 10/23/22, 10/22/22, 10/21/22, 10/20/22, or 10/19/22. Nurse staff postings were not available for 10/30/22, and 10/29/22. During an interview on 11/7/22, at 10:58 a.m. health unit coordinator (HUC)-A stated the nurse staffing was only posted downstairs in the backdoor entryway. Visitors and vendors were able to enter through this door. During an interview on 11/8/22, at 9:34 a.m. the director of nursing (DON) stated the posting of nursing hours had initially been the responsibility of the human resources department; then it became the HUC's responsibility; then it was the nurse managers (NM) responsibility because the HUC's thought they couldn't do it. The DON stated it was currently the responsibility of the NM. The DON stated there were four nurse managers so whoever was managing staffing would be the NM responsible to post the hours. The DON verified the postings had no nursing hours filled in from 10/19/22, to 11/7/22. The DON stated it was an important communication tool between the facility and families and gave families a sense of security to see the actual numbers of staff working. Registered nurse (RN)-A was present during the interview and added the nurse staff postings should be filled out daily, accurately, and timely. The facility policy titled Posting Direct Care Daily Staffing Numbers dated 8/2022, indicated the nurse staffing would be posted within two hours of the beginning of each shift, and include the number of licensed nurses and the number of unlicensed nursing personnel. It would be posted in a prominent location and accessible to residents and visitors in a clear and readable format. The posting would include the following: -The name of the facility -The current date (the date for which the information was posted) -The resident census at the beginning of the shift for which the information was posted -Twenty-four (24)-hour shift schedule operated by the facility -The shift for which the information was posted

Based on interview and document review, the facility failed to ensure precautions and interventions were set up to reduce the risk of falls or injuries for 1 of 1 residents (R19) reviewed for accidents who had severe cognitive impairment. Findings include: R19's Face Sheet printed 5/25/22, indicated admission to facility on 4/21/22. The Face Sheet also indicated diagnoses that included wedge compression fracture of T9-T12 vertebra, other specified fracture of right pubis, toxic [CONDITION(S)]-a condition that effects brain function, [CONDITION(S)] with behavioral disturbance, unsteadiness of feet, unspecified abnormalities of gait and mobility and cognitive communication deficit. R19's care plan printed 5/25/22, indicated a care plan for falls was initiated on 4/21/22. R19's fall care plan indicated the interventions including call light within reach, adequate lighting, and ensure R19 was wearing appropriate footwear. On 4/22/22, the following interventions were added: hourly checks, bed in lowest position, and anticipate and meet resident's needs. On 4/26/22, educate resident/family/caregivers about safety reminders was added. R19's 5 day Minimum Data Set (MDS) dated [DATE], indicated R19 had severely impaired cognition. R19's Morse Fall Scale-V 3 assessment, performed 4/21/22, indicated R19 had a score of 75. Morse Fall Scale scoring indicated a score of 45 or higher was a high risk of falls. R19's Progress Notes dated 4/22/22, at 11:29 a.m. indicated physical therapist found R19 on floor by the closet. The corresponding event note indicated R19's Morse fall score prior to fall was 75 and 75 after the fall. The corresponding event note indicated interventions added were to start hourly safety checks. R19's Progress Notes dated 4/22/22, at 2:27 p.m. indicated staff found R19 on floor by the closet for a second time. The event note indicated R19's Morse fall score prior to fall was 75 and 75 after the fall. The event note also indicated interventions added were bed in lowest position and fall mat at bedside. R19's Progress Notes dated 4/23/22, at 12:01 a.m. indicated staff found R19 on the floor leaning against the nightstand with the fall mat underneath him. The event note indicated R19's Morse fall score prior to fall was 90 and was 90, when rechecked, after the fall. The event note indicated interventions were administered [MEDICATION(S)] for restlessness and [MEDICATION(S)] for pain. R19's Progress Notes dated 5/6/22, indicated at 12:30 p.m. staff observed R19 in his recliner eating lunch. The event note indicated at 12:35 p.m. staff heard a loud bang from R19's room and found R19 on laying on the floor with the tray table pushed away. The event note indicated R19's Morse fall score prior to fall was 90 and 90 after. The event note indicated interventions were in place and no new interventions were added. R19's Progress Notes dated 5/13/22, indicated at 8:25 a.m. staff found R19 laying on the floor next to the bed, on left side facing the bed, and feet under bed and knees bent. The event note indicated R19 had last been seen 10-15 minutes prior to 8:25 a.m. sitting on the side of his bed eating breakfast. The event note indicated all interventions were in place. Due to significant medical concerns, including no use of left upper or lower extremity, R19 was transferred to the emergency room . On 5/23/22, at 2:38 p.m. registered nurse (RN)-A stated a Morse fall score was performed on admission for all residents and if the score was 45 or higher then interventions included call light in reach, adequate lighting and ensure wearing appropriate footwear. RN-A stated a lot of residents have a score of at least 45. RN-A reviewed R19's care plan and stated fall interventions included the call light, adequate lighting and ensure wearing appropriate footwear, as stated earlier in interview. RN-A stated the interventions of hourly rounding and bed in lowest position were noted to be added on 4/22/22. RN-A reviewed the fall event report from 4/23/22, at 12:01 a.m. and stated the medication given at time of fall was the only intervention performed at time of fall; there were no new interventions to try to prevent future falls. RN-A reviewed event documentation from 5/6/22, at 1:17 p.m. and stated no new interventions were placed after that fall; noting the documentation indicated all interventions were in place. RN-A stated after reviewing R19's records there were no interventions in place for when R19 was sitting up; there were only interventions for when R19 was in bed. RN-A stated more interventions should have been added based on the fact that R19 was sitting up and not in bed. On 5/25/22, at 9:56 a.m. RN-C stated the incident reports were reviewed to see if any changes needed to be made in regards to R19's care. RN-C reviewed all falls on 4/22/22, and stated the medication intervention for fall documented 4/23/22, at 12:01 a.m. was the only intervention added . RN-A reviewed the event report from 5/6/22, at 1:17 p.m. and stated R19 had been sitting up prior to the fall and no other interventions were needed due to this fall. RN-C asked, what else would be done? We don't do restraints, close observation or one on one observations in the facility. On 5/25/22, at 11:29 a.m. the director of nursing (DON) reviewed R19's event note from 4/23/22, at 12:01 a.m. and stated the intervention in place to give [MEDICATION(S)] was appropriate based on R19 self transferring several times. DON stated there were no other interventions documented at that time. DON reviewed R19's careplan and noted on 4/26/22, R19's careplan was modified to include education to the resident and family about falls and fall prevention. The DON reviewed R19's MDS from 4/27/22, and stated an education intervention was not an appropriate intervention based on R19's severely impaired cognition. The DON stated other interventions should have been set up. The facility's fall prevention policy was requested but not received. The facility Assessing Falls and Their Causes policy dated 2001, was received but did not discuss fall prevention.

Based on interview and document review, the facility failed to ensure an allegation of abuse was reported immediately (within two hours) to the administrator and State Agency (SA) for 1 of 1 resident (R156) reviewed for abuse. Findings include: R156's Admission Record printed on 5/25/22, indicated R156's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R156's admission Minimum Data Set (MDS) dated [DATE], indicated R156 was cognitively intact and required extensive assistance of two for activities of daily living (ADLs). R156's MDS indicated she received as needed pain medication in the past five days, had almost constant pain, the pain made sleeping difficult, and limited her day to day activities. R156 rated her pain a seven on a one to ten scale, with 10 being the most severe. In addition, R156 had received an opioid pain medication (medication used to treat pain) seven of the last seven days. R156's care plan initiated 5/13/22, indicated R156 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical immobility. Staff were directed to converse with resident while providing care. R156 had chronic pain related to [CONDITION(S)]. Staff were directed to administer analgesics as ordered, give 30 minutes prior to treatments, care, or therapy. The facility received a formal verbal report from R156 about a complaint of a staff member's conduct on 5/19/22. R156 reported the incident caused significant emotional distress due to the pain the EdemaWear was causing and caused her to lose sleep. R156 reported the staff member, registered nurse (RN)-B, said Nothing you say is going to ruin my day after she stated she said not you again. R156 stated she perceived this as what she said didn't matter. The facility filled out a Patient Concern Form. On 5/22/22, at 2:06 p.m. during an interview with R156 she stated she had lodged a complaint with the facility a few days ago about treatment received by a staff nurse. R156 stated the staff member, registered nurse (RN)-B, was abrupt and rude when he gave her pain medication on 5/19/22, at approximately 11:15 p.m. R156 stated she asked him to remove her EdemaWear, she said he argued with her and told her she had to wear it 24/7 (24 hours a day and seven days a week). R156 stated she told him it was causing pain and that it felt too tight. She asked if she could have the EdemaWear removed and wear her pumps (a pneumatic compression device for [CONDITION(S)] consists of an air pump and a sleeve that fits over the extremity. As air pressure is applied by the device, the limb experiences gentle changes in fluid movement) instead of the EdemaWear. According to R156, RN-B refused to remove the EdemaWear and apply the pumps. R156 stated it made her feel broken and not listened to. Later RN-B came into the bathroom at her request as she was having constipation issues and wanted a dose of [MEDICATION(S)] (a medication used to treat constipation). R156 described RN-B as abrupt and mean and stated he told her she didn't take any, R156 told RN-B that she missed her dose that morning because it was taken away by accident on her breakfast tray. R156 reported RN-B then said she couldn't have any but did offer to give her a senna (another medication used to treat constipation). R156 stated she thinks she said oh you again when he came into the room and he replied with nothing you say is going to ruin my day. R156 stated she was grieving the whole next day about the incident. On 5/22/22, at 2:58 p.m. R156's concern was reported to the director of nursing (DON), administrator, and RN-F. The DON stated they were aware of the incident but had not considered it abuse and had not reported the incident but stated they would make a report to the state agency (SA). The facility had filled out a Patient Concern Form on 5/20/22. A facility incident report was submitted on 5/22/22, at 3:27 p.m. which indicated R156 thought registered nurse (RN)-B was rude and abrupt and refused to remove her EdemaWear or put on her [CONDITION(S)] pumps. R156 stated this caused her to be in pain and lose sleep. During an interview on 5/24/22, at 11:57 a.m. RN-B verified he was working on 5/19/22, the 10:00 p.m. to 6:30 a.m. shift. RN-B stated NA-B and NA-C were with him in the room with R156 and that NA-C was with him when R156 asked him to adjust her EdemaWear. RN-B verified he told R156 that she had to wear the EdemaWear at all times unless she had the pumps on. RN-B stated she wanted the wrap adjusted on her right leg, she said it was leaving marks on her leg, he said said he did not remove the EdemaWear, stated it had just been put on her legs at 9:30 p.m., he could get his fingers under it and adjusted it by smoothing it around the ankle. RN-B stated R156 never asked him to put her pumps on. RN-B stated he never raised his voice and when she said, oh you again, he responded with I still have a job to do, how can I help you? RN-B stated R156 was her usual self, always demanding. RN-B stated he received a phone call from the DON on 5/22/22, telling him he was being put on a suspension. RN-B verified he received annual abuse training, and could not think of anything he said that might have been taken the wrong way by R156. A review of RN-B's personnel file indicated RN-B had completed an abuse and prevention education on 4/11/22. RN-B had a customer service violation (verbal altercation with a resident) on 6/29/09, which resulted in a three day suspension. On 5/24/22, NA-C was called, there was no answer and no voice mail set up. During an interview on 5/24/22, at 12:30 p.m. NA-B stated he and NA-D were working with RN-B and R156. NA-B stated he only heard the last part of the interaction between RN-B and R156 about the medication for constipation. NA-B stated R156 seemed upset and frustrated. NA-B said when RN-B came out of the room he seemed a little upset but, like he was trying. RN-B stated R156 was upset because she wanted something she couldn't have. During an interview on 5/24/22, at 2:31 p.m. NA-D stated she was told by RN-B that R156 was upset and to treat her gently/carefully in order to not get her more upset. During an interview on 5/25/22, at 9:43 a.m. RN-F stated she learned about the incident on 5/19/22-5/20/22, on the morning of 5/20/22, from RN-A. RN-A was told about it by R156. Social Services (SS)-A also was informed of the incident by RN-A. The incident was brought to the Interdisciplinary Team meeting on 5/20/22, and was discussed briefly. RN-F stated she tried to meet with R156 after the meeting but she was working with certified occupational therapy aide (COTA)-C and she asked RN-F to come back later. RN-F stated when she spoke to R156 later she said she was tired and hadn't slept well because of the incident stating she was uncomfortable and painful. After she interviewed R156 RN-F stated she called her director of nursing (DON) to discuss the incident and they determined it was a grievance. During an interview on 5/29/22, at 9:59 a.m. the DON stated initially they thought the incident was more of a communication error. The DON stated she would have expected the nurse to comply with the request to remove the EdemaWear, even though it would have been against orders. The DON stated it was a missed opportunity and they should have reported the incident and then investigated. During an interview on 5/25/22, at 10:25 a.m. nurse practitioner (NP)-D stated she would expect staff to tell the case manager when a resident has a complaint about a staff member and go from there. NP-D stated she would expect staff to remove EdemaWear if a resident wanted it removed, to give her a break. During an interview on 5/25/22, at 12:50 p.m. COTA-C stated she recalled R156 telling her about a problem she had with a staff member on 5/19/22-5/20/22. COTA-C stated R156 was upset, said she didn't feel like she was being heard. COTA-C's note dated 5/20/22, Pt reporting she had a 'rough night' and felt very mistreated by a nurse manager on duty last night. Pt reporting 'He was really angry when he addressed me.' Pt reporting also that 'He didn't make me feel heard and as a patient that is scary to feel like the nurse isn't even listening to what I have to say'. In addition pt reporting that 'They made me keep my [CONDITION(S)] sleeves on all night and that really hurt. I took a picture of the marks it left on my legs'. The facility policy titled Abuse Prevention Plan For Minnesota Skilled Nursing Facilities dated 3/14/18, directed staff to report an incident immediately as soon as possible from the time initial knowledge that the incident occurred had been received. The policy defined immediately as no later than two hours after an allegation of maltreatment/mistreatment if it involves abuse or results in a serious bodily injury; and no later than 24 hours after an allegation of maltreatment/mistreatment if it does not involve abuse and does not result in serious bodily injury.

Based on interview and document review, the facility failed to ensure an abuse allegation was thoroughly investigated and documented for 1 of 1 resident (R156) reviewed for abuse. Findings include: R156's Admission Record printed on 5/25/22, indicated R156's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R156's admission Minimum Data Set (MDS) dated [DATE], indicated R156 was cognitively intact and required extensive assistance of two for activities of daily living (ADLs). R156's MDS indicated she received as needed pain medication in the past five days, had almost constant pain, the pain made sleeping difficult, and limited her day to day activities. R156 rated her pain a seven on a one to ten scale, with 10 being the most severe. In addition, R156 had received an opioid pain medication (medication used to treat pain) seven of the last seven days. R156's care plan initiated 5/13/22, indicated R156 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical immobility. Staff were directed to converse with resident while providing care. R156 had chronic pain related to [CONDITION(S)]. Staff were directed to administer analgesics as ordered, give 30 minutes prior to treatments, care, or therapy. The facility received a formal verbal report from R156 about a complaint of a staff member's conduct on 5/19/22. R156 reported the incident caused significant emotional distress due to the pain the EdemaWear was causing and caused her to lose sleep. R156 reported the staff member, registered nurse (RN)-B said Nothing you say is going to ruin my day after she stated she said not you again. R156 stated she perceived this as what she said didn't matter. The facility filled out a Patient Concern Form on 5/20/22. On 5/22/22, at 2:06 p.m. during an interview with R156 she stated she had lodged a complaint with the facility a few days ago about treatment received by a staff nurse. R156 stated the staff member registered nurse (RN)-B was abrupt and rude when he gave her pain medication on 5/19/22, at approximately 11:15 p.m R156 stated she asked him to remove her EdemaWear, she said he argued with her and told her she had to wear it 24/7 (24 hours a day and seven days a week). R156 stated she told him it was causing pain and that it felt too tight, she asked if she could have the EdemaWear removed and wear her pumps (a pneumatic compression device for [CONDITION(S)] consists of an air pump and a sleeve that fits over the extremity. As air pressure is applied by the device, the limb experiences gentle changes in fluid movement) instead of the EdemaWear. According to R156 RN-B refused to remove the EdemaWear and apply the pumps. R156 stated it made her feel broken and not listened to. Later RN-B came into the bathroom at her request as she was having constipation issues and wanted a dose of [MEDICATION(S)] (a medication used to treat constipation). R156 described RN-B as abrupt and mean and stated he told her she didn't take any, R156 told RN-B that she missed her dose that morning because it was taken away by accident on her breakfast tray. R156 reported RN-B then said she couldn't have any but did offer to give her a senna (another medication used to treat constipation). R156 stated she thinks she said oh you again when he came into the room and he replied with nothing you say is going to ruin my day. R156 stated she was grieving the whole next day about the incident. On 5/22/22, at 2:58 p.m. R156's concern was reported to the director of nursing (DON), administrator, and RN-F. The DON stated they were aware of the incident but had not considered it abuse and had not reported the incident but stated they would make a report to the state agency (SA). The facility had filled out a Patient Concern Form on 5/20/22. A review of the Patient Concern Form on 5/22/22, which had been filled out by the facility on 5/20/22, had only the statement of concern/grievance portion filled out, there was no further information regarding an investigation. Actions taken by the facility on 5/22/22, at 3:27 p.m. were to re-assign RN-B to another unit and to place him on a suspension pending the investigation. On 5/23/22, R156 was educated on the right to refuse pumps or request changes to her care. R156 was informed RN-B would be re-assigned. When R156 was asked if she felt safe to remain in the facility, she responded yes. On 5/23/22, no times, seven residents were interviewed about their care, none of the residents had any concerns regarding their care or about any staff members. On 5/23/22, at 2:00 p.m. RN-B was interviewed by the director of nursing (DON) about the incident during the night of 5/19/22. On 5/23/22, no time, the nursing assistants, who were working with RN-B on the night of 5/19/22, were interviewed by the DON. During an interview on 5/24/22, at 11:57 a.m. RN-B verified he was working on 5/19/22, the 10:00 p.m. to 6:30 a.m. shift. RN-B stated NA-B and NA-C were with him in the room with R156 and that NA-C was with him when R156 asked him to adjust her EdemaWear. RN-B verified he told R156 that she had to wear the EdemaWear at all times unless she had the pumps on. RN-B stated she wanted the wrap adjusted on her right leg, she said it was leaving marks on her leg, he said said he did not remove the EdemaWear, stated it had just been put on her legs at 9:30 p.m., he could get his fingers under the it and adjusted it by smoothing it around the ankle. RN-B stated R156 never asked him to put her pumps on. RN-B stated he never raised his voice and when she said oh you again, he responded with I still have a job to do how can I help you? RN-B stated R156 was her usual self, she is always demanding. RN-B stated he received a phone call from the DON on 5/22/22, telling him he was being put on a suspension. RN-B verified he received annual abuse training, and could not think of anything he said that might have been taken the wrong way by R156. A review of RN-B's personal file indicated RN-B had completed an abuse and prevention education on 4/11/22. RN-B had a customer service violation (verbal altercation with a resident) on 6/29/09, which resulted in a three day suspension. On 5/24/22, NA-C was called, their was no answer and no voice mail set up. During an interview on 5/24/22, at 12:30 p.m. NA-B stated he and NA-D were working with RN-B and R156. NA-B stated he only heard the last part of the interaction between RN-B and R156 about the medication for constipation. NA-B stated R156 seemed upset and frustrated. NA-B said when RN-B came out of the room he seemed a little upset but like he was trying. RN-B stated R156 was upset because she wanted something she couldn't have. During an interview on 5/24/22, at 2:31 p.m. with NA-D she stated she was told by RN-B that R156 was upset and to treat her gently/carefully in order to not get her more upset. During an interview on 5/25/22, at 9:43 a.m. RN-F stated she learned about the incident on 5/19/22-5/20/22, on the morning of 5/20/22, from RN-A. RN-A was told about it by R156. Social Services (SS)-A also was informed of the incident by RN-A. The incident was brought to the Interdisciplinary Team meeting on 5/20/22, and was discussed briefly. RN-F stated she tried to meet with R156 after the meeting but she was working with certified occupational therapy aide (COTA)-C and she asked RN-F to come back later. RN-F stated when she spoke to R156 later she said she was tired and hadn't slept well because of the incident stating she was uncomfortable and painful. After RN-F interviewed R156 she called her director of nursing (DON) to discuss the incident and they determined it was a grievance. During an interview on 5/29/22, at 9:59 a.m. the DON stated initially they thought the incident was more of a communication error. The DON stated she would have expected the nurse to comply with the request to remove the EdemaWear, even though it would have been against orders. The DON stated it was a missed opportunity and they should have reported the incident and then investigated. During an interview on 5/25/22, at 10:25 a.m. nurse practitioner (NP)-D stated she would expect staff to tell the CM when a resident has a complaint about a staff member and go from there. NP-D stated she would expect staff to remove EdemaWear if a resident wanted it removed, to give her a break. During an interview on 5/25/22, at 12:50 p.m. COTA-C stated she recalled R156 telling her about a problem she had with a staff member on 5/19/22-5/20/22. COTA-C stated she reported this to a nurse who was on duty. COTA-C stated R156 was upset, said she didn't feel like she was being heard. COTA-C's note dated 5/20/22, Pt reporting she had a 'rough night' and felt very mistreated by a nurse manager on duty last night. Pt reporting 'He was really angry when he addressed me.' Pt reporting also that 'He didn't make me feel heard and as a patient that is scary to feel like the nurse isn't even listening to what I have to say'. In addition pt reporting that 'They made me keep my [CONDITION(S)] sleeves on all night and that really hurt. I took a picture of the marks it left on my legs'. The facility policy titled Ecumen Abuse Prevention Plan For Minnesota Skilled Nursing Facilities dated 3/14/18, directed incidents of maltreatment/mistreatment involving a resident were to be reported, documented, and investigated. The administrator or administrator's designee is responsible for ensuring that an internal investigation is completed and the results are reported to the Office of Facility Health Complaints (OHFC).

Based on observation, interview and document review the facility failed to provide routine nail care and grooming for 1 of 4 residents (R100) reviewed for activities of daily living (ADLs) and who were dependent on staff for care. R100's admission Minimum Data Set (MDS), dated [DATE], identified R100 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R100 had severe cognitive impairment, demonstrated no behaviors, was unable to ambulate and required extensive assistance with all activities of daily living (ADLs). R100's Care Plan Report, dated 4/26/22, identified R100 was dependent with all ADLs and required extensive assistance from staff. The care plan listed interventions R100 was totally dependent upon staff for personal hygiene and oral care. R100 had a communication problem and staff were directed to anticipate and meet his needs. On 5/23/22, at 9:33 a.m. R100 was observed lying in his bed on his back. He had numerous, white colored facial hairs covering his chin and extending down his neck. These facial hairs were several centimeters (cm) in length. R100 had visibly long fingernails on both of his hands, with some nails extending several millimeters (mm) in length. On 5/23/22, at 12:02 p.m. nursing assistant (NA)-A and registered nurse (RN)-H were observed assisting R100 to bathe, dress, groom and transfer into his recliner. During observation of care, R100 was never offered assistance with shaving his facial hair, oral care or to trim his fingernails. During subsequent observations on 5/24/22, at 9:07 a.m. R100 continued to have the same visible facial hairs present on his chin and neck and long fingernails on both hands. On 5/24/22, at 9:07 a.m. NA-A was observed assisting R100 to bathe, dress, and groom. During observation of care R100 was never offered assistance with shaving his facial hair, oral care or to trim his fingernails. On 5/24/22, at 9:45 a.m. R100 was observed seated in a recliner in his room. R100 continued to have the same visible facial hairs present on his chin and neck and long fingernails on both of his hands. R100 was observed flicking at his fingernails of his left hand with his right hand and rubbing along the edge of the fingernails. R100 indicated his long fingernails bothered him. During interview on 5/25/22, at 10:33 a.m. family member (FM)-A stated R100 had always been a clean shaven man. When he was cared for at home, he never went more than two days without a shave. His nails were always trimmed or he would scratch himself. When R100 was asked to shave or cut his fingernails, he would always answer no, but if you explained to him why it needed to be done or just say you need to have a shave or your nails trimmed, he would agree. FM-A indicated she had repeatedly told the facility staff this but they would still just ask him and he would always answer no, so it was never being done. FM-A stated the facility staff never made the attempt to explain things to him or present it in a different way so he would understand the necessity of the cares. During joint interview on 5/25/22, at 9:16 a.m. with NA-A and NA-B, NA-A verified he had never asked R100 if he would like assistance to shave and he should have. NA-B stated it looked as if R100 had not been shaved in quite a long time and his nails were very long. They would certainly try to assist R100 to shave and trim his nails today. When interviewed on 5/25/22, at 11:06 a.m. registered nurse (RN)-F indicated it was concerning R100 had not been offered assistance to trim his long fingernails or to shave. She had heard the primary nurse educating the NA's just that morning R100 did not have the understanding when he refused care or the consequences and needed to be approached in a different manner. RN-F stated the staff tended to have a rehabilitative focus and could do better with the long term residents care. During interview on 5/25/22, at 12:43 p.m. the director of nursing (DON) stated she expected all residents to receive the assistance with cares they needed. A policy was requested for dependent resident ADL care, however, none was received.

Based on interview and document review, the facility failed to ensure daily weights were completed for 1 of 3 residents (R156) reviewed for daily weights. Findings include: R156's Admission Record printed on 5/25/22, indicated R156 was admitted on [DATE]. R156's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R156's admission Minimum Data Set (MDS) dated [DATE], indicated R156 was cognitively intact and required extensive assistance of two for activities of daily living (ADLs). R156's MDS indicated she received a diuretic (medication used to treat [CONDITION(S)] [tissue swelling]) six of the last seven days. R156's care plan initiated 5/13/22, indicated R156 had altered cardiovascular status related to hypertension. Staff were directed to monitor, document, and report any changes in lung sounds on auscultation, [CONDITION(S)], and changes in weight. R156's Orders Summary Report printed 5/25/22, indicated the following orders: -Apply [CONDITION(S)] pumps to BLE (bilateral lower extremities) BID (twice daily) for one hour at a time - be sure to remove setopress (compression bandage) PRIOR to pumping - Reapply setopress AFTER pumping. every day and evening shift (ordered 5/12/22). -monitor CMS (color, movement, sensation) to RLE (right lower extremity) if compromised please remove and reapply in a lighter fashion every shift (ordered 5/10/22). -weight daily in the morning (ordered 5/10/22). -[MEDICATION(S)] tablet (medication used to treat fluid retention [[CONDITION(S)]]) Give 20 milligrams (mg) by mouth in the morning related to essential hypertension (ordered 5/10/22). On 5/23/22, at 8:49 a.m. R156 was eating breakfast; and stated all the staff had been very nice to her and she had been weighed at 4:00 a.m. per her request. R156 stated she typically declines to be weighed when they want to weigh her at 1:00 p.m. R156 stated she had told them it's okay with her if they weigh her at 4:00 a.m. R156's daily weight report printed on 5/25/22, indicated R156 had no weights documented on the following dates: 5/13/22, she refused at 11:32 a.m. 5/14/22, documented as not applicable at 1:36 p.m. 5/15/22, she refused at 2:18 p.m. and documented as not applicable at 4:58 p.m. 5/16/22, she refused at 1:48 p.m. and documented as not applicable at 6:45 p.m. 5/17/22, she refused at 1:07 p.m. 5/18/22, she refused at 11:22 a.m. 5/19/22, she refused at 9:15 a.m. 5/21/22, she refused at 12:49 p.m. 5/22/22, she refused at 12:06 p.m. 5/24/22, documented as not applicable at 5:02 p.m. Progress notes were reviewed from admission to 5/25/22, with no documentation of refusals to be weighed. During an interview on 5/25/22, at 9:59 a.m. the director of nursing (DON) stated she would expect staff to weigh a resident daily as ordered. The DON stated if a resident refused to be weighed she would expect staff to document the refusal along with re-education on the importance of doing daily weights. The DON further stated she would expect staff to try to determine why a resident was refusing daily weights. During an interview on 5/25/22, at 10:25 a.m. nurse practitioner (NP)-D stated she was aware of R156's refusal to be weighed daily, she was however, not aware that staff were asking R156 to be weighed at 1:00 p.m. NP-D stated she would have expected staff to try to figure out why R156 was refusing to be weighed and if it was too late in the day she would have expected staff to try to accommodate R156 in her request to be weighed earlier in the morning. During an interview on 5/25/22, at 1:37 p.m. RN-G stated she would expect weights to be completed per the order. RN-G stated if a resident was refusing a weight because it was offered too late in the day she would have expected staff to try to accommodate the request to be weighed earlier in the day.

Based on observation, interview, and document review, the facility failed to ensure therapy evaluation and a restorative range of motion (ROM) program was implemented for 1 of 1 residents (R25), reviewed for range of motion. Findings include:. R25's Facesheet printed 5/25/22, at 3:54 p.m. indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's care plan dated 4/23/22, indicated R25 had a care area for actvities of daily living (ADL) functional potential /rehabilitation for mobility, ambulation transfers, bed and wheelchair mobility. R25's care plan also indicated an ADL self care performance deficit related to [CONDITION(S)] and [CONDITION(S)] with interventions including occupational therapy (OT) to evaluate for ADL training. R25's careplan lacked any interventions discussing restorative program set up or a range of motion program. R25's medical record indicated a Situation, Background, Assessment and Response (SBAR) form was sent to the provider on 4/29/22, with please consider orders for passive ROM-range of motion to the body performed by somebody other than self, with frequency and duration. The provider signed the SBAR on 4/29/22, with orders every two hours next to the request. Provider orders for R25 placed 5/2/22, at 8:00 a.m. and signed by facility staff 5/3/22, indicated orders for physical therapy (PT)/OT to evaluate for wheelchair positioning and passive ROM program. The facility's 4/25/22, nursing home interdepartment team (IDT) update, indicated R25 would be seen for therapy. The IDT email indicated goals for R25 would be limited and may be evaluation only and set up with a nursing program. The facility's 5/5/22, nursing home IDT update, indicated R25's orders for wheelchair fitting was on hold. The IDT update indicated to provide basic passive ROM to all joints, and no program was needed. R25's Order Summary Report (OSR) included an order date range of 4/23/22, to 5/25/22, indicated an ordered dated 4/23/22 to have PT, OT, Speech therapy (ST) evaluate and treat. R19's OSR indicated a 4/29/22 order for passive range of motion every two hours. R25's OSR lacked orders for PT/OT to evaluate for wheelchair positioning or a passive ROM program. R25's treatment assessment record (TAR) printed 5/25/22, indicated passive ROM every two hours; but this was only documented as done once a shift since 4/29/22. R25's nursing progress notes from 4/23/22, to 5/23/22, were reviewed and lacked documentation of any passive ROM performed. On 5/23/22, from 8:15 a.m. to 10:30 a.m. continuous observation was performed of R25. Staff entered R25's room at 8:34 a.m., 8:48 a.m., and again at 10:03 a.m. to provide cares and repositioning. Passive ROM was not performed during these visits. On 5/22/22, at 4:38 p.m. family member (FM)-A stated after talking with nursing a couple of days ago it was discovered R25 was not receiving therapy services. FM-A stated family thought R25 was on therapy and FM-A wanted R25 to be evaluated for therapy. FM-A could not recall the staff member he spoke to. FM-A stated R25 was admitted to the facility on [DATE], with contractures to both upper extremities and both lower extremities. On 5/24/22, at 9:52 a.m. nursing assistant (NA)-E stated restorative would show up on a resident's computerized care sheets (Kardex) if the resident had restorative services. NA-E stated that Kardex information was also on the careplan. NA-E stated they were unaware of R25 being on a restorative or ROM program. NA-E reviewed R25's kardex and stated that prior to 5/23/22, R25 had not had range of motion or restorative program entered into the kardex. NA-E stated that R25 had not been receiving any formal ROM program from nursing or therapy. On 05/24/22, at 9:08 a.m. R25's provider, certified nurse practitioner (CNP)-F stated if somebody had contractures they should be on some kind of restorative program. CNP-F stated the facility should have an evaluation by therapy to build the restorative program. Then either nursing or therapy could follow through with the recommended program. CNP-F confirmed R25 did have contractures to the upper and lower body. CNP-F stated orders for PT/OT to evaluate were written when R25 was originally admitted and again, later on, she wrote orders for a wheelchair evaluation and for therapy to set up a passive range of motion program. CNP-F stated the facility had requested multiple times to have ROM program orders written for R25, but she declined since ROM programs were a specialty area. CNP-F stated she assumed R25 was on therapy of some sorts-either full therapy or a restorative program. CNP-F stated she expected all residents with contractures to have a therapy evaluation; and have an appropriate therapy or restorative program set up formally; and followed either by therapy or nursing and documented. CNP-F stated her expectation was orders written for therapy would be implemented by the facility as written. On 5/24/22, at 12:58 p.m. occupational therapist registered (OTR)-G stated evaluations for therapy were received by email and placed into a new patient folder by the TD. OTR-G stated goals were based on discharge planning and patient ability. OTR-G stated if resident was staying in the facility then the therapy department would set up restorative program. The program would have specifications in regards to what limbs, time frames, and how long each time each session would last. Nursing would perform the restorative program after training by therapy. OTR-G reviewed R25's medical record and stated there was no evaluation performed by OT and no restorative program set up by OT. OTR-G stated they were not sure why an evaluation was not done. OTR-G stated TD would need to be asked if an evaluation request was received for R25. OTR-G stated a person with contractures would benefit from a formal therapy evaluation and restorative program set up. On 5/24/22, at 1:16 p.m. the TD stated evaluation orders were received prior to patients arrival. Facesheet and demographics were received to prepare for patient and therapy services needed. TD stated remembered receiving notice of R25's admission and therapy orders. TD stated after several conversations within facility the decision was made that therapy would not do therapies. TD reviewed R25's therapy record and stated there was no therapy program setup for R25, therapy had not done an evaluation of R25 a for restorative program and therapy had not trained staff for appropriate restorative measures. TD stated that a restorative program would have benefited R25. TD stated a restorative program was important for residents with contractures to keep them at a steady baseline and to not make the contractures worse. TD stated a person with contractures could get better with a restorative program. On 5/24/22, at 2:02 p.m. registered nurse (RN)-C stated R25 did not have therapy orders. RN-C stated it was discussed in IDT and therapy orders were not appropriate for R25. RN-C stated R25 was not rehabable and a restorative program was not appropriate for R25 because restorative programs were only for residents that would get better. RN-C reviewed R25's medical record and stated there were orders for R25 to receive passive ROM every two hours. RN-C stated R25's orders did not indicate which extremities, how long to perform the exercises, nor what types of ROM exercises to perform. RN-C stated the order was an incomplete order. RN-C stated there were no other orders for therapy in R25's order summary. RN-C stated there were orders from the provider on 5/2/22, for PT/OT for wheelchair and passive ROM program. RN-C stated she was not sure why orders were not completed. On 5/25/22, at 11:54 a.m. director of nursing (DON) stated therapy would not evaluate unless there were orders. DON stated after nursing assessments were performed, and a resident was identified as benefiting from therapies, nursing would get therapy orders. However the DON stated one would have to ask TD if R25 would have benefited from therapy since therapy was not nursing expertise. DON stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON reviewed R25's medical record and stated there were orders placed on 5/2/22, for PT/OT for wheelchair and passive ROM program. DON stated she expected provider orders would be implemented; and if unable to be completed, then documented. The facility's Resident Mobility and Range of Motion policy revised 2017, indicated residents with limited range of motion would receive treatment and services to increase and/or prevent a further decrease in ROM. The care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.

Based on interview and document review, the facility failed to ensure a resident was treated by staff in a respectful and dignified manner when she requested removal of EdemaWear (compression garment) for 1 of 1 resident (R156) reviewed for dignity. Findings include: R156's Admission Record printed on 5/25/22, indicated R156's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R156's admission Minimum Data Set (MDS) dated [DATE], indicated R156 was cognitively intact and required extensive assistance of two for activities of daily living (ADLs). R156's MDS indicated she received as needed pain medication in the past five days, had almost constant pain, the pain made sleeping difficult, and limited her day to day activities. R156 rated her pain a seven on a one to ten scale, with 10 being the most severe. In addition, R156 had received an opioid pain medication (medication used to treat pain) seven of the last seven days. R156's care plan initiated 5/13/22, indicated R156 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical immobility. Staff were directed to converse with resident while providing care. R156 had chronic pain related to [CONDITION(S)]. Staff were directed to administer analgesics as ordered, give 30 minutes prior to treatments, care, or therapy. R156's Orders Summary Report printed 5/25/22, indicated the following orders: -Apply [CONDITION(S)] pumps to BLE (bilateral lower extremities) BID (twice daily) for one hour at a time - be sure to remove setopress (compression bandage) PRIOR to pumping - Reapply setopress AFTER pumping. every day and evening shift (ordered 5/12/22). -monitor CMS (color, movement, sensation) to RLE (right lower extremity) if compromised please remove and reapply in a lighter fashion every shift (ordered 5/10/22). -[MEDICATION(S)] Tablet 10-325 ([MEDICATION(S)]-acetaminophen) (narcotic medication used to treat pain) Give one tablet by mouth every four hours as needed for pain rated 4-6/10. May take 1-2 tabs: 1 tab for pain rated 4-6/10 or 2 tabs for pain rated 7-10/10. (ordered 5/17/22). -[MEDICATION(S)] packet ([MEDICATION(S)]) Give 17 gram by mouth in the morning for constipation (ordered 5/11/22). -Senna Plus Tablet 8.6-50 milligram (mg) (Sennoside-[MEDICATION(S)] Sodium) Give one tablet by mouth two times a day for constipation. HOLD for loose stools. (ordered 5/12/22). On 5/22/22, at 2:06 p.m. R156 stated she had lodged a complaint with the facility a few days ago about treatment received by a staff nurse. R156 stated the staff member, registered nurse (RN)-B, was abrupt and rude when he gave her pain medication on 5/19/22, at approximately 11:15 p.m. R156 stated she asked him to remove her EdemaWear, she said he argued with her and told her she had to wear it 24/7 (24 hours a day and seven days a week). R156 stated she told him it was causing pain and that it felt too tight, she asked if she could have the EdemaWear removed and wear her pumps (a pneumatic compression device for [CONDITION(S)] consists of an air pump and a sleeve that fits over the extremity. As air pressure is applied by the device, the limb experiences gentle changes in fluid movement) instead of the EdemaWear. According to R156, RN-B refused to remove the EdemaWear and apply the pumps. R156 stated it made her feel broken and not listened to. Later RN-B came into the bathroom at her request as she was having constipation issues and wanted a dose of [MEDICATION(S)] (a medication used to treat constipation). R156 described RN-B as abrupt and mean and stated he told her she didn't take any, R156 told RN-B that she missed her dose that morning because it was taken away by accident on her breakfast tray. R156 reported RN-B then said she couldn't have any but did offer to give her a senna (another medication used to treat constipation). R156 stated she thinks she said oh you again when RN-B came into the room and RN-B replied with nothing you say is going to ruin my day. R156 stated she was grieving the whole next day about the incident. On 5/22/22, at 2:58 p.m. R156's concern was reported to the director of nursing (DON), administrator, and RN-F. The DON stated they were aware of the incident.The facility had filled out a Patient Concern Form on 5/20/22. The form was filled out by RN-F. In the report staff member RN-B was described by R156 as rude, abrupt, and unwilling to remove her EdemaWear and put on the pumps. R156 stated the incident caused her significant emotional distress due to the pain the EdemaWear caused and caused her to lose sleep. The report indicated RN-B came into the room later and she said not you again, to which he replied, nothing you say is going to ruin my day. She wanted [MEDICATION(S)] and he told her she didn't take it, then said she couldn't have it until breakfast, but offered her senna which was an alternative medication for constipation. Nothing further was filled out on the Patient Concern Form as of 5/22/22. On 5/23/22, at 8:49 a.m. R156 was eating breakfast, she stated they were working on her pain control and she asked when she would get a written response from the facility about her complaint. A review of RN-B's personnel file indicated RN-B had completed an abuse and prevention education training on 4/11/22. RN-B's personnel file indicated he had a previous customer service violation (verbal altercation with a resident) on 6/29/09, which resulted in a three day suspension. During an interview on 5/24/22, at 11:57 a.m. RN-B verified he had been working on 5/19/22, the 10:00 p.m. to 6:30 a.m. shift. RN-B stated NA-B and NA-C were with him in the room with R156 and that NA-C was with him when R156 asked him to adjust her EdemaWear. RN-B verified he told R156 that she had to wear the EdemaWear at all times unless she had the pumps on. RN-B stated she wanted the wrap adjusted on her right leg, she said it was leaving marks on her leg, he stated he did not remove the EdemaWear, stated it had just been put on her legs at 9:30 p.m., he stated he could get his fingers under the EdemaWear and adjusted it by smoothing it around her ankle. RN-B stated R156 never asked him to put her pumps on. RN-B stated he never raised his voice and when she said, oh you again, he responded with I still have a job to do; how can I help you? RN-B stated R156 was her usual self, she is always demanding. RN-B verified he received annual abuse training, and could not think of anything he said that might have been taken the wrong way by R156. On 5/24/22, NA-C was called, there was no answer and no voice mail set up. During an interview on 5/24/22, at 12:30 p.m. NA-B stated he and NA-D, not NA-C, were working with RN-B and R156. NA-B stated he only heard the last part of the interaction between RN-B and R156 about the medication for constipation. NA-B stated R156 seemed upset and frustrated. NA-B said when RN-B came out of the room he seemed a little upset but like he was trying. RN-B told him R156 was upset because she wanted something she couldn't have. During an interview on 5/24/22, at 2:31 p.m. NA-D she stated she was told by RN-B that R156 was upset and to treat her gently/carefully in order to not get her more upset. During an interview on 5/25/22, at 9:43 a.m. RN-F stated she learned about the incident which occurred on the overnight shift of 5/19/22, on the morning of 5/20/22, from RN-A. RN-A was told about it by R156. Social Services (SS)-A also was informed of the incident by RN-A. The incident was brought to the Interdisciplinary Team meeting on 5/20/22, and was discussed briefly. RN-F stated she tried to meet with R156 after the meeting but she was working with certified occupational therapy aide (COTA)-C and she asked RN-F to come back later. RN-F stated when she spoke to R156 later she said she was tired and hadn't slept well because of the incident stating she was uncomfortable and painful. After RN-F interviewed R156 on the morning of 5/20/22, she called her director of nursing (DON) to discuss the incident and they determined it was a grievance at which time the Patient Concern Form was filled out. On 5/29/22, at 9:59 a.m. the DON stated initially they thought the incident was more of a communication error between the resident and the staff member. The DON, however, stated she would have expected the nurse to comply with the request to remove the EdemaWear, even though it would have been against orders. During an interview on 5/25/22, at 10:25 a.m. nurse practitioner (NP)-D stated she would expect staff to tell the clinical manager when a resident has a complaint about a staff member and go from there. NP-D stated she would have expected staff to remove EdemaWear if a resident wanted it removed, to give her a break. During an interview on 5/25/22, at 12:50 p.m. COTA-C stated she recalled R156 telling her about a problem she had with a staff member on the overnight shift of 5/19/22. COTA-C stated R156 was upset, said she didn't feel like she was being heard. COTA-C's note dated 5/20/22 read: Pt reporting she had a 'rough night; and felt very mistreated by a nurse manager on duty last night. Pt reporting 'He was really angry when he addressed me' . Pt reporting also that 'He didn't make me feel heard and as a patient that is scary to feel like the nurse isn't even listening to what I have to say'. In addition pt reporting that 'They made me keep my [CONDITION(S)] sleeves on all night and that really hurt. I took a picture of the marks it left on my legs.' The facility policy titled Grievance/Complaints, Filings review date 2/2020, indicated residents had the right to file a grievance orally or in writing. The policy further indicated the grievance officer, administrator and staff would take immediate action to prevent further potential violations of resident rights while the alleged violation was being investigated.

Based on interview and document review, the facility failed to effectively provide pain management for 1 of 6 residents (R156) reviewed for pain. Findings include: R156's Admission Record printed on 5/25/22, indicated R156's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R156's admission Minimum Data Set (MDS) dated [DATE], indicated R156 was cognitively intact and required extensive assistance of two for activities of daily living (ADLs). R156's MDS indicated she received as needed pain medication in the past five days, had almost constant pain, the pain made sleeping difficult, and limited her day to day activities. R156 rated her pain a seven on a one to ten scale, with 10 being the most severe. In addition, R156 had received an opioid pain medication (medication used to treat pain) seven of the last seven days. R156's care plan initiated 5/13/22, indicated R156 had chronic pain related to [CONDITION(S)]. Staff were directed to administer analgesics as ordered, give 30 minutes prior to treatments, care, or therapy. R156's Orders Summary Report printed 5/25/22, indicated the following orders: -Apply [CONDITION(S)] pumps to BLE (bilateral lower extremities) BID (twice daily) for one hour at a time - be sure to remove setopress (compression bandage) PRIOR to pumping - Reapply setopress AFTER pumping. every day and evening shift (ordered 5/12/22). -monitor CMS (color, movement, sensation) to RLE (right lower extremity) if compromised please remove and reapply in a lighter fashion every shift (ordered 5/10/22). -[MEDICATION(S)] Tablet 10-325 ([MEDICATION(S)]-acetaminophen) (narcotic medication used to treat pain) Give one tablet by mouth every four hours as needed for pain rated 4-6/10. May take 1-2 tabs: 1 tab for pain rated 4-6/10 or 2 tabs for pain rated 7-10/10. (ordered 5/17/22). On 5/23/22, at 8:49 a.m. R156 was eating breakfast, she stated the facility staff were working on her pain control. On 5/24/22, at 1:50 p.m. R156 stated she woke with pain around 4:00 a.m. and requested a [MEDICATION(S)], after she was situated in the bathroom an unidentified nursing assistant (NA) stated he would find the nurse. She called again for assistance out of the bathroom and was assisted to her bed (she stated she sat on the side of the bed) and asked again for a pain pill, she was told by the a different unidentified NA the nurse was busy and that they were having a busy night. She was asked to rate her pain by the NA, which was a 6/10. R156 stated she felt the NA was rushing her, the NA stated we have people waiting. R156 sat on the edge of her bed until 6:45 a.m. when the day nurse brought her something for pain. R156 stated it was unusual to wait that long for pain medication. R156 stated she called her husband at that time to tell him she was upset. The facility call log printed on 5/24/22, for the previous 24 hours indicated R156 put her call light on at 4:36 a.m. from her bed, 5:35 a.m. from the bathroom , 6:32 a.m. from the bathroom, and at 6:43 a.m. from her bed. R156's progress note dated 5/24/22, at 6:48 a.m. indicated she received pain medication. During an interview on 5/25/22, at 1:00 p.m. the director of nursing (DON) stated R156 had asked for pain medication on 5/24/22, at 4:30 a.m. and was due but did not receive the pain medication until 6:45 a.m The DON stated she would have expected the nursing assistant to find another nurse if the nurse was too busy to give the medication. The DON stated she was in the process of investigating why the medication was not given timely as would be expected. During an interview on 5/25/22, at 1:22 p.m. nursing assistant (NA)-F stated if a resident said they were in pain and wanted a pain pill she would find a nurse right away and tell them. During an interview on 5/25/22, at 1:28 p.m. NA-G stated she would find a nurse or the trained medication aide (TMA) right away if a resident told her they were in pain and wanted medication. NA-G said if she couldn't find the nurse she would look for another nurse. During an interview on 5/25/22, at 1:37 p.m. RN-G stated she would have expected the NA to find a nurse when a resident asked for pain medication. RN-G stated it is never okay to tell the resident that it's really busy as an acceptable reason for not being able to find a nurse to administer pain medication. The facility policy titled Pain - Clinical Protocol dated 3/2018, directed staff to assess each individual for pain upon admission and when there is onset of new or worsening of existing pain. The goal identified by the policy was with input from the resident to the extent possible to establish goals of pain treatment, to include improved functioning, mood, and sleep.

Based on observation, interview and document review, the facility failed to evaluate and analyze behaviors or develop and implement non-pharmacologic approaches and interventions for 2 of 7 residents (R100, R19) who received [CONDITION(S)] medications. In addition, the facility failed to ensure as needed (PRN) [CONDITION(S)] medications were limited to 14 days of use or re-evaluated by the medical provider to ensure necessity and reduce the risk for complication for 1 of 7 residents (R16) reviewed for unnecessary medication use. Findings include: R100 R100's admission Minimum Data Set (MDS), dated [DATE], identified R100 had diagnoses of disorder of the brain, violent behaviors and was oxygen dependent. R100 had severe cognitive impairment, demonstrated no behaviors, was unable to ambulate and required extensive assistance with all activities of daily living (ADLs). R100's Order Summary Report, active as of 5/25/22, identified R100's current physician ordered medications. This included orders for [MEDICATION(S)] (an antipsychotic used to treat certain mental and mood disorders) two times per day and [MEDICATION(S)] (an antipsychotic used to treat certain mental and mood disorders) one time per day. Review of R100's Behavior Monitoring logs May 1, 2022 through May 23, 2022, identified resistive or unusual behaviors had occurred on 5/15/22, 5/16/22, and 5/17/22. No further behaviors were documented. Progress Notes identified the following: -On 5/17/22, R100 was combative with cares. He refused his morning medications and breakfast. He was more cooperative for cares at 11:15 a.m. -On 5/18/22, R100 was calm and sitting up with his family present. R100 became agitated and struck out at staff when his family was gone. R100's Care Plan Report, dated 4/26/22, indicated R100 was dependent with all ADLs and required extensive assistance from staff. The care plan did not identify R100 could be resistive or combative when assisted with his care. R100 had a communication problem and staff would need to anticipate and meet his needs. The care plan identified R100 was receiving [CONDITION(S)] medications and staff were to monitor and record occurrence for targeted behavior symptoms of inappropriate responses to verbal communication and violence or aggression toward staff. Staff were to review behaviors and interventions and alternate therapies attempted and their effectiveness. The care plan lacked a behavior focus problem as well as goal and interventions and non pharmacological approaches to attempt to reduce R100's behavior (i.e., repositioning, explaining procedures before attempting, allow sufficient time to awaken before attempting care, leave and re-approach at later times). R100's medical record was reviewed and lacked evidence the staff had reviewed, evaluated or analyzed R100's behaviors in order to discover patterns or causative factors. The medical record also lacked evidence staff had attempted any non-pharmacological interventions to reduce R100's behaviors (i.e., repositioning, leave or re-attempt later) On 5/23/22, at 9:33 a.m. registered nurse (RN)-D and nursing assistant (NA)-A were observed assisting R100 with his morning cares, including a bed bath, dressing, grooming and assisting R100 into his recliner using a mechanical lift. The staff explained each action in a calm and deliberate manner and allowed R100 sufficient time to respond to commands and questions. R100 was cooperative and displayed no aggressive or combative behaviors during the entire time he was being assisted with his care. On 5/24/22, at 9:07 a.m. NA-A was observed assisting R100 with his morning cares, including a bed bath, dressing, grooming and assisting R100 into his recliner using a mechanical lift. R100 remained calm and cooperative during the entire time he was assisted with care. During interview on 5/23/22, at 10:45 a.m. NA-A stated R100 did not move or respond much and he had never known R100 to strike out or become aggressive with staff. NA-A indicated it was hard to get any reaction from R100 and he did not speak much. When interviewed on 5/23/22, at 12:02 p.m. registered nurse (RN)-H stated she had never known R100 to be aggressive or combative with care. When interviewed on 5/25/22, at 10:33 a.m. family member (FM)-A stated the facility had told her they had to give R100 some medication to relax him because he was combative with cares. FM-A indicated she had experienced this when caring for R100 at home before his admission. When R100 was startled awake and you tried to assist him right away he would push or strike out. But if you took the time to explain what you were doing and give him a chance to awaken and settle down, he would calm down and allow her to assist him. She had mentioned this to the facility staff but they did not seem to take the time to do it. During interview on 5/25/22, at 8:45 a.m. with RN-C and licensed practical nurse (LPN)-A, RN-C stated R100 may not be resistive to cares now, but due to his brain mass, the behavior would come and go. R100's behaviors should be a focus on his care plan and should have included non-pharmacological interventions and approaches. During interview on 5/25/22, at 11:06 a.m. RN-F verified R100's care plan did not address his behaviors or list interventions or approaches staff should attempt to reduce his behaviors. RN-F indicated it would be important to develop non pharmacological approaches to address patient's individual needs and in order to avoid use of [CONDITION(S)] medications when possible. On 5/25/22, at 12:43 p.m. the director of nursing (DON) indicated a patient's behavior symptoms should be care planned with approaches and interventions for staff to attempt when symptoms occurred. The facility's undated [CONDITION(S)] Use policy directed nursing staff to care plan patient's target behaviors with non pharmacological interventions. R19 R19's Face Sheet printed 5/25/22, at 1:42 p.m., indicated diagnoses that included wedge compression fracture of T9-T12 vertebra, other specified fracture of right pubis, toxic [CONDITION(S)] (brain disfunction caused by toxic exposure), [CONDITION(S)] with behavioral disturbance, unsteadiness of feet, unspecified abnormalities of gait and mobility and cognitive communication deficit. R19's five day Minimum Data Set (MDS) dated [DATE], indicated R19 had severely impaired cognition. R19's care plan printed 5/25/22, indicated a care plan R/T antidepressant with interventions that included monitor adverse reactions, changes in mood, behaviors, hallucinations, social isolationism. R19's care plan lacked a care plan for the use of [CONDITION(S)] medication, behaviors to watch for, target behaviors or non-pharmacological interventions to attempt prior to use of medication. R19's Order Summary Report with date range 4/21/22, to 5/14/22, indicated orders for [MEDICATION(S)] (a [CONDITION(S)] medication used as a sedative or to make people sleepy) 25 mg tablet, give 1 tablet by mouth every eight (8) hours as needed for anxiety/agitation was placed on 4/22/22 with no end date noted. R19's Medication Administration Record (MAR) dated 4/22, indicated R19 received [MEDICATION(S)]; 25 mg on 4/22/22, at 11:46 p.m. and again on 4/24/22, at 11:25 a.m. R19's Progress Notes indicated [MEDICATION(S)] was administered on 4/22/22, at 11:46 p.m. for restlessness. R19's progress notes lacked any documentation of specific target behaviors or non-pharmacological interventions attempted prior to the administration of [MEDICATION(S)] R19's Progress Notes indicated [MEDICATION(S)] was administered on 4/24/22, at 11:25 a.m. for anxiety. R19's progress notes lacked any documentation of specific target behaviors or non-pharmacological interventions attempted prior to the administration of [MEDICATION(S)]. On 5/23/22, at 2:38 p.m. registered nurse (RN)-A stated that if [CONDITION(S)] medications were used there should be target behaviors and non-pharmacological interventions attempted documented when the medication was given. RN-A stated that target behaviors and resident specific non-pharmacological interventions would also be on the care plan. RN-A stated [CONDITION(S)] medications should never be used until non-pharmacological interventions were attempted. RN-A reviewed R19's care plan and stated the care plan did not have any [CONDITION(S)] medication use careplan which was where the target behaviors and resident specific non-pharmacological interventions would be located so all staff would know where to find them. RN-A reviewed R19's progress notes for 4/22/22, and 4/24/22, and stated the progress notes for both days lacked documentation of resident specific target behaviors or non-pharmacological interventions documented as attempted prior to medication administration. On 5/25/22 at 9:56 a.m. RN-C stated if [CONDITION(S)] medication orders were obtained the care plan should be updated to include the specific medication ordered, target behaviors and non-pharmacological interventions attempted and document prior to giving medications. RN-C stated all resident specific target behaviors and non pharmacological interventions should be documented in the progress notes. RN-C stated progress notes was the only place to document true resident specific target behaviors and nonpharmacological interventions. RN-C reviewed R19's careplan and stated there were no care planned target behaviors or nonpharmacological interventions in R19's care plan. RN-C reviewed R19's progress notes for 4/22/22, and 4/24/22, and stated the progress notes for both days lacked documentation of resident specific target behaviors or non-pharmacological interventions documented as attempted prior to medication administration. On 5/25/22, at 11:29 a.m. the director of nursing (DON) stated if [CONDITION(S)] medications are needed then nonpharmacological interventions need to be attempted first. The DON stated target behaviors and biopharmaceutical interventions have to be documented in the notes. The DON reviewed R19's careplan and stated there were no care planed target behaviors or monochromic interventions in R19's care plan. The DON reviewed R19's progress notes for 4/22/22, and 4/24/22, and stated 4/22/22, indicated restlessness for reason for medication and on 4/24/22 indicated anxiety as reason for [MEDICATION(S)] administration. The DON stated there were no further resident specific target behaviors or non-pharmacological interventions documented as attempted prior to medication administration. The DON stated she expected staff to attempt biopharmaceutical interventions and document both behaviors and biopharmaceutical interventions attempted prior to use of [CONDITION(S)] medication. The facility [CONDITION(S)] Use Policy, undated, indicated nursing staff should care plan target behaviors on non pharmacological interventions. If it was an as needed order the staff would document target behaviors used and specific behaviors observed for each administration. PRN antipsychotic use R16's admission MDS dated [DATE], identified R16 had diagnoses of traumatic subarachnoid hemorrhage (bleeding in the space between your brain and the surrounding membrqane), [CONDITION(S)], history of falls, and fracture of left radius and right clavicle. R16 displayed severe cognitive impairment, demonstrated no behaviors and required extensive assistance with ADLs. R16's Order Summary Report dated 5/25/22, included [MEDICATION(S)] (an antianxiety medication) 0.5 milligrams every four hours as needed (PRN) and [MEDICATION(S)] (an antipsychotic medicine) 0.5 mg every four hours PRN with listed start date 4/15/22. R16's Care Plan Report dated 4/18/22, indicated R16 was on sedative/hypnotic therapy of [MEDICATION(S)] and used the anti-anxiety medication [MEDICATION(S)]. Both goals were to be free of discomfort or adverse side effects. Interventions included to administer the medication as ordered and monitor for side effects. R16's May 2022 Medication Administration Report (MAR) indicated R16's PRN [MEDICATION(S)] was administered 17 times and the [MEDICATION(S)] had not been administered at all. Pharmacist review with Note To Attending Physician dated 4/18/22, indicated R16 had the antipsychotic medication [MEDICATION(S)] ordered PRN and regulatory guidelines directed orders for antipsychotic medications on a PRN basis must be limited to 14 days with no exceptions. If a new order was needed, a direct examination of the resident by the prescribing practitioner was required to determine if the medication was still needed. The physician directed staff to refer the recommendation to the patient's hospice provider. The pharmacy review lacked evidence of recommendation related to the PRN anti-anxiety medication [MEDICATION(S)]. R16's medical record was reviewed and lacked any recorded physician statements or clinical justification supporting the ongoing use of PRN [MEDICATION(S)] or PRN [MEDICATION(S)] outside of the 14 day period since it was ordered on 4/15/22. During interview on 5/25/22, at 8:37 a.m. registered nurse (RN)-C stated if the physician statement for clinical justification to support the ongoing use of PRN [MEDICATION(S)] and PRN [MEDICATION(S)] was not in the chart, then it had not been addressed. RN-C indicated the physician had written to have hospice address the medications and hospice may have not gotten the information. When interviewed on 5/25/22, at 10:59 a.m. RN-F indicated R16 was enrolled in hospice and hospice managed all their patient medications. She thought hospice was aware of the regulation of the need for the physician to re-evaluate the use of PRN [CONDITION(S)] medications and should have had it taken care of. She stated she was unable to find documentation the pharmacists review had been forwarded to the patients hospice to be addressed and she would follow up with the nurse in charge of forwarding the information. During interview on 5/25/22, at 12:47 p.m. the director of nursing (DON) indicated she was not sure if hospice had gotten the pharmacist's recommendation to re-evaluate the use of PRN [CONDITION(S)] medications for R16 and the facility should have ensured it was addressed when the recommendation had been made on 4/18/22. The facility's undated [CONDITION(S)] Use policy indicated all PRN [CONDITION(S)] medications would be reviewed by the provider within 14 days to determine if the order should be continued or discontinued.

Based on interview and document review, the facility failed ensure residents were free from verbal abuse for 2 of 3 residents (R1, R2) reviewed for verbal abuse. Findings Include: R1's Admission Record printed 7/30/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had no behaviors or rejection of cares, and required extensive assistance with all activities of daily living except for eating. R1's care plan initiated 6/22/21, directed staff to assist with all activities of daily living (ADLs) including transfers, toileting, and personal cares. On 7/29/21, at 9:12 a.m. R1 was interviewed and stated when nursing assistant (NA)-A had been providing cares for him, NA-A had spoken rudely and used a loud tone. R1 stated NA-A also had made him feel rushed during cares. R1 stated he had reported his concerns to facility staff, and he no longer wanted NA-A to enter his room or provide cares. R1 stated NA-A continued to enter his room until he reported this concern again to another staff member. A facility document Record of Concern dated 5/18/21, indicated R1 reported to nursing staff NA-A had raised his voice when he had entered his room to answer his call light. R1 also reported NA-A had instructed R1 that he was to treat NA-A with respect when he was providing cares for him. The facility's action taken related to R1's concern included oral and written instruction for NA-A to be assigned to another hallway. The concern further indicated the director of nursing (DON) had been made aware of the incident. A Facility Reported Incident (FRI) submitted to the State Agency (SA) on 5/26/21, at 2:10 p.m. identified allegations of emotional or mental abuse that occurred on 5/26/21. The description of the incident included R1 stating, No I have not felt safe, I feel a little paranoid and worried when he (NA-A) is around. R2's Admission Record printed 7/30/21, indicated R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's admission MDS dated [DATE], indicated R2 was cognitively intact, had no behaviors or rejection of cares, and required extensive assistance with all activities of daily living except for eating. On 7/29/21, at 11:28 a.m. during interview social worker (SW)-A stated she had been involved with both R1 and R2's concerns related to NA-A providing cares. SW-A stated she had meet with R1 several times related to the concerns he had with NA-A providing cares for him. SW-A stated R1 had reported to her he had felt very rushed when NA-A cared for him, and NA-A had not listened to his wishes while providing cares. SW-A stated R1 had requested NA-A no longer be allowed to enter his room or provide cares. SW-A further stated she had knowledge of another unidentified resident had had also voiced their concern with NA-A's attitude towards them while providing cares. On 7/29/21, at 12:15 p.m. registered nurse (RN)-A was interviewed and stated on 5/18/21, an unidentified staff member had reported to her that R1 wished to speak to her. RN-A stated at that time, R1 had reported to her that NA-A had been rude and spoke in a loud tone while providing cares for him. RN-A stated R1 also reported to her that NA-A had rushed him during cares. RN-A stated R1 had told her he no longer wanted NA-A to be allowed to provide cares for him or enter his room. RN-A stated she had reported this to both the DON and the administrator. RN-A stated NA-A did not follow the instructions, and he continued to enter R1's room even though he was directed to not do so. RN-A stated the facility did not do any further investigation or interviews of other residents receiving care by NA-A. A FRI submitted to the SA 7/8/21, at 1:24 p.m. identified allegations of emotional or mental abuse that occurred on 7/8/21. The description of the incident included a staff member overhearing an interaction between RA and NA-A, where NA-A told R2, Don't you ever yell out for me again. On 7/29/21, at 11:18 a.m. physical therapy assistant (PTA)-A stated she had overheard an interaction between R2 and NA-A, in which NA-A had yelled at R2, Don't you ever yell or call out to me again. PTA-A stated she went to R2 to talk to him. PTA-A stated R2 was visibly upset with how NA-A had talked to him while providing cares. PTA-A stated she immediately reported the incident to her supervisor, who reported to nurse manager. On 7/29/21, at 1:16 p.m. NA-A was interviewed and stated he had been involved in a recent altercation with R2 on 7/8/21, which resulted in his suspension from work and re-education on abuse training. NA-A stated he also had been suspended on 5/26/21, related to an incident with R1. NA-A stated the incident with R1 had occurred on 5/18/21, and at that time he had been instructed to not enter and provide cares for R1, but he had continued to do so. NA-A stated there had been additional allegations of abuse towards him, including verbal abuse towards residents, but he had only been suspended on 5/26/21, and 7/8/21. On 7/30/21, at 11:59 p.m. an interview was conducted with the DON and administrator. The DON stated R1 had reported NA-A had been rude and rushed with cares on 5/18/21. The DON verified no other residents had been interviewed at that time to see if they had any concerns with NA-A. The DON stated this incident had not been reported to the SA. The DON stated NA-A had been instructed by RN-A not to enter R1's room or provide any cares for him. The DON stated NA-A continued to both enter R1's room, as well as provide cares. The DON stated it was not until 5/26/21, when an outside agency had reported R1's concerns with NA-A, the facility had reported to the SA. The DON stated at that time NA-A had been immediately suspended pending an investigation. The DON verified NA-A had been allowed to return to work with no formal re-education. The DON stated there had been a second incident related to staff to resident abuse involving NA-A and R2 which occurred on 7/8/21. The DON stated NA-A had been immediately suspended pending an investigation. The DON stated NA-A had been allowed to return to work after completing formal education, as well as a counseling session with herself. The DON stated she expected facility staff treated residents with dignity and respect. The facility's policy Ecumen's Abuse Prevention Plan For Minnesota Skilled Nursing Facilities revision date 3/14/18, directed staff that any alleged maltreatment/mistreatment involving abuse or neglect must be reported immediately, and the administrator would notify the appropriate State Agency immediately in accordance with State guidelines. The policy also included an internal investigation is to begin immediately to ensue that the appropriate reporting takes place and intervention are implemented to provide the vulnerable adult with a safe living environment.

Based on interview and document review, the facility failed to ensure incidents of potential abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of abuse. R1's Admission Record printed 7/30/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact, had no behaviors or rejection of cares, and required extensive assistance with all activities of daily living except for eating. A facility document Record of Concern dated 5/18/21, indicated R1 reported to nursing staff NA-A had raised his voice when he had entered his room to answer his call light. R1 also reported NA-A had instructed R1 that he was to treat NA-A with respect when he was providing cares for him. The facility's action taken related to R1's concern included oral and written instruction for NA-A to be assigned to another hallway. The concern further indicated the director of nursing (DON) had been made aware of the incident. On 7/29/21, at 9:12 a.m. R1 was interviewed and stated when nursing assistant (NA)-A had been providing cares for him, NA-A had spoken rudely and used a loud tone. R1 stated NA-A also had made him feel rushed during cares. R1 stated he had reported his concerns to facility staff, and he no longer wanted NA-A to enter his room or provide cares. R1 stated NA-A continued to enter his room until he reported this concern again to another staff member. On 7/30/21, at 11:59 p.m. an interview was conducted with the DON and administrator. The DON verified R1 had reported to staff that NA-A had been rude and rushed him with cares on 5/18/21. The DON verified the incident had not been reported to the SA. The facility policy Ecumen's Abuse Prevention Plan for Minnesota Skilled Nursing Facilities revision date 3/14/18, directed staff that any alleged maltreatment/mistreatment involving abuse or neglect must be reported immediately, and the administrator would notify the appropriate State Agency immediately in accordance with State guidelines.

Based on interview and document review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) reviewed for abuse. R1's Admission Record printed 7/30/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had no behaviors or rejection of cares, and required extensive assistance with all activities of daily living except for eating. A facility document Record of Concern dated 5/18/21, indicated R1 reported to nursing staff NA-A had raised his voice when he had entered his room to answer his call light. R1 also reported NA-A had instructed R1 that he was to treat NA-A with respect when he was providing cares for him. The facility's action taken related to R1's concern included oral and written instruction for NA-A to be assigned to another hallway. The concern further indicated the director of nursing (DON) had been made aware of the incident. On 7/29/21, at 9:12 a.m. R1 was interviewed and stated when nursing assistant (NA)-A had been providing cares for him, NA-A had spoken rudely and used a loud tone. R1 stated NA-A also had made him feel rushed during cares. R1 stated he had reported his concerns to facility staff, and he no longer wanted NA-A to enter his room or provide cares. R1 stated NA-A continued to enter his room until he reported this concern again to another staff member. On 7/29/21, at 12:15 p.m. during interview registered nurse (RN)-A stated R1 reported to her he no longer wanted NA-A to be allowed to provide cares for him or enter his room. RN-A stated she had reported this to both DON and administrator. RN-A stated NA-A did not follow the instructions and continued to enter R1's room even though he was directed to not do so. RN-A stated the facility did no further investigation or interviews of other residents receiving care by NA-A. On 7/29/21, at 1:16 p.m. NA-A was interviewed and stated he had been suspended on 5/26/21, related to an incident with R1. NA-A stated the incident with R1 had occurred on 5/18/21, and at that time he had been instructed to not enter and provide cares for R1, but he had continued to do so. On 7/30/21, at 11:59 p.m. an interview was conducted with the DON and administrator. The DON stated R1 had reported NA-A had been rude and rushed with cares on 5/18/21. The DON verified no other residents had been interviewed at that time to see if they had any concerns with NA-A. The DON stated NA-A had been instructed by RN-A not to enter R1's room or provide any cares for him. The DON stated NA-A continued to both enter R1's room, as well as provide cares. The DON verified NA-A had been allowed to return to work with no formal re-education. The facility policy Ecumen's Abuse Prevention Plan for Minnesota Skilled Nursing Facilities revision date 3/14/18, directed staff that any alleged maltreatment/mistreatment involving abuse or neglect must be reported immediately, and the administrator would notify the appropriate State Agency immediately in accordance with State guidelines. The policy also included an internal investigation is to begin immediately to ensue that the appropriate reporting takes place and intervention are implemented to provide the vulnerable adult with a safe living environment.

Based on interview and record review, the facility failed to provide assistance and supervision according to the individualized assessment for 1 of 10 residents, R1, reviewed for falls. This resulted in actual harm when R1 fell out of her wheelchair after staff left the resident unattended and sustained a subdural /subarachnoid hematoma as a result of the fall. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment and required extensive staff assistance with all activities of daily living. R1's care plan dated 3/9/18, indicated the resident was at risk for falls due to a prior head injury and the inability to recognize safety precautions. Staff were directed to ensure the resident was not left unattended in the bathroom or in her wheelchair. Due to R1's history of falls, staff placed a sign in R1's room reminding staff to not leave R1 unattended in the wheelchair or bathroom. R1's nursing progress note dated 3/31/18, at 12:30 p.m. indicated physical therapy assistant (PTA)-F left R1 in the wheelchair unattended in her room following a therapy session. The note indicated the resident's family member (FM)-H was heard yelling, I need a nurse she's on the floor. The resident was laying on the floor in her room and stated, I hit my head, and it hurts. The note indicated it was unclear if R1 fell forward out of her wheelchair, or if she was attempting to self-transfer from the wheelchair to the bed and fell during the transfer. The note indicated neurological checks were initiated and R1's physician was updated about the fall. The physician directed staff to monitor R1 for injury or any changes in condition or cognition. R1's nursing progress note dated 4/2/18, at 1:26 p.m. indicated R1 complained of a headache which was not relieved by medication. The on-call physician was contacted and directed staff to send the resident to the hospital for evaluation. R1 was transferred to the hospital at 1:20 p.m. on 4/2/18. An emergency room note dated 4/2/18, at 2:24 p.m. indicated R1 had a history of [REDACTED]. At the time of the emergency room visit, R1 stated she hit her head when she fell out of her wheelchair on 3/31/18. R1 denied loss of consciousness secondary to the 3/31/18, fall but complained of having intermittent headaches and neck stiffness/tenderness since the fall occurred. R1's nursing progress note dated 4/2/18, at 9:10 p.m. indicated the hospital notified the facility the resident was diagnosed with [REDACTED]. R1 had a neurological surgery consultation while at the hospital and was given permission to return to the facility and resume her rehabilitation appointments. R1 returned to the facility at 8:15 p.m. on 4/2/18. When interviewed on 6/1/18, at 10:30 a.m., director of nursing (DON)-B stated R1 was impulsive and had a history of [REDACTED]. R1's cognition declined after the 3/31/18, fall and her shunt had to be re-adjusted while she was hospitalized related to the fall. PTA-F was familiar with R1's care plan and knew R1 had a history of [REDACTED]. R1 also had a sign which was clearly visible posted in the resident's room reminding staff to not leave the resident alone in her room unattended in the wheelchair. DON-B stated PTA-F was employed through a contract agency, and the agency provided PTA-F with re-education after the 3/31/18, incident. PTA-F continued to work at the facility. When interviewed on 6/1/18, at 12:45 p.m. the Rehabilitation director (RD)-D stated she is PTA-F's supervisor and provided education to her after leaving R1 unattended in the wheelchair which resulted in a fall on 3/31/18. During interview on 6/1/18, at 1:45 p.m. PTA-F stated she worked with R1 on a daily basis prior to the 3/31/18, fall. PTA-F stated following R1's therapy session on 3/31/18, she brought the resident back to her room, locked the brakes on the wheelchair, and left the room. PTA-F stated R1's family member, FM-H, was usually in R1's room when she brought R1 back after the therapy sessions but was not in the room that day. PTA-F stated she was aware R1 was not to be left unattended in the wheelchair, however, it was an oversight and she forgot to transfer the resident out of the wheelchair prior to leaving the room. PTA-F stated she no longer works with R1.