Every finding on record at Edenbrook of St Cloud

Based on observation, interview, and document review, the facility failed to identify, assess, monitor, and respond to changes in skin integrity, including notification of the provider and implementation of appropriate interventions, for 1 of 3 residents (R2) reviewed for pressure ulcers.Findings include:R2's hospital discharge summary note dated 6/9/26 identified R2's diagnoses included catheter associated urinary tract infection (UTI), acute toxic metabolic encephalopathy, proximal muscle weakness and sepsis due to UTI.R2's hospital wound care instructions dated 6/9/26 included the following:Apply layer of Zinc oxide paste to buttocks and perianal skin and surrounding tissue twice a day and as needed for incontinence. Remove all barrier cream with skin assessment. Then only remove soiled barrier cream and re-apply more with each incontinence episode.R2's admission Minimum Data Set (MDS) dated 6//22/26 indicated R2 was at risk of developing pressure ulcers and had moderate cognitive impairment. The MDS also indicated R2 required extensive total assistance with activities of daily living (ADL).R2's care plan dated 6/18/26, indicated R2 was at risk for alteration in skin integrity related to incontinence, impaired mobility, weakness, and deconditioning with staff interventions to position R2's body with pillows/support devices, and protect bony prominence, routinely turn and reposition as tolerated by R2, apply barrier cream to affected sites as ordered, assess/monitor the alteration in R'2 skin integrity and document status weekly. R2's skin evaluation document, dated 7/15/26 at 2:33 p.m. indicated R2 had no new skin alterations identified. The evaluation did not address R2's pressure ulcers (PU) at her coccyx area.R2's Point of Care (POC) monitor task records dated from 7/9/26 through 7/21/26 indicated skin checks were documented as completed during cares with no new skin alteration noted recorded for each assessment. Review of R2's medical record including skin assessments and progress notes lacked documentation of PU assessment for the coccyx area prior to the survey entrance conference on 7/21/26. The medical record lacked documentation of wound measurements, staging, or description of the coccyx PU. During this time period, facility nursing staff were responsible for monitoring, assessing, documenting, and maintaining R2's skin integrity.During an observation on 7/22/26 at 9:05 a.m., a licensed practical nurse (LPN)-A stated R2 had a stage 1 PU on the coccyx area with blanchable tissue surrounding the wound. LPN-A stated the PU was an existing wound and the provider was aware of the wound condition. During an interview on 7/22/26 at 10:24 a.m., LPN-A explained during weekly skin assessments, nursing staff were expected to assess existing wounds, compare current findings with previous assessments, and document the wounds' progress. LPN-A stated any newly identified skin impairment should be reported to the nurse manager and the provider for further evaluation and treatment instructions.During an observation on 7/22/26 at 10:10 a.m., R2 remained lying flat on her back in bed.During an interview on 7/22/26 at 10:49 a.m., a nursing assistant (NA)-A stated she was assigned to care for R2 during the day shift. NA-A stated R2 was to be repositioned every two hours using pillows for pressure relief. NA-A was unable to recall when R2 had last been repositioned and confirmed she had not repositioned R2 during her shift as of the time of the interview.During an observation on 7/22/26 at 3:45 p.m., LPN-B identified a new stage 2 PU (partial-thickness skin loss with exposed dermis) on R2's left gluteus measuring 2.19 cm x 1.24 cm. LPN-B described the wound as having light serosanguinous drainage, excoriation of the surrounding tissue and no odor. Additionally, LPN-B also identified a new stage 1 PU on R2's right gluteus measuring 0.68 cm x 0.62 cm. The wound bed was pink and fragile, and the surrounding tissue was intact. LPN-B confirmed R2 had been lying on her back and had not been repositioned before the assessment.During an interview on 7/22/26 at 3:14 p.m., LPN-B stated when a new skin impairment was identified, nursing staff were expected to complete a skin assessment, initiate a risk management report, document the wound description and measurements, record the finding in the progress note, notify the nurse manager and the provider, initiate treatment according to the provider's orders, and inform the resident's family. RN-A stated nursing staff did not document measurements or a description of R2's PU in the coccyx area and did not notify the provider of the wound. LPN-B explained R2 was at risk for developing PU and should have been repositioned every two hours, with any refusal documented in the medical record. LPN-B confirmed R2 had not been repositioned at that time.During an interview on 7/22/26 at 4:16 p.m., the DON stated she expected nursing staff to follow the facility's wound care policy. The DON stated when a new skin impairment was identified, nursing staff were required to notify the wound care team and the primary provider, document the wound measurements and description as well as initiating appropriate interventions. Additionally, The DON stated residents at risk for pressure ulcers were to be repositioned every two to three hours, as directed by the care plan. The DON confirmed nursing staff did not notify the provider regarding R2's newly identified wound. The DON stated the facility would provide house-wide education to nursing staff regarding wound care practices and timely physician notification.During an interview on 7/22/26 at 4:47 p.m., a nurse practitioner (NP)-A stated she expected nursing staff to follow the facility's change in condition and wound care policies. NP-A stated when a new skin impairment was identified, nursing staff were required to notify the provider and the dietitian. NP-A confirmed she was not notified of R2's PU in the coccyx area. The facility Change in Condition policy dated 8/1/15 and revised 11/13/24 instructed nurses to notify the physician of changes in the resident's condition. Nurse will complete assessment and document findings in resident record including but not limited to vital signs, pain, respiratory status as applicable etc. The care plan will be updated as necessary.

Based on interview and document review, the facility failed to provide timely notification for change in skin condition to the physician for 1 of 3 residents (R2) reviewed for pressure ulcers. Findings include:R2's hospital discharge summary note dated 6/9/26 identified R2's diagnoses included catheter associated urinary tract infection (UTI), acute toxic metabolic encephalopathy, proximal muscle weakness and sepsis due to UTI.R2's admission Minimum Data Set (MDS) dated 6//22/26 indicated R2 was at risk of developing pressure ulcers and had moderate cognitive impairment. The MDS also indicated R2 required extensive total assistance with activities of daily living (ADL).During an observation on 7/22/26 at 3:45 p.m., a licensed practical nurse (LPN)-B identified a new stage 2 pressure ulcer (PU) (partial-thickness skin loss with exposed dermis) on R2's left gluteus measuring 2.19 cm x 1.24 cm. LPN-B described the wound as having light serosanguinous drainage, excoriation of the surrounding tissue and no odor. Additionally, LPN-B also identified a new stage 1 PU on R2's right gluteus measuring 0.68 cm x 0.62 cm. The wound bed was pink and fragile, and the surrounding tissue was intact. During an interview on 7/22/26 at 3:14 p.m., LPN-B stated when a new skin impairment was identified, nursing staff were expected to complete a skin assessment, initiate a risk management report, document the wound description and measurements, record the finding in the progress note, notify the nurse manager and the provider, initiate treatment according to the provider's orders, and inform the resident's family. LPN-B stated nursing staff did not document measurements or a description of R2's PU in the coccyx area and did not notify the provider of the wound.During an interview on 7/22/26 at 4:16 p.m., the DON stated she expected nursing staff to follow the facility's wound care policy. The DON stated when a new skin impairment was identified, nursing staff were required to notify the wound care team and the primary provider, document the wound measurements and description as well as initiating appropriate interventions. The DON confirmed nursing staff did not notify the provider regarding R2's newly identified wound. The DON stated the facility would provide house-wide education to nursing staff regarding wound care practices and timely physician notification.During an interview on 7/22/26 at 4:47 p.m., a nurse practitioner (NP)-A stated she expected nursing staff to follow the facility's change in condition and wound care policies. NP-A stated when a new skin impairment was identified, nursing staff were required to notify the provider and the dietitian. NP-A confirmed she was not notified of R2's PU in the coccyx area. The facility Change in Condition policy dated 8/1/15 and revised 11/13/24 instructed nurses to promptly notify the physician of changes in the resident's condition. Specific information that require prompt notification include, but is not limited to: Onset of pressure ulcer and a need to alter the resident's medical treatment significantly.

Based on interview and document review, the facility failed to provide a written notice of bed hold for 2 of 2 residents (R20, R21) reviewed for hospitalization. Findings include: R20's quarterly minimum data set (MDS) dated [DATE], included R20 was cognitively intact. R20 had diagnoses of heart failure, malnutrition (the body not getting or absorbing enough nutrients), and respiratory failure. R20's discharge MDS dated [DATE], included R20 had an unplanned discharge with return anticipated and was discharged to a short-term acute hospital. R20's discharge MDS dated [DATE], included R20 had an unplanned discharge with return anticipated and was discharged to a short-term acute hospital. R20's discharge MDS dated [DATE], included R20 had an unplanned discharge with return anticipated and was discharged to a short-term acute hospital. Bed hold agreements requested for hospitalizations on 4/4/25, 5/11/25 and 6/6/25. However, none provided. R21's quarterly MDS, dated [DATE], indicated R21 was cognitively intact. R21's diagnoses included cerebral infarction (stroke), end-stage renal disease (ESRD), and congestive heart failure (CHF). R21's progress note, dated 3/3/25 at 4:39 p.m., indicated R21 was transferred to the hospital on 2/27/25 for headaches worsening with position changes and elevated blood pressures (BPs). R21 returned to the facility on 3/3/25. However, R21's medical record lacked evidence a written notice of bed hold was provided to the resident and/or resident representative for the 2/27 - 3/3/25 hospitalization. During interview on 6/25/25 at 10:52 a.m., licenses practical nurse (LPN)-A stated the nurse manager (NM) usually completed the bed hold paperwork but the floor nurse could complete it if the NM was not available. During interview on 6/25/25 at 11:09 a.m., NM-A stated the floor nurse was in charge of completing the bed hold paperwork. However she would collect it if she was working when the transfer happened. NM-A stated the bed hold paperwork should have been uploaded to the chart and was not done for R20's transfers on 4/4/25, 5/11/25 and 6/6/25. During interview on 6/26/25 at 9:43 a.m., director of nursing (DON) confirmed a bed hold should be completed when a resident was transferred to the hospital. The DON stated it was important to collect the bed hold, so a resident was able to return to the facility if that was their preference and for billing purposes. On 6/26/25 at 10:48 a.m., the nurse manager (LPN)-B verified a written notice of bed hold had not been provided to R21 for the 2/27 - 3/3/25 hospitalization. LPN-B stated staff were expected to provide a written notice of bed hold at the time of transfer to the resident and/or the resident representative. The facility's Admission, Readmission, Bed Hold, and Transfer/Discharge Policy, revised 10/12/21, indicated at the time of transfer of a resident for hospitalization or therapeutic leave, the facility will provide to the resident and the resident representative written notice which specifies duration of the bed-hold, during which the resident is permitted to return and resume residence in the facility, the reserve bed payment policy in the state plan, and the facility policies regarding bed-hold periods.

Based on observation, interview and document review the facility failed to store thawing meat in a manor to prevent it from dripping onto other items stored in the refrigerator. Furthermore, the facility failed to ensure food stored in the unit refrigerators and main kitchen were labeled, dated and discarded properly. These deficient practices had the potential to affect all 67 residents received food from the facility kitchen and unit refrigerators. Findings include: On 6/23/25 at 12:03 p.m., during the initial tour of the walk-in refrigerator, a metal sheet pan held ground up meat in a plastic package. The package of meat was hanging over the edge of the sheet pan by approximately 1.5 inches. Below the the ground up meat, was a closed container of cantaloupe, and a bowl of peeled cantaloupe covered with cling wrap. Additionally, in the stand-alone refrigerator in the main kitchen were three small containers of partially melted substance. One was white with small brown chunks, and the other two were orange in color, all three were uncovered, and undated. On 6/23/25 at 12:23 p.m., the cook (C)-A confirmed the meat should not have been stored above the other food while thawing, within the pan's borders, and on the bottom of the rack with nothing below it. The Dietary manager (CDM) entered the walk-in refrigerator, and confirmed the meat should not have been place above the cantaloupe. They expected thawing meat was stored at the bottom of the rack with no other food below it. On 6/23/25 at 3:11 p.m., the unit refrigerator in long term care had open and undated bottles of ranch dressing and mayonnaise. On 6/24/25 at 9:43 a.m., the unit refrigerator in long term care still had the open and undated bottles of ranch dressing and mayonnaise. On 6/23/25 at 3:26 p.m., in the memory care unit refrigerator there was a large bottle of open and undated grape juice. The certified nursing assistant (NA)-A was unable to state or locate when the bottle had been opened. NA-A stated it should have had an open date on the bottle so they would know when it had been opened. NA-A removed the juice from the refrigerator. On 6/25/25 at 3:16 p.m., the standing refrigerator in the main kitchen had a small opened, uncovered, and undated clear container of melting orange substance in the refrigerator. On 6/25/25 at 3:18 p.m., the cook (C)-B confirmed the container was undated and uncovered. C-B stated the substance was most likely from a snack or the previous meal and should have either been thrown away or covered and dated to know how long it was good for. On 6/26/25 at 8:32 a.m., the CDM confirmed the ground meat should have been placed below the other times on the rack. It was important to monitor how things were placed within the refrigerator to prevent any bacteria growth, maintain temperatures, and prevent cross contamination. Further, the CDM expected all opened items in unit and main kitchen refrigerators were covered/closed, dated and stored at the appropriate temperature for the item. It was important to maintain basic food safety to prevent food borne illnesses and prevent cross contamination. On 6/26/25 at 8:52 a.m., the administrator expected all open items in the unit and the main kitchen refrigerators were covered, labeled and dated. The administrator stated the importance of covering and dating each item for the facility to know whether each item was good and had not expired. The Food Safety Requirements Policy dated 11/26/17, indicated staff will monitor for food requiring refrigeration for proper and immediate storage including labeling and dating. Additionally, staff will also check for situations where potential for cross-contamination is high (e.g. raw meat stored over ready-to-eat items.)

Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively sustained ongoing compliance related to repeat citations from past surveys regarding food storage and labeling open items. This had the potential to affect all 67 residents residing in the facility. Findings include: Review of the facility CASPER Report dated 5/15/25, indicated the facility was cited F812 for food procurement, store/prepare/serve sanitary on the survey exited 5/15/24. See F812: Based on observation, interview and document review the facility failed to store thawing meat in a manor to prevent it from dripping onto other items stored in the refrigerator. Furthermore, the facility failed to ensure food stored in the unit refrigerators and main kitchen were labeled, dated and discarded properly. The facility's QAPI committee meeting minutes from July 2024 through May 2025 lacked ongoing data related to the above repeat citation. On 6/26/25 at 12:52 p.m., the administrator acknowledged the importance of continued monitoring of QAPI projects. The facility's QAPI Plan, undated, revealed focused areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in their organization. The policy also indicated the facility would conduct Performance Improvement Projects (PIPs) there were designed to take a systemic approach to revise and improve care or services in the areas that they identify as needing attention. The facility would conduct PIPs that would lead to changes and guide corrective actions in their systems, which cross multiple departments, and have impact on the quality of life and quality of care for residents living the their community. They will conduct PIPs that would improve care and service delivery, increase efficiencies, lead to improved staff and resident outcomes, and lead to greater staff, resident, and family satisfaction. Their PIPs are a plan to determine the effectiveness of their performance improvement activities and whether the improvement is sustained.

Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 6 of 6 residents (R2, R3, R4, R5, R6, R7) reviewed who had food concerns. This deficient practice had the potential to affect all 63 residents residing in this facility. Findings included: Review of November 2024 grievances identified dinner was cold 11/11/24 and 11/12/24. Review of resident council meeting minutes dated 12/2/24 at 11:00 a.m. identified three officers and seven residents in attendance. Dietary: meals were still cold. The overview of action plan included a chart: current situation, what is our goal, what do we need to get there, who will help us get there, and status (resolved, not resolved/action needed, partially resolved/further steps needed) was left blank. During an interview on 12/17/24 at 9:30 a.m. family member (FM) stated sometimes the food was undercooked, chicken was pink, overcooked vegetables such as broccoli were mushy, and cold such as pizza, toast, and eggs. FM stated there were times when the biscuits and French toast were hard, and the residents could not bite into them. FM stated she had brought in food for her family member and warmed it up in the microwave. During an interview on 12/17/24 at 3:40 p.m. R3 stated this morning the temperature of food was cold. His French toast sticks and a tiny piece of ham steak was cold, hard, and tough to bite into. On other occasions when food was cold, he would tell staff and sometimes they offered to warm up his meal but then it became hard and unable to eat. Today R3's lunch included spaghetti and meatballs, broccoli, which were cold, and the sherbet was melted. He had seen the meal cart located in the hallway up to 30 minutes before the meal was served to residents. R3 stated we have the option of going to the dining room or stay in our rooms, and he had done both. During an interview on 12/17/24 at 4:21 p.m. R2 stated meals were frequently served late and the hot food was cold and overcooked most of the time. R2 stated pancakes edges were crispy, hard to cut with a knife and eat. R2 stated the garlic bread was chewy and unsure why. R2 stated he had informed the manager of the kitchen of the concerns but was hard to talk to and things had not improved. Facility regular dinner menu dated 12/17/24, identified: Homemade vegetable beef soup Grilled cheese sandwich Marinated cucumbers Cinnamon applesauce Milk During a continuous observation on 12/17/24 at 5:16 p.m. located in main dining room [ROOM NUMBER] residents sat at tables and waited for supper to be served. At 5:20 p.m. noted from kitchen doorway two staff placed the food onto the plates with gloves on. The grilled cheese sandwiches were located in the steam table and when removed cut up in half or fourths with a large knife. The vegetable beef soup was located in a large metal pot located on the steam table and steam was seen coming from the top of the soup after it was placed into a bowl for each resident. At 5:40 p.m. R6 sat at table in dining room, yelled out twice can I get a sandwich that was not cold cannot eat this one. An unidentified staff went over to R6, removed her grilled cheese sandwich, brought it into the kitchen and at 5:42 p.m. returned with a grilled cheese sandwich. R6 stated thank you, took a bite and stated the sandwich was warm. R6 stated food was served cold frequently, wait time was long for meals to be served, and was frustrated, would have liked a hot meal once without requested to be warmed up. R6 stated the soup was too hot and blew on it until it was the temperature she wanted and ate the grilled cheese sandwich. Review of the Food Temperature Log on 12/17/24 at approximately 5:45 p.m. identified dinner food temperatures were documented once at an undetermined time: Soup 180 degrees Fahrenheit (F.) Regular meat 175 degrees F. Ground meat 175 degrees F. Vegetable 180 degrees F. Pureed vegetable 180 degrees F. Starch 185 degrees F. Alternatives 165 degrees. F Dessert 35 degrees F. Milk/juice/coffee 35 degrees F. During an observation/interview on 12/17/24 at 5:48 p.m. cook (C)-A had placed a cut grilled cheese sandwich along with a bowl of soup on a plate and it was delivered by an unidentified staff to a resident in the dining room. C-A stated the foods that remained on the steam table she had just finished serving at 5:45 p.m. to residents were grilled cheese sandwiches and vegetable beef soup. C-A stated she had checked the temperature of the hot foods prior to when she started to serve the meals and entered the temperatures onto the log sheet. C-A stated she had never checked temperatures on the food during serving. C-A stated a female resident had complained the grill cheese sandwich was cold and her sandwich was replaced three times. At 5:52 p.m. C-A was asked to check the temperature on one of the grilled cheese sandwiches that remained in the stream table. Kitchen manager (KS) walked over to steam table and placed the thermometer into the center of a sandwich while it remained in the steam table and verified it was 124 degrees F. KS stated the temperature of the grilled cheese sandwich was low, should have been above 130 degrees F. or higher, and verified the steam table remained turned on. KS stated they had been having issues with the steam table, sometimes warmed up but not hot enough, and waited on verification of a new steam table. KS stated in the meantime, staff were expected to have checked food temperatures to make sure they where they should be and served safely. KS wiped off end of thermometer and place the end of it into the large pot of vegetable soup and read 182 degrees F. stated should have been 135 to 160 degrees F. but 182 degrees F was fine. KS stated those foods were safe to have been served to the residents. Facility regular noon menu dated 12/18/24, identified: -pork chops -cream gravy -roasted butternut squash -French green beans -banana cream cheesecake -milk Facility Temperature Record for lunch dated 12/18/24, indicated all hot foods must be held at 140 degrees Fahrenheit (F) or higher. Recommended temperature for foods held on the serving line is 160 to 180 degrees F. Identified food temperatures were documented once at an undetermined time: Regular meat 180 degrees F. Ground meat 180 degrees F. Vegetable 176 degrees F. Starch 176 degrees F. Gravy 168 degrees F. Alternatives 177 degrees F. Dessert 169 degrees F. Milk/Juice/Coffee 169 degrees F. During an observation on 12/18/24 at 12:00 p.m. over 20 residents sat at tables in the large dining room while staff served them lunch. During an observation on 12/18/24 at 12:20 p.m. no residents remained in large dining room. At least 15 plates were observed on the tables with approximately up to 50 % of the food remained on the plates. During an observation on 12/18/24 at 12:25 p.m. two kitchen staff, C-B, and dietary aide (DA) prepared plates of food to be delivered to the resident rooms. The resident plates were stacked freely on the counter. C-B dished up hot foods (pork chops in sour cream gravy, squash, French green beans located in the steam table, the steel container of carrots was located outside of the steam table on top of steam table covers, placed the foods on a plate on top of a silver steel plate from a stack located on the counter. DA placed a cover that had a hole in the top of it over the plate of food and a piece of banana cream cake with whipped topping on each tray. DA placed each tray onto a shelf into a large brown colored cart. There were steel containers located on top of the steam table covers over the third and fourth well with foods in them: pureed meat, carrots, mashed potatoes, minced pork meat, squash, and boneless chicken breasts. At 12:40 p.m. all trays of food were loaded up into the brown cart and the doors were closed. C-B confirmed the stream table remained turned on (all four burners). C-B stated she had taken the temperature of all the foods when she cooked them and again prior to serving them to residents. C-B stated she had entered the temperatures into the log sheet. C-B stated the steam table was turned on hours before the food was placed in there at 6:00 a.m. C-B stated there were four knobs one for each part of the steam table to total four knobs. Four sections in the steam table were observed. C-B stated she had set the first knob and turned it one click to the right and the same with knob three and four. C-B stated there were no makings on the knobs that indicated what each one was set at. C-B stated the second knob was the only one out of the four that had a silver plate with markings on it so that she knew to set it just below high. C-B verified three of the four dials were missing the silver plate and each dial was for a separate section of the steam table. At 12:45 p.m. C-B completed a temperature check on the following foods: Pork chops in sour cream gravy (no meat remained in the large metal container located in the steam table first section) Large amount of sour cream gravy remained in the metal tray located in the steam table section one and was temped at 167 degrees F. French green beans (located in the steam table first section) 162 degrees F. Food that was located out of the steamer and on top of the metal covers that were placed on top of the steam table section three and four: Chicken boneless 127.0 degrees F. C-B stated she had placed in steamer and just removed it prior to when surveyor came into the kitchen. Sliced carrots (approx. four inches of carrots in bottom of metal container) 101.4 (stated should be at least 150 degrees F. or higher) were not located in the steam table and C-B stated they were just served to residents. C-B stated the temperature of the carrots was not up to 150 or higher and should have not been served to the residents. Pureed pork chops 92.0 degrees F. C-B stated they should have been at least 160 degrees F. and not sure why they were so cold, had not been that long since they were served, and the steam table should have kept these hot. On 12/18/24 at 12:55 p.m. kitchen manger (KM) entered the large kitchen and walked over to the steam table. Foods were not placed in the steam table and located on to top of the metal covers that were placed over the steam table. The following foods were checked by KM for temperatures: Pureed pork 101.0 degrees F. Mashed potatoes 135.0 degrees F. Minced pork meat 104.0 degrees F. Squash 90.0 degrees F. French green beans 100.0 degrees F. located in the steam table. Previous observation identified the green beans were served /delivered to more than 10 residents until 12:40 p.m. KM stated the steam table should have maintained the expected temperature for all the hot foods and where the temperatures should presently be at so that the temperatures were kept at where it would be servable. KM stated not sure why would have collected temperatures of these foods now that they were done serving. On 12/18/24 at 1:00 p.m. while steam table remained turned on surveyor requested a scoop of gravy from pork chop pan located in first section of steam table, French green beans located in the steam table and sliced carrots located in a metal container on top of the metal covers over the steam table be placed on a plate to sample. KM and surveyor sampled the carrots, and both agreed they were not hot, and KM stated just warm, and surveyor identified them as cold. Surveyor sampled the gravy and green beans and were warm. KM stated unsure why the food needed to be sampled now, the residents had already been served their meal. During the interview on 12/18/24 at 1:01 p.m. KM stated all food for the facility and assisted living was made in this large kitchen. Once the cook has made the food they are expected to check all the temperatures, divide it up and place in holding ovens set at 225 degrees F. KM stated one hour prior to serving the steam tables should have been turned on and one to two inches of water added to the bottom of each well, there were four wells in the steam table on the mainline. KM stated the mainstream table had four dials only one had numbers and the other three did not. KM stated it was an old piece of equipment and he instructed his staff to turn the unmarked dials one click to the right when there was steam it was working properly. KM stated the water in the steam table wells could have been tested for the temperature but had not been done. KM stated was not aware or been told by kitchen staff the steam table had not been working properly. KM stated when water was steaming would guarantee it was over 200 degrees F. KM verified C-B would have been expected to have used a perforated pan placed in the steamer for the pureed foods and carrots to have maintained correct temperatures. Those foods that we temped were not servable due to low temperatures that should have been maintained throughout the serving of the meal. KM stated none of the pureed food or the carrots were placed in the team table as expected. KM stated he was aware of resident complaints of cold food during the resident council meeting and completed an audit. KM stated the audit showed the food stayed hot only if the steel plate warmers and a lid were used and served in a timely manner before 12:30 p.m. (copy of two audits were received and dated 10/10/24 and 10/11/24). KM stated would have expected staff to have turned on the plate warmer and those plates used to keep the food hot. KM stated staff would be expected to re-temp foods that no longer seemed warm enough. KM stated residents could have gotten sick if the pork they served was under 165 degrees F. and should have been thrown out. KM stated the vegetables and gravy should have been maintained at to at least 165 degrees F. to have been safe to be served and eaten. KM stated he assumed the pureed meat temperature were taken to meet the requirements for safety to eat and should have been entered on the log form, but the temperatures were not on the form. KM stated all foods are to be expected to be temped and meet the recommended temperature guidelines prior to serving otherwise service would have to wait until the correct temperature has been reached. KM stated the log form required adjustments so that all foods temped were documented. On 12/18/24, DM provided surveyor an untitled dietary log form that listed all three meals (breakfast, lunch, and supper) for one week with each type of food to have been served during that meal with the acceptable temperature(s) required. DM stated this was the log form the cooks were required to use when they served meals, and they were currently using the wrong form. Each section at the top listed the day of the week with three boxes located below that labeled beginning, middle and end and included a column below each one for the meal. Lunch section identified: Meat/entree 160 to 180 degrees F. Ground Meat/Entree 160 to 180 degrees F. Pureed Meat/Entree 160 to 180 degrees F. Alternative Entree 160 to 180 degrees F. Gravy 180 degrees F. Potato/Starch 160 to 180 degrees F. Pureed Potato 160 to 180 degrees F. Main Vegetable 160 degrees F. 2nd Vegetable 160 degrees F. Pureed Vegetable 160 degrees F. Soup 170 to 190 degrees F. Alternative Soup 170 to 190 degrees F. Cold Entree/Vegetable 40 degrees F. During a follow up interview on 12/18/24 at 10:55 a.m. R3 stated he had gone to the dining room for supper last night. R3 stated the grilled cheese sandwich was cold and hard. R3 stated was unable to eat the sandwich and had not requested anything different. During an interview on 12/18/24 at 11:15 a.m. R4 stated has had cold food and/or that was barely warm. R4 stated went to the dining room last night for supper. R4 stated the cheese on the grilled cheese sandwiches was not melted and cold. R4 stated staff offered to warm up food when requested. During an interview on 12/18/24 at 4:40 p.m. R7 stated the food during meals was occasionally cold such as sandwiches. R7 stated when she had chosen to eat in her room the food arrived lukewarm and usually colder than what she had received in the dining room. R7 stated there were many times she had made her own sandwich out of her refrigerator located in the room. R7 stated she had not told anyone but felt she should have. During an interview on 12/19/24 at 9:35 a.m. R5 stated usually went to dining room for meals. R5 stated food was good except the hot food was cold, especially the eggs. R5 stated there had been discussion at resident counsel and there were concerns about cold food. R5 stated food was cold the same for all meals, no specific one and this really should not have been happening. Facility policy titled Safe Food Temperatures dated 3/2023, identified foods are to be maintained at a safe a palatable temperature during meal service. Safe food temperatures conform to Hazard Analysis Critical Control Points (HACCP) principles (an internationally recognized method of identifying and managing food safety related to risk and can provide assurance to customers that a food safety program is well managed). All hot foods were to be held at 150 degrees F. or above. Staff were directed to have taken temperature on all foods on the steam table prior to serving and at the end of the serving. If serving had taken longer than 30 minutes, temperatures would also be expected to be taken during the middle of the serving to ensure food were at their optimum holding temperatures. Food temperatures which fail to reach or maintain acceptable minimum temperatures would be required to have received corrective action such as reheated until the acceptable temperature was reached. Completed temperature records would be kept on file.

Based on interview and record review the facility failed to ensure dignified and respectful maintain or promote their quality of life for 2 of 3 residents (R2, R4) reviewed when services were not provided to empty bedside urinals and bathing was not provided as scheduled. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], identified he had moderate impaired cognition, sometimes socially isolated himself without behaviors. R2 had impaired mobility of one lower extremity and required partial to moderate assistance of staff for roll left/right, lying to sitting, sit to stand, chair/bed/chair/toilet transfers, and toileting hygiene. R2 was occasionally incontinent of bladder and continent of bowel. R2 used a walker and wheelchair for mobility. R2 had a diagnosis of benign prostatic hyperplasia (BPH) (enlargement of the prostate found just below the bladder and can block the flow of urine), diabetes mellitus, manic depression, and schizophrenia. R2's Kardex undated identified he required assistance with emptying urinal every shift, required assistance of one for shower every Friday evening (PM) shift, dressing and toileting. R2 required assist of one for bathing, uses urinal independently needs staff to empty. During interview/observation on 12/17/24 at 4:20 p.m. R2 stated the sign on the door leave me alone when the door was closed was the reason some staff told him they do not come into his room. R2 currently had three empty urinals located on his bedside table next to his bed. He wanted some privacy but still needed help with the urinals and staff to check on him. One week ago, a staff told him he was independent now and was able to empty his own urinals. During the night he had to urinate a lot, which was reason he had three full urinals sitting on his bedside table, the staff do not want to empty them especially during the night shift. When R2 uses his call light on to get them emptied it takes up to one hour for staff to assist him. R2 stated he was able to use the urinals himself but had to have more than one because he was afraid if one had filled up and used it again, he would spill urine on himself. During an observation on 12/18/24 at 10:47 a.m. R2's room door was open and located on his bedside table was a urinal 3/4 full of yellow colored urine visible from the hallway. R2 was not in his room. R2's care plan dated 12/19/24 identified R2 had a self-care deficit related to impaired mobility and pain. Staff were directed to have assisted with cleaning post incontinence. R2 used urinal independently and needed staff to empty urinal. During an interview on 12/19/24 at 8:30 a.m. licensed practical nurse (LPN)-A stated staff were expected to go into R2's room at least every two hours and check to see if his urinal should be emptied. LPN-A stated R2 was unable to empty the urinals (had three of them) himself and required staff assistance. LPN-A stated when the urinal filled up, sat on his bedside table for a length of time would be considered an infection problem and could have spilled onto the floor. LPN-A stated every resident should be checked on at least every two hours to make sure their needs were met. LPN-A stated for R2 it was a dignity issue made him not want to be here because he was not getting the care he needed, and he felt bad about it. LPN-A stated she had talked to R2 about his lack of help he had received, and he was very frustrated about it. LPN-A stated she had planned to provide that information to the facility social worker. During an interview/observation on 12/19/24 at 8:50 a.m. R2's room door was open with television on. Three urinals were located on the bedside table visible from door. All three urinals had yellow urine in them: #1 urinal full (approximately 1000 milliliters (ml) ), #2 was 3/4 full (approximately 750 ml), #3 was 1/2 full (approximately 500 ml). R2 was in his wheelchair and stated my urinals were not emptied on nights and that was why there are three urinals almost full on my table. R2 stated staff had not checked on him this morning, been up since 5:00 a.m. and would have expected staff to empty the urinals before the night shift left. R2 place his call light on at 8:55 a.m. R2 stated he had urinary urgency problems, staff had scanned his bladder at times, saw a urologist, scheduled to see him again on January 14th, 2025, and still unable to urinate a lot at one time. He explained it was difficult for him to empty the urinals himself, unable to walk and carry the urinals, and a tight fit to get into to bathroom with his wheelchair. He has had urinary accidents because he was unable to get into the bathroom and that was why he has used urinals instead. When the urinals filled up, he had to ask to have them emptied and felt like a burden, wished he could go home because it was hard to see people walk by and see them on the bedside table full of urine, and he felt embarrassed. R2 stated he had placed his call light on waited up to 45 minutes, went out and smoked a cigarette, returned to his room [ROOM NUMBER] minutes later, the call light was turned off and urinals remained on the table by the bed full of urine. He placed the urinals on the table next to the bed so that it would be high enough up for staff to see and they would be emptied but has not worked. R2 stated he was upset, frustrated, and no longer wanted to live at this facility and just need to move out. He had talked to the social worker and staff nurse about his concerns. At 9:05 a.m. (15 minutes later) nursing assistant (NA)-A entered the room, asked what R2 needed, applied gloves, emptied the urinals, removed gloves, washed hands, and exited the room. R4's admission MDS dated [DATE], identified intact cognition without behaviors. R4 had an impairment on upper extremity located on one side. R4 required partial to moderate assistance with personal hygiene, substantial to maximal assistance with roll left and right, sit to lying, lying to sit, sit to stand, chair/bed/chair and toilet transfers, and dependent for toileting hygiene and ambulation. R4 used a wheelchair for locomotion. R4 was frequently incontinent of bowel and bladder. R4's diagnoses included cancer, peripheral vascular disease (PVD), diabetes mellitus, and anxiety. R4's care plan dated 12/19/24 identified she had a self-care deficit, limited mobility, and directed staff to have provided assistance of one for personal hygiene and toileting, and transfers with front wheeled walker. R4 had an alternation in urinary elimination, overflow bladder incontinence, and directed staff to have provided incontinence cares after each incontinent bowel or bladder episode. R4 preferred to use bed side commode. R4's Kardex date 12/19/24 identified she required assistance of one for bathing on Tuesday and Friday morning (a.m.), dressing, transfers, personal hygiene, and offer and assist with toileting. R4's bath schedule dated 12/16/24 identified her bath was scheduled for Tuesday morning (a.m.). R4's bath schedule undated, identified her bath times were changed to two days a week and scheduled for Tuesday and Friday a.m. R4's NA bathing documentation from 11/29/24 through 12/17/24 identified: -11/29/24 physical help required. -12/6/24 did not occur. -12/10/24 did not occur. -12/13/24 total dependence required. -12/17/24 did not occur. R4's urinary toileting record from 12/1/24 through 12/5/24 identified: 12/1/24 at 12:45 a.m. refused 12/1/24 at 1:53 p.m. continent 12/2/24 at 1:59 p.m. continent 12/2/24 at 9:59 p.m. incontinent 12/2/24 at 11:15 p.m. continent 12/3/24 at 1:59 p.m. continent 12/3/24 at 9:49 p.m. incontinent 12/4/24 at 2:56 a.m. continent 12/4/24 at 1:59 p.m. continent 12/4/24 at 8:46 p.m. incontinent 12/4/24 at 11:57 p.m. incontinent 12/5/24 at 1:55 p.m. incontinent 12/5/24 at 9:19 p.m. incontinent R4's Treatment Administration Record (TAR) for the month of November 2024, there was no order entered for bath/shower to be signed off that it was given. R4's TAR from 12/1/24 through 12/19/24, identified ensure resident received scheduled bath/shower every day shift every Tuesday and Friday. Order date 12/13/24 at 1:37 p.m. On 12/17/24 singed off No (N). During an interview on 12/18/24 at 11:19 a.m. R4 stated it was hard to get staff into her room for assistance to the bathroom and the long wait times frequently resulted in her having urinary incontinence, wetting herself in her pants. It made her feel awful, embarrassed. R4 stated she took water pills (a medication to excrete excess fluid from the body). About two weeks ago, she had to use the bathroom and could not wait any longer then had urinate in her pants. R4 stated a person should have not had to wait that long to get some help but was now able to take myself to the bathroom. There are still days when she is tired when staff need to help her to the bathroom though. R4 stated would have liked a shower twice a week but there were times when she was unable to get one shower a week. She was scheduled to have a shower yesterday; staff came and asked her if she was ready and was just going to have breakfast. She waited for someone to come after breakfast, but no one came back. She said her last shower was last Friday (5 days ago), her hair needed to be washed, and scalp felt itchy. R4's hair appeared unkept and uncombed. She was ok at times with one shower a week but then had to go two weeks without one in the past month, one of those days the facility had no hot water about two weeks ago. R4 stated her family had not assisted with her weekly bathes. During an interview on 12/18/24 at 2:16 p.m. NA-C stated he had transferred R4 on and off toilet in the a.m. and then therapy came in and worked with her around 11:00 a.m. R4 was supposed to have a assistance with bathing, did not offer to assist her with washing up, it did not get done. NA-C stated it was staff responsibility to have helped R4 and to check back with her. NA-C identified on the shower/bath schedule located on a clip board dated 12/16/24, indicated R4 was scheduled for a shower one day a week on Tuesdays. NA-C stated if R4's frequency of a bath had changed staff was not aware of it, they followed the bath schedule. During an interview on 12/19/24 at 1:38 p.m. NA-B stated staff were expected to have checked on each resident at least hourly. Resident urinals should have been emptied at least on each walk around and/or as soon as you saw urine in them. It would be important to keep them empty, and not have them sitting around for an extended amount of time because it could cause infection, and the resident might be unable to use the urinal if it is full due to spillage of urine. NA-B stated the urinals should be emptied as soon as possible after use, dumped in the bathroom toilet, and rinsed out. NA-B stated a urinal with urine in it and visible to others can affect dignity and not pleasant for others to see and could embarrass a resident. On 12/17/24 NA-B charted no bath was given to R4 and verified she had not received her bath that day due to staff called in sick and they ran behind all day. When this happens, the evening (p.m.) shift should have done R4's bath and it was missed. NA-B stated he was not aware R4's bathes had increased to two times a week the bath schedule should have been updated to reflect that. During an interview on 12/19/24 at 1:55 p.m. floor manager LPN-B stated staff were expected to offer the resident a bath/shower once a week. R4's bathes were changed from one a week to two a week and should have started on 12/13/24. LPN-B stated the bath/shower would have been important to monitor skin, general hygiene, to prevent skin breakdown and dignity in general. During an interview on 12/19/24 at 3:09 p.m. director of nursing (DON) staff was expected to complete hourly safety rounds, turn/reposition/toileting every 2 to 3 hours, and a.m. morning cares to have included: wash face/hands/all crevasses/abdominal folds, perineal cares, toileting, comb hair, and brush teeth. DON stated staff were expected to empty urinals if in the resident's room and saw it being used and for sure at the end of the shift as well. DON stated the urinals get smelly and bacteria grows when not emptied. During an interview on 12/19/24 at 3:30 p.m. administrator stated one of R2's interventions was for staff to empty his urinals but R2 was able to empty his own urinal and struggled with motivation to do it himself. The administrator stated a urinal full of urine located on the table could be a dignity issue when people walked by his room, and it was visible. Facility policy Activities of Daily Living (ADLS) dated 3/15/21, the facility must provide necessary care and services consistent to the resident's needs and choices and to maintain or improve his or his ability to carry out the activities of daily living. The facility will provide care and services such as hygiene: bathing, dressing, grooming and oral cares and elimination/toileting. Facility policy Resident Rights: Dignity dated 10/24/23, identified the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence and to be treated with respect, kindness, and dignity.

Based on observation, interview, and document review, the facility failed to ensure ambulation interventions were implemented for 1 of 3 residents (R3) reviewed for falls. This resulted in actual harm for R3 who fell while ambulating in the hallway and sustained a head laceration requiring emergency medical care. The facility implemented corrective action prior to the investigation so the deficiency was issued at past noncompliance. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 had diagnoses of dementia, and had moderate cognitive impairment. The MDS also indicated R3 required supervision or touching assistance when ambulating. R3's care plan dated 4/14/23 indicated R3 required assistance of one staff and front wheeled walker. On 7/25/24 at 5:45 p.m., a progress note indicated R3 had a fall with bleeding at the back of her head. On 7/25/24, at 9:59 p.m., a progress note indicated R3 had a witnessed fall with a staff member in the hallway while walking to the dining room. R3 had shoes and a transfer belt. R3 reported weakness, lightheadedness, and feeling dizzy. The nursing assistant (NA)-A decided to get R3 her wheelchair, and saw R3 falling to the floor. R3 had laceration on the back of her head. R3 was lifted off the floor with a mechanical lift and three staff members. R3's range of motion to her extremities was normal. Staff cleansed the back of her head and began neuro checks. On 7/25/24 a note from the ER indicated R3 was treated for a 2 centimeter (cm) laceration to the posterior scalp with three staples. R3 had a head CT scan to rule out intracranial hemorrhage while in the emergency room and discharged back to the facility. Review of facility video surveillance footage on 7/25/24 showed NA-A and R3 as they walked out of room. A gait belt can be seen around R3's waist. R3 and NA-A took several steps together, then stopped. NA-A left R3 unattended in the hall and walked back into her room. R3 fell to left side to the floor in the hall as NA-A came out of the room with the wheelchair. The video did not include time stamps. On 7/29/24 a progress note indicated an interdisciplinary team (IDT ) review of the fall. Early evening 7/25/24 R3 experienced a fall during staff transfer assistance, which resulted in an injury to the back of her head. Emergency Medical Services (EMS) was contacted and R3 was brought to the emergency room (ER) for evaluation and treatment. She received three staples to the back of her head and returned to facility. On 7/31/24 at 3:03 p.m., licensed practical nurse (LPN)-A stated she was called on 7/25/24 just before 6:00 p.m. because R3 had fallen. Registered nurse (RN)-A told her the fall occurred in the hallway. Nursing assistant (NA)-A walked R3 out of her room, into the hallway with her walker. They stopped because R3 felt weak. NA-A walked away from R3 to get her wheelchair from her room, leaving her standing in the hallway with her walker. R3 then fell , NA-A should not have left R3 unattended related to her history of falls. On 8/1/24, at 9:13 a.m., NA-A stated she was working with R3 on 7/25/24, at 5:30 p.m., when R3 fell in the hallway. She was familiar with R3's care plan, and had reviewed R3's Kardex prior to providing cares, stating the Kardex is reflective of the resident's current care plan. The Kardex directed ambulation assist of one staff and a walker for R3. Once R3 walked out of her room into the hallway, she began to feel weak. She asked R3 if she wanted a wheelchair, and R3 stated she did. She knew she shouldn't have left R3 alone to get her wheelchair, but her coworkers were all in the dining room at the time, did not have a walkie talkie so she went into R3's room to get her wheelchair. As she came back into the hallway, she observed R3 fall. NA-A stated she was provided with re-education on 7/25/24, explained she should have remained in attendance with R3. NA-A stated she completed the mandatory re-education required by all staff in response to this incident and understands how to respond to a resident who becomes weak while ambulating. On 8/1/24 at 9:27 a.m., RN-B stated he became aware of the fall when he heard NA-A yell. He responded to the fall and assessed R3. He sent R3 into the ER for further medical treatment due to her head laceration. R3 had a history of falls, and should not have been left unattended. RN-B stated he participated in the required re-education in response to the this incident. RN-B stated staff are expected to remain with the resident at all times and call for help. On 8/1/24 at 10:43 a.m., RN-A stated NA-A should not have left R3 unattended, she should have called for help, keeping hold of the gait belt, and safely lowered R3 to the floor if she started to fall. Education was provided to NA-A immediately following the incident. RN-A stated she completed the mandatory re-education and understood the expectations to respond to a resident who became weak while providing assistance while ambulating. On 8/1/24, at 11:28 a.m., the director of nursing (DON) stated NA-A could have tried to yell for assistance or lowered R3 to the floor. NA-A was re-educated immediately following the incident. All nursing staff were educated over the following days. The facility Activities of Daily Living (ADLs) Policy and Procedure dated 3/15/21 directed based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. A resident will be given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following activities of daily living including mobility: transfer and ambulation, including walking. The re-education provided to all nursing staff, following the incident included the facility Procedure for Assisting a Weakening Resident During Ambulation to Prevent Falls directed: 1.Stay close and maintain support. 2. Communicate with the resident. 3. Guide to a safe position. 4. Supportive descent to the floor (if necessary). 5. Stay with the resident. 6. Call for help. 7. Document and report the incident. By following these steps, staff can help prevent injuries from fall and ensure the safety and well-being of resident during ambulation.

Based on observation, interview and document review, the facility failed to ensure food items were properly labeled and dated after packaging was opened. In addition, the facility failed to maintain a clean and sanitary kitchen area and failed to serve food in a sanitary and clean manner. This deficient practice had the potential to affect all 65 residents residing in the facility. Findings include: During an initial tour of the kitchen on 5/13/24 at 12:37 p.m., with registered dietician (RD)-A and kitchen supervisor (KS)-A the vegetable and fruit freezer were noted to have some multicolored, irregular shaped spills and crumbs on the bottom of the freezer covering a few inches in the front bottom area. In the meat freezer, a package of chicken patties was opened and undated. There was a box of breaded steaks three quarters full opened and undated. RD-A stated foods should have been dated when opened. There were three slices of garlic bread in a bag, opened and undated and a Styrofoam covered cup with straw not labeled and undated on the top shelf. RD-A indicated dietary manager (DM)-A should have been inspecting the kitchen, including the freezers, routinely. In the chest freezer, there was a bag of garlic bread opened, undated and about 12 breadsticks in a bag opened and undated. In the dry storage area, there were four plastic covered containers of dishes stored on the floor under the shelves. KS-A and RD-A stated they should not have been stored on the floor and identified those dishes were not being used at the time. Metal steam table containers were stored upside down on a shelf and one still had water drops on the inside. RD-A said she would have it re-run through the dishwasher. In front of a shelving unit storing bread, buns, and muffins, a metal fan covered with brown fuzzy substance on two thirds of the front and back was noted. RD-A picked up the fan, took it to a storage room and confirmed that it was very dirty and should not have been stored in the kitchen. A long metal table with clean food trays was stored next to the steam table. One of the trays had drops of water on it and another one had a red food crumb item on it. RD-A confirmed they were wet and soiled and removed them from the area. In the refrigerator in the main kitchen, there was a bag of shredded carrots opened and undated, a box of orange juice open and undated, ten small covered containers of tarter sauce undated and one container of beef base opened and undated. During an observation on 5/13/24 at 5:12 p.m., cook (CO)-A moved the cart with trays on it towards the steam table. CO-A was wearing gloves and serving brats with buns and other food items. CO-A was observed to touch paper meal tickets, trays, other utensils, handle the buns from the bag, place them onto the plates repeatedly without removing gloves, washing hands, or replacing gloves. On 5/14/24 at 4:11 p.m. a voice mail was left for CO-A for interview however, no return call was received. During an interview on 5/14/24 at 3:41 p.m., dietary manager (DM)-A confirmed boxes of dishes should not have been stored on the floor. DM-A stated it was the expectation that all foods would have been labeled and dated when opened and was important for food safety. DM-A stated it was expected staff used gloves for single use only and if they had to switch from using utensils and other food items; they should change gloves, wash hands and put on new gloves before touching foods. DM-A stated he had just reviewed hand hygiene and glove use a week ago with dietary staff. DM-A stated proper infection control techniques were important for residents' health and to prevent food born illness. DM-A stated multiple people could have been touching those meal slips and the cooks should not touch them prior to touching the foods. DM-A stated dietary aides should have placed the meal slips on the trays. Review of the facility policy titled Basics For Handling Food Safety, undated, identified safe steps in food handling, cooking, and storage were essential to prevent foodborne illness. In every step of food preparation, follow the four steps of the Food Safe Families campaign to keep safe, which included: clean- wash hands and surfaces often, separate-don't cross-contaminate, cook-to the right temperature, and chill-refrigerate promptly. The facility policy titled Handwashing, undated, identified keeping hands clean through improved hand hygiene was one of the most important steps we could take to avoid getting sick and spreading germs to others. The policy included when hands were to be washed, which included: before, during and after preparing foods, before switching from one to a different food prep task, before each meal service, and before handling food for service.

Based on interview and document review, the facility failed to submit complete and accurate data for staffing information based on payroll during Quarter 1 (October 1-December 31, 2023) to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This deficient practice had the potential to affect all 66 residents residing in the facility. Finding includes: Review of the Payroll-Based Journal Report (PBJ) [NAME] report 1705D identified the Quarter 1 from 10/1/23-12/31/23, identified excessively low weekend staffing. 10/14/23 was identified for low weekend staffing. During an interview on 5/14/24 at 1:15 p.m., the administrator stated the director of human resources (DHR) director submitted the PBJ. The administrator provided copies of staff timecard punches for the weekends. Review of the facility schedules and time cards from 10/1/23 to 12/31/23, revealed the following: Nursing assistant(NA)-C was scheduled for a three-hour shift on 10/14/23. NA-C worked a total of 6.25 hours according to her timesheet. NA-C worked from 1:45 p.m. to 8:30 p.m. LPN-B was not on the schedule to work according to the schedule. According to her time card punches, LPN-B worked a total of eight hours from 6:30 a.m. to 3:00 p.m. A review of the facility's staffing schedules and timecards identified discrepancies with the facility schedules, time cards, and the PBJ report. During an interview on 5/14/24 at 4:29 p.m., the director of human resources (DHR) stated the process for submitting the PBJ included the cooperate office running a spreadsheet and then sending it to the DHR. The DHR added data to the spreadsheet and then sent the spreadsheet back to cooperate. DHR reported weekend staffing consisted of four to six nursing assistants. The number of nursing assistants depended on the facility's census. The facility scheduled two nurses on the night shift and three nurses on the day shift. During a follow-up interview on 5/14/24 at 5:56 p.m., DHR verified an inaccuracy with the schedule compared to the time card punches for two staff NA-C, and LPN-B on 10/14/23.

Based on observation, interview and document review, the facility failed to ensure an environment that was free of accident hazards, related to hot water temperatures in 5 of 5 resident bathrooms and the sink at the eye wash station tested for safe water temperatures. This deficient practice had the potential to affect 4 residents who were independent with mobility on the memory care unit and 2 residents on the main units. Findings include: On 5/13/24 at 1:30 p.m., during a resident screening the water temperature in R 29's room [ROOM NUMBER] bathroom felt very hot to the touch after running water for only a few minutes. On 5/13/24 at 1:36 p.m., the sink at the eye wash station in the memory care unit felt very hot after running the water briefly. On 5/13/24 at 1:55 p.m., maintenance director (MD) verified the water in R29's room and at the eye wash station felt too hot and used a thermometer to measure the water temperatures using the facility thermometer in several other resident bathrooms they were as follows: -Memory Care eye wash station sink was 123 degrees Fahrenheit (F) - MD verified these temperature were too hot and had the potential to cause a burn. -RB 102 was 122 degrees F. -RB 118 was 121 degrees F. -RB 119 was 122 degrees F. -RB 152 was 131 degrees F. -RB 157 was 130 degrees F. During an interview 5/13/24 at 2:05 p.m., licensed practical nurse (LPN)-A verified there were four residents who were independent with mobility on the memory care unit who had the potential to turn on the above sinks. During an interview on 5/13/24 at 2:33 p.m., MD stated he had not been checking any of the water temperatures and was not aware they were running hot. MD stated water temperatures should remain between 110 degrees F and 120 degrees F because any water temperatures above 120 degrees F had the potential to burn someone. During a resident council meeting on 5/15/24 at 10:21 a.m., R37 stated the water from her bathroom had recently felt warm when the staff were providing her personal cares. During an interview on 5/15/24 at 11:00 a.m., administrator stated his expectation was that the water temperatures would remain within the State and Federal guidelines. Review of a facility document titled Water Management Program dated 5/18/22, identified federal guidelines advise water temperatures to be kept below 120 degrees F. Indicated resident rooms at the end of wings should have been routinely checked for water temperatures as well as common area bathrooms and any other areas having sinks should have been checked and temperatures recorded.

Based on observation, interview and document review, the facility failed to ensure donning/doffing of personal protective equipment (PPE) was performed in order to prevent the spread of infection for 1 of 15 residents (R36) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) In addition, the facility failed to identify and ensure implementation of EBP for 14 of 15 residents (R3, R6, R18, R22, R26, R30, R36, R38, R47, R62, R115, R116, R266, R268) observed for EBP. Further, the facility failed to ensure personal laundry was transported and delivered in a manner that prevented risk of contamination for and hand hygiene was completed as required during observation for linen transportation for 3 of 5 hallways. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. Review of CDC guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) which include a gown and gloves in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated when performing high contact resident care activities with any resident with an Infection or colonization with an MDRO when Contact Precautions do not otherwise apply or has Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status any residents Examples of high-contact resident care activities requiring gown and glove use for EBP include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. ENHANCED BARRIER PRECAUTIONS AND PPE USE R36's R36's significant change Minimum Data Set (MDS) dated [DATE], identified R36 had severe cognitive impairment and had diagnoses which included: hypertension (elevated blood pressure) Benign Prostatic Hyperplasia (condition in men where the prostate gland is enlarged), and traumatic brain injury. Identified R36 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and personal hygiene. R36's care plan revised 5/2/24, identified R36 had a urinary catheter (a medical device that helps drain urine from the bladder). Instructed staff to change urinary catheter as ordered. R36's Order Summary Report dated 5/2/24 identified R36 had a urinary catheter and directed staff to change the catheter monthly. During an observation on 5/13/24 at 5:41 p.m., there was no identification R36 who had a urinary catheter, was in EBP. In addition, there was no PPE located near R36's room for staff to wear when performing high contact care activities for R36. During an observation on 5/15/24 at 7:05 a.m., there was a small bin on the floor outside R36's room which contained hand sanitizer gloves and masks. There was also a sign on R36's door that said Enhanced Barrier Precautions; Everyone Must clean their hands, including before entering and when leaving the room. Wear gloves and gown for the following high contact resident activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. In addition, the sign contained a picture of hand sanitizer gown, and gloves. During an observation on 5/15/24 at 7:06 a.m., R36 was lying in bed and nursing assistant (NA)-A and NA-B turned R36 back and forth to place a hoyer lift sheet under R36. NA-A wore a gown and gloves and NA-B only wore gloves during the high contact activity. NA-A and NA-B proceeded to hook R36 up to the hoyer lift and placed R36 into his wheelchair. NA-A and NA-B stood within an inch of R36 during the hoyer lift transfer. NA-A removed her gown and gloves and sanitized her hands and NA-B removed her gloves and sanitized her hands. During an interview on 5/15/24 at 7:10 a.m., NA-B verified the only PPE she had worn while transferring R36 into his wheelchair were gloves. NA-B stated she had asked a nurse for a gown since there were none in the bin however, had not received a gown prior to transferring R36 into the wheelchair. NA-B indicated she was not familiar with EBP and had not received any clear education on what PPE was required while caring for a resident on EBP. 49620 HAND HYGIENE During an observation on 5/14/24 at 4:22 p.m., dietary aide (DA)-A passed empty drink glasses in the dining room to all tables. DA-A took each glass from the dining cart and flipped them over touching the top of the glass with his bare hands and placing the glass onto each designated area for the residents at the tables. DA-A touched the top of the glasses with the palm of his hand and his fingers. During an interview on 5/14/24 at 4:31 p.m., DA-A verified he had touched the top of the glasses with his bare hands when removing them from the dining cart. DA-A stated he should have touched only the bottom area of the glasses to prevent the possible spread of germs. LAUNDRY/ HAND HYGIENE During an observation on 5/14/24 at 2:29 p.m., nursing assistant (NA)-D pushed the laundry cart down the hallway uncovered and delivered laundry to R268's room. Visitors were observed to walk past the uncovered cart. NA-D proceeded to deliver laundry to R62's room, knocked on R267's door and delivered laundry to R267. NA-D delivered laundry to R56's room and R266's room. NA-D pushed the uncovered laundry cart down the hall past visitors and staff, knocked on R265's door and delivered laundry to R265. NA-D delivered laundry to R6's room, R27's room and R40's room. NA-D knocked on R26's door, delivered laundry to R26, knocked on R12's door and delivered laundry to R12. NA-D did not sanitize her hands and the cart remain uncovered during the entire laundry pass observation. During an interview on 5/14/24 at 2:29 p.m., NA-D verified the laundry cart should have been covered to prevent cross-contamination of germs from others and stated she should have sanitized her hands in between resident rooms to prevent the spread of germs. During an observation on 5/15/24 at 8:26 a.m., housekeeper (H)-A delivered laundry to R26's room H-A exited R26's room with used hangers and hung on the laundry cart. The laundry cart was observed to be partially covered with a blanket on half of the cart. Visitors and residents were observed to go past the uncovered cart. The blanket was observed to fall onto the floor, H-A picked the blanket up and again covered half of laundry in the cart. H-A delivered laundry to R23's room, hung clothing in R23's closet and exited R23's room with used hangers and hung hangers on the laundry cart. H-A delivered laundry to R35's room. H-A knocked on R5's door, opened R5's closet door, hung clothing in closet, removed hangers and placed on cart. H-A delivered laundry to R46's room and placed in R46's closet. H-A brought laundry cart into R4's room, opened closet door and hung laundry in R4's closet, removed hangers and placed on cart. The laundry cart remained partially covered and H-A was not observed to sanitize her hands during the entire observation. During an interview on 5/15/24 at 8:34 a.m., H-A verified she did not sanitize her hands during the entire laundry pass observation. H-A stated she only touched the door handles and did not feel she needed to sanitize her hands. H-A stated she was unaware of the laundry pass policy on sanitizing hands and keeping the cart completely covered. ENHANCED BARRIER PRECAUTIONS R3 R3's significant change MDS dated [DATE], identified R3 had no cognitive impairment and had diagnoses which included type two diabetes, anxiety, chronic kidney disease, paranoid schizophrenia, obesity, non-pressure chronic ulcer of skin of other sites with fat layer exposed. Identified R3 required substantial assistance with ADL's which included bed mobility, transfers, and personal hygiene. R3's care plan revised 3/1/24, identified R3 had a moisture associated skin damage to her left thigh. Staff to administer treatments as ordered. R3's Order Summary Report dated 5/16/24, identified R3 had a left medial thigh wound. Staff were to cleanse with wound cleanser, pat dry, apply medihoney to wound bed, cover with four by four dressing with silicone border foam dressing. Change every three days and as needed if soiled or dressing fell off. During an observation on 5/13/24 at 5:45 p.m., there was no identification R3 who had a wound, was in EBP. In addition, there was no PPE located near R3's room for staff to wear when performing high contact care activities for R3. R62 R62's admission MDS dated [DATE], identified R62 had no cognitive impairment and had diagnoses which included displaced fracture of right tibia, depression, fusion of spine. Identified R62 required supervision with activities of ADL's which included bed mobility, transfers, and personal hygiene. R62's care plan revised 3/22/24, identified R62 had an alteration in skin integrity related to surgical incisions. Staff to administer treatments as ordered. R62's Order Summary Report dated 5/16/24, identified R62 had a surgical incision. Staff to monitor incisions to right ankle every day and evening shift. During an observation on 5/13/24 at 5:45 p.m., there was no identification R62 who had a surgical incision, was in EBP. In addition, there was no PPE located near R62's room for staff to wear when performing high contact care activities for R62. R115 R115's admission MDS dated [DATE], identified R115 had no cognitive impairment and had diagnoses which included aftercare following artificial hip joint replacement, bipolar disorder, chronic kidney disease, depression. Identified R115 required moderate assistance with ADL's which included bed mobility, transfers, and personal hygiene. R115's care plan revised 5/11/24, identified R115 had an alteration in skin integrity related to surgical incision to right hip and cellulitis. Staff to administer treatments as ordered. R115's Order Summary Report dated 5/16/24, identified R115 had a surgical incision to right hip. Document status in progress note every shift. During an observation on 5/13/24 at 5:45 p.m., there was no identification R115 who had a surgical incision, was in EBP. In addition, there was no PPE located near R115's room for staff to wear when performing high contact care activities for R115. R268 R268's admission MDS dated [DATE], identified R268 had no cognitive impairment and had diagnoses which included aftercare following surgical amputation of both lower extremities below the knee, type two diabetes, hypertension. Identified R268 required extensive assistance with ADL's which included bed mobility, transfers, and personal hygiene. R268's care plan revised 5/9/24, identified R268 had an alteration in skin integrity related to surgical incision to bilateral lower extremities. Staff to administer treatments as ordered. R268's Order Summary Report dated 5/16/24, identified R268 had a surgical incision to bilateral lower extremities. Monitor incisions every shift. During an observation on 5/13/24 at 5:45 p.m., there was no identification R268 who had a surgical incision, was in EBP. In addition, there was no PPE located near R268's room for staff to wear when performing high contact care activities for R268. R22 R22's admission change MDS dated [DATE], identified R22 had no cognitive impairment and had diagnoses which included depression, other symptoms and signs involving the musculoskeletal system, hallucinations, post-polio syndrome, chronic obstructive pulmonary disease. Identified R22 required total assistance with ADL's which included bed mobility, transfers, and personal hygiene. R22's care plan revised 4/4/24, identified R22 had an alteration in skin integrity related to pressure injury to right and left buttocks. Staff to administer treatments as ordered. R22's Order Summary Report dated 5/16/24 identified R22 had wound care. Apply thin layer of barrier ointment or paste to buttocks and gluteal folds twice a day. During an observation on 5/13/24 at 5:45 p.m., there was no identification R22 who had a pressure injury, was in EBP. In addition, there was no PPE located near R22's room for staff to wear when performing high contact care activities for R22. R266 R266's admission MDS dated [DATE], identified R266 had severe cognitive impairment and had diagnoses which included displaced fracture of left and right femur, hypertension, type two diabetes, dementia. Identified R266 required extensive assistance with ADL's which included bed mobility, transfers, and personal hygiene. R266's care plan revised 5/3/24, identified R266 had an alteration in skin integrity related to surgical incisions to left and right hip. Staff to administer treatments as ordered. R266's Order Summary Report dated 5/16/24, identified R266 had a surgical incision to right hip. Check on wound dressings to right and left hips every shift to ensure dressings are in place. Replace dressings as needed if dressing missing or not adhered every shift. During an observation on 5/13/24 at 5:45 p.m., there was no identification R266 who had a surgical incision, was in EBP. IN addition, there was no PPE located near R266's room for staff to wear when performing high contact care activities for R266. R116 R116's admission MDS dated [DATE], identified R116 had no cognitive impairment and had diagnoses which included infection due to internal right knee prosthesis, depression, schizoaffective disorder, non-pressure chronic ulcer of skin of other sites. Identified R116 required total assistance with ADL's which included bed mobility, transfers, and personal hygiene. R116's care plan revised 5/14/24, identified R116 had an peripherally inserted central catheter line (PICC) a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the resident's heart. A PICC line is used to get medication treatments over a period of time. R116's care plan revised 5/8/24, identified R116 had an alteration in skin integrity related to surgical site to right knee. Staff to administer treatments as ordered. R116's Order Summary Report dated 5/16/24, identified R116 had a PICC line to be monitored for signs of infection and infiltration every shift and a surgical incision to right knee. Document status in progress note every shift. During an observation on 5/13/24 at 5:45 p.m., there was no identification R116 who had a surgical incision, was in EBP. In addition, there was no PPE located near R116's room for staff to wear when performing high contact care activities for R116. R26 R26's quarterly MDS dated [DATE], identified R26 had severe cognitive impairment and had diagnoses which included dementia, chronic kidney disease, acute kidney failure. Identified R26 required total assistance with ADL's which included bed mobility, transfers, and personal hygiene. R26's care plan revised 5/11/24, identified R26 had a urinary catheter (a medical device that helps drain urine from the bladder). Instructed staff to change urinary catheter as ordered and an alteration in skin integrity related to pressure injury. Staff to administer treatments as ordered. R26's Order Summary Report dated 5/16/24, identified R26 had a urinary catheter and directed staff to change the catheter monthly and a wound. Apply bordered foam to bilateral buttocks and left hip every three days and as needed. Wound care to right heel-cleanse with soap and water. Cover with silicone/mepilex foam dressing. Change every three days and as needed. During an observation on 5/13/24 at 5:45 p.m., there was no identification R26 who had a urinary catheter and a pressure injury, was in EBP. In addition, there was no PPE located near R26's room for staff to wear when performing high contact care activities for R26. R47 R47's quarterly MDS dated [DATE], identified R47 had severe cognitive impairment and had diagnoses which included dementia, quadriplegia, congestive heart failure. Identified R47 required total assistance with ADL's which included bed mobility, transfers, and personal hygiene. R47's care plan revised 2/26/24, identified R47 had an alteration in skin integrity related to moisture associated skin damage to sacrum and an arterial wound to right fifth toe. Staff to administer treatments as ordered. R47's Order Summary Report dated 5/16/24, identified R47 had wound care orders for left fifth toe-cleanse with soap and water. Apply skin prep to scabbed areas two time a day. Wound care orders for sacrum-cleanse with wound cleanser. Apply Calmoseptine cream to open area two times a day. During an observation on 5/13/24 at 5:45 p.m., there was no identification R47 who had a surgical incision, was in EBP. In addition, there was no PPE located near R47's room for staff to wear when performing high contact care activities for R47. R30 R30's significant change MDS dated [DATE], identified R30 had moderate cognitive impairment and had diagnoses which included dementia, muscle wasting and atrophy unspecified, adult failure to thrive, hypertension. Identified R30 required total assistance with ADL's which included bed mobility, transfers, and personal hygiene. R30's care plan revised 3/14/24, identified R30 had an alteration in skin integrity related to moisture associated skin damage to left rear thigh. Staff to administer treatments as ordered. R30's Order Summary Report dated 5/16/24, identified wound care to right and left rear thighs-cleanse with soap and water. Apply Calmoseptine cream to open areas two times a day. During an observation on 5/13/24 at 5:45 p.m., there was no identification R30 who had a surgical incision, was in EBP. In addition, there was no PPE located near R30's room for staff to wear when performing high contact care activities for R30. R38 R38's significant change MDS dated [DATE], identified R38 had moderate cognitive impairment and had diagnoses which included neuromuscular dysfunction of bladder, chronic kidney disease, type two diabetes, dementia, unspecified open wound of lower leg. Identified R38 required total assistance with ADL's which included bed mobility, transfers, and personal hygiene. R38's care plan revised 4/21/23, identified R38 had a urinary catheter (a medical device that helps drain urine from the bladder). Instructed staff to change urinary catheter as ordered. R38 had a pressure ulcer to right heal and sacrum. Staff to administer treatments as ordered. R38's Order Summary Report dated 5/16/24, identified R38 had a urinary catheter and staff to change monthly. Wound care to right heel-cleanse with wound cleanser, apply calcium Alginate with silver to wound bed. Cover with dressing and wrap with kerlix every shift. Wound care to sacrum-cleanse with soap and water, apply triad paste two times a day. During an observation on 5/13/24 at 5:45 p.m., there was no identification R38 who had a surgical incision, was in EBP. In addition, there was no PPE located near R38's room for staff to wear when performing high contact care activities for R38. R6 R6's significant change MDS dated [DATE], identified R6 had no cognitive impairment and had diagnoses which included open wound of abdominal wall, complications of amputation stump, acquired absence of right and left below knee amputation, fetal alcohol syndrome, depression. Identified R6 required extensive assistance with ADL's which included bed mobility, transfers, and personal hygiene. R6's care plan revised 4/11/24, identified R6 had an alteration in skin integrity related to left buttock pressure injury, sacrum pressure injury and gluteal fold moisture. Staff to administer treatments as ordered. R6's Order Summary Report dated 5/16/24, identified R6 had wound care to left buttock-cover with mepilex border dressing, this may stay on for one week as needed and change dressing every Monday. Wound care to sacrum-cleanse with wound cleanser, apply Calazime paste, Purscol Plus dressing, exufiber into ulcer fold and change daily and as needed. During an observation on 5/13/24 at 5:45 p.m., there was no identification R6 who had a surgical incision, was in EBP. In addition, there was no PPE located near R6's room for staff to wear when performing high contact care activities for R6. During an observation on 5/15/24 at 7:05 a.m., there were no enhanced barrier precautions in place outside of R266's room or a sign posted on the door. R18 R18's annual MDS dated [DATE], identified R18 had moderate cognitive impairment and had diagnoses which included dementia, gastrostomy status, adjustment disorder with depressed mood. Identified R18 required extensive assistance with ADL's which included bed mobility, transfers, and personal hygiene. R18's care plan revised 1/14/24, identified R18 had a gastrostomy tube (a surgically placed device in the abdomen used to give direct access to the stomach for supplemental feeding, hydration or medicine) with moisture associated skin damage to gastrostomy tube site. Staff to assess skin integrity weekly. Staff to provide tube feeding as ordered. R18's Order Summary Report dated 5/16/24, identified R18 had a gastrostomy tube feed order to administer one carton TwoCal HN three times a day and flush with water three times a day. Calmoseptine to tube site three times a day. During an observation on 5/13/24 at 5:45 p.m., there was no identification R18 who had a surgical incision, was in EBP. In addition, there was no PPE located near R18's room for staff to wear when performing high contact care activities for R18. During an interview on 5/15/24 at 3:49 p.m., director of nursing (DON) confirmed her expectation that staff would not touch the area of a drinking glass with their bare hands due to possible contamination and could result in residents becoming ill. DON verified her expectation was staff would sanitize their hands in between resident rooms to prevent the spread of germs and the laundry cart would remain covered to prevent cross-contamination. Review of a facility policy titled Handling Linens and Laundry Policy revised 1/16/23, indicated laundry should have been packaged, transported and stored in a manner that ensured cleanliness and protected the laundry from dust and soil. Clothing was to be taken out of cart and covered again while unattended in the hallways. Laundry staff were to sanitize hands on the way out of the resident room. Review of a facility policy titled Hand Hygiene Policy revised 1/16/23, indicated staff would utilize hand washing and hygiene techniques to aid in the prevention of the transmission of infections. During an interview on 5/15/24 at 2:10 p.m., infection prevention nurse (IP) stated she had not been aware CDC made recommendations for EBP. IP indicated the facility was training staff about EBP beginning that day. IP stated EBP was important to prevent the spread of infections. During a follow-up interview on 5/15/24 at 3:49 p.m., DON verified EBP had not been implemented for residents per CDC recommendations. DON stated her expectations were staff would utilize EBP and PPE per recommendations.

Based on observation, interview, and document review, the facility failed to ensure timely assistance with repositioning and failed to implement care planned interventions for 1 of 4 resident (R26) with current pressure ulcers and at risk for further development of pressure ulcers. Findings include: R26's quarterly Minimum Data Set (MDS), dated [DATE], identified R26 had diagnoses which included cognitive impairment, hypertension,dementia and anxiety. R26 required total assistance of two staff for bed mobility and transfers. Indicated R26 was a risk for pressure ulcers, currently had an unhealed pressure ulcer in foot. R26's comprehensive Care Area Assessment (CAA), dated 2/14/24, identified R26 was at risk for skin breakdown and potential pressure ulcers due to requiring total assistance with bed mobility. R26's care plan revised on 5/15/24, identified R26 had actual complications with impaired skin integrity related to a pressure ulcer on the right heel. Indicated R26 was to have heel protectors on while in bed and staff were to reposition every two hours. R26 was dependent on staff for all cares. Special air mattress to bed to relieve pressure. Check each shift to make sure pressure was correct. During an observation on 5/14/24 at 2:43 p.m., R26 was laying in bed without heel protectors on, heels rested on the mattress and the air mattress for the bed was off. During an observation on 5/14/24 at 3:56 p.m., R26 was laying in bed without heel protectors on, heels rested on the mattress and the air mattress for the bed was off. During continuous observations on 5/15/24 from 7:04 a.m. to 10:25 a.m., revealed the following: -R26 was seated in wheelchair (Broda chair-specialized tiltable wheelchair) at area near nurses desk. -R26 was seated in the dining room being assisted with breakfast. R26's feet rested on wheelchair foot pad. - R26 continued to be in the same position. R26 was seated at the dining room table talking with other residents. - R26 was pushed back to area by nurses station. - R26 continued to sit in her wheelchair by the nurses station. - R26 continued to sit in her wheelchair in the same location by the nurses station. - R26 continued to sit in her wheelchair in the same location by the nurses station. - R26 continued the same position and in the same location. - R26 continued the same position and in the same location. - At 10:22 a.m., infection preventionist (IP) and licensed practical nurse (LPN)-D assisted R26 to lay down in bed when prompted by surveyor. R26 was covered with a blanket. R26 had not been offered to reposition every two hours as directed by her care plan. R26 had not been offered to be or repositioned for a total of three hours and 21 minutes during the entire observation. During an interview on 5/15/24 at 2:00 p.m., nursing assistant (NA)-F identified staff completed all activities of daily living (ADLs) for R26. NA-F stated R26 was to be transferred with two people and the hoyer lift. NA-F stated R26 required total assistance with turning and repositioning. NA-C indicated she was unaware of the order to place heel protectors on R26's heels while in bed. NA-F stated R26 did not have heel protectors on when NA-F assisted R26 out of bed that morning. NA-F was unaware if R26 had a special air mattress to her bed. During an interview on 5/15/24 at 10:28 a.m., IP indicated staff were expected to reposition R26 every two hours. IP reviewed and confirmed the above orders for R26. IP explained R26 had a wound on her right heel that staff were to complete dressing changes and to monitor. IP confirmed R26 was laying on her right side and did not have heel protectors on R26's heels. IP was unaware the special air mattress was not on and attempted to turn it on. The air mattress did not turn on and IP indicated she would change it out when R26 was assisted up for lunch in a few hours. IP was not aware R26 had been sitting in the same position since 7:04 a.m. IP did not place heel protectors on R26. IP indicated her expectations were staff would reposition residents every two hours and were to follow the provider's orders along with resident's care plans. During an interview on 5/15/24 at 3:41 p.m., director of nursing (DON) was not aware R26 had not been repositioned within two hours. DON confirmed the above findings and explained R26 should not have experienced prolonged sitting. DON indicated staff should have placed heel protectors on R26 while in bed. DON stated her expectations were staff would be following providers orders and if staff were unable to complete the orders they would inform the DON or charge nurse. Review of facility policy titled Turning and Repositioning dated 8/1/15, would be to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. Indicated dependent residents would be turned every two hours. Float the heels off the bed if the resident is at risk for heel breakdown.

Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for 1 of 4 residents (R54) who had a soiled wet shirt reviewed for dignity. Findings include: R54's quarterly Minimum Data Set, dated dated dated (MDS) 4/11/24, identified R54 was cognitively intact and had diagnoses which included: quadriplegia (paralysis that affects both arms and legs) and traumatic brain injury. Identified R54 was dependent on staff for dressing, bathing and personal hygiene. R54's care plan revised 1/8/24, identified R54 had activities of daily living (ADL) self-care performance deficit related to quadriplegia, morbid obesity, weakness, and dependency on staff. Interventions included assist of one for dressing and dependence for personal hygiene. During an observation and interview on 5/14/24 at 9:17 a.m., R54 was seated in his electric wheelchair in the therapy room. R54 had an irregular shaped wet and brown soiled area on his shirt by the neckline approximately 3-4 inches in diameter. R54 used a communication board during interview, and indicated it bothered him and made him feel uncomfortable that his shirt was soiled and wet. R54 stated he used a towel at home to keep his shirt clean and dry. During an observation on 5/14/24 at 4:22 p.m., R54 continued to have the wet soiled area on his shirt, which appeared larger now, approximately 4-5 inches in diameter. At 5:57 p.m. R54 was seated in his wheelchair in the dining room, now wearing a clothing protector however, was wearing the same shirt. During an interview on 5/14/24 at 6:01 p.m., nursing assistant (NA)-H indicated she had not completed any cares for R54 yet, however, had seen him sitting in the dining room watching television. NA-H stated she had not noticed R54's shirt was soiled and wet and would check him after the supper meal was over. NA-H stated R54 drooled at times, and would have a little wetness on his shirt as a result and if it was a larger spot they would change his shirt. NA-H stated a visibly soiled shirt would affect R54's dignity. During a follow up interview on 5/15/24 at 2:04 p.m., NA-H stated R54's shirt was wet and soiled yesterday evening and it appeared to be from drool and chocolate pudding or something similar. NA-H stated she had asked R54 if he wanted his shirt changed and R54 stated he wanted his night gown put on at that time. NA-H stated if she had observed it sooner, she would have asked him if they could change his shirt. During an interview on 5/15/24 at 2:00 p.m., clinical manager registered nurse (RN)-B stated R54 had quadriplegia and communicated with a communication board. RN-B indicated R54 was cognitively intact. RN-B stated if R54's shirt became soiled, she would expect musing staff to change the shirt right away for R54's dignity and comfort. During an interview on 5/15/14 at 2:24 p.m., interim director of nursing (IDON) stated her expectations were if a resident's shirt was soiled or wet, she would expect nursing staff to change it. IDON stated it was important to complete that task in order to maintain a resident's dignity. Review of facility policy titled Resident Rights: Dignity revised 10/24/23, identified the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

Based on observation, interview and document review, the facility failed to ensure housekeeping services were provided for a clean environment for 1 of 2 residents (R115) who had a soiled privacy curtain and floor. Findings include: R115's admission Minimum Data Set (MDS) dated [DATE], identified R115 was cognitively intact and had diagnoses which included anxiety, depression, hip and ankle replacement, and aftercare following joint replacement surgery. During an observation and interview on 5/13/24 at 6:58 p.m., R115 indicated her family was unhappy because her room was filthy. R115 pointed to the privacy curtain which had brown smears and spots covering eight to 10 inches across the bottom center of the curtain. In addition, R115 indicated the floor was not cleaned often and the cupboards needed to be wiped down. R115's floor had dust, crumbs, plastic medication cups and a wadded paper towel under her bed. A drip/spill was noted on the outside of her wardrobe closet. R115 said it had been four to five days since they mopped her floor and indicated they did not mop under the bed. During an observation on 5/14/24 at 2:32 p.m., R115 was lying in her bed, and stated her room was still dirty and the curtain was gross. Areas of dark brown spots and smears continued to be present on the bottom portion of the privacy curtain. R115's floor continued to have dust, crumbs, plastic medication cups and a wadded paper towel under the bed. During an interview on 5/14/24 at 2:37 p.m., housekeeper (HSK)-B indicated her usual practice for resident room cleaning included wiping down handles, bathroom, main area, to sweep and mop the room, including under the bed. HSK-B stated when a curtain was noted to be soiled, they would take them down and replace them. HSK-B observed R115's room, confirmed the curtain was soiled and verified the floor was not clean under the bed. HSK-B said it appeared it had been at least a couple of days since staff had swept under the bed. During an interview on 5/14/24 at 2:52 p.m., housekeeping lead (HSKL) indicated when a floor appeared to be clean then her usual practice was to sweep and mop the floor once or twice a week. HSKL indicated her expectations for cleaning the floors included to move the bed and sweep and mop under the beds as well. HSKL indicated the facility's usual practice was to remove and replace the privacy curtain once a resident moved out, during a turn over, (a deep cleaning of the room), such as when R115 would move out of her room. HSKL stated she would expect the curtain to be taken down if it became soiled. HSKL indicated she was unaware if R115's privacy curtain had been changed prior to her moving into the room. During a follow up interview on 5/15/24 at 10:09 a.m. R115 stated her curtain was soiled when she arrived at the facility, and indicated she had tried to stay away from it, yuck. R115 said she noticed her floor dirty under her bed a day or two after she arrived. R115 said she was concerned about all the dust, that it may affect her breathing. R115 said there were three to four people in her room yesterday cleaning it and her privacy curtain had been changed. The facility policy titled Cleaning A Resident Room revised 5/8/24, procedures included: wash closets/wardrobe-inside and out, thoroughly mop entire floor with approved cleaning solution (under furniture, behind doors, along baseboards). The facility form titled Deep Clean Sheet, undated, tasks included: move bed and furniture to sweep & mop underneath, wipe out nightstands, closets and dressers, and check privacy curtain for stains (remove if dirty and send to wash).

Based on observation, interview and document review, the facility failed to change soiled clothing for 1 of 3 residents (R54) reviewed for activities of daily living (ADL's). In addition, the facility failed to remove facial hair for 1 of 3 residents (R36) who was dependent on staff for assistance with grooming and personal hygiene. Findings include: R54's quarterly Minimum Data Set (MDS) dated [DATE], identified R54 was cognitively intact and had diagnoses which included: quadriplegia (paralysis that affects both arms and legs) and traumatic brain injury. Indicated R54 was dependent on staff for dressing, bathing and personal hygiene. R54's care plan revised 1/8/24, identified R54 had an ADL self-care performance deficit related to quadriplegia, morbid obesity, weakness and dependency on staff. Interventions included assist of one for dressing and dependent for personal hygiene. During an observation and interview on 5/14/24 at 9:17 a.m., R54 was seated in his electric wheelchair in the therapy room. R54 had an irregular shaped wet and brown soiled area on his shirt by the neckline approximately three to four inches in diameter. R54 used a communication board during interview, and indicated it bothered him and made him feel uncomfortable that his shirt was soiled and wet. R54 stated he used a towel at home to keep his shirt clean and dry. During an observation on 5/14/24 at 4:22 p.m., R54 continued to have the wet soiled area on his shirt, which appeared larger, approximately four to five inches in diameter. At 5:57 p.m., R54 was seated in his wheelchair in the dining room, now wearing a clothing protector, however continued to wear the same shirt. During an interview on 5/14/24 at 6:01 p.m., nursing assistant (NA)-H indicated she had not completed any cares for R54 yet. NA-H stated she had not noticed R54's shirt was soiled and wet, however would check him after the supper meal was over. NA-H stated R54 drooled at times,would have a little wetness on his shirt however, if it was a larger spot they would change his shirt. During a follow up interview on 5/15/24 at 2:04 p.m.,NA-H stated R54's shirt was wet and soiled yesterday evening and it appeared to be from drool and chocolate pudding or something similar. NA-H stated she had asked R54 if he wanted his shirt changed and R54 stated he wanted his night gown put on at that time. NA-H stated if she had noticed it sooner, she would have asked him if they could change his shirt. During an interview on 5/15/24 at 2:00 p.m., clinical manager registered nurse (RN)-B stated R54 had quadriplegia and communicated with a communication board. RN-B stated R54 was cognitively intact. RN-B indicated if R54's shirt was soiled, she would expect staff to change it right away. 45844 R36 R36's significant change MDS dated [DATE], identified R36 had severe cognitive impairment and had diagnoses which included hypertension (elevated blood pressure) Benign Prostatic Hyperplasia (condition in men where the prostate gland is enlarged), and traumatic brain injury. Identified R36 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and personal hygiene. R36's current care plan last revised 8/22/23, indicated R36 had deficits with ADL's related to weakness and impaired cognition. Indicated R36 required staff assist with personal hygiene. R36's significant change Care Area Assessment (CAA) dated 3/25/24, identified R36 was dependent on staff for ADL's. During an observation on 5/13/24 at 2:30 p.m., R36 was lying in bed and had several gray one inch long facial hairs present on his cheeks, chin and above his lips. During an interview on 5/13/24 at 2:39 p.m., family member (FM)-A stated R36 preferred to have a mustache however, always shaved the rest of his face every day. FM-A stated at times someone in the family would shave R36 at the facility because his facial hair was long. During an observation on 5/14/24 at 8:03 a.m., R36 was seated in his wheelchair in the dining room. R36 continued to have several gray one inch long facial hair present on his cheeks and on his chin. During an interview on 5/14/24 at 8:16 a.m., nursing assistant (NA)-A stated R36 required staff assistance to shave facial hair. NA-A stated she had assisted R36 with cares that morning however, had not offered to assist R36 with shaving and was unsure of the last time R36 had been shaved. During an interview on 5/14/24 at 8:20 a.m., licensed practical nurse (LPN)-A stated R36 required staff assistance to shave facial hair. LPN-A verified R36 had several long facial hairs present and was unsure of when the last time R36 had been shaved. LPN-A stated her expectation was that staff would have shaved R36 daily or when facial hair was present. During an interview on 5/14/24 at 4:44 p.m., interim director of nursing (IDON) indicated R36 required staff assistance with shaving. IDON stated her expectation was R36 would have been shaved daily or when facial hair was present. During an interview on 5/15/14 at 2:24 p.m., IDON stated her expectations were if a resident's shirt was soiled or wet, staff would change it. Review of a facility policy titled Activities of Daily Living (ADL's) dated 3/15/21, indicated the facility would provide care and services such as hygiene, bathing, dressing, and grooming. Indicated ADL's would be provided based on resident preferences.

Based on observation, interview and document review, the facility failed to provide hand splinting and range of motion (ROM) services to prevent a potential decrease in ROM for 1 of 2 residents (R11) reviewed who required hand splinting and range of motion for restorative nursing exercises. Findings include: R11's significant change Minimum Data Set (MDS) dated [DATE], identified R11 had moderate cognitive impairment and had diagnoses which included stroke, hemiplegia (paralysis on one side of body) and hemiparesis (weakness on one side of body) and aphasia (loss of ability to understand or express speech). Indicated R11 had no behaviors, no rejection of cares, and was dependent on staff for dressing, hygiene and transfers. The MDS lacked identification of R11 being on a restorative nursing program. R11's care plan revised 4/5/24, identified R11 had a self care performance deficit related to hemiplegia, impaired balance, limited mobility and contractures. R11's interventions included resting hand splint on in morning (am) and off at bedtime (HS). Identified restorative program related to right hand splint with goal to maximize ROM for quality of cares. Interventions included to apply blue palm protector to right hand in AM to be worn during day. Apply gray splint to right hand at bedtime. See instructions on closet door for step by step instructions. Nursing rehab/restorative: passive ROM program number one to right upper extremity ten reps per instructions. R11's Restorative Nursing Program form dated 11/23/23, identified the following: Details-complete passive ROM (PROM) to right hand each morning during activities of daily living (ADL) routine before donning blue palm protector. Frequency-Daily. Goal-Decrease further contractures/Improve tone. Education provided to-Staff. R11's Restorative Nursing Program dated 11/30/23, identified the following: Details-gray splint donned every bed time (QHS) Blue Palm protector every day (QD). Frequency-Gray splint-night (NOC) Blue palm protector-Day. Goal-sustain maximum (max) ROM for quality of cares and contracture management. R11's Occupational Therapy Toolkit Passive Range Of Motion form dated 11/23/23, included the following: Do the checked exercises one time per day, seven days per week. Notes: complete the checked exercises in the morning during ADL routine before donning blue palm protector. -PROM right side weakness fingers and thumb-make a fist, finger spread, thumb across, all to be repeated five times. -Wrist flexion and extension-with instructions. Review of R11's Occupational Therapy (OT) Discharge Summary dated 12/11/23, identified the following: -R11 continued to demonstrate (demo) need for ROM daily splinting for further contraction prevention. -Restorative program established/trained=restorative ROM program, restorative splint and brace. -ROM program established/trained: Required daily ROM in UE shoulder, fingers, wrist hand. -Splint and brace program established/trained: daily, nightly. Review of R11's Occupational Therapy Treatment Encounter Notes from 11/24/23 to 12/11/23, identified the following: -11/24/23 at 8:53 a.m., -R11 demonstrated improved tolerance to all Right Upper Extremity (RUE) prolonged stretching. Plan-initiate training of staff for decreased overall flexion tone. -11/27/23 at 2:30 p.m. -plan to address staff training. -11/28/23 at 3:08 p.m., R11 demonstrated improved tone in right hand/wrist/fingers. Continue staff education. -11/29/23 at 11:43 a.m.,-staff education provided with optimal use of splints. -11/30/23 at 11:33 a.m., -staff education provided for increase success with NOC plaint and day palm protector. Updated instructions on closet to include use of palm protector during the day. -12/1/23 at 12:52 a.m., -R11 compliant with adaptations and compliant with skilled interventions. -12/4/23 at 3:43 a.m.,- R11 continued to benefit from daily PROM in RUE wrist, elbow and shoulder. R11 continued to benefit form using of splint at HS and right palm protector during day time. -12/7/23 at 4:23 p.m., -R11 demonstrated need for ongoing gains in PROM in UE plan-continue ROM retraining. -12/11/23 at 3:19 p.m., -all ROM in RUE improved from original tightness in right hand, finger, wrist and shoulder. R11 program established for ongoing ROM, splint wearing. Review of R11's OT Evaluation & Plan Of Treatment dated 11/7/23 to 12/6/23, identified the following: -Right Upper Extremity (RUE) ROM-shoulder=impaired:Elbow/Forearm=impaired: Wrist=impaired: Hand=impaired: Thumb=impaired:Index Finger=impaired: Middle Finger=impaired: Ring Finger=impaired: Little Finger=impaired. AROM-right shoulder-flexion=10 degrees, Extension=0 degrees. AROM-right elbow/forearm Flexion =30 degrees, extension =0 degrees. AROM right wrist flexion=30 degrees, extension=50 degrees. Review of R11's Occupational Therapy (OT) Discharge Summary dated 12/11/23, identified the following: -R11 continued to demonstrate (demo) need for ROM daily splinting for further contraction prevention. -Restorative program established/trained=restorative ROM program, restorative splint and brace. -ROM program established/trained: Required daily ROM in UE shoulder, fingers, wrist hand. -Splint and brace program established/trained: daily, nightly. Review of R11's Documentation Survey Report v2 from 11/1/23 to 5/14/24, identified the following: -11/1/23 to 11/30/23: -apply blue palm protector to right hand in AM to be worn during the day, every shift (Qshift) 6 a.m. to 2 p.m.: -entries included: began on 11/30/23-A (accepted) one time -apply gray splint to right hand at bedtime. See instructions on closet door for step by step instructions, Qshift 6 a.m. to 2 p.m. and Qshift 2 p.m. to 10 p.m. : -entries included: 97 (not applicable)- three times, 98 (refused)- four times, 7 (refused)-twenty two times, 8 (activity did not occur or family or non-facility staff completed)-twenty nine times, and one entry left blank. -12/1/23 to 12/31/23: -apply blue palm protector to right hand in AM to be worn during the day, Qshift 6 a.m. to 2 p.m.: -entries included: A-fourteen times, R (removed)- two times, 97-three times, 98-ten times, and two entries left blank. -apply grey splint to right hand at bedtime. See instructions on closet door for step by step instructions, Qshift 6 a.m. to 2 p.m. and Qshift 2 p.m. to 10 p.m. : -entries included: 97-five times, 98-nine times, 7-twenty one, 8-twenty three times, and three entries left blank. -1/1/24 to 1/31/24: -apply blue palm protector to right hand in AM to be worn during the day, Qshift 6 a.m. to 2 p.m.: -entries included: A-thirteen times, R-two times, 97-two times, 98-eleven times, and three entries left blank. -apply grey splint to right hand at bedtime. See instructions on closet door for step by step instructions, Qshift 6 a.m. to 2 p.m. and Qshift 2 p.m. to 10 p.m. : -entries included: 97-three times, 98-eight times, 7-nineteen times, 8-twenty seven times, and five entries left blank. -2/1/24 to 2/29/24: -apply blue palm protector to right hand in AM to be worn during the day, Qshift 6 a.m. to 2 p.m.: -entries included: A-nineteen times, R-four times, 97-one time, 98-four times. -apply grey splint to right hand at bedtime. See instructions on closet door for step by step instructions, Qshift 6 a.m. to 2 p.m. and Qshift 2 p.m. to 10 p.m. : -entries included: 97-four times, 98-fourteen times, 7-thirteen times, 8- twenty two times, and two additional 8 entered. -3/1/24 to 3/31/24: -apply blue palm protector to right hand in AM to be worn during the day, Qshift 6 a.m. to 2 p.m.: -entries included: A- fifteen times, R -three times, 97- two times, 98- ten times -apply grey splint to right hand at bedtime. See instructions on closet door for step by step instructions, Qshift 6 a.m. to 2 p.m. and Qshift 2 p.m. to 10 p.m. : -entries included: 97-eleven times, 98-thirteen times, 7-seventeen times, 8-nineteen times. -4/1/24 to 4/30/24: -apply blue palm protector to right hand in AM to be worn during the day, Qshift 6 a.m. to 2 p.m.: -entries included: A- twenty times, R- four times, 98- three times, 97-three times. -apply grey splint to right hand at bedtime. See instructions on closet door for step by step instructions, Qshift 6 a.m. to 2 p.m. and Qshift 2 p.m. to 10 p.m. : -entries included: 97- twenty five times, 98- seven times, 7- thirteen times, 8-fifteen times. -5/1/24 to 5/14/24: -apply blue palm protector to right hand in AM to be worn during the day, Qshift 6 a.m. to 2 p.m. -entries included: A-three times, 97-three times, 98-six times, and two entries left blank -apply grey splint to right hand at bedtime. See instructions on closet door for step by step instructions, Qshift 6 a.m. to 2 p.m. and Qshift 2 p.m. to 10 p.m. : -entries included: 97-eight times, 98- seven times, 7- four times, 8- seven times, and one entry left blank. Review of R11's Documentation Survey Report v2 from 11/1/23 to 5/14/23, identified R11 approved of blue palm protector application 85 times and all other entries were identified as not applicable, refused, activity did not occur, or were left blank. R11's grey splint entries all identified the splint was not worn due to not applicable, refused, activity did not occur or were left blank. R11's Document Survey Report v2 documentation lacked documentation of the PROM restorative nursing program. Review of R11's progress notes from 11/3/23 to 5/15/24, lacked documentation of implementation of R11's restorative nursing program, R11's refusal of restorative nursing services, notification of refusals to licensed nurses/provider or re-evaluation of R11's ROM. During an observation on 5/13/24 at 3:09 p.m., R11 was seated in his wheelchair in his room, no hand splint or palm protector was worn. -A hand written note on an eight by eleven white paper was taped to R11's wardrobe cupboard. The sign read: Nighttime Splint: -Donn in bed when relaxed, approximately (aprox) 8 p.m.-8 a.m. -follow instructions on closet. -Doff in the morning. -Blue palm protector during day. Right hand. During an observation on 5/15/24 at 9:46 a.m., R11 was seated in his wheelchair in the fire place lounge. R11 was not wearing a palm protector and R11's right hand was tightly fisted. At 2:17 p.m., R11 was seated in his wheelchair in his room. R11 continued to not have his palm protector on and R11's right hand was tightly fisted. At 4:43 p.m., R11 was wheeled by registered nurse (RN)-A out to the smoking area. R11 continued to not have his blue palm protector on. At 5:07 p.m., R11 was in his wheelchair in the dining room. It was noted R11 continued to not have the blue palm protector on and R11 held his right tightly fisted hand in his left hand resting on his lap. During an observation and interview on 5/15/24 at 7:07 a.m., R11 was dressed in street clothes seated in his wheelchair near the nurses' station. R11 had no brace or palm protector on his right hand. At 7:31 a.m., licensed practical nurse (LPN)-C transported R11 down the hall to the nurses cart. At 7:45 a.m., LPN-C was in R11's room administering medications. From 8:04 a.m. to 9:02 a.m., R11 was observed to be in the dining room and at 9:02 a.m., was brought back to his room. R11 continued to not have the palm protector on, while he held his right tightly fisted hand in his left hand on his lap. At 9:29 a.m., LPN-C prepared supplies for R11's wound care, applied a gown, gloves and entered R11's room. In addition, RN-C applied gown and gloves and entered R11's room. LPN-C indicated R11 wore the splint at night and confirmed R11 did not have the blue palm protector on. LPN-C looked around and found the blue palm protector on top of R11's wardrobe cupboard, with a gray hand splint under it, and other items such as clothing and boxes. LPN-C stated R11's blue palm protector was hit or miss when asked if it ever was worn. LPN-C indicated the nursing assistants were responsible to complete R11's range of motion and apply hand splints. At 9:41 a.m., RN-B and LPN-C transferred R11 to bed using a mechanical lift, completed incontinence cares and wound cares. RN-B indicated R11 had been on hospice for about 2 months. After the interview was completed, LPN-C attempted to apply R11's blue palm protector at that time however, R11 refused. During an interview and observation on 5/15/24 at 10:39 a.m., certified occupational therapy assistant (COTA)-A reviewed R11's past ROM measurements, went to R11's room and assessed R11's ROM. COTA-A talked with R11, while moving his right wrist, then stated it seemed tighter. COTA-A moved R11's arm and stated his elbow extension appears to have decreased extension a little bit. COTA-A stated it was obvious R11 did not have as much ROM in the wrist and elbow extension now. COTA-A indicated his ROM decline could have been caused by not wearing the splint, not completing ROM exercises and inadequate positioning. COTA-A stated if R11 had worn the splint regularly and completed ROM exercise daily, there would have been a better chance R11's contractures would have been at least maintained. During an interview on 5/15/24 at 10:48 a.m., nursing assistant (NA)-G indicated R11 wore a splint, which nursing staff were expected to apply at night and was removed in the morning. NA-G stated R11 did not wear a hand brace during the day, however indicated if it was on at night, they took it off in the morning. NA-G stated R11 did not have the splint on that morning when they got him up from bed. NA-G indicated she was unaware if R11 was to receive ROM services. NA-G stated therapy performed all ROM and restorative services at the facility. NA-G stated she had never completed passive ROM for R11. During an interview on 5/15/24 at 12:59 p.m., NA-F stated restorative nursing services were provided by nursing assistants and the services to complete were usually posted on the resident's closet door. NA-F indicated nursing staff were expected to look at the pictures posted on the closet doors and read through them to know what to do for restorative nursing services. NA-F stated she was not sure who was in charge of the facility's restorative nursing program. NA-F stated she had tried to complete ROM for R11 in the past however, stated R11 became upset and was reluctant to do it. NA-F could not remember the last time she had attempted to complete ROM on R11. NA-F indicated she had documented that she was not able to complete the task. NA-F stated she could not recall if she had notified the nurse about R11's refusals. NA-F indicated R11 would not let them apply his hand braces and indicated she had never seen him wear one. NA-F stated she had never been instructed on how to apply the hand braces. During an interview on 5/15/24 at 1:05 p.m., therapy director COTA-B indicated it was possible that not completing ROM exercises could cause a decline in R11's ROM. COTA-A stated if R11 had received ROM exercises routinely, it could have assisted R11 to maintain function. COTA-B stated was unaware of who was in charge of the facility's restorative program however, indicated the therapy department provided the restorative program information to the nursing staff when therapy discontinued services. COTA-B stated the hand braces, including the blue palm protector were to keep things neutral and decrease pain and could have assisted in preventing decline. COTA-B agreed with COTA-A that R11 may have had a decline and stated his condition was also in decline. COTA-B stated would expect staff to notify the therapy department if a resident refused or if staff were not able to complete the restorative program. Once the therapy department had been notified, they could re-screen to see if was appropriate to begin therapy again or to complete re-education if needed. COTA-B stated they provided a general education on splinting to nursing during new employee orientation however, did not provide ROM education to nursing staff. COTA-B indicated when a resident was transitioning from therapy to nursing they attempted to educate two shifts on the restorative program and leave written instructions with the nursing staff. During an interview on 5/15/24 at 1:31 p.m., NA-E indicated R11 wore a brace at night and a different one during the day. NA-E stated she could not remember the last time she had seen R11 wear a brace on his right hand. NA-E stated she had tried with LPN-C earlier that day to apply R11's blue brace after LPN-C had attempted to apply brace however, he refused. NA-E stated R11's plan of care (POC) identified the braces and ROM, and indicated R11 would not let her complete passive ROM. NA-E stated if R11 refused she would have informed the nurse however, could not recall the last time she had informed a nurse of R11's refusals. During an interview on 5/15/24 at 1:35 p.m., clinical manager RN-B stated the restorative nursing program consisted of therapy writing up the resident's restorative plan once therapy discontinued services and then placing the plan in the resident's POC for nursing staff to complete and document on. RN-B stated she was not in charge of the nursing restorative program and confirmed there was no designated individual in charge of the nursing restorative program. RN-B indicated no staff had ever reported to her that R11 refused his brace or ROM exercises. RN-B stated if she had been informed, she would have evaluated why R11 refused and if he consistently refused. RN-B stated she would expect the refusals to be documented in the progress notes and therapy to be notified so they could reassess the restorative program. RN-B stated she could not remember the last time she had seen R11 wear his brace. During a telephone interview on 5/15/24 at 4:28 p.m., R11's primary care physician (PCP)-A confirmed she had not been informed by the facility ROM exercises and the braces were not being consistently implemented for R11. PCP-A indicated she would expect the nursing staff to report when R11 was not wearing the braces or ROM exercises were not being completed so they could re-assess to determine if the orders were still needed. PCP-A stated R11 was now on hospice and stated they would consider backing down on passive ROM exercises and possibly R11's braces at that time. PCP-A indicated if the brace was not worn or the ROM exercises were not completed, it could cause an increase in contractures from his stoke and tightness. During an interview on 5/15/24 at 2:29 p.m., interim director of nursing (IDON) indicated she was not aware if the facility had a restorative nursing program in place. IDON indicated she would expect staff to follow the POC and resident tasks and instructions. IDON stated when a resident refused, she would expect the resident to be re-approached, document the refusals, notify the nurse and inform therapy as well. IDON stated it was important to complete the ROM and apply the hand braces so residents did not lose their function and were able to maintain their highest level of function as possible. During an observation and interview on 5/15/24 at 4:33 p.m., COTA-B and PTA-A were in R11's room, while he sat in his wheelchair. PTA-A completed measurements on R11's right elbow flexion and noted it was 120 degrees and extension was 90 degrees. R11's right wrist flexion was 33 degrees and R11's wrist extension was lacking four degrees, which PTA-A stated meant R11 could not reach full extension. COTA-B confirmed R11 had a decline in the ROM of his right elbow and wrist. The facility policy titled Establishment Of An Individual Restorative Program dated 8/1/15, identified the facility provided treatment and services to maintain and improve functional abilities per physician orders. The policy identified restorative program may be recommended by the therapists for evaluation and establishment of a restorative program following a therapy screen. The policy indicated the residents recommended for restorative programming would be referred by the nurse in charge of restorative programming using the Restorative Assessment form. The individualized goals and interventions towards achievement would be developed by the interdisciplinary team and implemented by the restorative nurse and restorative aide with input from the therapist when applicable.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R2, R44) were offered or received pneumococcal and/or influenza vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the current CDC recommendations 3/15/2023, revealed The Center for Disease Control and Prevention (CDC) identified adults age 19 of age or older should receive the influenza vaccination annually and adults [AGE] years of age or older who had not previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and who had previously received one or more doses of Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive a dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Pneumococcal 20-valent Conjugate Vaccine (PVC20). The dose of PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 dose. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 was received at age 65 and older, based on shared clinical decision-making, one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R2's immunization report, R2, age 77, was admitted to the facility on [DATE]. Review of R2's Minnesota Immunization Information Connection (MIIC) undated, recommended R2 to receive the influenza vaccine. R2's medical record indicated R2 received the influenza vaccine 12/27/22. R2's medical record lacked documentation R2 had been offered or received the influenza vaccine for the current seasonal flu year. Review of R44's immunization report, R44, age 67, was admitted to the facility on [DATE]. Review of R44's MIIC undated, recommended R44 to receive the pneumococcal vaccine. R44's medical record lacked documentation R44 received the PCV15 or PCV20 vaccines based on shared clinical decision-making with the provider. During an interview on 5/15/24, at 2:10 p.m. infection preventionist (IP) confirmed her expectation was for all residents on admission to be offered the influenza and pneumococcal vaccinations if eligible. IP stated the influenza and pneumococcal vaccine was on the facility standing orders to be provided to the residents. IP verified she was unaware if R2 and R44 had been offered or received the vaccinations and the facility lacked a process to ensure immunizations were completed for residents. During an interview on 5/15/24, at 3:53 p.m. director of nursing (DON) confirmed her expectation was for all residents on admission to be offered the influenza and pneumococcal vaccinations if eligible. DON stated she would expect (IP) to follow the facility policies of vaccinations offered and to document results. DON confirmed she was unaware if R2 and R44 had been provided education or offered the vaccinations. The facility policy titled Seasonal Influenza Vaccine, revised 9/29/23, identified all residents would be offered influenza vaccines to aid in prevention of influenza infections. The policy identified residents would be assessed for eligibility to receive the influenza vaccine, and when indicated would be offered unless medically contraindicated or the resident had already been vaccinated. The policy indicated before receiving the vaccine, the resident or legal representative would receive information and education regarding the benefits and potential side effects of the vaccine. The policy identified residents had the right to refuse vaccination, and if refused, appropriate entrees would be documented in each residents' medical record indicating the date of the refusal. The facility policy titled Pneumococcal Vaccine, revised 6/28/23, identified all residents would be offered pneumococcal vaccines to aid in prevention of pneumococcal infections. The policy identified residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated would be offered the vaccine series unless medically contraindicated or the resident had already been vaccinated. The policy indicated before receiving the vaccine, the resident or legal representative would receive information and education regarding the benefits and potential side effects of the vaccine. The policy identified residents had the right to refuse vaccination, and if refused, appropriate entrees would be documented in each residents' medical record indicating the date of the refusal.

Based on observation, interview, and document review, the facility failed to maintain safe storage of medications when the nurses left medication carts unlocked and unattended in 2 of 3 medication carts. Findings: On 4/23/24 at 11:48 a.m., licensed practical nurse (LPN)-A gathered supplies to check R2's blood glucose. LPN-A pressed the north medication cart lock partially into the cart. LPN-A walked away from the medication cart in the hall and into R2's room. LPN-A closed the door for privacy. Following the procedure, LPN-A returned to the cart and pulled the medication cart lock out with his fingers, and accessed the contents of the medication cart. LPN-A did not use a key to access the medication cart. LPN-A stated the importance of locking the medication cart when not in attendance was to make sure no medications were stolen. LPN-A stated he trusted the people and the residents at the facility. LPN-A stated the lock on the medication was in working order. LPN-A stated leaving the medication cart unlocked and unattended was not a safe idea. On 4/23/24 at 12:01 p.m., LPN-B was observed from approximately 30 feet away, walking down the hall, approaching the west medication cart and pulling the lock out with her fingers to access the medication cart. LPN-B did not use a key to access the medication cart. LPN-B stated she had a key to the medication cart and the locking mechanism was in working order. LPN-B stated, I guess I just do it that way, when asked why the medication cart was not locked. On 4/23/24 at 12:34 p.m., LPN-C stated the medication carts were to be locked if the nurse was not near the cart. CM-A stated the unlocked cart posed a danger that residents, staff or family could access the cart. On 4/23/24 at 2:12 p.m., the director of nursing (DON) stated the medication carts should be locked whenever the nurse was not in direct attendance of the cart. The DON stated the medication carts should not be left unattended and unlocked as anybody could get into the medication cart. A facility document Medication Storage dated 2/12/24, directed to ensure medications and biological are stored in a safe, secure storage and safe handling. Compartments containing medications should be locked when not in use. Trays or carts used to transport such items should not be left unattended. (Note: Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes).

Based on observation, interview and document review, the facility failed to maintain infection control practices while conducting blood glucose checks for 2 of 3 residents (R2, R3) reviewed for medication administration. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had a diagnosis of diabetes mellitus type 2. R2's Physician's Order dated 4/15/24, directed to check blood glucose three times daily. On 4/23/24 at 11:51 a.m., after checking R2's blood glucose, licensed practical nurse (LPN)-A was observed to place a contaminated lancet and cotton ball in the cover of the plastic container used to hold R2's glucometer, insulin pens, and blood glucose testing supplies. LPN-A carried the container to the medication cart, and placed the contaminated lancet (a pricking needle, used to obtain drops of blood for testing) in a plastic cup sitting on the top of the medication cart. There were a total of five used lancets in the cup. LPN-A closed the plastic container in the medication cart, and did not disinfecting the glucometer or the plastic container. LPN-A stated the sharps container was on the medication cart. The sharps container on the medication cart was observed to be full with lancets pressing out of the top of the container. The contents was approximately two inches above the full line. LPN-A stated glucometers were cleaned once weekly, unless they were used for another resident, then you would have to use the disinfectant wipe on it. R3's significant change MDS dated [DATE], indicated R3 had diagnosis of diabetes mellitus type 1 and end stage renal disease. R3's Physician's order dated 1/4/24, directed to check blood glucose four times per day. On 4/23/24 at 12:03 p.m., LPN-B was observed to gather supplies from the medication cart to test R3's blood glucose. LPN-A removed the plastic container from the medication cart. LPN-A inserted the test strip into the glucometer. She prepared R3's finger by wiping it, then pricked R3's finger with the lancet, and put pressure on R3's finger with both of her ungloved hands to produce a drop of blood. LPN-B stated gloves should be worn when handling bodily fluids such as vomit, urine, bowel movements, or blood. LPN-B stated she was never instructed to wear gloves when checking blood glucose. LPN-B stated glucometers were only cleaned once weekly, unless visibly dirty. LPN-B stated there was not a process for the day of the week the glucometers were cleaned. On 4/23/24 at 12:34 p.m.,LPN-C stated gloves were to be worn for all glucometer testing. LPN-C stated the sharps containers were to be changed when the contents reached the fill line. LPN-C stated the nurses working on the medication carts were responsible to replace the sharps container and properly dispose of the full ones. On 4/23/24 at 1:49 p.m., CM-A stated the glucometers were to be properly disinfected after each use. On 4/23/24 at 2:12 p.m., the director of nursing (DON) stated glucometers were expected to be cleaned after each use. The DON stated gloves should be worn with all glucometer checks. The DON stated sharps containers should be replaced when the contents reached the full line. The DON stated it was unacceptable to place five contaminated lancets on top of the medication cart in a plastic cup. She stated the lancets should be discarded promptly after each use. A facility document Care of the Diabetic Resident dated 8/22/23, directed blood glucose monitoring procedure: Wash your hands or use hand sanitizer to clean hands Put on gloves Discard test strip when finished Clean the glucometer per facility policy Remove and discard gloves; wash hands Store the glucometer in a clean and dry location A facility document Cleaning and Disinfection of a Glucometer dated 3/8/23, directed: 1. Gather necessary equipment for procedure. 2. Perform hand hygiene and apply gloves. 3. Wipe all external surfaces, including top, bottom and sides, using the approved cleaning solution or commercially prepared EPA germicidal wipe; avoid allowing the solution to penetrate the test strip and/or key code ports of the meter. 4. Ensure the meter remains wet for the time recommended by the manufacturer of the wipe and allow to air dry for an additional minute before using on the next resident. 5. If blood is visibly present on the meter, the procedure should be repeated a second time. 6. Discard soiled items in approved containers. 7. Remove gloves and perform hand hygiene.

Based on interview and document review, the facility failed to test all employees for COVID-19 during a facility outbreak status as directed by the Center for Disease Control (CDC). The facility failed to review employee testing logs, and as a result 12 staff members worked with residents during the outbreak without being tested every 3-7 days. Of those 12 staff that have worked with residents but not tested , 3 were not vaccinated and at higher risk of contracting COVID-19 when exposed. This deficient practice resulted in an immediate jeopardy (IJ) situation for all 66 residents residing in the facility during a COVID-19 outbreak. 7 of those residents ( R7, R8, R9, R10, R11, R12 and R13) were not vaccinated for COVID-19 and at a higher risk of contracting COVID-19 when exposed and had a higher risk of adverse outcome. 34 residents (R6, R8, R11, R13, R14, R15, R16, R17, R18, R19, R20 , R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43) had contracted COVID-19 between 12/11/22 and 12/27/22, two of those residents were unvaccinated (R8 and R11), and (R6) was hospitalized with COVID-19. The IJ began on 12/11/22, when R13 became positive for COVID-19 and the facility failed to either conduct contact tracing, or ensure all staff were testing every 3 - 7 days during the outbreak as directed by the Center for Disease Control (CDC) and facility policy. The administrator and director of nursing (DON) were notified of the IJ on 12/29/22, at 5:15 p.m. The IJ was removed on 12/30/22, at 2:30 p.m., but noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The current Center for Disease Control (CDC) guidance indicated testing with authorized nucleic acid or antigen detection assays was an important addition to other infection prevention and control (IPC) recommendations aimed to prevent COVID-19 from entering nursing homes, detecting cases quickly, and stopping transmission. Swift identification of confirmed COVID-19 cases allows the facility to take immediate action to remove exposure risks to nursing home residents and staff. When one case of COVID-19 is identified, either contact tracing or broad based outbreak testing is required. With broad based testing, all staff would need to be tested every three to seven days until there were fourteen days without a COVID-19 positive staff or resident. The facility's policy COVID-19 Testing Plan last revised 12/28/22, indicated upon identification of a single new case of COVID-19, all staff and residents would be tested regardless of vaccination status and testing would continue until there were no new cases for fourteen days. Review of the facility resident COVID-19 positive log indicated the following: On 12/11/22, one resident (R13) was positive for COVID-19. On 12/12/22, five residents (R6, R11, R14, R15, R16) were positive for COVID-19. R6 was sent to the emergency roiagnom on [DATE], and hospitalized . On 12/14/22, two residents (R17, R18) were positive for COVID+19. On 12/15/22, four residents (R19. R20, R21, R22) were positive for COVID+19 On 12/16/22, one resident (R23) was positive for COVID-19. On 12/17/22, one resident (R24) was positive for COVID-19. On 12/19/22, three residents (R34, R35, R36) were positive for COVID-19. On 12/20/22, one resident (R37) was positive for COVID-19. On 12/22/22, four residents (R38, R39, R40, R41) were positive for COVID-19. On 12/23/22, on resident (R25) was positive for COVID-19. On 12/24/22, one resident (R26) was positive for COVID-19. On 12/25/22 two residents (R27, R28) were positive for COVID-19 On 12/26/22 four residents (R8, R29, R30, R31) were positive for COVID-19. On 12/27/22 three residents (R32, R42, R43) were positive for COVID-19. The facility's Resident Vaccination log identified the following residents were not vaccinated against COVID-19, therefore at higher risk of adverse outcome if they were to contract the virus: R7, R8, R9, R10, R11, R12, and R13. Review of staff schedules and facility testing logs from 12/11/22, to 12/24/22, indicated 12 staff members had worked without being tested as required. The information about the 12 staff member is as follows: Nursing assistant (NA)-A worked 12/17/22, and 12/18/22, but did not test for COVID-19 for the weeks that began with 12/11/22, and 12/18/22. NA-B worked 12/13/22 and did not test for COVID-19 the week that began 12/11/22. NA-C worked 12/18/22 and did not test for COVID-19 the week that began 12/18/22 NA-D worked 12/12/22, 12/13/22, 12/14/22, 12/15/22, 12/17/22, 12/18/22, 12/19/22, 12/20/22, 12/21/22, 12/22/22, and 12/24/22, but failed to test for COVID-19 the weeks beginning 12/11/22, and 12/18/22. NA-E worked 12/19/22, 12/20/22, and 12/24/22 and failed to test for COVID-19 the week that began 12/11/22. NA-F worked 12/19/22, 12/20/22, 12/23/22, and 12/24/22, but failed to test for COVID-19 the week that began 12/18/22. NA-G worked 12/18/22, but failed to test for COVID-19 the week that began 12/18/22. Licensed practical nurse (LPN)-A worked 12/12/22, 12/13/22, 12/14/22, 12/15/22, 12/16/22, 12/17/22, 12/18/22, 12/19/22, 12/20/22, 12/21/22, 12/22/22, 12/23/22, 12/24/22, but failed to test for COVID-19 the weeks that began 12/11/22, and 12/18/22. LPN-B worked 12/19/22, and 12/23/22, but failed to test for COVID-19 the week that began 12/18/22. Cook (C)-A worked 12/19/22, 12/21/22, 12/22/22, 12/23/22, and 12/24/22, but failed to test for COVID-19 the week that began 12/18/22. The staff vaccination record identified had not been vaccinated for COVID-19. Dietary Aide (DA)-A worked 12/11/22, but failed to test for COVID-19 the week that began 12/11/22. The staff vaccination log identified DA-A had not been vaccinated against COVID-19. DA-B worked 12/11/22, 12/13/22, 12/15/22, 12/16/22, 12/17/22, 12/18/22, 12/19/22, 12/21/22, 12/22/22, and 12/24/22, but failed to test for COVID-19 the weeks that began 12/11/22, and 12/18/22. DA-C worked 12/11/22, 12/13/22, 12/15/22, and 12/16/22, but failed to test for COVID-19 the week that began 12/11/22. The staff vaccination log identified DA-C had not been vaccinated against COVID-19. During an interview on 12/29/2022, at 2:47 PM NA-E stated she tested twice a week until she became COVID-19 positive in August. NA-E stated she had not tested the week of 12/11/22 because she had been positive in August, 4 months prior. During an interview on 12/29/2022, at 3:59 PM NA-F stated staff tested every time they came in. NA-F stated she could not remember if she had tested the week that started 12/18/22. When explained what was on the testing log NA-F stated she could not remember why she had not tested that week. During an interview on 12/29/2022, at 4:19 PM NA-C acknowledge testing was done twice a week if you were working. NA-C acknowledge she only worked two times that week so did not test even though she was supposed to. During an interview on 12/29/2022, at 4:29 PM DA-C acknowledged staff should covid test twice a week while in outbreak. DA-C stated he forgot to test the week of 12/11/22. R6's face sheet indicated diagnoses that included Type two diabetes with ketoacidosis, peripheral vascular disease, hypertensive heart disease, and Acute kidney failure. R6's hospitalization admission history and physical (HP) dated 12/20/22, at 1:05 a.m. indicated R6 had fever of 103 degrees Fahrenheit (F), cough, headache, congestion, and generalized weakness, which contributed to a fall as part of hospitalization . The HP indicated the white blood cell count was normal but did show a left shift which indicated an infectious process occurred. R6 was started on Lovenox-injectable blood thinner, due to COVID-19 diagnosis. The hospital records identified R6 was admitted on [DATE] and returned to the facility on [DATE] with a diagnosis of COVID-19. During an interview on 12/29/22, at 12:03 p.m. the director of nursing (DON) stated she was also the infection preventionist (IP) for the facility and was in charge of COVID testing. The DON acknowledge they did not do contact tracing but started facility wide testing right away. The DON stated there was a table at the employee entrance with testing supplies, and a sign that stated all staff needed to test weekly due to facility being in outbreak status. The DON acknowledge that testing was done by staff and nobody oversaw to make sure each staff working actually got tested . There was no tracking to ensure that happened. The DON reviewed the COVID-19 testing log and the staff schedule from 12/11/22, to 12/24/22, and acknowledge that 12 staff members had worked around residents in that time period and had not tested according to policy. The DON stated all 12 staff should have tested at least weekly. During interview on 12/29/22, at 2:48 p.m. the administrator stated her expectation was that all staff tested according to facility policy while in outbreak status. The IJ which began on 12/11/22, was removed on 12/30/22, at 2:30 p.m. when it could be verified through observation, interview and document review the facility had tested all their employees to ensure all employees had a verified negative COVID-19 test result prior to the start of their shift. Administration had trained all employees on COVID-19 test requirements. Policies were reviewed and revised to reflect protocols for testing procedures and tracking to ensure all staff were tested for COVID-19 in a manner consistent with current standards of practice for conducting and tracking COVID-19 tests; Education was provided to all staff on current and updated COVID protocols for staff and would continue for continued outbreak testing; and completion of testing and training would be tracked, analyzed, and acted on to ensure compliance with routine and outbreak testing.

Based on observation, interview and document review, the facility failed to identify possible elopement behaviors and develop interventions for 1 of 1 residents (R1) who was cognitively impaired, wandered and left the building without staff knowledge. This resulted in an Immediate Jeopardy (IJ). The IJ began on [DATE], when R1 left the building without staff knowledge and was found at the bottom of a steep hill, near a busy street. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 6:50 p.m. The immediate jeopardy was removed on [DATE], at 4:26 p.m. and the non-compliance remained at the lower scope and severity of a D, no actual harm with a potential for more than minimal harm. Findings include: R1's significant change Minimum Data Set (MDS), dated [DATE], indicated R1 had severe cognitive impairment, non-traumatic [CONDITION(S)], traumatic brain injury (TBI), and no wandering behaviors. Additionally, R1 needed supervision with locomotion on and off the unit, was not steady walking, needed a walker, and had two or more falls since prior assessment. R1's care plan printed [DATE], identified R1; had limited physical mobility related to dementia, impaired cognitive function related to history of head injury (resident required cues and reminders for Activities of daily living), unsteady gait/balance, high risk for falls, impaired visual function, poor decision making, and exhibited delusions about her husband that was deceased . There was no indication R1 was at risk for wandering. A progress note dated [DATE], at 12:03 p.m. stated R1 ambulated around the building as she looked for her mother and father-in-law, (who were deceased ), and at 9:08 p.m. R1 wandered the building as she searched for Santa [NAME], and wanted to go to [NAME] to see her husband. A progress note dated [DATE], at 11:08 p.m. RN-A documented at approximately 8:00 p.m. nursing assistant (NA)-C was unable to find R1. RN-A went to foyer, where she had seen R1 earlier, and noted the front maglock system was disarmed. R1 was found outside standing at the bottom of a the hill with her walker. R1 told staff she went outside to get some fresh air. Although progress notes of [DATE] identified R1 was wandering around the building, and left the building without staff knowledge on [DATE], the facility had not completed a wander risk assessment until after the [DATE] event. R1's Wander Risk Scale assessment, dated [DATE], identified risk factors included history of wandering, mental status, diagnosis, and mobility. The assessment indicated R1 has no reported episodes of wandering in past 6 months and no diagnosis of dementia; which resulted in a score of 4 (a score chart indicated ,d+[DATE] Low Risk). The assessment, indicated R1 was not at risk and did not need a new care plan or interventions even though the progress notes identified R1's wandering behavior. On [DATE] R1's care plan indicated R1 left the faciity on [DATE]. Interventions were initiated for 15-minute checks, monitor resident for tailgating (follow close behind) when visitors are in the building, and wander risk assessment per facility policy. R1's care plan was updated on [DATE] and identified R1 was safe and removed 15-minute check intervention. Although the facility removed the 15-minute checks, they did not implementy any interventions to prevent R1 from going outside unsupervised, even though she continued to have wandering behaviors. Review of facility's investigation as of [DATE], indicated video footage was reviewed and it appeared NA-B may have disarmed the door at 6:30 p.m. R1 was sitting in the lobby area then seen going out the front door and was outside for 10 minutes before staff assisted her back in the facility. NA-B was re-educated on the importance of making sure the door is armed for alarm. On [DATE], at 2:09 p.m. RN-A stated she had been alerted by NA-C on [DATE], at approximately 8:00 p.m. that he could not locate R1. RN-A had seen R1 less than 20 minutes earlier sitting in the foyer of the facility. She noticed the front door was disarmed, so she walked out of the building, and saw R1 at the bottom of the hill with her walker. RN-A stated R1's had impaired cognition and she [R1] is not somebody I would be willing to just send outside on her own. On [DATE], at 3:27 p.m. interim director of nursing (DON) stated the entry door had a maglock system and was kept locked to make sure people that entered the facility were screened for COVID-19, not to keep any residents from getting out of the facility. DON stated she had not yet completed the investigation, but video from [DATE], revealed R1 did not leave facility grounds. Therefore, the incident was not an elopement. The facility grounds where R1 ambulated down the hill in her walker was observed on [DATE], at 9:20 a.m. was steep and adjacent to a busy city street that had 2 apartment complexes on one side and the facility on the other side of the street. On [DATE], at 10:32 a.m. nursing assistant (NA)-A stated the facility kept an Elopement Book at the front desk with photos of residents at risk for elopement. NA-A further stated that she knows R1's abilities and even though it was not on R1's plan of care (POC), R1 would need to be supervised or she could wander outside the facility. On [DATE], at 10:46 a.m. NA-B stated that after the incident, she was educated to make sure the door was locked every time the alarm was turned off. NA-B further stated R1 wandered in the building but could not go outside without supervision because of R1's impaired cognition. On [DATE], at 2:05 p.m. assistant director of nursing (ADON) stated after R1 was found outside without supervision, 15-minute checks were initiated, but had been discontinued on [DATE]. ADON stated after the incident, a history of wandering should have been identified on the updated wandering risk assessment. She stated, R1 was not safe to go outside without supervision due to her impaired cognition and mobility. On [DATE], at 3:29 p.m. DON stated R1 had a purpose and was very clear about her purpose to go outside. Therefore, she would not call it wandering, and R1's care plan had not been updated to have her supervised when outside. DON acknowledged she did not ask direct care staff about supervision of R1. Further, she was not aware if family had been contacted. DON stated Wandering Risk assessments were completed on [DATE], and [DATE], and R1 was a low risk for wandering/eloping. DON stated, I consider her to be safe to be outside unsupervised. On [DATE], at 4:22 p.m. Regional Director of Clinical Services (RN)-B stated going outside with the intent to get fresh air would not be wandering. It was a purposeful choice. RN-B clarified you can be high risk, but not necessarily an elopement risk. RN-B stated it was case-by-case, provider and family directed. Further, RN-B stated her expectation was staff would follow the process which was to notify provider and family. Additionally, RN-B stated she would expect the front-line staff would be asked for their observations and comments when determining resident safety to be outside unsupervised. R1's physician progress notes, dated [DATE], [DATE], [DATE], [DATE], all indicated R1's diagnoses included dementia with moderate-advanced impairment level. The facility's Elopement Risk and Prevention Policy, revised [DATE], indicated all residents were afforded adequate supervision to provide the safest environment possible, and all residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. The policy defines wandering as random or repetitive locomotion that may be goal-directed, or non-goal-directed or aimless. The immediate jeopardy began on [DATE], when R1 was unsupervised when exiting the building. The immediacy was removed [DATE], at 4:26 p.m. Audit of facility documents verified the facility updated the elopement risk and prevention policy, created a new elopement risk assessment, and conducted facility-wide elopement and maglock system education. Staff interviews on [DATE], confirmed training had been completed regarding updated elopement policy, and R1's wandering/elopement risk interventions. Audit of R1's documents verified a new elopement risk assessment was completed and care plan was updated on [DATE]. R1's photo and wandering interventions were placed in the Elopement Book.

Based on interview and document review the facility failed to ensure 1 of 1 resident (R1) was appropriately supervised and prohibited from keeping a cigarette lighter and smoking material in his room. R1 was smoking with oxygen on while in his room which resulted in [CONDITION(S)] to his face. The deficiency was identified as past non compliance and issued at Immediate Jeopardy (IJ). The IJ began on 3/8/22, at 4:25 p.m. when R1 received [CONDITION(S)] to his face while smoking and wearing oxygen. However, the facility immediately implemented corrective action to prevent reoccurrence by 3/15/22 before survey started. The administrator and director of nursing (DON) were notified of the IJ past noncompliance on 3/17/22 at 5:25 p.m. as a result of corrective action taken by the facility. Findings include: R1's admission record indicated R1 was admitted [DATE]. R1 was his own responsible person. R1 diagnosis included chronic [CONDITION(S)] with [CONDITION(S)], chronic obstructive pulmonary disease ([CONDITION(S)]-a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs). R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. R1 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. The MDS did not identify R1 smoked. R1's care plan dated 6/2/21, lacked any indication R1 smoked cigarettes or used illegal substances. There was no indication in the medical record the faciltiy assessed R1's smoking safety. R1's pulmonology clinic consult dated 8/20/21, indicated R1 had smoked four packs of cigarettes a day for [AGE] years and had a history of using illegal drug. R1 used continuous oxygen at three liters per minute (LPM). Progress notes revealed the following: -10/24/21, registered nurse (RN)-A documented R1's room smelled of smoke and R1 was told to not smoke in the room due to high risk of causing fire because R1 was on continuous oxygen. -10/28/21, director of nursing (DON) documented smell of smoke coming from R1's room. R1 denied smoking. -11/12/21, licensed practical nurse (LPN)-C documented R1 was found smoking. -1/16/22, RN-B documented R1 was observed smoking by the chapel door. She searched R1's room and notified the DON. -1/30/22, LPN-B documented R1 was observed smoking in the corner on the fireside area of facility, DON notified. -2/22/22, LPN-A documented staff smelled smoke coming from R1's room, staff took contraband and educated on facility smoking policies. -2/22/22, LPN-B documented entry into R1's room and observation of R1 lighting smoking material. She contacted the DON, searched the room and R1 was yelling I will smoke whenever I feel like it and refused to give LPN-B the contraband. -3/1/22, the administrator documented R1's room smelled of smoke he was informed resident rooms were not authorized smoking areas. -3/8/22, RN-C documented approximately at 4:20 p.m. R1 had lit his oxygen on fire attempting to smoke in his room. Emergency medical services (EMS) were called to transport to the hospital. When RN-C asked him what happened R1 stated nothing. R1's face was black, the air smelled of burnt hair and flesh. A lighter was found on the bedside table. R1's nasal cannula was destroyed. EMS arrived and took R1 to the hospital for evaluation. R1's room was searched and the contraband was given to the administrator. Provider note dated 1/10/21, identified R1's smelled of marijuana which suggested either strong or heavy use, and therefore no drug screen was necessary. An untitled document dated 1/17/22, indicated R1 was provided education on illegal substance use and storage in the facility was prohibited. R1 agreed to abstain from illegal substance use and storage in the facility while he resided. He expressed an understanding of the information and signed the document. During an interview on 3/17/22, at 11:53 a.m. licensed practical nurse (LPN)-A stated she had found R1 in his room on 2/22/22, with a pipe and lighter in his hands. LPN-A informed R1 he could not smoke in the facility. LPN-A searched R1's room, confiscated and removed the contraband. LPN-A told R1 that he could blow himself and others up if R1 kept smoking with his oxygen on. LPN-A stated she had informed the director of nursing (DON) what had occurred. LPN-A stated she had caught R1 smoking a few times before this. However, LPN-A could not recall if his oxygen was on. During an interview on 3/17/22, at 12:25 p.m. the DON stated R1 lacked compliance with having smoking substances in the building. On 3/18/22, the DON stated R1 had no consequences given to him when found smoking or suspected of smoking in the facility in January 2022. The DON stated she did not know that R1 smoked anything, however she suspected. The DON stated there was no smoking assessment completed for R1. They should have completed a smoking assessment when they became aware of R1 smoking in January 2022. LPN-B stated on 3/8/22, at 4:30 p.m. she heard R1 calling out and found from him in his room calling out oh boy several times and the room smelt of burnt flesh. R1 was putting out flames on his upper chest, beard area, nose, lips, left arm and hand. R1's had black soot on his face and chest area. LPN-B helped to smother out the flames. The oxygen concentrator was on in the room and LPN-B shut it off and removed the oxygen concentrator out of R1's room. LPN-B stated the oxygen nasal cannula tubing had been burnt and was in two pieces, it had not burned to R1's face but came off easily. The smoking contraband was confiscated. LPN-B stated she did not see R1 smoking but smelled it in the room. During an interview on 3/18/22, at 12:06 p.m. the administrator stated R1 was his own person. R1 had signed a contract but was never given any written consequences for previous smoking infringements. The administrator stated this was the first time R1 had lit himself on fire with the oxygen on. The administrator was not aware that R1 had smoked with the oxygen on before this event. The facility policy Smoking ad E-Cigarettes dated 3/1/21, revealed smoking was only permitted in posted designated areas. No oxygen containers/tanks/materials or other flammable substances are permitted in the designated smoking area. It further indicated, smoking will only be permitted by residents after safety assessment by the interdisciplinary team. The past non-compliance that began on 3/8/22, was verified during the 3/17/22, in the afternoon and identified the immediacy was corrected on 3/15/22. During an interview on 3/17/22, at 12:25 p.m. the DON stated the facility had reviewed all care plans and updated with smoking assessments, risk verses benefits, illegal substances contracts, and acknowledgement of smoking policy. Further, if smoking substances were found, a room search would be ordered and put on the treatment administration record (TAR). All residents on oxygen had signs put on their doors. The facility had a Safety Council meeting, updated the contraband, smoking, and oxygen use policies, conducted a facility wide smoking education and a mock fire drill. Audit of resident documents verified smoking assessments were completed and care plans were updated on 3/9/22. Documented notes verified a Safety Council Meeting and fire drill on 3/9/22. Staff interviews on 3/17/22, confirmed training had been completed and were aware of smoking policy, and the reporting of smoking concerns. Staff interviews indicated staff were aware of R1's smoking restrictions. Other documentation provided, revealed that as of 3/15/22, the facility had over 90% of staff re-educated on Improper/Unsafe Resident Smoking and the Prohibition of Illegal/Illicit Materials in the facility. Facility conducted audits on resident smoking safely.

Based on observation, interview, and document review, the facility failed to comprehensively develop appropriate interventions to ensure adequate supervision was provided to prevent known off-campus activities which increased the risk of harm and/or injury for 1 of 1 resident (R5) assessed and care planned to require supervision in the community and identified to repeatedly be leaving the nursing home to purchase and/or use alcohol and marijuana (an illegal psychoactive drug). These findings constituted an immediate jeopardy (IJ) situation for R5. The IJ began on 8/27/21, when R5 left the nursing home campus and was later found at a gas station intoxicated by the local police department. R5 demonstrated mumbled speech and was unable to safely operate his electric scooter. R5 was returned to the nursing home; however, was not comprehensively or accurately reassessed for his wander risk nor were interventions placed to ensure adequate supervision. This resulted in R5 repeatedly leaving the campus, purchasing, and using alcohol and/or marijuana which increased his risk of serious injury or harm while off-campus. The administrator and director of nursing (DON) were notified of the IJ for R5 on 1/14/22, at 4:35 p.m. The IJ was removed on 1/18/22, at 11:35 a.m. after an acceptable removal plan was implemented, however, non-compliance remained at an isolated pattern with potential for more than minimal harm which is not immediate jeopardy (Level D). Findings include: R5's Face Sheet undated, indicated R5 admitted to the facility on [DATE]. R5's Care Plan revised 11/22/21, indicated R5 was considered a vulnerable adult due to his cognitive and functional deficits and was not to leave the facility without supervision from his guardians or aunt, and R5 refuses to comply with plan to not leave the facility unsupervised. (date initiated 8/17/21). R5's significant change Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intact, had no behaviors and no wandering. R5's MDS further indicated he received antidepressant medications (used to address symptoms of depression), antipsychotic medications (used to manage [CONDITION(S)], including delusions, hallucinations, paranoia or disordered thought) and hypnotic medications (produce sleep). R5's Wandering Risk Scale assessment dated [DATE], indicated R5 was dependent on activities of daily living (ADL)'s, and cannot move with out assistance and required assistance from staff for transfers and was independent with the use of an electric wheelchair. The assessment further indicated R5 was at low risk for wandering. R5's Risks vs Benefits assessment dated [DATE], recommeded R5 would not leave facility unsupervised due to high risk for abuse by others and exploitation due to his cognition and [CONDITION(S)] diagnosis. In addition, the assessment indicated R5's guardian agreed with the plan not to allow R5 to leave the facility without supervision however, the guardian did express R5 is going to do what [R5] wants to do. R5's Occupational Therapy assessment dated [DATE], indicated R5 had [CONDITION(S)] (paralysis of the arms and legs caused by neurological damage), alcohol addiction and abuse, nicotine dependence, depression and [CONDITION(S)] (a mental disorder in which a person consistently shows no regard for right and wrong and ignores the rights and feelings of others). The assessment further indicated R5 lacked capacity for chronic disease management and lacked insight into condition. R5's Medical History undated, indicated he was diagnosed with [CONDITION(S)] and a traumatic brain injury following a car accident and uses a mobilized wheelchair for mobility. Review of R5's progress notes indicated on 8/27/21, the facility received a phone call from St. Cloud police that R5 was found at a nearby gas station. R5's speech was mumbled and did not appear to be able to safely drive himself back to the facility in his motorized wheelchair. He was sent to the emergency room (ER) and treated for alcohol toxicity. During interview 1/13/22, at 4:05 p.m. assistant director of nursing (ADON) stated she had concerns with R5 leaving the facility and coming back smelling like marijuana along with his old roommate. The ADON stated he was hospitalized in the past for alcohol intoxication. The ADON stated he will make phone calls and go off the facility grounds to buy marijuana which they would then confiscate from him. During interview on 1/14/22, at 1:00 p.m. the director of nursing (DON) stated R5 had a motor vehicle accident in his teens and was diagnosed with a traumatic brain injury following the car accident and now used a motorized wheelchair for mobility. The DON stated she was unsure how he obtained the alcohol for his 8/27/21, ER visit. Further the DON stated R5 had made plans to go get medical marijuana that day (8/27) and his dad said he could not go, so the facility canceled his cab. The DON stated the facility was aware R5 was upset and took off (left campus unsupervised) but did not consider this an elopement. He was found later at the gas station very intoxicated by the police. During interview on 1/14/22, at 11:39 a.m. receptionist stated she was informed about 2 weeks ago that she could let R5 leave the building to smoke and was given no instruction to observe him. She stated she was unable to see him or keep him in her line of sight while he was outside. She does not keep track of how long he was outside or when/if he returns. During observation and interview on 1/14/22, at approximately 11:00 a.m. surveyor was informed R5 had left the facility and the DON had just called 911. Both surveyor and ADON went outside and found R5 driving down the middle of the road in his motorized wheelchair toward the facility during moderate snow fall, with difficult visibility. R5 was observed to be wearing just a sweatshirt and pants with footwear, no jacket or other outerwear. The temperature was 10 degrees. The facility was unsure what time R5 may have left the building that morning. -while outside looking for R5, the ADON pointed out a secured smoking area that was monitored by staff. Later at 3:30 p.m. the ADON was interviewed and asked why R5 does not use the secured smoking area, at which time the RN manager stated that R5 does what he wants, when he wants. During interview on 1/14/22, at 2:10 p.m. the DON stated R5 had left the facility unsupervised at least 5 times since admission. The DON further indicated on multiple occasions he was found with marihuana they had to confiscate from him. Record review of R5's drug screening indicated on 8/12/21, 8/27/21, and 12/28/21, R5 tested positive for tetrahydrocannabinol (THC). During interview on 1/14/22, at 2:53 p.m. nursing assistant (NA)-B stated R5 was allowed to go outside for about 10 minutes. She is not sure who monitors him, it would have to be the person who let him out. NA-B indicated she received training that R5 and his roommate could go outside but had to have coats on first. She was not aware they had to be supervised. Review of Realis computer training records indicated on 1/7/22, R5 and his roommate can go outside for 10 minutes if they put a coat on. Communication to employees lacked evidence R5 required supervision if leaving the facility as indicated in his Care Plan. During interview on 1/14/22, at 2:57 p.m. licensed practical nurse (LPN)-B stated R5 was allowed to leave the facility. In addition, LPN-B stated with his behavior changes they are reassessing if this should be allowed. LPN-B also stated that today he had an incident and they did not know where he was so they had to call 911. During interview on 1/14/22, at 3:04 p.m. ADON stated R5 was able to go outside for 10 minutes and could not leave the grounds, and needs supervision per his guardian. Furthermore the ADON stated she just had gotten off the phone with R5's dad minutes before this interview and stated his dad does not want him to be leaving the facility grounds because he engages in self destructive behavior such as heavy drinking, drugs, ect. and R5 is very difficult to work with. In addition, the ADON stated she had been instructed when R5 leaves the facility it was not considered an elopement since he had a destination he was going to. During interview at 1/14/22, at 3:30 p.m. the DON stated the facility does not have any formal plans for when R5 leaves the facility grounds to direct the staff what to do if they suspect he had been under the influence of alcohol or drugs. In addition the DON stated they were not following the care plan as stated and should have had a better system in place for staff to be monitoring when R5 was leaving and returning, including the staff at the front desk monitoring his exit. During interview 1/17/22, at 11:00 a.m. R5's guardian stated he does not want R5 to leave the facility grounds without supervision since he does not make safe decisions. The facility's Elopement Policy revised 9/2/21, indicated, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents identified will have these issues addressed in their individual care plan. The IJ which began on 8/27/21, was removed on 1/18/22 at 11:28 a.m., when the facility successfully implemented a removal plan which included reviewing the applicable policies and procedures, ensured all residents were reassessed and care planned for their elopement risks and needs, and ensured all facility tools (i.e. w binder) were updated with current, correct information to help staff ensure safety and prevent elopements of residents identified to be at risk and those at risk are supervised. On 1/18/22, from approximately 9 a.m. to 11:00 a.m. direct care staff were interviewed and verified education had been completed and systems were in place to ensure residents were not at continued significant risk of elopement and those at risk are supervised but, non-compliance remained at an isolated pattern with potential for more than minimal harm which is not immediate jeopardy (Level D).

Based on observation, interview and document review, the facility failed to have a preventative maintenance plan for resident Hoyer slings to ensure the integrity of the slings for safe resident use for 1 of 2 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R1 when the sling split open while R1 was being transferred in the Hoyer lift and he fell , sustaining minor injuries. The IJ began on 11/17/21, when R1 fell while being transferred in the Hoyer lift when the sling split open and R1 fell to the floor, sustaining minor injuries. The administrator and director of nursing (DON) were informed of the IJ on 12/16/21, at 5:53 p.m. The immediate jeopardy was removed, and the deficient practice corrected on 11/18/21, prior to the start of the survey and was therefore Past Noncompliance Findings include: R1's Diagnosis Information, undated, indicated R1's diagnoses included diabetes, unsteadiness on feet, other abnormalities of gait and mobility and [CONDITION(S)]. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated no cognitive impairments and required assistance of staff with transfers. R1's care plan dated 10/7/21, indicated R1 had impaired mobility related to his obesity. The care plan indicated R1 required assistance of two staff with Hoyer transfers and was non-ambulatory. On 12/13/21, a common entry point (CEP) was submitted to state agency (SA) which indicated on 11/17/21, R1 was going to take a shower. Only one nursing assistant was using the Hoyer lift during the transfer. R1 was up five feet, cleared bed and straps broke. R1 dropped five feet. On 11/17/21, at 9:00 p.m. a progress note indicated R1 had a fall; at 9:15 p.m. another progress note indicated R1 had a bath/shower and had a fall. No further details were noted in progress notes. On 11/17/21, at 8:48 p.m. a facility risk assessment indicated an incident description from registered nurse (RN)-A was called to R1's room where R1 was on floor. Aide stated that the sling had ripped and R1 fell to floor. R1 voiced pain in left shoulder, neck, and right hip. R1 was alert and oriented. R1 was interviewed and agreed with aide description. R1 was immediately assessed for bruises, RN-A did a neuro exam, and checked vitals. No bruises noted, nothing appeared to be broken. Sling replaced. No injuries were observed at time of incident. During observation and interview on 12/15/21, at 11:50 a.m. R1 was sitting in his wheelchair in his bedroom. R1 stated he was being transferred from his bed as he was getting ready for a bath. R1 stated only one nursing assistant was performing the transfer with the Hoyer lift. R1 stated he fell while in the sling and believed one of the loops ripped. R1 stated he was not interviewed about how the fall occurred. R1 stated he did not suffer any major injuries, only a sore shoulder. During observation R1's Hoyer sling was not observed in his room. When interviewed on 12/15/21, at 4:28 p.m. RN-A stated she completed the assessment after R1 fell , she was not a witness. RN-A stated the nurse aide came to her and stated R1 had fallen from the Hoyer and believed she was alone but did not remember which aide it was. RN-A stated the sling was removed by assistant director of nursing (ADON) and given a new sling to use. RN-A stated she did not make a report to the State Agency. When interviewed on 12/16/21, at 10:16 a.m. director of nursing (DON) stated she completed the investigation when R1 fell on [DATE]. DON stated it was unknown who was assisting R1 with the transfer. At request of survey staff, DON reviewed camera footage and it was identified at that time, only one aide preformed the Hoyer lift transfer resulting in a fall. DON stated it is policy to have a minimum of two staff assisting in a Hoyer transfer. DON stated the sling had been removed when it ripped during the transfer. DON stated after the incident the sling was thrown away and added they did not contact the manufacturer to report the malfunction of the sling. DON stated the sling was ripped on a loop and noted the rip was not at the seam but rather in the center of the fold of the loop. DON stated staff were re-educated on checking slings integrity before use, reviewed importance of following R1's care plan and reviewed facility policy. DON stated an audit was developed and completed for all slings which resulted in no concerns with the integrity of other slings in the facility. DON stated there was no audits performed on slings prior to this incident. DON stated the incident was not reported to the SA as R1 did not suffer any injuries. When interviewed on 12/16/21, at 11:19 a.m. assistance director of nursing (ADON) stated she worked the day of R1's fall on 11/17/21. ADON stated she was called to R1's room after the fall occurred and assisted getting R1 off the floor. ADON stated when she arrived after the fall there were three staff present but was not sure who performed the transfer or how many were present, ADON did not investigate with staff interviews. Phone call interview on 12/16/21, at 1: 25 p.m. with sling manufacturer INVOCARE representative who stated when a facility had an incident with a sling, they would want all incidents reported and would want the sling sent back so they could complete their own investigation to determine the cause of the fall/rip. During observations on 12/16/21, starting at 3:25 p.m. two separate resident Hoyer lift transfers were observed with no concerns regarding sling integrity or care plan implementation noted. Nursing assistant (NA)-A was attempted to be interviewed for this survey; calls were not returned. On 11/18/21, facility provided education on sling integrity with all floor staff. On 11/18/21, facility administered a Hoyer sling integrity audit resulting in no other issues with the slings in the facility. R1's sling was removed and provided a new sling. Facility's Policy and Procedure Using a Mechanical Lift dated 8/1/15, indicated the portable lift should be used by two nursing assistants to perform the procedure. Facility's Policy and Procedures Post Fall Policy dated 3/23/20, indicated to complete a Risk Management incident. The report should include but is not limited to the following information: residents account of the incident. The past non-compliance immediate jeopardy began on 11/17/21. The immediate jeopardy was removed, and the deficient practice corrected by 11/18/21, after the facility implemented education with all staff concerning implementation of care plan needs of residents, integrity of slings, removal of the malfunctioned sling and current and ongoing audits of all the slings in use at the facility. Audits concluded no other slings were malfunctioning. Verification was identified onsite through interview, observation, and record review.

Based on interview and document review, the facility failed to test staff for COVID-19 according to county transmission rate, and outbreak status as directed by the Center for Disease Control (CDC). The facility was in COVID-19 outbreak status since 9/17/21 which resulted in four staff (NA-D, NA-E, PT-A, DA-A) testing positive for COVID-19. Further, the facility failed to restrict 1 of 1 staff (DA-A) to return to work whom had COVID-19 symptoms 3 days earlier, pending the results of COVID-19 testing. This practice resulted in an immediate jeopardy (IJ) situation which had the likelihood to cause serious illness or death for all 67 residents residing in the facility. The immediate jeopardy began on 9/17/21, when the facility was notified a staff member tested positive for COVID-19. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 10/7/21, at 5:57 p.m. The immediate jeopardy was removed on 10/12/21, at 10:30 a.m. but noncompliance remained at the lower scope and severity level of F, which indicated widespread scope, and no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: During entrance conference on 10/4/21, at 11:48 a.m. administrator and DON (Director of Nursing) stated she was the Infection Preventionist, the facility census was 67 residents, and the facility was currently testing staff twice a week because of high community transmission rate. Additionally, the DON stated there had been no active or suspected COVID-19 cases in the building for the last two weeks. The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated 9/10/21, indicated a single new case of [CONDITION(S)]-CoV-2 infection in any health care personnel (HCP) or a facility-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak, and the facility should perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but not earlier than 2 days after the exposure, if known) and, if negative, again 5-7 days later. If no additional cases are identified during the broad-based testing, no further testing is indicated after 14 days. However, if additional cases are identified, testing should continue every 3-7 days until there are no new cases for 14 days. The document further indicated unvaccinated HCP should continue routine testing based on the CDC Reports of COVID-19 Community Transmission Levels, and in nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have [CONDITION(S)] testing twice a week. Additionally, anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test as soon as possible; and symptomatic HCP, regardless of vaccination status, should be restricted from work pending evaluation for [CONDITION(S)]-CoV-2 infection. According to the CDC Reports of COVID-19 Community Transmission Levels per CDC Data Tracker for Minnesota, [NAME] County was at a High Level of Community Transmission between 8/11/21 to 10/8/21. The facility provided an untitled document, printed 10/4/21, with the handwritten text 83% COVID Vax (vaccination) on the top of the document. The document was a list of resident names and their COVID-19 vaccination record for each resident. The facility provided an untitled document, dated as of 9/20/21, with the hand written text 49% COVID Vax at the top of the document. The document identified a list of staff names, cell phone number, job title, and COVID-19 vaccination status. The DON provided in the morning on 10/5/21, several stacks of rubber-banded, untitled forms. She identified these were the facility testing forms. Each untitled form indicated the staff name, gender, date of birth, home address, contact phone number, symptoms, pregnancy status, date, time, and COVID testing results. The DON also provided in the morning on 10/5/21 an untitled, undated document with a list of staff names. The DON stated the document was, a listing of COVID positive staff for 2021. The list contained 13 staff names and the date each tested positive for COVID-19. The positive staff ranged from January to August 2021, with the last staff identified being positive was on 8/23/21. The DON identified on 10/6/21, at 1:35 p.m. the stacks of rubber-banded documents was their tracking method for COVID-19 testing of staff. Additionally, DON reported she did not have a system in place to ensure unvaccinated staff were completing COVID testing as identified by county transmission rate or that all staff were tested as required when the facility was in outbreak status. The DON was unable to determine which staff completed testing or if they tested at all. The facility's List of COVID Positive Staff for 2021 indicated the previously identified COVID-19 infection had been 8/23/21, 23 days before NA-D's positive result on 9/17/21. Review of the rubber banded documents and COVID testing (POC testing results) identified the following: NA-D NA-D's POC Testing Result Report identified she was COVID positive on 9/16/21. On 10/7/21, at 9:21 a.m. DON stated NA-D received a polymers chain reaction (PCR) test on 9/15/21, NA-D worked on 9/16/21, and the facility became aware on 9/17/21 NA-D was positive. DON further stated NA-D was asymptomatic and worked on 9/15/21, 9/16/21, and was removed from the schedule on 9/17/21 until 9/30/21. The facility's vaccination document, identified NA-D was fully vaccinated. The DON stated, because NA-D was positive the facility started testing residents and staff twice a week for outbreak testing starting on 9/17/21. NA-E DON stated on 10/7/21, at 9:21 a.m. NA-E received a COVID-19 test outside the facility on 9/22/21, 6 days after NA-D tested positive. DON stated, NA-E was asymptomatic when she last worked at the facility 9/16/21 and had not worked since, and then became symptomatic and tested positive on 9/22/21. DON further stated NA-E was removed from the schedule until 10/6/21. The 9/20/21 staff vaccination form, identified NA-E was fully vaccinated. The POC Test Result form, printed on 10/7/21 indicated that NA-E was last tested on [DATE], even though she was not required to be tested because she was fully vaccinated per CDC recommendations. PT-A PT-A's POC Test Results report, printed 10/7/21, indicated PT-A tested positive for COVID-19 on 10/1/21, and tested negative for COVID-19 on 9/29/21. The facility Labor Details Report printed 10/7/21 indicated PT-A worked on 9/18, 9/23 and 9/24/21. The facility provided no evidence PT-A was tested twice a week between 9/17/21 and 9/28/21 while the facility was in outbreak status. During interview on 10/7/21, at 9:21 a.m. the DON stated PT-A became symptomatic and did not work but was tested on [DATE]. PT-A was removed from the schedule after testing positive. Her return date was undetermined. The DON stated at 5:12 p.m. that PT-A had not been tested for COVID-19 between 9/17/21 and 9/28/21 and acknowledged PT-A should not have worked on 9/18, 9/23, and 9/24/21 without first being tested , as the facility was in outbreak status. DA-A: The DON stated on 10/7/21, at 9:21 a.m. that dietary aide (DA)-A arrived at work at 7:00 a.m. on 10/3/21 and was sent home at 7:15 a.m. after notifying her supervisor that she had a headache. DA-A was not tested for COVID-19 even though DA-A had COVID symptoms. DA-A returned to the facility on [DATE], at 2:00 p.m. and did not have any COVID symptoms. On 10/6/21, at 3:30 p.m. the DON identified DA-A has not completed any testing for the day, and had DA-A complete a test. DA-A tested positive for COVID-19. DA-A had worked for 90 minutes on 10/6/21 before she was tested . Review of a facility provided form, untitled, dated 10/6/21, indicated DA-A's name, gender, date of birth, home address, contact phone number, pregnancy status, symptoms none, dated 10/6/21 at 3:30 p.m. results positive, and the DON's initials were written on the form. The facility provided document, untitled, dated as of 9/20/21, indicated DA-A was not vaccinated for COVID-19. Review of DA-A's POC Test Results report, printed 10/7/21, indicated DA-A tested negative for COVID-19 on 9/24/21, 9/14/21, 9/8/21, 9/4/21, 9/3/21, 9/2/21, 8/30/21, 8/27/21, and 8/26/21. DA-A did not test biweekly as identified by the county transmission rate for routine testing. DA-A only tested weekly during this time. In addition, the facility provided no evidence DA-A completed outbreak testing between 9/17/21 to 9/24/21, and 9/25/21 to 10/6/21. Further, there was no indication DA-A completed testing before she worked with residents and other staff. Review of Talahi Nursing and Rehab Center Schedule, dated 9/1-9/30/21, and 10/1-10/7/21, indicated DA-A consistently worked 4-5 days a week from 9/2-10/6/21. After review of facility provided testing paperwork, there was no indication the facility implemented outbreak status testing guidelines as identified by the CDC. There was no indication the facility had completed staff testing twice a week, testing immediately (but not earlier than 2 days after the exposure, if known) and, if negative, again 5-7 days later, until there were 14 days where no staff have tested positive for COVID. On 10/7/21, at 9:21 a.m. the DON stated PCR tests were done on Tuesdays, POC tests were done on Fridays, and outbreak testing lasted until the facility had 14 days without any new positive cases. In addition, DON stated if staff missed scheduled testing dates, they were expected to complete a POC test the first date they returned to work before going on the floor stating, I encourage everyone to get tested . The DON confirmed a tracking system was not in place to monitor for staff COVID-19 testing compliance. During interview on 10/7/21, at 5:12 p.m. the DON confirmed DA-A was unvaccinated and removed from the schedule after testing positive for COVID-19 with an undetermined return date. The DON further confirmed DA-A had not completed routing testing twice a week between 9/5/21 and 9/16/21. In addition, the DON stated DA-A was not tested for COVID-19 between 9/24/21 and 10/5/21 while the facility was in outbreak status. The DON acknowledged DA-A should not have worked 10/1/21 and 10/2/21. The facility's COVID-19 Testing Plan policy revised 9/13/21, indicated the facility would test all unvaccinated staff at the frequency prescribed by the CDC based on community transmission level. The policy further indicated outbreak means there is a new COVID-19 infection in any staff, or any nursing home-onset COVID-19 resident infection. In response to an outbreak, all residents and staff would be tested regardless of vaccination status and serial testing would be completed every 3-7 days until there were no new positive cases for 14 days. In addition, the policy indicated staff with COVID-19 signs or symptoms would be tested regardless of vaccination status, and the staff member would not report to work while waiting for test results. The IJ was removed on 10/12/21, at 10:30 a.m. when it was verified through interview and document review the facility policies were reviewed and an addendum dated 10/8/21, was added to reflect protocol for outbreak testing, routine testing of unvaccinated staff, and staff that do not comply with testing requirements. The facility developed a testing plan which included daily review of staff schedules to validate testing compliance. Education to all staff was provided on updated COVID-19 testing protocols prior to scheduled shifts. Regional Director of Clinical Services provided the DON with additional education, and will continue to provide oversight, education, and support. Completion of testing and training will be tracked, analyzed, and acted upon to ensure compliance.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R2) with escalating behaviors, including newly recorded sexual behaviors, was comprehensively assessed and interventions implemented to mitigate risk to others and prevent subsequent sexual assault of 1 of 1 residents (R1) reviewed whom was non-verbal and dependent on staff for their care. These findings resulted in an immediate jeopardy (IJ) situation for R1 when she was sexually assaulted by R2 while at the nursing home. The IJ began on 10/19/20, when R2 refused routine laboratory monitoring and his ordered antipsychotic medication was held without timely notification to the provider. R2 then demonstrated escalating behaviors, including newly recorded sexual behaviors, which the facility had knowledge of but failed to comprehensively assess and develop interventions to help manage and reduce the risk of injury or assault to others. This contributed to R2 subsequently entering R1's room and sexually assaulting her; and although R2 was removed from the nursing home, the facility had not reassessed R1's vulnerability to potential abuse from others despite being sexually assaulted. The regional director of operations for Minnesota (RDO) and director of nursing (DON) were notified of the IJ for R1 on 11/17/20, at 3:39 p.m. The IJ was removed on 11/18/20, at 4:36 p.m. when the facility successfully implemented a removal plan; however, non-compliance remained at an isolated scope with actual harm (Level G). Findings include: A submitted state agency (SA) Incident Report, dated 11/6/20, identified a facility's reported allegation of sexual abuse involving R1 and R2. The report outlined R2 had been found in R1's room . having sexual intercourse. The report outlined the police were contacted and removed R2 from the facility, and R1 was transported to the hospital for evaluation. Further, the report listed several witnesses to the allegation which included nursing assistant (NA)-A, NA-B, licensed practical nurse (LPN)-A and registered nurse (RN)-B. R2's quarterly MDS, dated [DATE], identified R2 had [MEDICAL CONDITION] (a disorder which affects a person's ability to think, feel, and behave clearly) and moderate cognitive impairment. Further, R2 demonstrated no hallucinations, delusions or rejection of care behaviors, and required only supervision with ambulation in the corridor and his room. R2's most recent [MEDICAL CONDITION] Medication Review and Evaluation, dated 9/22/20, identified R2 had [MEDICAL CONDITION] and received several [MEDICAL CONDITION] medications including [MEDICATION NAME] (an antipsychotic), [MEDICATION NAME] (used to reduce anxiety), and [MEDICATION NAME] (another antipsychotic medication). The form identified a primary target behavior which read, Hearing voices, and this was listed as happening every two weeks. The assessment listed a radio-button style question which read, Do these behaviors cause the resident to present a danger to themselves or others . of interfere with the staff's ability to give care? This was answered, No. Further, the assessment identified R2's behaviors and management as, Controlled. R2's care plan, dated 10/5/20, identified R2 had a communication deficit and directed staff to, Anticipate and meet needs. R2 consumed antipsychotic medication and the care plan listed a goal of being free of [MEDICAL CONDITION] medication related complications with several interventions to help R2 meet this goal including, but not limited to, administering the medication(s) as ordered, consulting with the pharmacist and physician on potential dose reductions, and monitoring for adverse side effects including agitation and restlessness. Further, the care plan identified R2 was considered a vulnerable adult due to his cognitive impairments and outlined several interventions which included discussing behavioral issues with the interdisciplinary team (IDT), evaluating for possible causative factors if issues are identified, and, Resident requires close observation. The care plan lacked further dictation on how R2 would be closely observed to ensure his or others safety. R2's medical record was reviewed and identified the following: On 8/18/20, a progress note identified R2's ordered [MEDICATION NAME] was reduced to 25 milligrams (mg) due to an abnormal ECG (records the electrical signal from your heart to check for heart conditions). There were orders to follow-up with the psychiatric nurse practitioner (NP)-A in one month. On 10/1/20, a progress note identified R2 had refused his bath despite re- approach. The note did not identify any other demonstrated behaviors by R2 despite refusing his bath. On 10/15/20, a FOCUS progress note was recorded which listed, Behaviors, as the reason for review. R2 was recorded as having [MEDICAL CONDITION] and R2's [MEDICATION NAME] reduction (from 8/18/20) was identified. R2 had moderate cognitive impairment and a section labeled, Mood/Behavior, identified R2 as having anxiety and restlessness. However, the note lacked any further information on these listed behaviors, including how often the behaviors were happening, if at all, or specifics around any demonstrated episodes of them. Further, the note identified a section labeled, Care plan interventions, which directed, Notify MD (medical doctor) with any mood changes are observed, trauma informed approach observing and monitoring, provide opportunities for expression of feelings. There were no further recorded behaviors demonstrated by R2 in the progress note(s) from 9/1/20 to 10/19/20. On 10/19/20, a progress note identified the pharmacy came to deliver R2's antipsychotic medication and draw routine laboratory work. R2 refused and threw his coffee at the employee. The note outlined, Pharmacy unable to delivery (sic) medication since resident refused lab draw. The note identified registered nurse (RN)-A was updated. On 10/22/20 (three days later), a progress note identified R2 had refused the laboratory draw on 10/19/20, and it was ordered they continue to re-approach R2 and attempt to obtain the lab(s) so R2's [MEDICATION NAME] prescription could be filled. A corresponding Genevive (Physican Group) Progress Note, dated 10/22/20, identified R2's medical nurse practitioner (NP)-B was updated on R2's refusal to allow the laboratory draw on 10/19/20, so no medication was available for administration as a result. R2 was listed as consuming (receiving) 500 mg of [MEDICATION NAME] everyday. The note outlined NP-B responded, Please call and tell (nursing home) to keep trying with labs. His psychiatrist is the ordering provider I believe. On 10/23/20, a late-entry progress note was recorded which identified NP-B had been updated on R2's refusal to allow laboratory draw(s) for his [MEDICATION NAME]. The note continued, (NP-B) wanted Nystrom appointment made ASAP (as soon as possible). Nystrom (psychiatry clinic) appointment made for 11/12/20. On 10/31/20, a progress note identified R2 came and sat by the 'West Desk.' R2 was questioned if he needed anything by the staff, but then . began yelling at writer to shut up. After a few minutes a (NA) came down the hallway and he looked at her and yelled 'you [***] ing nigger' X3 (three times). R2 was recorded as spending a good portion of the day outside of his room walking around, including standing by the front door and pushing buttons in attempt to open it. The note lacked any evidence of interventions attempted by the staff to calm or redirect R2 despite these behaviors. On 11/1/20, a progress note identified R2 was recorded as being, . very agitated, restless and having hallucinations during shift . (nurse) waved at him and resident flicked nurse off, said '[***] you' . drew his arm back as if acting he was going to punch nurse. The note continued, This is very abnormal behavior for resident. The nurse sat down next to R2 and talked with him which was effective in calming him down. The note identified the laboratory had attempted to draw R2's lab(s) on the prior shift which is what caused resident to become upset. R2 was provided education on the importance of the lab draw, however, the note outlined R2 continued to be observed as restless but without physical aggression or agitation. The note continued, (R2) approached nurse stating 'I am hearing voices.' Nurse asked what the voices were telling him and resident replied 'That no one likes me, everyone hates me, and that I should just die. The note identified the nurse provided comfort to R2 whom proceeded to hug the nurse and become upset and start crying. Genevive (physician service) was contacted due to R2's continued restlessness and an order for [REDACTED]. This was administered to R2 and the note recorded, . appeared to have effectiveness. R2's corresponding Genevive Phone Encounter note, dated 10/31/20, identified the nursing home had contacted the service reporting R2 . is experiencing increased agitation, aggression and hallucinations . patient was receiving [MEDICATION NAME] (sic), though a script has not been sent as they are waiting for lab work to be completed, though patient continues to refuse labs . staff are concerned for his agitation. The note identified an order for [REDACTED]. On 11/1/20, another progress note was recorded which identified R2 was . noted to be pacing around facility through out the morning. Per (night shift) report, resident was up all night pacing and did not sleep. Resident asking staff to purchase cigarettes for him. Yelling at staff 'I can smoke if I want! I'm over 18!' Emotional support and reassurance provided. Resident then approached staff member at front desk. Became upset with staff member when unable to get cigarettes and threw desk supplies across lobby. The note outlined education and encouragement was provided, however, R2 . Becomes more and more angry as staff re-approach. R2 was then provided time and space to express his feelings and . appeared to calm down but continues to refuse medications. On 11/2/20, a progress note identified staff entered R2's room and R2 . had his pants off and was laying in bed. (R2) was masturbating. R2 proceeded to cover himself and the nurse provided R2 his oral pills when R2 then . put his right hand around the writers clavicle area then took his hand away and started to laugh. The note identified the nurse explained it was not appropriate to grab them in such a manner and left the room. On 11/2/20, a subsequent progress note identified, New behavior symptom noted. Behavior addressed with NP and guardian. On 11/3/20, a progress note identified order(s) were received from NP-B to send R2 to the emergency room (ER). A subsequent note, dated 11/3/20, identified R2 had met with his guardian (G)-A and the nurse attempted to get the needed laboratory draw completed while she was present. The note recorded, . resident yelled '[***] you, you ain't taking any labs', then resident picked up an orange traffic cone and threw it at his guardian. NP-B was updated regarding the continued inability to draw the needed lab(s) and R2 . had been off his [MEDICATION NAME] for almost two weeks, and that writer believed resident needed to be sent in to the hospital for further evaluation. R2 was sent to the hospital ER via ambulance. R2's corresponding Genevive Progress Note, dated 11/3/20, identified NP-B was contacted as R2 had gone without his ordered [MEDICATION NAME] for two weeks as he was refusing to allow laboratory draws. The note identified, Behaviors increased (due to) not getting med. R2's guardian was present, and typically was able to get R2 to have labs drawn, so the nursing home staff were seeking an order for [REDACTED]. (R2) threw a traffic cone at his guardian. Guardian states that she has never seen (R2) as agitated and aggressive as he is right now, wants sent into ED. Facility staff also aren't able to manage behaviors at this time. A telephone order was provided to send R2 to the ED. R2's corresponding ED Provider Notes, dated 11/3/20, identified R2 presented to the ED with a chief complaint listed as, Aggressive behavior. R2 reported he was homeless before then voicing he resided at the nursing home, and also was recorded as throwing a telephone at one of the nurses. R2 voiced he was unaware why he had been sent to the ED, but did endorse having suicidal ideation. R2's needed laboratory draw(s) were completed and a behavioral consultation was completed and cleared him for discharge back to the nursing home. R2 was recorded as, . he is now willing to go back on his medications. Further, R2's Behavioral Access progress note, dated 11/3/20, identified R2 reported not taking his medications as they made him feel stressed out. R2 voiced he would return to the nursing home and . be on my best behavior and I'll take my medicine. R2 denied command hallucinations to hurt himself or others, but acknowledged having visual hallucinations at times. Further, R2's clinical status was listed which identified highly impulsive and aggressive behavior(s) towards others. R2 was cleared to return to the nursing home. On 11/4/20, a progress note identified R2 returned from the ER and had several labs, including a urinalysis completed. The results were negative for a bladder infection and no new medication or treatment orders were provided. The note concluded, He is to see (nurse practitioner) in 2 days. On 11/4/20, a subsequent progress note identified the pharmacy had been updated on the completed laboratory draws, and R2 . needed his [MEDICATION NAME] (sic) medication as soon as possible. The pharmacist voiced they would contact the hospital to review the laboratory results and would contact the nursing home. The note concluded, Writer is awaiting call back from pharmacy. Further, an additional note, dated 11/4/20, identified the pharmacy was again contacted. The pharmacist voiced they needed more information on how many days R2 had been without his [MEDICATION NAME]; which the nursing home expressed had been two weeks since his last administration . The pharmacist then expressed they needed to speak with the provider who prescribed the medication to see if it needed to be re-titrated given the length of time R2 had been off the medication. The pharmacist voiced a message had been left for the provider, and the note concluded, Writer is awaiting a respond from pharmacist . On 11/6/20, at 1:38 a.m. a progress note identified R2 was seen coming out of his room at approximately 11:30 p.m. (on 11/5/20) and voiced he was going to get a soda. The note continued, . When he didn't come back in 15 minutes . asked CNA to go se if he was still by pop machine but CNA couldn't find him. Writer, nurse from east (sic) and 2 CNA's split up to check all rooms and other areas of the building . (NA-A) found him raping a female resident and screamed for help. The 2 male CNA's pulled him off her and walked him back to his room. The DON (director of nursing) and charge RN were called. The police were called and the police took him about (1:30 a.m.). For more details see VA (vulnerable adult) report. R2's Medication Administration Record [REDACTED]. An order was listed for [MEDICATION NAME] 500 milligrams (mg) everyday; which had a listed start date of 6/25/20. The medication was recorded as being given and consumed by R2 until 10/20/20. From 10/21/20 to 11/5/20, the MAR indicated [REDACTED]. R2's Documentation Survey Report, dated 9/2020 to 11/2020, was reviewed and identified R2's recorded behaviors using a legend and corresponding code system. The report demonstrated R2 had no recorded behaviors, including hitting, threatening, cursing at others or sexually inappropriate behaviors, in the month of September and October 2020. However, R2 had a single episode of sexually inappropriate behavior recorded on 11/2/20 which was outlined as, disrupted (the) environment. R2 was re-directed but the intervention was ineffective. The report lacked any further dictation on what the demonstrated sexual behavior was, and no other behaviors were recorded for R2 on these reports despite the repeated progress note(s) which identified him as cursing, throwing objects and wandering around the facility. R2's medical record was reviewed and lacked evidence R2's escalating behaviors had been comprehensively assessed to help determine all contributing factors and subsequent interventions to help reduce and/or eliminate them despite the abrupt stopping of his prescribed antipsychotic medication. There was no evidence interventions had been implemented on a consistent basis to ensure R1 was adequately supervised and monitored to prevent altercations and potential abuse towards or from other residents despite R2 being independently mobile and ongoing documentation of escalating behaviors, including physically throwing items, hallucinating and being found masturbating in his room. On 11/13/20, at 12:22 p.m. R2's appointed guardian (G)-A was interviewed. G-A stated she had been involved in R2's care for over the past year and explained R2 admitted to the nursing home in June 2020 for some rehabilitation therapy after a hospitalization . G-A described R2's mentation as stable until he went off his meds and outlined she felt he was doing quite well before 10/19/20. G-A expressed R2 had refused his laboratory draw which is what led him to not be provided his ordered antipsychotic medication and subsequently have worsening behaviors. G-A voiced she had never known or seen R2 to act with the demonstrated behaviors he had in the weeks prior to his arrest and subsequent discharge from the nursing home. G-A then recalled the events which led up to 11/6/20 and him sexually assaulting another resident. G-A was aware R2 had been found masturbating in his room on 11/2/20, and then expressed the facility had contacted her regarding moving R2 to a different room as he had previously been witnessed standing in the doorway of another resident's room and making inappropriate sexual comments. However, the facility never provided the documentation to her of him doing that as it had just been expressed verbally to her by a staff member whom she could not recall. G-A stated she was not notified timely of R2 refusing the laboratory draw, nor the subsequent holding of his antipsychotic medications, which was frustrating to her as the nursing home should have contacted her and he could have been hospitalized or treated sooner before sexually assaulting someone. Further, G-A stated R2 was currently locked in jail with multiple charges pending against him from the sexual assault which made her upset as she believed the entire escalation of R2's behaviors and subsequent sexual assault on another resident could have been prevented if the facility had responded appropriately. G-A reiterated, I believe this could have been prevented! R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had anxiety and depression, and had both long-term and short-term memory impairment. R1 was recorded as having no speech ability and was rarely, or never, able to understand others verbally. Further, R1 required extensive assistance with her activities of daily living (ADLs). R1's Social Services Data Collection/Assessment, dated 8/28/20, identified R1 had short and long-term memory impairment with severely impaired decision making capabilities. A staff assessment was conducted of her mood which identified no episodes of feeling down, depressed or hopeless or other indicators of mood impairment. The assessment listed a section labeled, Vulnerability Review, which identified R1 demonstrated no visible welts, bruises or injuries and had no history of abuse towards others. The assessment identified R1 was unable to report any abuse and/or neglect allegations and demonstrated no behaviors which would be indicative of abuse; however, the report did not outline which behaviors they reviewed or considered to make such determination. Further, R1 was recorded as being identified at risk for abuse from others. The assessment then listed a conclusion which read, Client is considered vulnerable but there are no signs of abuse, along with bolded font which outlined, Further develop individual resident prevention plans for any findings. Plan should include steps to minimize the risk of abuse / neglect for each vulnerable area identified in the assessment. Consider resident's history when identifying areas of risk. A series of generic care plan options were then listed to be selected. These identified a goal was chosen of, Resident will be provided a safe environment, and a total of three interventions were checked including observing for pain, discomfort and/or mental anguish; providing a safe environment; and, removing R1 from potentially abusive situations. The assessment had other options for interventions which were not selected including, . requires close observation. The assessment lacked any identified interventions specific to R1's inability to call for help or report abuse (i.e. formal safety checks on a routine basis, doorway left open when not providing care, etc.). R1's care plan, dated 11/6/20, identified R1 was considered vulnerable due to cognitive and physical impairments. The care plan listed a goal which read, Resident will be provided a safe environment, along with three interventions which directed to observe for potential pain, discomfort or mental anguish; provide a safe environment, and, remove R2 from potentially abusive situations. These were the only interventions listed on the care plan prior to 11/6/20 to help ensure R1 remain free of abuse despite being identified on her Social Services Data Collection Assessment (dated 8/28/20) as being unable to report abuse and being at risk for abuse from others. On 11/13/20, at 9:09 a.m. R1's family member (FM)-A was interviewed and recalled the incident from 11/5/20. FM-A explained he had been told another resident (R2) had got into her (R1) room and was caught in the act of sexually assaulting her. R1 was transported to the local hospital and a rape kit was completed which verified R1 had been sexually assaulted as they found injuries and bruising on R1's arms where the other resident had pinned her back while assaulting her. FM-A expressed relief the alleged perpetrator had been arrested and was no longer allowed to come back to the nursing home. Further, FM-A stated the nursing home had since moved R1 to a room closer to the nurses station to help her be more visible to the staff. R1's medical record identified the following: On 11/6/20, a progress note identified R1 had left the facility for evaluation after resident to resident incident. R1 returned to the nursing home on the same date. R1's corresponding hospital Sexual Assault Community Care Plan, dated 11/6/20, identified R1 had been transported to the hospital. A Date of Assault was listed of 11/6/20, with a physical location of the nursing home recorded. A section labeled, Patient Description of Assault, was outlined which identified information was gathered from NA-A, LPN-A and the St. Cloud Police Department which read, (R1) found in room by (NA-A), being vaginally penetrated by assailant. Assailant was pinning her down by her arms . it took 3 staff members to pull assailant off of patient . reported that he (R2) was thrusting in and out of patient for about 5 minutes. The report explained R1 as . tensing up with nursing cares, at the hospital and versed (used to make patients feel relaxed before procedures) was given. R1 was recorded as grinding her teeth during the examination which the report dictated, Guardian (FM-A) reported that (R1) grinds her teeth when in pain or distress. The report listed R1 as having visible petechiae (pinpoint, round spots that appear on the skin as a result of bleeding which can be due to localized trauma) to her arms and her left elbow region. The report outlined a vaginal examination was conducted which identified a reddened cervix, an abrasion to the clitoral head and hymen, and a laceration near the anus. On 11/6/20, a subsequent progress note identified the social services department contacted FM-A whom consented for psychiatric services for R1. Further, FM-A was offered and accepted moving R1 to a different room which was closer to the nursing station as . safety is more important than anything. On 11/7/20, a progress note identified a nurse entered R1's room and comforted her. The note continued, During this resident noted to get teary-eyed with some tears falling from face. Resident was observed to be grabbing at brief frequently. [MEDICATION NAME] was administered to help relax resident. On 11/10/20, a progress note outlined an order for [REDACTED]. response following the sexual assault by R2 with dictation reading, (R1) was recently sexually assaulted by a male resident and staff ask for psychological assessment to address ongoing trauma symptoms and concerns that may come to light post trauma. The report listed several recommendations for R1 which included having only female caregivers, observing for startle responses, and being closer to the nursing station. However, the completed report lacked any evident assessment of R1's vulnerability to continued abuse by others while residing at the nursing home. On 11/13/20, at 9:41 a.m. NA-A was interviewed and explained R1 required total assistance from staff to complete her cares while R2 was more independent. NA-A then recalled the incident involving R1 and R2 from 11/5/20, and detailed R2 had left his room and voiced he was going to walk down to the soda machine. R2 was gone for about 15 minutes when the nurse working (RN-B) had asked staff to start looking for R2 as he had been acting weird the last few days and had not returned yet. NA-A stated a facility-wide search was started involving herself and several other staff members including NA-B and RN-A. While helping search for R2, NA-A stated she walked by R1's closed room door which made her pause and check inside as R1's door was usually left open at night as she was unable to verbally call for assistance, so staff tried to keep a closer eye on her room. NA-A opened R1's closed door and saw R2 on top of R1 in her bed. R2 had no pants or underwear on and was holding her hands (down) on top of her and having sex with her. NA-A expressed R1's brief had been removed and R2's naked buttocks were visible immediately above her peri-area moving up and down. NA-A stated she immediately yelled at R2 to get off of her, but R2 just turned and looked at NA-A while he continued assaulting R1. NA-A then ran back into the hallway and called out loud for help from the male staff members who were standing in the hallway. They responded and removed R2 from R1's bed and took him to his room. NA-A explained the police were contacted and R2 was subsequently removed from the nursing home. Further, NA-A explained she had never known R2 to demonstrate sexual behaviors prior, but verified he was not on any formal supervision or monitoring despite being identified as acting weird the past few days. When interviewed on 11/13/20, at 10:20 a.m. RN-B stated R1 was mostly non-verbal and typically remained in bed all night as she required total assistance from staff whom completed rounds on her every two hours. RN-B described R2 as someone who didn't need much care and would often walk around the nursing home at night. RN-B stated R2 was not known to enter other resident's rooms to her knowledge. RN-B then recalled the incident involving R1 and R2 from 11/5/20, and explained R2 had come out of his room and voiced he was going to walk to the soda machine. R2 did not return after 15 to 20 minutes, so RN-B asked the floor staff to look for him as she wanted to make sure R2 did not accidentally wander onto the COVID-19 unit. They were initially unable to find him after searching the commons areas, so she directed the staff to begin checking each resident's room. RN-B was searching rooms on the North hallway when she heard her (NA-A) scream and responded. NA-A then told her R2 was found in R1's room and described the incident. R2 was removed and escorted back to his room, and RN-B stated she immediately contacted the DON who then provided instructions on how to handle the situation. The police department was contacted and responded whom then interviewed R2. The police then told RN-B that R2 had admitted he had done it and was then removed from the nursing home. RN-B recalled R2 never typically demonstrated any hallucinatory or aggressive behaviors which she could recall, however, voiced R2 had seemed to become more restless in the weeks leading up the 11/5/20 incident and R2's subsequent discharge from the nursing home. RN-B stated she was not sure why R2 had become more restless and expressed she wasn't aware there had been recorded notes outlining him as being aggressive or masturbating prior to the incident on 11/5/20; however, had learned of the notes since he was arrested and removed from the nursing home. Further, RN-B stated she had not received any education on how to handle sexual assaults or the facility's abuse prevention policies since the incident had happened. During interview on 11/13/20, at 11:16 a.m. LPN-A stated he was familiar with R1 and R2, and described R2 as being an independent resident who mainly (took) care of himself and often stayed in his room. LPN-A recalled the incident from 11/5/20, and voiced he was working on the locked unit when two NA staff had approached him and asked if he had seen R2 who had not returned from getting a soda. LPN-A stated he offered to help them search for him when he heard NA-A scream and yell down the hallway, He's raping her! LPN-A stated he immediately ran down to R1's room and witnessed R2 on top of R1 in her bed with R2's pants, boxers and shoes on the floor. R1's night gown was pulled up and her brief had been opened. LPN-A stated he did not witness R2 penetrating R1, but vividly recalled R2 was on top of her (R1) with his penis out and by her vagina. LPN-A added R2 was attempting for sure to have sexual intercourse with R1, if he had not already. R2 was immediately removed from R1 and they escorted him back to his room and told him his behavior and actions were totally inappropriate. Further, LPN-A stated he was unaware of any specific education or guidance the facility had implemented since the assault; however, added there was a nursing meeting coming up in the next weeks and he was hoping we're going to talk about that (the sexual assault incident). R1's medical record was reviewed and lacked evidence R1 had been comprehensively reassessed for her vulnerability since being sexually assaulted by R2 on 11/5/20, despite R1 being non-verbal and unable to report abuse or her physical impairment(s) resulting in a lack of being able to physically fight against a potential assailant. On 11/13/20, at 1:07 p.m. registered nurse manager (RN)-A and licensed social worker (LSW)-A were interviewed. They explained R2 admitted to the nursing home after a hospitalization and planned to discharge to a venue of less care when able to. They described R2 as calm and responsive and never really identif (TRUNCATED)

Based on interview and document review, the facility failed to ensure escalating behaviors were appropriately assessed and interventions implemented to ensure safety and reduce the risk of adverse events for 1 of 1 residents (R2) reviewed who demonstrated increased physical aggression and hallucinations after abruptly stopping their antipsychotic medication. This resulted in actual psychosocial harm for R2 when the lack of assessment and interventions contributed to escalating behaviors and the sexual assault of another resident resulting in R2's imprisonment. Findings include: A submitted state agency (SA) Incident Report, dated 11/6/20, identified a facility' reported allegation of sexual abuse involving R2 sexually assaulting another resident. The report outlined R2 had been found in the resident's room . having sexual intercourse. The report outlined the police were contacted and removed R2 from the facility. Further, the report listed several witnesses to the allegation which included nursing assistant (NA)-A, NA-B, licensed practical nurse (LPN)-A and registered nurse (RN)-B. On 11/13/20, at 12:22 p.m. R2's appointed guardian (G)-A was interviewed. G-A stated she had been involved in R2's care for over the past year and explained R2 admitted to the nursing home in June 2020 for some rehabilitation therapy after a hospitalization . G-A described R2's mentation as stable until he went off his meds and outlined she felt he was doing quite well before 10/19/20, when his prescribed [MEDICATION NAME] (an antipsychotic medication) was stopped abruptly. G-A expressed R2 had refused his laboratory draw which is what led him to not be provided his ordered antipsychotic medication and subsequently have worsening behaviors. G-A voiced she had never known or seen R2 to act with the demonstrated behaviors he had in the weeks prior to his arrest and subsequent discharge from the nursing home. G-A then recalled the events which led up to 11/6/20 and him sexually assaulting another resident. G-A was aware R2 had been found masturbating in his room on 11/2/20, and then expressed the facility had contacted her regarding moving R2 to a different room as he had previously been witnessed standing in the doorway of another resident's room and making inappropriate sexual comments. However, the facility never provided the documentation to her of him doing that as it had just been expressed verbally to her by a staff member whom she could not recall. G-A stated she was not notified timely of R2 refusing the laboratory draw, nor the subsequent holding of his antipsychotic medications, which was frustrating to her as the nursing home should have contacted her and he could have been hospitalized or treated sooner before sexually assaulting someone. Further, G-A stated R2 was currently locked in jail with multiple charges pending against him from the sexual assault which made her upset as she believed the entire escalation of R2's behaviors and subsequent sexual assault on another resident could have been prevented if the facility had responded appropriately. G-A reiterated, I believe this could have been prevented! R2's quarterly MDS, dated [DATE], identified R2 had [MEDICAL CONDITION] (a disorder which affects a person's ability to think, feel, and behave clearly) and moderate cognitive impairment. Further, R2 demonstrated no hallucinations, delusions or rejection of care behaviors, and required only supervision with ambulation in the corridor and his room. R2's most recent [MEDICAL CONDITION] Medication Review and Evaluation, dated 9/22/20, identified R2 had [MEDICAL CONDITION] and consumed several [MEDICAL CONDITION] medications including [MEDICATION NAME] (an antipsychotic), [MEDICATION NAME] (used to reduce anxiety), and [MEDICATION NAME]. The form listed a primary target behavior which read, Hearing voices. This was listed as happening every two weeks. The assessment listed a radio-button style question which read, Do these behaviors cause the resident to present a danger to themselves or others . of interfere with the staff's ability to give care? This was answered, No. Further, the assessment identified R2's behaviors and management as, Controlled. R2's care plan, dated 10/5/20, identified R2 had a communication deficit and directed staff to, Anticipate and meet needs. R2 consumed antipsychotic medication and the care plan listed a goal of being free of [MEDICAL CONDITION] medication related complications with several interventions to help R2 meet this goal including, but not limited to, administering the medication(s) as ordered, consulting with the pharmacist and physician on potential dose reductions, and monitoring for adverse side effects including agitation and restlessness. Further, the care plan identified R2 was considered a vulnerable adult due to his cognitive impairments and outlined several interventions which included discussing behavioral issues with the interdisciplinary team (IDT), evaluating for possible causative factors if issues are identified, and, Resident requires close observation. The care plan lacked further dictation on how R2 would be closely observed to ensure his or others safety. R2's medical record, including progress notes, were reviewed and identified the following: On 8/18/20, a progress note identified R2's ordered [MEDICATION NAME] was reduced to 25 milligrams (mg) due to an abnormal ECG. There were orders to follow-up with the psychiatric nurse practitioner (NP)-A in one month. On 10/1/20, a progress note identified R2 had refused his bath despite reproach. The note did not identify any other demonstrated behaviors by R2 despite refusing his bath. On 10/15/20, a FOCUS progress note was recorded which listed, Behaviors, as the reason for review. R2 was recorded as having [MEDICAL CONDITION] and R2's [MEDICATION NAME] reduction (from 8/18/20) was identified. R2 had moderate cognitive impairment and a section labeled, Mood/Behavior, identified R2 as having anxiety and restlessness. However, the note lacked any further information on these listed behaviors, including how often the behaviors were happening, if at all, or specifics around any demonstrated episodes of them. Further, the note identified a section labeled, Care plan interventions, which directed, Notify MD (medical doctor) with any mood changes are observed, trauma informed approach observing and monitoring, provide opportunities for expression of feelings. On 10/19/20, a progress note identified the pharmacy came to deliver R2's antipsychotic medication and draw routine laboratory work. R2 refused and threw his coffee at the employee. The note outlined, Pharmacy unable to delivery (sic) medication since resident refused lab draw. The note identified registered nurse (RN)-A was updated. On 10/22/20 (three days later), a progress note identified R2 had refused the laboratory draw on 10/19/20, and it was ordered they continue to re-approach R2 and attempt to obtain the lab(s) so R2's [MEDICATION NAME] prescription could be filled. A corresponding Genevive Progress Note, dated 10/22/20, identified R2's medical nurse practitioner (NP)-B was updated on R2's refusal to allow the laboratory draw on 10/19/20, so no medication was available for administration as a result. R2 was listed as consuming 500 mg of [MEDICATION NAME] everyday. The note outlined NP-B responded, Please call and tell (nursing home) to keep trying with labs. His psychiatrist is the ordering provider I believe. On 10/23/20, a late-entry progress note was recorded which identified NP-B had been updated on R2's refusal to allow laboratory draw(s) for his [MEDICATION NAME]. The note continued, NP(-B) wanted nystrom appointment made ASAP (as soon as possible). Nystrom (psychiatry clinic) appointment made for 11/12/20. On 10/31/20, a progress note identified R2 came and sat by the 'West Desk.' R2 was questioned if he needed anything by the staff, but then . began yelling at writer to shut up. After a few minutes a (NA) came down the hallway and he looked at her and yelled 'you [***] ing nigger' X3 (three times). R2 was recorded as spending a good portion of the day outside of his room walking around, including standing by the front door and pushing buttons in attempt to open it. The note lacked any evidence of interventions attempted by the staff to calm or redirect R2 despite these behaviors. On 11/1/20, a progress note identified R2 was recorded as being, . very agitated, restless and having hallucinations during shift . (nurse) waved at him and resident flicked nurse off, said '[***] you' . drew his arm back as if acting he was going to punch nurse. The note continued, This is very abnormal behavior for resident. The nurse sat down next to R2 and talked with him which was effective in calming him down. The note identified the laboratory had attempted to draw R2's lab(s) on the prior shift which . is what caused resident to become upset. R2 was provided education on the importance of the lab draw, however, the note outlined R2 continued to be observed as restless but without physical aggression or agitation. The note continued, (R2) approached nurse stating 'I am hearing voices.' Nurse asked what the voices were telling him and resident replied 'That no one likes me, everyone hates me, and that I should just die. The note identified the nurse provided comfort to R2 whom proceeded to hug the nurse and become upset and start crying. Genevive (physician service) was contacted due to R2's continued restlessness and an order for [REDACTED]. This was administered to R2 and the note recorded, . appeared to have effectiveness. R2's corresponding Genevive Phone Encounter note, dated 10/31/20, identified the nursing home had contacted the service reporting R2 . is experiencing increased agitation, aggression and hallucinations . patient was receiving [MEDICATION NAME] (sic), though a script has not been sent as they are waiting for lab work to be completed, though patient continues to refuse labs . staff are concerned for his agitation. The note identified an order for [REDACTED]. On 11/1/20, another progress note was recorded which identified R2 was . noted to be pacing around facility through out the morning. Per (night shift) report, resident was up all night pacing and did not sleep. Resident asking staff to purchase cigarettes for him. Yelling at staff 'I can smoke if I want! I'm over 18!' Emotional support and reassurance provided. Resident then approached staff member at front desk. Became upset with staff member when unable to get cigarettes and threw desk supplies across lobby. The note outlined education and encouragement was provided, however, R2 . Becomes more and more angry as staff re-approach. R2 was then provided time and space to express his feelings and . appeared to calm down but continues to refuse medications. On 11/2/20, a progress note identified staff entered R2's room and R2 . had his pants off and was laying in bed. (R2) was masturbating. R2 proceeded to cover himself and the nurse provided R2 his oral pills when R2 then . put his right hand around the writers clavicle area then took his hand away and started to laugh. The note identified the nurse explained it was not appropriate to grab them in such a manner and left the room. On 11/2/20, a subsequent progress note identified, New behavior symptom noted. Behavior addressed with NP and guardian. On 11/3/20, a progress note identified order(s) were received from NP-B to send R2 to the emergency room (ER). A subsequent note, dated 11/3/20, identified R2 had met with his guardian (G)-A and the nurse attempted to get the needed laboratory draw completed while she was present. The note recorded, . resident yelled '[***] you, you ain't taking any labs', then resident picked up an orange traffic cone and threw it at his guardian. NP-B was updated regarding the continued inability to draw the needed lab(s) and R2 . had been off his [MEDICATION NAME] for almost two weeks, and that writer believed resident needed to be sent in to the hospital for further evaluation. R2 was sent to the hospital ER via ambulance. R2's corresponding Genevive Progress Note, dated 11/3/20, identified NP-B was contacted as R2 had gone without his ordered [MEDICATION NAME] for two weeks as he was refusing to allow laboratory draws. The note identified, Behaviors increased (due to) not getting med. R2's guardian was present, and typically was able to get R2 to have labs drawn, so the nursing home staff were seeking an order for [REDACTED]. (R2) threw a traffic cone at his guardian. Guardian states that she has never seen (R2) as agitated and aggressive as he is right now, wants sent into ED. Facility staff also aren't able to manage behaviors at this time. A telephone order was provided to send R2 to the ED. R2's corresponding ED Provider Notes, dated 11/3/20, identified R2 presented to the ED with a chief complaint listed as, Aggressive behavior. R2 reported he was homeless before then voicing he resided at the nursing home, and also was recorded as throwing a telephone at one of the nurses. R2 voiced he was unaware why he had been sent to the ED, but did endorse having suicidal ideation. R2's needed laboratory draw(s) were completed and a behavioral consultation was completed and cleared him for discharge back to the nursing home. R2 was recorded as, . he is now willing to go back on his medications. Further, R2's Behavioral Access progress note, dated 11/3/20, identified R2 reported not taking his medications as they made him feel stressed out. R2 voiced he would return to the nursing home and . be on my best behavior and I'll take my medicine. R2 denied command hallucinations to hurt himself or others, but acknowledged having visual hallucinations at times. Further, R2's clinical status was listed which identified highly impulsive and aggressive behavior(s) towards others. R2 was cleared to return to the nursing home. On 11/4/20, a progress note identified R2 returned from the ER and had several labs, including a urinalysis completed. The results were negative for a bladder infection and no new medication or treatment orders were provided. The note concluded, He is to see (nurse practitioner) in 2 days. On 11/4/20, a subsequent progress note identified the pharmacy had been updated on the completed laboratory draws, and R2 . needed his [MEDICATION NAME] (sic) medication as soon as possible. The pharmacist voiced they would contact the hospital to review the laboratory results and would contact the nursing home. The note concluded, Writer is awaiting call back from pharmacy. Further, an additional note, dated 11/4/20, identified the pharmacy was again contacted. The pharmacist voiced they needed more information on how many days R2 had been without his [MEDICATION NAME]; which the nursing home expressed had been two weeks since his last administration . The pharmacist then expressed they needed to speak with the provider who prescribed the medication to see if it needed to be re-titrated given the length of time R2 had been off the medication. The pharmacist voiced a message had been left for the provider, and the note concluded, Writer is awaiting a respond fro pharmacist . On 11/6/20, at 1:38 a.m. a progress note identified R2 was seen coming out of his room at approximately 11:30 p.m. (on 11/5/20) and voiced he was going to get a soda. The note continued, . When he didn't come back in 15 minutes . asked CNA to go se if he was still by pop machine but CNA couldn't find him. Writer, nurse from east (sic) and 2 CNA's split up to check all rooms and other areas of the building . (NA-A) found him raping a female resident and screamed for help. The 2 male CNA's pulled him off her and walked him back to his room. The DON (director of nursing) and charge RN were called. The police were called and the police took him about (1:30 a.m.). For more details see VA (vulnerable adult) report. R2's Medication Administration Record [REDACTED]. An order was listed for [MEDICATION NAME] 500 milligrams (mg) everyday; which had a listed start date of 6/25/20. The medication was record as being given and consumed by R2 until 10/20/20. From 10/21/20 to 11/5/20, the MAR indicated [REDACTED]. R2's Documentation Survey Report, dated 9/2020 to 11/2020, was reviewed and identified R2's recorded behaviors using a legend and corresponding code system. The report demonstrated R2 had no recorded behaviors, including hitting, threatening, cursing at others or sexually inappropriate behaviors, in the month of September and October 2020. However, R2 had a single episode of sexually inappropriate behavior recorded on 11/2/20 which was outlined as, disrupted (the) environment. R2 was re-directed but the intervention was ineffective. No other behaviors were recorded for R2 on these reports despite the repeated progress note(s) which identified him as cursing, throwing objects and wandering around the facility. R2's medical record was reviewed and lacked evidence R2's escalating behaviors had been comprehensively assessed to help determine all contributing factors and subsequent interventions to help reduce and/or eliminate them despite the abrupt stopping of his prescribed antipsychotic medication. There was no evidence the facility had implemented any subsequent increased monitoring or supervision of R1 despite his antipsychotic medication being abruptly stopped and the ongoing documentation of escalating behaviors, including physically throwing items and being found masturbating in his room which had not been recorded or identified before 11/2/20 in his record. When interviewed on 11/13/20, at 9:41 a.m. NA-A was interviewed and explained R2 was more independent with his needs and typically did not require much care from the staff. NA-A recalled the incident involving R2 and another resident being sexually assaulted and explained R2 had left his room on the night of 11/5/20, voicing he was going to walk down to the soda machine. R2 was gone for about 15 minutes when the nurse working (RN-B) had asked staff to start looking for R2 as he had been acting weird the last few days and had not yet returned yet. NA-A stated she opened a female resident's closed door and saw R2 on top of her in her bed with no pants or underwear on as he held her down and was having sex with her. NA-A expressed R2's naked buttocks were visible immediately above her peri-area moving up and down. NA-A stated she immediately yelled at R2 to get off of her, but R2 just turned and looked at NA-A while he continued assaulting the female resident. NA-A voiced she yelled for help and male staff members then responded and removed R2 from the female residents bed and took him back to his room. NA-A explained the police were contacted and R2 was subsequently removed from the nursing home. Further, NA-A explained she had never known R2 to demonstrate sexual behaviors prior, but verified he was not on any formal supervision or monitoring despite being identified as 'acting weird' the past few days. During interview on 11/13/20, at 10:20 a.m. RN-B described R2 as someone who didn't need much care and would often walk around the nursing home at night adding R2 was not known to enter other resident' rooms to her knowledge. RN-B verified R2 was found in a female resident's room on 11/5/20, and had sexually assaulted her which resulted in the police being contacted. The police responded and interviewed R2 who, according to RN-B, then admitted he had done it and was then removed from the nursing home. RN-B recalled R2 never typically demonstrated any hallucinatory or aggressive behaviors which she could recall, however, voiced R2 had seemed to become more restless in the weeks leading up the 11/5/20 incident and R2's subsequent arrest and discharge from the nursing home. RN-B stated she was not sure why R2 had become more restless and expressed she wasn't aware there had been recorded notes outlining him as being aggressive or masturbating prior to the incident on 11/5/20; however, had learned of the notes since he was arrested and removed from the nursing home. On 11/13/20, at 1:07 p.m. registered nurse manager (RN)-A and licensed social worker (LSW)-A were interviewed. R2 admitted to the nursing home after a hospitalization and planned to discharge to a venue of less care when able to. They described R2 as calm and responsive and never really identified him to have behaviors prior to the weeks leading up to the incident on 11/5/20. LSW-A explained the facility typically reviewed a resident and their behaviors on a quarterly basis using FOCUS meetings along with a daily review completed through the stand-up meeting. They reviewed R2's FOCUS progress note (dated 10/15/20) and verified R2 displayed no hallucinations or aggressive behaviors at that time. They recalled no major concerns with him at the meeting adding they were actually unsure how they decided to record him as having restlessness and anxiety at that meeting. LSW-A stated the meetings were a newer process and they were still trying to figure out how to use them. RN-A explained R2 admitted using [MEDICATION NAME] for his [MEDICAL CONDITION] and consistently took the medication until 10/19/20, when he refused the routine laboratory monitoring and the pharmacist would not fill the prescription. RN-A explained the cart nurse then contacted R2's nurse practitioner (NP)-B a couple days later (on 10/22/20) who voiced she did not feel comfortable starting new medication or re-dosing the [MEDICATION NAME] and directed an appointment with R2's psychiatry team should be made for as soon as possible. RN-A stated she then attempted to contact the psychiatric team via telephone, however, was unable to reach anyone so she left a message. A return call was never provided though and RN-A verified she never again attempted to contact the psychiatry provider as, at the time, she didn't feel anybody was in immediate danger. They verified no increased supervision or monitoring had been placed on R2 despite abruptly stopping his antipsychotic medication; however, RN-A added such an intervention would be a good intervention to do for someone who abruptly ceased their medication. RN-A and LSW-A then reviewed R2's medical record and progress notes. They explained the behaviors being recorded after 10/19/20 were not normal behaviors R2 had demonstrated prior, and expressed no assessment or discussion of them had occurred at the daily stand-up meeting(s). RN-A voiced the floor nurses documenting the behaviors should be making sure the management team was aware of them and added they had definitely not been updated on these behaviors including the hallucinations, physical aggression and masturbation. They recalled the incident involving R2 sexually assaulting a female resident and reiterated they had not ever considered and assessed all the displayed behaviors R2 had since 10/19/20, including masturbation, when he abruptly stopped taking his antipsychotic medication. RN-A reiterated if they had been updated on the behaviors and known they were happening, they would have done some more comprehensive assessment of them and taken the situation a little more seriously. LSW-A added she didn't know the behaviors were escalating like that and voiced she would have contacted the facility' psychiatry team (ACP) and tried to include them if we (had been) aware of these crazy behaviors. RN-A and LSW-A verified no changes were made to R2's care plan, aside from a room change, from 10/19/20 until the incident involving R1 on 11/5/20 and added maybe some education was needed. Further, RN-A stated the behaviors not being forwarded to the management team was something we need to address in upcoming nurses meetings. On 11/13/20, at 3:12 p.m. R2's medical nurse practitioner (NP)-B was interviewed. R2 was someone who was very reserved and quiet prior to 10/19/20, and NP-B verified she was not aware of any behaviors prior to the [MEDICATION NAME] being abruptly stopped. NP-B explained she did not personally order or manage R2's [MEDICATION NAME] as the prescriber is required to have a special certification as it was a very dangerous medication. The medication required certain laboratory values to be checked periodically and, at times, pharmacies would not even release the medication until these lab(s) were obtained. As a result of those things, NP-B stated R2's psychiatry team was managing his ordered [MEDICATION NAME]. NP-B explained when R2 refused the laboratory monitoring on 10/19/20, their on-call provider service was notified about it a couple days later on 10/22/20. NP-B voiced no new medication orders were given as she assumed the nursing home had already been in touch with R2's psychiatry team and she would have no idea what they ordered or did. On 10/31/20, NP-B stated they were again notified R2's behaviors seemed to be worsening and, at that time, a three (3) day dose of [MEDICATION NAME] (a medication used for anxiety) was provided. Then on 11/3/20, NP-B was updated again and told R2 was now being very aggressive and had gone for two weeks without his antipsychotic medication. NP-B stated this was the first time she realized he had not had his [MEDICATION NAME] for awhile and then ordered him to be evaluated in the ED as the nursing home felt they couldn't control him anymore. The ED completed the necessary laboratory draw(s) and, to her knowledge, the nursing home was working on getting his [MEDICATION NAME] restarted when he returned to the facility on [DATE]. NP-B expressed she was not aware R2's psychiatry team had never been notified of his refusal to allow the laboratory draw(s) and subsequent holding of his [MEDICATION NAME] voicing that was unfortunate. Further, NP-B voiced if she had been told R2's psychiatry service had not been updated and R2 had started on [MEDICATION NAME] sooner, it may potentially have helped to calm and reduce R2's behaviors before he required treatment in the ED and subsequently sexually assaulted another resident. On 11/13/20, at 3:37 p.m. the consulting pharmacist (CP) was interviewed and explained [MEDICATION NAME] was a medication typically used when other antipsychotics had not worked due to it's potentially dangerous side effects and required special laboratory monitoring to ensure safety while the patient is on it. CP voiced it probably wouldn't be a good idea to abruptly stop the medication without slowly titrating down prior, and doing so could yield the sudden return of [MEDICAL CONDITION] symptoms or other adverse effects. Further, CP stated she was unaware of the specifics regarding R2 and his missed [MEDICATION NAME] medication; however, explained if he had stopped taking the medication abruptly and then had a return of symptoms that perhaps a different antipsychotic to help reduce or calm the symptoms may have helped. CP added the nursing home should have a policy on what to do when the patient refuses medications and how to address it. On 11/17/20, at 11:32 a.m. the director of nursing (DON) was interviewed. The DON explained she received a telephone call shortly after midnight on 11/6/20, and the staff voiced something terrible has happened which they described as finding R2 raping our poor (female resident). The DON instructed them to contact the police department and then contacted and updated the administrator on the allegation. The DON voiced when she arrived at the nursing home, the police were present and voiced R2 was going to be arrested for sexual misconduct as R2 admitted to the police he committed the act. R2 was arrested and removed from the nursing home. The DON verified no formal supervision or safety checks were placed on R2 despite him abruptly stopping his antipsychotic medication and having documented escalating behaviors recorded in his progress notes. The DON stated masturbation, in itself, may or may not be considered behavioral as he could have been doing the act in private many times before; however, she did voice she had no knowledge of him being found doing it by staff throughout his stay prior to 11/2/20. The DON expressed R2 had no prior history of sexual behaviors to their knowledge and they were trying to find lesser care placement for him as he did not required skilled care. R2 did have a history of becoming upset with his roommate(s) though over various things like television volume, so they made the decision to move him to a private room just prior to the assault as R2 was unpredictable at times and would, at times, get aggressive when he was irritated. The DON explained she had heard about R2 not getting his scheduled [MEDICATION NAME] when standing out by the nurses station and a nurse reported they did not have the medication to give. She could not recall the exact date she was first told R2 had not been getting his prescribed [MEDICATION NAME], but felt pretty confident she was not told until the week just prior to the sexual assault of the female resident. The DON voiced her expectation would have been to be informed the same day he initially refused the laboratory draw and subsequently had his medication not provided. The DON stated she then directed staff to ensure the guardian and NP-B were updated on the situation, and they attempted several times to draw the needed laboratory tests, but R2 would not allow it. The DON then reviewed R2's progress note(s) in his medical record verified there were more behaviors documented after 10/19/20, and added her expectation was for RN-A and LSW-A to review the progress notes each day and bring concerns, like escalating behaviors and missed medications, to the IDT meeting so they can be reviewed and addressed including reviewing for possible triggers, patterns and other issues. The DON verified R2's missed doses of [MEDICATION NAME] were never raised at their IDT meetings and explained had the issues been presented at the meeting, she would have intervened and made sure appropriate action was taken adding RN-A and LSW-A were responsible to ensure the behaviors were assessed and put all that together. The DON stated those assessments would have lead to multiple interventions which could have then been attempted to help ensure residents, including R2 himself, were kept safe and protected from his escalating behaviors. A Sherburne County Inmate Locator, printed 11/17/20, identified R2 as a current inmate of the jail system with two charges listed. These charges included a misdemeanor charge for 5th degree assault; and, a felony charge of 3rd degree criminal sexual conduct. R2's custody date was recorded as 11/6/20, and no bail amount was posted. During the abbreviated survey, from 11/13/20 to 11/18/20, multiple phone calls were attempted to interview NP-A regarding R2's behavior and the incident which happened on 11/5/20, where R2 was found in R1's room sexually assaulting her. A missed return call was provided on 11/18/20, and a message was left indicating a telephone interview would not be possible until 12/2/20. On 12/2/20, at 1:41 p.m. NP-A was interviewed and verified she helped oversee his psychiatric care for the duration of his nursing home admission. NP-A described R2 as a very poor historian who often displayed poor insight into his own mental health. NP-A recalled seeing R2 in person on 8/27/20, where a staff person was present and voiced R2 was doing well overall and having no concerning behaviors. NP-A stated their clinic was notified on 10/19/20, when R2 refused his laboratory draw and pharmacy would not fill his ordered [MEDICATION NAME]; however, NP-A was on vacation at the time so she was not personally updated. N (TRUNCATED)

Based on observation, interview and document review, the facility failed to ensure pressure ulcers were comprehensively assessed, monitored, and interventions implemented timely to prevent pressure ulcers from developing and worsening for 1 of 3 residents (R1) reviewed for pressure ulcers. This resulted in actual harm when R1 developed one stage 3, and two unstageable, pressure ulcers and required surgical intervention. Findings include: Pressure ulcer stages from the National Pressure Ulcer Advisory Panel (NPUAP): Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. R1's physician orders [REDACTED]. Change every 3 days and as needed if soiled for wound care. R1's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R1 required extensive assistance with bed mobility, dressing, personal care, and total assistance with transfers. R1 was at risk, but had no pressure ulcers. R1 did not have a pressure reducing wheelchair cushion or a pressure reducing bed. The Care Area Assessment (CAA) for pressure ulcers dated 6/4/18, indicated R1 had no current open areas. In addition, the CAA indicated a Skin protectant was applied with incontinent episodes, R1 had a dressing in place to coccyx, and skin prep applied to left upper thigh for recurrent open areas. The CAA also indicated R1 would refuse repositioning and incontinence care and that staff should re-approach as needed. R1's current care plan identified an intervention initiated 11/29/17, indicating R1 required extensive assistance of 2 staff for bed mobility and directed to turn and reposition in bed with rounds and as necessary. On 10/1/18, an additional intervention to reposition using a mechanical lift when in chair was added. (R1) continues to require education on prevention skin breakdown. R1's Braden Scale for Predicting Pressure Sore Risk dated 2/1/19, indicated R1 was at moderate risk for pressure ulcer development. In addition the Braden indicated R1 does not make even slight changes in body or extremity position without assistance; Requires moderate to maximum assistance with moving; and indicated R1's nutrition was adequate. R1's quarterly MDS assessment dated [DATE], indicated R1 was at risk, but had no current pressure ulcers. R1 had a pressure reducing wheelchair cushion. The MDS did not identify the use of a pressure reducing mattress for use on R1's bed. R1's Weekly Skin Check dated 2/13/19, indicated no concerns R1's quarterly Nutrition Screening dated 2/13/19, indicated R1 had no skin concerns, had weight gain related to excessive calorie intake, and did not wish to engage in weight loss efforts at this time. R1's medical record between the dates of 1/1/19 and 2/14/19, lacked documentation of the presence of pressure ulcers. R1's Progress notes between 2/15/19 and 2/25/19 identified multiple refusals of cares, including re-positioning and incontinent cares. The notes also identified the presence of pressure ulcers as identified below: -2/15/19: When changing (R1's) [MEDICATION NAME] dressing per order, writer noticed (R1's) wounds have gotten bigger and noticed black spot on sacral area and in left gluteal fold. RN updated and will pass onto oncoming shift. Although the note identified R1's wounds were getting bigger, R1's medical record lacked documentation as to when the pressure ulcers developed. -2/16/19 [MEDICATION NAME] dressing changed during check and change at 5:30 p.m. -2/17/19, indicated .(R1) had BM (bowel movement) and soiled bordered foam bandages covering bed sores on coccyx, anal crack and between buttocks and upper back legs. These areas were cleaned, dried and re-bandaged with new foam bordered bandages. -2/18/19, indicated With treatment to sacral/buttocks wounds this shift: worsening with blackness noted to gluteal fold wound. Large amounts of [MEDICAL CONDITION] (drainage tinged with a milky fluid of varying color) drainage noted to old dressing. Areas cleansed with normal saline and [MEDICATION NAME] dressing reapplied. Message left with registered nurse (RN) case manager to re-assess wounds and update MD. -2/19/19 at 7:58 a.m., incontinent. R1 allowed staff to provide cares before getting out of bed. -2/19/19 at 2:43 p.m. R1 refused to lay down all shift to allow RN to look at wound on R1's bottom. -2/19/19 at 3:50 p.m. Occupational therapy to evaluation and treat regarding wheelchair positioning with new wheelchair. -2/20/19 R1 refusing to be turned and repositioned. Redirection and explanation to R1 provided regarding the importance of repositioning with wounds on buttocks. -2/21/19 R1 continued to consistently allow every 2 hour repositioning. -2/22/19 Late entry note regarding R1 refusing to allow RN to assess wound this week. Attempted multiple times since altered to worsening wounds on 2/18/19. Refusing repositioning. Although the RN documented she'd been unable to assess R1's pressure ulcers, the documentation indicated dressing changes did occur on 2/15/19, 2/16/19, 2/17/19, 2/18/19. However, there was no comprehensive assessment of the pressure ulcers completed at the time of the dressing changes. -2/25/19 Dressing change completed. Old dressing from sacral/buttocks wound had moderate-large amounts of yellow-green-tan drainage and a very foul odor. Right gluteal fold continues to have blackened area to center with yellow green slough surrounding. Areas cleansed with normal saline and [MEDICATION NAME] re-applied. R1 informed wounds are not healing and getting worse with more drainage. Educated in the importance of off-loading as much as possible. The documentation lacked measurements of the pressure ulcers. Although documentation identified the presence of pressure ulcers prior to 2/15/19, Staff did not notify the provider until 2/25/19, at 12:05 p.m. when a progress note indicated the nurse practitioner (NP)-A was notified that R1 had wounds to the buttocks and frequently refused to allow staff to cleanse, dress and assess wounds. Frequently refuses repositioning. The notes also indicated the NP-A was provided with the 2/25/19, dressing change progress note. Staff requested and obtained an order for [REDACTED]. Although documentation identified the presence of pressure ulcers prior to 2/15/19, the first comprehensive wound assessment did not occur until 2/27/19. A 2/27/19 Skin & Wound Evaluation wound measured 4.6 cm x 4.2 cm. The assessment lacked identification of type of wound and when wound developed. Wound bed had 10% slough and 90% eschar. Moderate purulent drainage with a strong odor. Interventions included a cushion, foam mattress, incontinence care and turn and repositioning program. A second 2/27/19 Skin & Wound Evaluation identified a stage 3 pressure ulcer on right thigh, acquired in the facility present for 1-3 months. Measured 4.3 cm x 4.6 cm with a depth of 2.8 cm. Wound bed had 70% slough and 30% eschar. R1 had a fever, increased drainage and tiredness. Heavy purulent drainage with a strong odor. NP-P notified and diagnosed infection. Keflex (antibiotic) started. R1's physician orders [REDACTED]. Pack wound with Calcium Alginate AG. Cover with large non adherent foam and secure in brief. one time daily and as needed. On 2/27/19 a Risk vs Benefits indicated R1 and R1's guardian were informed of the recommendation to allow staff to reposition R1 every 2 hours for offloading, including time spent in R1's wheelchair with the assistance of 2 staff. Risks of not allowing include new or worsening wounds. R1 agreed with the recommendation as well as limiting time spent in the wheelchair to 2 hours at a time. Weekly comprehensive assessments of the wounds were completed on 3/4/19, 3/7/19 and 3/14/19 as indicated below: 3/4/19 -Unstageable sacrum pressure ulcer. 3.7 x 4.3 cm. 10% granulation, 70% slough, 20% eschar. Light purulent drainage. No new treatment or intervention. -Stage 3 right ischial tuberosity pressure ulcer. 3.5 cm x 4.7 cm. 80% granulation, 10% slough, 10% eschar. Heavy drainage with strong odor. Identified as improving. No new interventions. NP-A updated. 3/7/19 -Unstageable sacral pressure ulcer. 3.8 x 4.6 x 1.4 cm. 80% slough and 20% eschar. Moderate drainage and odor. Treatment and interventions unchanged. Progress identified as improving. -Stage 3 right ischial tuberosity pressure ulcer. 4.2 x 4.9 x 2.9 cm. 90% granulation and 10% slough. Heavy drainage with strong odor. Treatment and interventions unchanged. Progress note identified as improving. 3/14/19 documentation identifies 3 versus 2 pressure ulcers. -Unstageable sacrum pressure ulcer. 3.4 x 2.8 cm. 80% slough and 20% eschar. Moderate drainage with heavy odor. Interventions remained unchanged. Identified as improving. -Unstageable sacrum pressure ulcer 3.7 x 4.2 x 1.5 cm. 50% slough and 50% eschar. Moderate drainage with strong odor. Interventions unchanged. Identified as improving. -Right Ischial Tuberosity pressure ulcer. 4.5 x 4.5 x 2.8 cm. 90% granulation and 10% slough. Heavy drainage with strong odor. Interventions unchanged. Identified as improving. A 3/11/19 significant change MDS indicated R1 had 1 stage 3 and 2 unstageable pressure ulcers with a pressure reducing bed and chair. A Care Area Assessment identifies R1 requires a special mattress and seat cushion to reduce pressure. Has been followed by wound consultant. Areas improving in depth. Staff reposition every 2 hours and if refuses staff encourage to reposition. Has limited times up in wheel chair at meals and activities. R1's medical record lacked documentation as to when the special mattress was initiated. A 3/21/19 progress note indicated R1 was transferred to the hospital due to a temperature of 102, pale, diaphoretic, clammy, vomiting and dark amber and foul odor of urine. 3/30/19 Hospital Discharge Summary indicated R1's sacral pressure ulcers .were very malodorous, purulent, very large and deep. Ultimately surgery was consulted who recommended I & D (incision and drainage) with the creation of diverting [MEDICAL CONDITION], which was done 3/25/19. A PICC line was placed prior to discharge for treatment of [REDACTED]. 3/30/19 physician orders [REDACTED]. Change dressing Mondays, Wednesdays, Fridays. Bridge wound from right gluteal to sacral if possible and pay attention to pad tubing pressure. If dressing not functioning, unable to be repaired, remove vac therapy and [MEDICATION NAME] dressing. Gently pack with normal saline moistened Kerlix and cover with abd dressing. Change twice daily and PRN until vac dressing is able to be re-applied. During observations on 4/1/19, at 3:28 p.m., R1 was laying in bed watching television. Wound vac on and set at as ordered at 125 mmHg. Mattress on bed covered with foam [MEDICATION NAME]. During observation on 4/2/19, at 8:26 a.m. R1 was laying in bed. Nursing assistant (NA)-A and nursing assistant (NA)-B entered R1's room and repositioned R1 onto left side. Staff offered R1 to get up in chair for an hour and R1 declined. During an interview on 4/2/19, at 10:15 a.m. NA-B stated R1 is a total assist. R1 is repositioned from side to side every 2 hours. NA-B stated R1 does refuse to be repositioned at times, sometimes she will refuse the entire day to be repositioned. NA-B stated she notifies the nurse and re-approaches when R1 refuses. During an interview on 4/2/19, at 10:50 a.m. R1's guardian stated R1 had a long history of refusing cares going back prior to admission to the facility. The guardian stated a meeting was held on 2/27/19 as R1 had developed pressure ulcers and was refusing to be repositioned every 2 hours. During the meeting the risks and benefits of repositioning were discussed. This included the risks that R1 could become septic and get infections into the bone. The guardian stated R1 does not like to be out of bed. During an interview on 4/2/19, at 1:00 p.m. registered nurse (RN)-A stated she was reviewing R1's record on 2/25/19, as she was going to be taking over as RN case manager. In reviewed the progress notes, she came across documentation of the pressure ulcers. RN-A stated she spoke with registered nurse RN-B, who was R1's case manager at the time. RN-A stated RN-B told her R1 continuously refused to let her look at the pressure ulcers and had made several attempts. RN-A stated further steps should have been completed upon the discovery of the pressure ulcers. The same day, RN-A notified NP-A of R1's pressure ulcers and refusals to reposition. RN-A stated R1 had a history of [REDACTED]. Staff had continued to use [MEDICATION NAME] to protect the coccyx skin. RN-A stated she did not know when the pressure ulcers developed. RN-A completed the first assessment of the pressure ulcers on 2/27/19. R1 had 1 right ischial tuberosity stage 3 pressure ulcer and 2 unstageable sacral pressure ulcers. RN-A stated on the first 3 assessments the 2 sacral pressure ulcers were measured as one, until directed by another nurse to assess the pressure ulcers separately. RN-A stated she was shocked the first time she assessed the pressure ulcers on 2/27/19. RN-A stated I feel they were preventable. When asked about interventions since the development of the pressure ulcers, RN-A stated she has consulted with a wound nurse and NP-A several times since 2/27/19 to determine the best wound treatment. RN-A stated R1 had a foam [MEDICATION NAME] on the mattress. RN-A stated she did not know when the foam [MEDICATION NAME] was put on the bed, but it was present the first time she assessed the pressure ulcers on 2/27/19. RN-A stated R1 is currently spending more time in bed, repositioning R1 from side to side every 2 hours to allow for better healing. RN-A also indicated R1's mattress has not been reassessed. RN-A stated an air mattress that was in use by another resident has just become available, and plans to replace R1's foam [MEDICATION NAME] with the air overlay. When asked about the intervention on the weekly assessments of a nutritional supplement to aid in wound healing. RN-A stated dietician-A was aware of R1's pressure ulcers. RN-A reviewed R1's record and stated the nutritional supplements were not started. During an interview on 4/3/19, at 10:15 a.m. NP-A stated R1 was had a history of [REDACTED]. On 2/27/19 a meeting with R1 and R1's guardian was held to discuss R1's refusal to turn and reposition. NP-A stated R1 used to be up in the chair all the time and discussed the need for her to be in bed more to allow the pressure ulcers to heal. NP-A stated R1 was on the dieticians list to evaluate. NP-A stated supplements are usually started to help heal wounds. During an interview on 4/3/19 at 1:28 p.m. dietician-A stated Typically, I would follow everyone with wounds more often then quarterly. adding I do not do another assessment with the development of a new pressure ulcer. Dietician-A stated he looked at the skin wound evaluation notes and the wounds were healing and had no nutritional concerns. Dietician-A stated if a supplement is determined to be needed the nurses would let me know by email. I would usually order it, but I am not usually there. During an interview on 4/3/19, at 12:33 p.m. the director of nursing (DON) stated an assessment for pressure ulcer risk is completed weekly for 3 weeks upon admission and quarterly. Interventions are determined based on the assessment and care planned. The DON stated she had reviewed R1's record and was unable to determine when the pressure ulcers developed. The DON stated wounds are discussed in morning meetings. The DON stated she was not aware of the pressure ulcers until discussed on 2/27/19. The DON went on to say We need to better with communication with wounds. When a pressure ulcer develops, an RN is to complete an assessment and notify the physician. Weekly wound rounds are completed and interventions are discussed with each assessment. The DON stated \when a pressure ulcer develops, the dietician is to complete a nutritional assessment. The DON stated the dietician did not complete a nutritional assessment after the development of the pressure ulcers. The DON stated although nurses can contact the physician for a nutritional supplement order, the dietician would normally contact the physician for this order. The facility's policy Pressure Injury Prevention and Management, dated 12/3/18, indicated the facility will ensure a resident who is admitted without a pressure ulcer does not develop a pressure ulcer, unless clinically unavoidable. A resident who has an ulcer will receive care and services to promote healing and to prevent additional ulcers. A complete assessment is essential to an effective pressure ulcer prevention and treatment program. If a pressure ulcer is present, at least weekly there should be documentation of an assessment or evaluation of the wound characteristics: The date the wound is observed, location, staging, size, color, odor, drainage, pain, wound bed, description of wound edges and surrounding tissue. Referral to a dietician should be considered for residents with pressure sores, to evaluate the current clinical nutritional status and or appropriate recommendations for supplementation of dietary and fluid intake.

Based on record review and interview, the facility failed to ensure a resident was free from accidents for one of four (R1) residents reviewed when staff did not provide adequate supervision and adaptive devices during mealtime. R1 spilled hot coffee on her left thigh and sustaining a second degree burn. Findings include: R1's medical record was reviewed. R1 had dementia, heart failure, cerebral infarct and [MEDICATION NAME] degeneration. R1's care plan dated 12/29/18 indicated staff needed to tell R1 placement of foods on her plate; to use a red divided plate for visibility; offer finger foods if possible and staff assist of one if R1 was unable to feed self. R1's care plan dated 1/3/18 indicated R1 had activities of daily living (ADL) performance deficits due to dementia, impaired balance and poor vision. R1 needed assistance with all ADL cares. Interventions included extensive assist of one staff for eating. R1 could feed herself parts of a meal. R1's Minimum Data Set (MDS) assessment dated [DATE] indicated R1 needed extensive assistance with eating and drinking. R1's MDS assessment for functional rehabilitation potential indicated R1 and R1's direct care staff did not believe R1 was capable of increasing independence in at least some ADLs. R1's brief interview for mental status (BIMS), dated 4/24/18 with a score of 8, indicated moderate cognitive impairment. Facility surveillance video footage dated 7/8/18 at 6:05 p.m. showed R1 in the dining room seated at a table with two staff members, including NA-E, and three other residents. The camera view was somewhat blocked by R1's body and wheelchair. R1 was served a cup of coffee. The coffee mug flipped up from R1's lap, brown liquid spilled and the cup bounced and rolled across the table. There was no audio. The DON-D confirmed R1 and NA-E in the footage. An incident note, dated 7/8/18 at 21:30 indicated a nurse's aide informed the nurse about hot coffee spilled onto R1's left medial proximal hip during the evening meal around 18:00. The nurse's aide indicated R1 screamed ouch but did not complain of pain after the incident. The nurse assessed R1 and noted a mildly reddened area with a rectangular shaped actively forming blister. A skin wound note, dated 7/9/18 at 9:45 indicated nursing staff performed a skin assessment on R1 and noted an injury to R1's left upper thigh from a coffee spill. R1 had a reddened area on her left thigh measuring 27 cm x 7 cm with 2 fluid filled blisters. The blister at the proximal end of the reddened area measured 7 cm x 2.8 cm. The second blister to the medial end measured 5 cm x 2.8 cm. A reddened area on R1's lower abdomen was noted and measured 6 cm x 3.5 cm. with no blistering. A Situation, Background, Assessment and Recommendation (SBAR) form was left for the physician to review. R1's family and hospice were contacted and updated on the incident. A skin wound note, dated 7/9/18 at 11:19 indicated the blisters on R1's left thigh burst during morning cares. An order note, dated 7/11/18 at 10:53 indicated R1's nurse practitioner addressed the coffee burn and directed staff to continue to monitor for signs and symptoms of infection. R1's care plan dated 7/13/18 indicated R1 needed to have covered coffee mugs with all hot liquids. A physician's orders [REDACTED]. During an interview on 8/1/18 at 1:09 p.m. registered nurse (RN)-A said dietary makes referrals to physical therapy or occupational therapy for adaptive equipment. During an interview on 8/1/18 at 1:39 p.m. nursing assistant (NA)-B said R1 had bad vision and needed help with set up at mealtime but then did pretty well feeding herself. NA-B said there are paper meal tickets for each resident at each meal. The tickets have a section at the bottom listing food likes, allergies and any adaptive devices needed for meals. During an interview on 8/1/18 at 2:03 p.m. dietary director (DD)-C said R1 was given a coffee cup with a cover as a trial a few months earlier but did not like the lid. DD-C said she did not know why the coffee mug lid wasn't on and thought the nurses said to stop using the lids. DD-C said dietary can immediately give residents an adaptive piece of equipment to try if it's a safety issue. DD-C said nursing asked dietary not to chart issues or incidents; nursing would chart. DD-C said there are gaps in the system and nursing does not always chart dietary's concerns or there aren't always good follow-up notes. During an interview on 8/1/18 at 2:26 p.m., director of nursing (DON)-D said when R1 was admitted she was more talkative and told staff she did not like lids on her coffee mug. DON-D said the spill was an accident but the coffee mug lids are now back on R1's cup and staff that were at the table were re-educated. DON-D said she thought dietary documented not to have lids on R1's coffee mug but putting the lids back on was a nursing decision. During an interview on 8/1/18 at 2:45 p.m. NA-E said she was at R1's table helping feed another resident next to R1. She heard R1 scream. NA-E said she saw coffee spilled on R1's left hip and poured cold water onto R1's hip. NA-E said another nursing assistant assigned to care for R1 was helping another resident. An undated facility policy titled Assistive Devices, indicated if a resident is unable to complete a meal without assistance, the occupational therapist or designees evaluates the resident's self feeding skills and potential of adaptive devices for increasing independent eating. Dietary staff ensures that the device is placed on the resident tray at each meal. An undated facility policy titled Serving Meals/Snacks to Residents indicated staff need to make sure all residents have appropriate utensils, covered cups, nosey cups.

Based on observation, interview and document review, the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable; and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 of 1 resident (R18) reviewed in the sample. Findings include: R18, who was assessed at high risk for pressure ulcers, was noted to have a pressure ulcer upon a readmission to the facility from the hospital and was not comprehensively assessed for all relevant factors at that time. In addition, interventions and necessary care and treatment was not initiated in a timely manner until 10 days after the pressure ulcer was first documented in the facility clinical record. The facility practice resulted in worsening of the pressure ulcers (three separate stage 2 ulcers) and resulted in actual harm to the resident. R18, originally admitted to the facility 8/2011, had [DIAGNOSES REDACTED]. The most recent full minimum data set (MDS), admitted d 8/26/11 identified R18 with cognitive independence, no sign/symptoms of [MEDICAL CONDITION] or behaviors, extensive assistance of two staff for bed mobility and transfers and most activities of daily living (ADL's). The MDS noted functional range of motion limitations in both upper and lower extremities, usual bowel incontinence and no open areas were noted. The care area assessment (CAA) summary from the admission MDS (8/26/11) noted R18 was at risk for pressure ulcers related to immobility from diagnosis, extensive assistance for mobility and hygiene and other ADL's. Every two hour repositioning was determined from this tissue tolerance and at this time the skin was noted to be intact. The temporary care plan dated 12/8/11 was the currrent working care plan for R18. The care plan noted every two hour repositioning, elevate heels and wheelchair cushion. There was no change in pressure ulcer interventions from the previous temporary care plan dated 12/3/11. A complete care plan had not been developed at the time the pressure ulcers were noted again on 12/18/11. R18 was recently hospitalized on three occasions for medical issues related to [MEDICAL CONDITION] and lethargy with possible medication interactions and pneumonia. hospitalization s were from 11/26/11 to 12/3/11, 12/5/11 to 12/8/11 and 12/10/11 to 12/14/11. The facility re-admission body audit dated 12/3/11 identified an old scar over the sacrum/coccyx area, but no open areas were noted and the care plan continued every two hour repositioning. The re-admission body audit dated 12/8/11 noted a circle and the code (8) for a pressure ulcer on the diagram located over the sacrum/coccyx; however, the narrative portion of the body audit noted there were no problems or pressure ulcers and no interventions were included on the care plan dated 12/8/11. The tissue tolerance also completed by the same nurse on 12/8/11 was incomplete but noted skin color was normal after two hours sitting and while in bed. The re-admission body audit from the 12/14/11 readmission, could not be initially located in the records; the admission flow sheet record had a blank space with no signature for completion of the body audit that date and the re-admission care plan was not redone but carried over from the 12/8/11 care plan. Another flow sheet located noted the statement: (Needs body audit yet,} on 12/14/11. A notation on 12/15/11 read: (Body audit done, cream to buttocks.) Further search by nursing staff revealed two additional body audit forms. One audit form noted open areas on the coccyx/sacrum/buttocks but was not dated or signed; the other audit located was signed and dated 12/14/11 but no open areas on the buttocks area were noted. The narrative 24 hour observation charting and nurses notes reviewed did not identify the presence of a pressure ulcer until 6:14 a.m. on 12/18/11 when three separate pressure ulcers were discovered and noted to be stage one, with no drainage. Two of the ulcers were one by one centimeter (cm.) and one was noted to be three by three cm., barrier creme was applied and R18 was turned to the side. Dressing and cleansing treatment were started later on 12/18/11. A wound care flow sheet was started on 12/19/11 and the pressure ulcers were measured at one by one cm. for two separate ulcers located on the lower and mid buttocks, and one ulcer measuring five by five centimeters on the coccyx. The wound flow sheet did not identify the stage of the ulcers. The record did not contain any referrals or reassessment by Occupational Therapy after the electric wheelchair had been discontinued and the manual chair utilized after 12/8/11 was an extra wide chair with a gel pressure cushion. R18 reported during interview at 7:40 a.m. on 12/21/11 he had severe spasms the night before while in bed and had asked to sit up in the wheel chair. R18 also stated he had been using an electric wheelchair earlier in December, but he ran into things with it and it was taken away and replaced by the manual chair. R18 stated some times he sat up in the chair all day and staff did not reposition him unless he went to bed or toilet. R18 reported the pressure ulcers he has got worse from the electric wheelchair he used and had, "just started as a pimple." R18 was noted to be sitting in the wheelchair on a gel pressure reduction cushion; however, his hips were over to the left side of the chair and his weight unevenly distributed on the right buttocks. Nursing assistant-G (NA-G) reported at 9:35 a.m. R18 was repositioned every hour and a half and earlier that morning his pressure ulcers did not have any dressing on and were noted to be bleeding when cares were done, but the nurse had replaced the dressings after notification they had come off. Because the dressing had just been replaced and were designed to last three days, the pressure ulcers were not observed by surveyor during the survey. The tissue tolerance that was completed on 12/18/11 and the current nursing assistant care sheets directed that repositioning be done with assist of two staff each hour. The unit nurse manager (RN-C) verified on 1:30 p.m. on 12/21/11 she thought R18 returned from the hospital on [DATE] without any pressure ulcers and was not aware of the body audit from the 12/8/11 nursing home readmission that identified a pressure ulcer at that time. RN-C also reported the licensed practical nurse (LPN) that completed that readmission no longer worked at the facility and verified the LPN should have followed facility policy and initiated charting on the pressure ulcer, communicated the information to the nurse manager so the complete assessment, wound care flow sheet, and treatment orders would have been requested/started at that time. RN-C could not initially locate any body audit from the readmission to the facility on [DATE] and discovered the flow sheet for it's completion had not been signed off by staff. RN-C verified R18 currently had three separate stage two pressure ulcers on the coccyx (outer skin layers not intact), lower and middle buttocks areas and interventions had been started including cleansing/dressings(Allevyn), nutritional supplements and one hour repositioning. The director of nursing (DON) reported during interview at 9:56 a.m. on 12/22/11 she had reviewed the record and verified there was some hospital record charting that noted at least one pressure ulcer (stage one) on 12/11/11. The DON also reported the hospital transfer information did not include information on the status of any pressure ulcers and the DON was unable to contact the LPN that did the readmission on 12/8/11 to obtain any further information. A copy of the hospital charting was requested at that time but was not provided by the completion of the survey.

Based on interview, record review, and policy review the facility failed to assure that 6 of 71 residents (R99, R84, R75, R26, R14, and R28) in the facility had the correct code status identified by their physician. The facility lacked a system to identify and assure each residents code status was authenticated by the physician and readily available for staff to implement. These findings constituted an immediate jeopardy situation for these six residents. In addition the facility did not provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) for 1 of 1 residents, (R60) who requested CPR to be completed if her heart stopped which resulted in her death. The findings constituted an immediate jeopardy situation and an extended survey was conducted. The administrator and Director of Nursing were informed of the Immediate Jeopardy, with a pattern (K level) deficiency on [DATE] at 3:38 p.m. The immediate jeopardy (IJ) was removed on [DATE] at 10:31 a.m. which reduced the scope and severity to no actual harm with more than minimal harm, with a pattern. Furthermore the facility failed to ensure 3 of 3 residents ( R30, R55 & R46) who received outpatient [MEDICAL TREATMENT] services had necessary services, monitoring, and coordination of care with the [MEDICAL TREATMENT] centers and 1 of 1 residents, resident (R)94, received necessary respirtory equipment and services to attain or maintain the highest level of function. The facility failed to ensure that 1 of 3 residents, (R91) that received hospice services from an outside agency, lacked coordination of care between the hospice agency and the facility. Findings include: CPR The facility did not provide Cardio [MEDICAL CONDITION] Resuscitation (CPR) for Resident 60 who requested CPR to be completed if her heart stopped which resulted in her death. Resident 60 (R60) Admission Minimum Data Set ((MDS) dated [DATE] identified the resident as having no memory problems, modified independence for daily decision making, and having no advanced directives. The "Admission 24 hour Vital and Observation" form dated [DATE] describes the resident as "alert." The resident arrested on [DATE] and the facility did not provide CPR in accordance with the resident wishes or the physician orders. R60 was admitted to the facility on [DATE] from an acute care facility. R60 had [DIAGNOSES REDACTED]. A discharge summary from the Palliative care Physician at the hospital dated [DATE] stated, "It was the opinion of her family that she (R60) would prefer a more palliative approach and they were in favor of discharging her with hospice care and changing her code status to No code blue. The patient herself, however, became very agitated and upset when the No code wrist band was placed on. Therefore that order had to be rescinded ....resuscitation status remains full code ..." Discharge orders from the acute care facility dated [DATE] identified the resident as discharged from the hospital to the facility was a full code, meaning she wanted full resuscitation in the event she stopped breathing and had no pulse. The primary physician orders [REDACTED]. R60's "Individual Resident Care Plan" dated [DATE] identified the resident as a full code. R60's "Face Sheet" in the chart listed her code status as "CPR." However, the pink "Resuscitation Status" form, which the facility uses for staff to identify each residents code status, dated [DATE] and signed by a family member listed the residents code status as a "Do Not Resuscitate", meaning in the event of cardiac or respiratory arrest, no resuscitation would be initiated. This form was not signed by the resident or the physician. On [DATE] R60 was seen in the facility by her physician for a "...decreased level of consciousness with a drop in blood pressure and oxygen saturation." According to the physicians dictated note dated [DATE] identified, "I previously reviewed her chart several days ago and have had detailed conversations with one of her daughters yesterday. Family and living will were clear that the patient would want to be a full code, but even though she was competent to make decisions herself, her family expressed a strong preference that I not talk to her about advance directive because they wanted her to be a DNR/DNI. We had a very long conversation about the meaning and role of health care agents, and that the health care agent can not make decisions for a competent person. Her advanced directive indicates she desires a full code status, this was confirmed with one of the daughters earlier this week ..." The facility physician progress notes [REDACTED]. Plan: to St. Cloud Hospital." R60 was sent to the Hospital emergency roiagnom on [DATE] for evaluation. The emergency room (ER) physician note on [DATE] indicated "They (family) did want to try to discuss her code status again with her doctors." R60 was "comfortable," her vital signs were stable, and "she was able to answer a couple questions of yes and no" and was sent back to the facility. The emergency room doctor refers to the prior request of the patient wanting to be a full code, and did not change her code status from a full code. There is no documentation of anyone asking R60 if she wished to change her code status at that time. A facility nurses note from [DATE] at 3:30 p.m. indicated that R60's daughter called the facility and wanted to have an emergency meeting with the physician before coming back to the facility from the ER. The family was concerned about having R60's pain medication increased. There was nothing in the note about the family wishing to speak to the physician or the facility about changing R60's code status. According to the ER social workers note dated [DATE] at 12:39 a.m., R60 was released from the ER at approximately 3:15 p.m. and brought back to the facility by Care Cab. There is no indication of what time the resident returned to the facility per the facility documentation. On [DATE] according to the emergency room notes R60 received 10 mg of [MEDICATION NAME] concentrate, a medication used for severe pain, at 10:42 a.m. and again at 3:15 p.m. The facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She also received [MEDICATION NAME] 0.5 mg, an anti-anxiety medication, at 5:30 p.m. per "family request." Side effects of both of these medications are drowsiness. On the facility's "Pain flow sheet and data collection" form R60's level of arousal was documented as "lethargic" on [DATE] at 4:00 p.m. On that data collection tool the level of arousal can be identified as "alert, lethargic, Responds only to maximal stimulation" or "Coma: unable to respond." On the facility nurses note [DATE] at 4:30 p.m. it indicated, "Doctor...updated with family's request to increase [MEDICATION NAME] (pain medication). Director of Nursing reported that resident was very difficult to arouse. New order issued to increase [MEDICATION NAME] to 10 mg every 3 hours as needed (if) respiratory rate is greater than 20." This was signed by LPN-C. On [DATE] Hospice came to the facility for an initial visit which was ordered on [DATE] by the residents physician. The hospice note indicated that the hospice nurse actual visit time was from 5:10 p.m.-7:10 p.m. The hospice notes indicated the hospice nurse called the Physician and "he verbalized his reluctance to increase pain or anxiety medications as he does not want to suppress her respiratory drive [MEDICATION NAME] (anti-anxiety medication) sublingually and nebulizer treatment was begun. Patient did cease to breath during her nebulizer treatment and was pronounced dead within minutes of the start of the nebulizer treatment after I was called back in to assess if she had died or not. I was unable to hear an apical pulse. Priest was called ...death occurred on [DATE] at 6:05 p.m." The note further went on to state that the hospice nurse was informed R60 died when she was calling the physician to obtain new medication orders. The hospice documentation of R60's demographics dated [DATE] lists the resident's code status as "DNR pending." There was no indication that code status was discussed with the resident or that her physician changed her code status. A facility nurses note dated [DATE] at 6:00 p.m. by Licensed Practical Nurse (LPN)- C indicated, "Called to room by staff. Resident lying supine in bed with family members at bed side weeping. No spontaneous respirations, pupils fixed and dilated. Unable to oscillate heart sounds, skin cold to the touch." Although the resident's code status was identified as a full code, CPR was not initiated nor was 911 called. On [DATE] at 11:10 p.m. the residents physician stated he had not changed her code status and she had wanted to be a full code. He had no contact with the resident or her family after R60 returned from the emergency roiagnom on [DATE]. As far as the physician was aware, R60's code status remained a full code. He stated he would expect that CPR should be preformed for anyone whose code status is a full code. On [DATE] at 12:20 p.m. the Director of Nursing stated that she was in the facility the night of [DATE] and CPR was not performed on R60. She understood that hospice was involved so they did not need to do CPR. She did not check R60's chart on [DATE] to verify what her code status was. She stated she was not aware until today that the resident may have been a full code on [DATE]. On [DATE] at 2:45 p.m. LPN-C stated she was the charge nurse working the evening of [DATE] when R60 died . She stated they would know a residents code status by looking at the facility "Pink Resuscitation Status" form. She was informed that R60 died and she did not check the chart for the code status and assumed the resident was a DNR because hospice was there. During interview via telephone on [DATE] at 3:10 p.m. with the supervisor from the hospice agency who saw R60 on [DATE], stated the hospice nurse arrived at the facility and the resident passed away quickly. R60 was never admitted to hospice services. They did not have a physician order [REDACTED]. When interviewed on [DATE] at 3:40 p.m. LPN-E stated he was the nurse responsible for medications for R60 on [DATE]. He gave R60 the nebulizer treatment the night she died . However, he finished the nebulizer treatment and left the room. He stated he was not in the room when R60 quit breathing and he thinks he was told by the hospice nurse that the resident had died . LPN-E stated he did not start CPR because "word of mouth it was known that family did not want her to be a full code." He did not check the facility Resuscitation status form or physician orders [REDACTED]. R60 had a Health Care Directive signed by herself, a son, and a daughter dated [DATE]. No directions were given by R60 within this document regarding her end of life wishes. The Health care Directive stated, "My health care agent must make health care decisions for me based on the instructions I provide in this document, if any, the wishes I have made known to him/ her, or must act in my best interest..." Although R60's family was aware she wanted to be a full code, they did not follow R60's wishes to initiate CPR if her heart were to stop. Review of the facility "Do Not Resuscitate" policy dated [DATE] revealed, "The attending physician is to determine the appropriateness of the DNR order for any given medical condition. The patient who is competent has the final decision as to the extent of care, or withdrawal, withholding, continuance or initiation of treatment. Regardless of the degree of competence, the patient should be involved in the decision-making process to the fullest. The DNR order will not be in effect until all of the following information is documented: When the DNR decision is made, the directive shall be written as a formal order by the attending physician. This order shall be dated and signed with a full signature." Although the facility was aware of R60's wishes to remain a full code, on [DATE] no one asked the resident what her current wishes were that evening. When reviewed, R60's chart on [DATE] lacked a copy of a pink Resuscitation status form. On [DATE] at 4:00 p.m. the Director of Nursing provided a copy of R60's Resuscitation status form. She stated that it was in the administrators office and was unsure if it was in the residents chart on [DATE]. She stated that on [DATE] she should have looked in R60's chart regarding her code status and "we need to change our policy" regarding how they handle resident code status. During interview on [DATE] at approximately 9:45 a.m. the Health Records staff- E stated the facility staff should be looking at the pink Resuscitation Status form to determine a resident's code status. The Resuscitation status form identified the resident code status by placing a check mark in front of "To Resuscitate" "DNR" "DNI" or "Comfort care." The form has a place for the "Resident/ Family/or Guardian signature." The form also indicates, "Your physicians participation and signature is required in these decisions." Health Records staff-E stated, "The pink sheet (resuscitation sheet) once it is signed is the final doctors order regarding code status." If the Resuscitation status form is not signed by the physician the nurses should be going by the actual physician order. If the facility does not have a physician order [REDACTED]. She was unable to give a specific amount of time the physician has to sign this order, but stated the facility physician comes up to three times a week and she makes sure they are signed. She was unsure why R60's Resuscitation Status form was never signed. When interviewed on [DATE] at 10:23a.m., with LPN-D stated that if a resident were to code she would get a stethoscope and get another nurse to verify. She would then check to see if the resident is full code or DNR by checking the pink sheet. If the resident was full code she would start CPR. If the pink sheet was not signed by the physician she stated she was not sure what she would do but that the sheets get signed quickly and if not signed she would call the physician. In interview with LPN-B on [DATE] at 10:35a.m. stated she was not aware which resident's on her wing are a full resuscitation or a do not resuscitate. No information of code status is communicated between shifts and code status is not placed on the nurse's daily worksheet. If she found someone unresponsive she would check vital signs, review the resuscitation status (pink sheet), and follow the directive on that sheet. LPN-B reviewed R75 pink "Resuscitation Status" form and stated R75 code status is DNR. Although the pink resuscitation sheet was not signed by a physician, she stated she would still follow the DNR order on the form. During interview on [DATE] 10:45 a.m. with Registered Nurse (RN)- B she stated she checks a residents code status by checking the pink Resuscitation status form. She indicated that she would follow the order on that form even if there was no physician signature regardless if it was signed by the family member or the resident. On [DATE] at 3:20 p.m. the Director of Nursing was interviewed and stated that upon hire the staff goes through a four hour training with human resources but nothing is covered regarding resident code status (pink resuscitation form). The new staff works with another nurse on the floor and does on the job training. They do not have any competency checklists regarding what needs to be covered in training, but the nurse should be informing the new staff about the pink sheets. They also do not have a formal policy about the Pink Resuscitation Status form and how they train staff regarding code status of the residents. Upon hire the facility does not require proof of CPR certification for LPN or RN's. On [DATE] at approximately 10:00 a.m. the facility used the resident face sheets to identify 37 residents in the facility were DNR status, and 34 residents were full code status. Upon review of those charts, 6 of 71 resident pink Resuscitation Status forms did not have a physician signature. R28 had [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident was moderately impaired in cognition. The pink "Resuscitation Status" form in the residents chart indicated the resident requested CPR, however it lacked a physician's signature and was only signed by the family on [DATE]. The most recent physician's orders [REDACTED]. R14 had [DIAGNOSES REDACTED]. recent quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident was rarely/never understood. The pink "Resuscitation Status" form in the residents chart indicated the resident requested CPR, however it lacked a physician's signature, and was only signed by the family (undated) and a facility nurse on [DATE]. The most recent physician's orders [REDACTED]. Resident 99 (R99) mental status form dated [DATE] indicated he had no memory problems and had no signs or symptoms of [MEDICAL CONDITION]. The pink "Resuscitation Status" form in the residents chart identified the resident as a DNR which was signed by R99 on [DATE]. However, there was no physician signature on the form or any telephone order regarding code status in the residents chart. The unsigned physician orders [REDACTED]. R26 had [DIAGNOSES REDACTED]. The pink "Resuscitation Status" form in the residents chart indicated the resident requested CPR, however it lacked a physician's signature, and was only signed by the residents guardian on [DATE]. The most recent signed physician orders [REDACTED]. R84 had [DIAGNOSES REDACTED]. The most recent quarterly MDS dated [DATE] indicated the resident was able to make himself understood. The pink "Resuscitation Status" form in the residents chart indicated the resident requested CPR, however it lacked a physician's signature, and was only signed by the resident on [DATE]. The most recent physician orders [REDACTED]. Resident (R) 75 Annual Assessment Minimum Data Set ((MDS) dated [DATE] identified the resident having no memory problems and was independent with cogitative skills for daily decision making. The MDS states her advance directive was do not resuscitate. The pink Resuscitation Status form in the resident chart indicated DNR and DNI signed by the resident but did not have a physician signature. The physician orders [REDACTED]. When reviewed, 7 of 10 licensed nursing staff employee files (E1- E7) lacked evidence of cardiac [MEDICAL CONDITION] resuscitation (CPR) training. On [DATE] at 2:30 p.m. the human resource director provided the facility's Talahi Care Center Licensed Practical Nurse (LPN) job description which directed that a LPN must "maintain CPR certification." The facility's Clinical Nurse Manager job description for registered nurses (RN) was also provided, and lacked any information regarding CPR certification requirements. The following nursing staff employee files lacked evidence of any CPR training. According to a facility Employee Information form dated [DATE], the employees titles and dates of hire were as follows: E1, LPN- [DATE] E2, LPN- [DATE] E3, RN-[DATE] E4, LPN [DATE] E5, RN- [DATE] E6, RN- [DATE] E7, LPN- [DATE] On [DATE] at 2:15 p.m. during interview with the Human Resource director she stated that the RN job description does not require CPR training and the facility does not ask for proof of CPR certification upon employment. The administrator and DON were informed that the facility lacked a system to identify and ensure each resident code status was authenticated by the physician and readily available for staff to implement. These findings constituted an immediate jeopardy situation on [DATE] at 3:38 p.m. and an extended survey was conducted. The facility submitted a written plan for the removal of the immediate jeopardy on [DATE] which included implementation of a policy dated [DATE] regarding identifying resident resuscitation status and the location of the form in the chart, all resident charts were audited to ensure resusicition forms were signed by a physician, all licensed staff was trained on obtaining a resuscitation status directive policy, all nurses will be required to be CPR certified by [DATE], every shift will include a licensed CPR nurse working which will be identified in the daily shift check in sheet and will be highlighted in pink, and the CPR staff policy was rewritten. On [DATE] between 10:05 a.m. and 10:25 a.m. multiple staff were interviewed regarding the new policy and how they determine a residents code status and who in the facility was CPR trained. Facility staff (NA-X, RN-B, RN-A, NA-Y, TMA-A, and LPN-A) indicated that they received training to determine a residents code status they should look at the residents pink resuscitation form. They locate the current staff who are CPR trained by looking at the staffing book for the person who will be highlighted in pink. In addition, 10 charts were selected at random to ensure the Resuscitation status form was signed by the physician, and the staffing for the week was reviewed to ensure a nurse with current CPR certification was on every shift. The administrator and the DON were notified on [DATE] at 10:31 a.m. that the immediate jeopardy had been removed. [MEDICAL TREATMENT] Resident (R) 30 lacked any nursing monitoring of the care and services related to her [MEDICAL TREATMENT]. R30 had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) lacked any further information regarding the [MEDICAL TREATMENT] services. A facility Care Conference Summary note dated [DATE] lacked any notation that the resident was receiving off-site [MEDICAL TREATMENT] services. An Individual Resident Plan of Care dated [DATE] and initiated within 24 hours of admission, simply noted the resident had a left fistula [MEDICAL TREATMENT] access. A Comprehensive Evaluation of Skin Risk Factors form dated [DATE] noted R30 was on a 1500 cc fluid restriction and a ADA/[MEDICAL TREATMENT] diet. The narrative document also noted "monitor for bruit, thrill daily". It lacked any indication where the access site was located. The current plan of care dated [DATE] lacked any information related to [MEDICAL TREATMENT] services such as where, when, or any emergency and routine cares of the access site. On [DATE] the resident left the facility for [MEDICAL TREATMENT] services at an outside agency. When interviewed on [DATE] at 6:50 a.m., Licensed Practical Nurse- F verified the resident left the facility for [MEDICAL TREATMENT] services on Tuesdays, Thursdays and Saturdays. On [DATE] at 8:00 a.m., the resident was observed eating in the dining room and drank 4 oz of water. At 9:45 a.m., the resident stated she also drank a small glass of lemonade with her breakfast that morning. The total ounces would amount to 240 cc of fluid. The facilities Food Consumption Record (FCR) indicated the resident received only 100 cc of fluid. When interviewed on [DATE] at 8:00 a.m., the dietary manager stated the nursing assistants record the amount of fluids the residents consumed on the FCR at each meal. She stated R30 was on an ADA/[MEDICAL TREATMENT] diet and had a 1500 fluid restriction. When interviewed at 1:25 p.m., she stated the intake sheets were not recorded accurately. She knew that on [DATE] "for example" that R30 did not receive 600 cc's at breakfast as the FCR indicated. She stated that dietary department typically would only provide 8 oz (240 cc's) at meals, and nursing who provide the remainder. She stated she was not sure how the nursing assistants were instructed to record the intake. When reviewed, the clinical record contained seven [MEDICAL TREATMENT] Communication Record forms in the chart from [DATE] to [DATE]. The form requested information to be completed by the facility prior to sending the resident, and information to be completed by the [MEDICAL TREATMENT] unit such as vital signs and weights Although the facility completed their information when sending the resident to the off-site [MEDICAL TREATMENT] unit, only 2 of 7 entries were completed by the off-site [MEDICAL TREATMENT] nurse when the resident returned making it difficult to determine how the resident tolerated [MEDICAL TREATMENT] for these days. When interviewed on [DATE] at 11:14 a.m., registered nurse (RN) -B stated the December intake and output (I&O) form for R30 was located in the medication administration book, but there was missing intake date for 3 of out 8 a.m. shifts and lacked a daily tally. When interviewed at 1:39 p.m., RN-B reviewed the FCR and the I&O form and stated they "do not jive". She stated nursing assistants should record intake on the FCR and report the totals to the nurse at the end of their shift who was responsible for tallying it on the I&O form. She stated it appeared staff needed to be re-educated. RN-B reviewed the care plan and verified nothing was in the care plan regarding [MEDICAL TREATMENT] care. She stated they were not routinely checking the fistula site or checking for a bruit or thrill. She verified the clinical record lacked information related to [MEDICAL TREATMENT] care and services which included monitoring of the access site and routine and emergency plans for care. When interviewed in [DATE] at 2:15 p.m. Licensed Practical Nurse- E stated he was not aware of any thing special that had to be monitored when R30 returned from her [MEDICAL TREATMENT] run. Resident 55 (R55) lacked any nursing monitoring of the care and services related to her [MEDICAL TREATMENT]. Resident 55 Admission Minimum Data Set ((MDS) dated [DATE] identified the resident as having some short term memory problems, severely impaired cognitive skills for daily decision making, rarely able to understand others or make herself understood, an extensive assist with all activities of daily living, and receiving [MEDICAL TREATMENT]. On review of the residents care plan dated [DATE] there was no information regarding [MEDICAL TREATMENT] treatments, where the residents [MEDICAL TREATMENT] access was or emergency procedures regarding the access, and what staff should be monitoring for. On [DATE] at 8:45 a.m. during interview with Registered Nurse (RN)- C she indicated that she was unsure what [MEDICAL TREATMENT] access the resident is currently using. RN-C was aware that the resident had a [MEDICAL TREATMENT] access in her chest because she "could see it." She stated there is nothing special that the facility needed to know regarding the residents access except that they could not get the access in her chest wet. She verified there was nothing on the medication record, the treatment sheet, the care plan, or the nursing assistant care sheets regarding what kind of access R55 used or care regarding it. On [DATE] at 9:20 a.m. during interview with the RN charge nurse at the outpatient [MEDICAL TREATMENT] unit she stated that the R55 had a [MEDICAL TREATMENT] access in her right forearm as well as in her chest. The facility should make sure that the access in her chest does not get wet and should know what to do if the [MEDICAL TREATMENT] catheter in her chest would come loose or fall out. In addition, the facility should make all staff aware that no blood pressures can taken in the arm where R55 [MEDICAL TREATMENT] access is. On [DATE] at 8:15 a.m. during interview with nursing assistant (NA)-P stated she gives R55 a bath and checks her blood pressure on bath days. She stated that she takes her blood pressure on the left arm because that is the side of the bathtub that she stands on. She stated, "I think we can take blood pressures anywhere on her (R55)." Resident 46 (R46) lacked any nursing monitoring of the care and services related to her [MEDICAL TREATMENT]. Resident 46 Admission Minimum Data Set ((MDS) dated [DATE] identified the resident as having no memory problems, needing limited assistance with most activities of daily living, and receiving [MEDICAL TREATMENT]. Review of R46 care plan dated [DATE] there was no information regarding [MEDICAL TREATMENT] treatments, where the residents [MEDICAL TREATMENT] access was or emergency procedures regarding the access, and what staff should be monitoring for. During interview with NA-R on [DATE] at 8:30 a.m. she stated that she did not know what kind of [MEDICAL TREATMENT] access R46 had because "It does not pertain to me so I don't ask." She stated that the only thing they need to do is keep track of his fluid at meals. During interview with NA-S on [DATE] at 8:45 she stated that she did not know what kind of access R46 had for [MEDICAL TREATMENT]. On [DATE] at 9:20 a.m. during interview with the RN charge nurse at the outpatient [MEDICAL TREATMENT] unit she stated that R46 used a [MEDICAL TREATMENT] catheter in his chest for an access. The facility should make sure the access does not get wet and be aware of emergency procedures if the catheter would come loose or fall out. On [DATE] at 1:55 p.m. during interview with RN-B she stated that they did not have any policy or procedures regarding [MEDICAL TREATMENT] residents until this morning which the Director of Nursing added some into the policy book. She verified that there was no information regarding the residents access that the staff could refer to regarding emergency procedures. No further information was provided. [MEDICAL CONDITION] Resident (R) 94 was not provided the necessary services and treatment for [REDACTED]. Resident (R) 94 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was in the hospital from ,[DATE] to [DATE], for complications related to his ALS. The hospital medical progress note of [DATE] identified " Has significant respiratory weakness due to progression of [MEDICAL CONDITION] ...which is consistent with diaphragmatic weakness." The hospital discharge summary of [DATE] identified R94 needed a bi-pap machine (a medical machine to assist with breathing) and was to be used 24 hours a day. The admission Minimum Data Set ((MDS) dated [DATE] identifies R 94 had no problems with cognition, and needed extensive assist with locomotion, dressing, and bathing. The mood status identified R94 felt depressed or hopeless ,[DATE] days over the last 2 weeks and going outside, doing his favorite activities, and participating in religious activities were very important to him. It also identified that doing things with groups of people was also somewhat important to him. On [DATE] at 9:17 a.m.., R94 stated it had been three weeks since he came to the facility and had not left his room because he has to use the [MEDICAL CONDITION] machine to breathe. His [MEDICAL CONDITION] machine was electric and does not have a battery source. As R94 talked about this his eyes well up with tears and stated he felt isolated at times and wishes he could leave his room. On [DATE] at 10:50 a.m.., R94 stated "Breathing is something you take for grant until you can't do it." On [DATE] at 3:R30., the clinical manager A, stated a request for a portable bi-pap was faxed to Northwest Respiratory Services, durable medical equipment company (DME) on [DATE]. Northwest Respiratory Services informed the facility they did not have a battery for the bi-pap. They have had no further contact with No