Every finding on record at Elim Wellspring Health Care Center

Based on observation, interview and record review, the facility failed to follow standard precautions (infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status and includes use of gloves before potential contact with blood) to prevent the potential for spread of blood borne infections for 1 of 2 residents (R67) who were reviewed for point-of-care testing using a blood glucose monitor. Findings include:R67's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition with a diagnosis of diabetes and use of insulin.R67's orders dated 7/11/25, directed staff to monitor his blood glucose four times a day.During observation on 12/17/25 at 8:45 a.m., registered nurse (RN)-A prepared to perform R67's morning blood glucose testing. RN-A performed hand hygiene using hand sanitizer, retrieved R67's dedicated blood glucose monitor, a single use test strip, lancet and alcohol wipe from the unit cart then approached R67 who was sitting at a table in the unit dining room. RN-A verified R67's identity and obtained his permission to perform his blood glucose test at the table. RN-A then inserted the test strip into the monitor and set it and the lancet on the table next to R67 on his left side. Without donning gloves, RN-A used the alcohol prep to cleanse R67's finger. Without donning gloves, RN-A then used the lancet to stick R67's finger inducing the flow of blood. Without donning gloves, RN-A then picked up the glucose monitor from the table and used the inserted test strip to obtain R67's blood sample. RN-A then carried R67's blood glucose monitor with inserted used test strip with blood sample, the used lancet and used alcohol wipe with wrapping back to the unit treatment cart across the hall using her bare hands. Without donning gloves, RN-A removed the used test strip from the monitor using the alcohol prep wrapping to dispose of it and the used lancet into the sharps container on the cart. RN-A then proceeded to a sink and performed hand hygiene with soap and water.When interviewed on 12/17/25 at 9:00 a.m., RN-A confirmed she had not used gloves when performing R67'S blood glucose test and then stated, Why is that a thing? RN-A stated working at the facility for approximately 2 months and confirmed she had received infection control training and competency testing.When interviewed on 12/18/25 at 11:08 a.m., the director of nursing (DON) stated her expectation for blood glucose testing was for staff to follow facility policy including standard precautions and use of gloves related to the potential to transmit blood borne pathogens.The facility policy Blood Glucose Monitoring dated 3/10/25, identified the procedure steps including performing hand hygiene, apply gloves, wash the resident's hands with soap and water or use alcohol wipe then use the lancet to obtain a small sample of blood.

Based on interview and document review, the facility failed to properly account for 34 tablets of hydromorphone (a controlled narcotic pain medication) for 1 of 3 residents (R1) reviewed for controlled medications. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated diagnoses of infection of multiple sites of the spine, septicemia (infection in the blood) and low back pain. The MDS also indicated R 1 had recent spinal surgery and she had received scheduled and as needed pain medication. R1's care plan dated 9/17/24 indicated she had pain related to diagnosis of lumbar fusion (spinal surgical procedure) and complaints of back pain. R1's hospital discharge orders included an order for hydromorphone (a narcotic pain medication) 2 milligrams (mg) every 3 hours as needed for severe pain. R1 was discharged from the hospital on 9/17/24. R1's September 2024 medication administration record (MAR) indicated she received hydromorphone 2 mg on 9/17/24 and 9/19/24. On 10/15/24, nurse practitioner (NP)-A wrote an order to discontinue hydromorphone 2 mg. On 10/16/24 at 9:36 a.m. a progress note indicated R1 discharged to home at 9:00 a.m. On 11/5/24 at 9:45 a.m., the director of nursing (DON) stated R1 was discharged home from the facility on 10/16/24, and the hydromorphone was not sent home with R1. On 11/5/24 at 10:47 a.m., R1 stated she did not take the hydromorphone often while at the facility, as she did not have the need for it. She also stated she did not take the hydromorphone home with her when she discharged on [DATE]. On 11/5/24 at 11:27 a.m., licensed practical nurse (LPN)-A stated she and LPN-B discovered R1's hydromorphone was missing on 10/21/24 around 7:00 p.m., when they conducted their narcotic count at the change of shift. When the medication was discovered to be missing, she sent an email to the DON to notify her of the discrepancy. On 11/5/24 at 1:19 p.m., LPN-B stated she remembered seeing R1's hydromorphone the morning of 10/18/24. She stated when she came to work on 10/21/24 at 7:00 p.m. she completed her narcotic count with LPN-A, and they discovered R1's hydromorphone was missing. LPN-A sent an email to the DON. On 11/5/24 at 2:34 p.m., the DON stated she would have expected the nurses to have called her immediately upon discovering any discrepancies with narcotic counts. She did receive an email regarding R1's missing hydromorphone. On 11/5/24 at 3:44 p.m., LPN-C stated he recalled seeing R1's hydromorphone on 10/18/24. He did not follow policy and did not verify the narcotics were physically present in the medication cart. It was, Kind of a trusting situation. He knew the process of viewing each actual medication and looking at the count sheet to verify the actual number of medications, and this was an essential step to the process of narcotic counting. On 11/5/24 at 4:31 p.m., the assistant director of nursing (ADON) stated narcotic counts should be completed anytime a new staff person worked on a medication cart. The oncoming nurse should be counting the bin/locked box of medication. The nurse who was leaving should be reviewing the book to verify the quantity. If there was any discrepancy, they were to notify the DON immediately. The ADON also stated discontinued medications should be destroyed timely with two nurses. On 11/6/24 at 9:22 a.m., the pharmacist stated all medications were destroyed on site. The pharmacy no longer accepted returned medications. Best practice was to destroy a medication as soon as it was discontinued. R1's Narcotic Record indicated 36 tablets were received on 9/17/24. 1 tablet was removed from the card on 9/17/24, and another tablet was removed on 9/19/24, leaving 34 tablets. The facility policy Narcotic Count dated 7/19 directed the count is done by having one nurse look at the index and corresponding sign out page. A second nurse confirms the quantity remaining in the medication card, box, or bottle. Both staff sign the count notebook to indicate the count was current. a) if the count is not correct, notify the nursing supervisor promptly and search for the missing medication(s). b) if missing medication(s) cannot be accounted for, notify DON (or designee) who will determine the appropriate course of action The facility policy Medication Disposition dated 2/23 directed controlled medications: 1. When a scheduled II-V medication is discontinued, upon resident death, or upon discharge of a resident when a schedule II-V medications are not sent with resident upon discharge these medication must be destroyed by DON (or designee) and a second nurse. 2. Medications are to remain locked in the locked narcotic box on the medication cart and will be counted per the narcotic count policy until they are removed for destruction. 3. As soon as practical after discontinuance, death or discharge the following should occur: Narcotic medications are destroyed via state and federally acceptable practices.

Based on Interview and document review, the facility failed to ensure resident families and/or representatives were updated timely for a change in condition related to a fall for 1 of 2 residents (R34) reviewed for falls. Findings include R34's quarterly Minimum Data Set (MDS) dated [DATE], included severed cognitive deficit with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R34's care plan listed problem of cognition/mood dated 10/10/22, indicated R34, Relies on family to assist with major decision making prn [as needed], and directed staff to, Encourage family support and involvement. When interviewed on 10/31/22, at 12:14 p.m. R34's responsible family member (FM)-A stated, R34 had a fall on 9/30/22, at around 1:00 a.m. The facility did not notify him until 9/30/22 around 3:30 p.m. He was traveling for work that day. He would have chosen not to travel if he had know R34 required family assistance. It should have been more timely, if not at the time of occurrence, at least way before 3:30 p.m. R34's fall event report indicated a fall on 9/30/22, at 12:56 a.m. and FM-A was notified at 3:51 p.m. R34's progress note dated 9/30/22, at 12:56 a.m. identified, Resident found on the floor, lying on right side facing the bed. He was screaming for help. Wheelchair within reach. Denies pain, denies hitting his head. ROM [range of motion] intact. Wearing white whites. He reports he was trying to get up to go to the bathroom and slipped out of bed. Assisted off the floor with assist of Nurse and aide. Aide assisted to the bathroom. Skin check completed, no discoloration noted. R34's progress note dated 9/30/22, at 3:31 p.m. identified, Updated [FM-A] this afternoon regarding fall that happened during previous shift. Was upset that he wasn't updated sooner than later. Said he was on the road and was 10 hours away and wouldn't have been able to get here had anything serious transpired. Was reassured that resident was stable and sustained no injuries from fall. [FM-A] said he would be contacting management regarding timely communication. When interviewed on 11/3/22, at 1:20 PM registered nurse (RN)-C stated, with any resident fall or incident, facility protocol is to notify resident's primary care provider, family or representative and nurse managers. RN-C stated if a resident had a fall that did not result in an injury on an overnight shift facility protocol was for the incoming day shift nurse to make those notifications. When interviewed on 11/3/22, at 2:36 p.m. RN-A stated, [FM-A] had not made a complaint to any management staff that she was aware of therefore no grievance had been initiated. RN-A stated nurse managers normally reviewed all facility progress notes and any noted concerns should have been brought forward to the interdisciplinary team. RN-B stated she had spoken to FM-A on 9/30/22, regarding another matter and he had expressed no concern regarding lack of notification. RN-B stated normally if there is no resident injury or transfer to the emergency room , the day shift staff would make notifications of any incidents on overnights. RN-B stated she did follow-up with FM-A today (11/3/22) to discuss his concern. RN-B stated FM-B had agreed to a care plan change for R34 instructing staff to notify family no matter what the time of day. The facility policy titled, Notification of Physician and Resident Representative, dated 5/4/22, included, Primary physicians, residents, and the resident representative, consistent with their authority, will be updated with all resident condition changes as soon as possible. The names of those contacted will be documented in the progress note.

Based on interview and document review, the facility failed to ensure incidents of alleged abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of abuse who obtained a significant injury from a fall. Findings include: R1's Face Sheet undated indicated R1 admitted on [DATE], with recent fracture of right femur, dementia, repeated falls and aged related [CONDITION(S)]. R1's Care Plan with start date of 5/20/22, indicated R1 was a fall risk related to fall prior to admission resulting in a right hip fracture requiring surgical repair, pain, impaired mobility, medications, new environment and diagnoses. The Care Plan further indicated R1's interventions were toGive verbal reminders not to ambulate/transfer without assistance. Call light accessible and within reach whenever resident is in own room. Explain risks and benefits of asking for help to transfer or ambulate. Keep environment free of clutter. Keep personal items of interest within easy reach next to resident's chair and/or bed. Ensure use of proper, well-maintained footwear. Toilet per schedule. PT/OT as needed/ordered. A facility reported incident report dated 5/23/22, at 3:01 p.m. indicated on 5/22/22, at 10:00 a.m. just shortly after staff left the room staff heard commotion and upon entering R1's room, was found on the floor on her right side. Minor first aide applied to bump on resident's head and vital signs were with in normal limits. Staff had just left R1's room and she was in her recliner and call light was found not next to her. There report further indicated R1 was a recent admission, had been noted to have confusion and not consistent with call light use during her stay at Elim. RE-education was provided to staff about appropriate placement of call light. Resident did report pain in right lower extremity when bearing weight and was sent to hospital for further imaging and confirmed fracture of femur. Surgical repair was scheduled for 5/24/22. During interview on 5/31/22, 1:40 p.m. director of nursing (DON) stated she was informed immediately of R1's fall and did not realize until the following day the report needed to be reported and in fact thought they had 24 hours to file the report to the state agency. In a follow up interview on 6/1/22, at 9:15 a.m. the DON stated after she reviewed the regulation and there policy the facility should have reported the incident immediately with in 2 hours due to the serious injury of R1. Facility Policy Vulnerable adult-MN revised 10/31/19, indicated each employee is responsible to report suspected/alleged violations of mistreatment, neglect, exploitation of residents, and abuse of residents and/or misappropriation of resident property immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, interview, and document review, the facility failed to maintain tub equipment in a safe operating condition, which had the potential to effect all 14 residents residing on the Skyview unit. Findings include: During observations of the Skyview Unit, on 3/10/21, at 10:08 a.m. the following environmental concerns were noted: the bath tub (MasterCare brand) seat cushion had a worn vinyl and exposed foam to both front outer edge corners, along with cracked vinyl and exposed foam to the seams of the middle oval cutout section. In addition, the seat had approximately four inches of cracked vinyl and exposed foam to the left front edge. The leg rest cushion had numerous areas of cracked vinyl with exposed foam along the surface and sides. Many of the worn and cracked vinyl areas were jagged and had the potential to scratch a residents skin due to the rough edges. In an interview on 3/11/21, at 9:24 a.m. registered nurse (RN)-B stated, after she was shown the Skyview unit bath tub chair cushions and touched the cushions' surface, the cracked and worn areas on the cushions were rough and had the potential to cut their (residents) skin, along with an additional statement that bacteria could get in there (the cushions). RN-B explained a maintenance request should be filled out due to the damaged chair cushions and risk of injury to the residents. Further, RN-B explained due to the nature of the tub chair cushions a sign should be put into place which indicated staff should not use the tub until it could be fixed. RN-B denied knowledge of the damaged cushions and had been unable to identify how long the cushions had been damaged; however, she stated she had felt the damage had been present for some time due to the nature of the damage. During interview on 3/11/21, at 10:11 a.m. trained medication aide (TMA)-A stated she had recently assisted staff with managing the tub door during a bath for R57; however, she had not visualized the tub chair at that time. TMA-A explained she would have filled out a maintenance work order to have the chair cushions replaced or to have something placed over them to prevent the cushions from being sharp as there had been a potential to cause resident skin tears. Further, TMA-A explained the damaged cushions could harbor microorganisms if they became wet. When interviewed on 3/11/21, at 2:36 p.m. nursing manager RN-A denied any knowledge of Skyview unit tub chair concerns. RN-A verbalized she expected staff to report any tub chair damage to maintenance. RN-A explained, after she was shown the Skyview unit bath tub chair cushions and touched the cushions' surface, the cushions should be replaced due to an infection control risk and due to the cracked vinyl having been a little bit sharp. RN-A stated all surfaces need to be cleanable and cannot be porous. RN-A had been unable to identify how long the cushions had been damaged; however, she stated the damage did not happen overnight. RN-A denied knowledge of facility bath equipment audit processes. During the interview, RN-A filed a maintenance request to have the tub cushions replaced. During interview on 3/11/21, at 2:58 p.m. the plant operations director (POD) stated maintenance work orders were reviewed daily and prioritized based on fire, water, and resident safety hazards. The POD explained it should not take more then two days to fix a tub cushion if concerns were reported. During the interview, the POD reviewed the last 30 days of maintenance work orders for the Skyview tub chair in which he identified a work order had been placed that day by RN-A. The POD denied any other work orders had been submitted. Further, the POD denied knowledge of concerns with the Skyview tub chair. After the POD visualized the tub chair cushions, he stated the seat and foot pads needed to be replaced. The POD felt the cushion damage had not happened over night and he would have expected to see a maintenance work order submitted prior to RN-A's. The POD denied maintenance staff performed routine audits on tub bathing equipment. Point of Care History reports, dated 2/11/21 through 3/11/21, identified R35 had received a tub bath on 3/7/21 and R57 had received a tub bath on 2/13/21 and 2/26/21. On 3/11/21, at 2:58 p.m. the Skyview unit tub room lacked any indication which alerted staff not to use the tub. A Reporting of Repairs Needed policy, dated 7/13/20, indicated staff were to immediately report any facility area that was in need of repair to maintenance or the environmental services department.

Based on observation, interview and record review, the facility failed to ensure resident's rights to privacy for 1 of 1 residents (R38) whom staff walked into room without receiving permission. Findings include: R38's quarterly minimum (MDS) data set [DATE], indicated no cognitive impairment and required one assist with bed mobility and transfers and required two assist when walking. Resident is being monitored for mood and behaviors each shift. R38's care plan revised 3/4/21, indicated alteration in behavior related to major [MEDICAL CONDITION], psychosocial well-being, and being monitored mood as resident is on antidepressants. During observation on 3/8/21, at 4:46 p.m. staff knocked on R38's door and R38 told them to wait a minute as she was talking with someone. Staff observed walking into room and wanted R38 to take her medication, despite R38's request to wait. During interview on 3/8/21, at 4:46 p.m. R38 stated that staff just walk in her room all the time without her giving them consent. During interview on 3/9/21, at 8:40 a.m. R38 stated that staff do not always knock on the door before entering her room, stated staff also attempt to give her medications while she is sitting on the toilet. R38 further stated staff do not make her bed and when she was younger she was always taught to have a clean house and make your bed. R38 stated this was important to her as she likes to have her privacy and wishes respected. During observation on 3/10/21, at 8:00 a.m. R38 had two signs on her door, one stated; keep door closed, please give resident her privacy and only come in for necessary task and the other sign indicated please knock and give me a minute to put on my shield and mask, thanks. During interview on 3/10/21, at 9:26 a.m. R38 stated since state survey evaluators have arrived, staff have been good about making her bed and knocking on her door. In an interview on 3/10/21, at 1:27 p.m. nursing assistant (NA)-B stated R38 plays her music loud and when knocking on her door maybe she can't hear the knocking. NA-B stated she will peak her head in and ask to come in. NA-B stated R38 has a right to privacy and she respects that. During interview on 3/10/21, at 1:47 p.m. trained medication aide (TMA)-A stated all staff should be knocking before entering a resident's room as this is their home and they have a right to privacy. In an interview on 3/10/21, at 2:08 p.m. registered nurse (RN)-A stated she was unaware of staff just walking into R38's room and stated that it was unacceptable for staff to be walking into any resident's room without being invited to come in. RN-A stated this is the residents home and we should treat it as such and every resident is entitled to their privacy. During interview on 3/11/21, at 10:08 a.m. social worker stated R38 had reported on multiple occasions that her bed was left unmade which was very important to her and staff should respect this. Social worker stated she had addressed this concern with the unit manager. Social worker stated R38 had never came to her with concerns about staff not coming into her room. Social worker further stated that it is unacceptable for staff to barge into anyone's room without being let in as this is their home and they have a right to privacy. In a final interview on 3/11/21, at 11:58 a.m. RN-A stated she spoke with R38 but R38 was unable to recall who the staff where that barged into her room or when this happened. RN-A further stated that they will be re-educating all staff about customer service as all residents have the right to privacy as this is their home. Resident's bill of rights The right to privacy and the right to be treated with dignity.

Based on observation, interview, and document review the facility failed to reassess the resident's ability to utilize the standing lift for transfers for 1 of 1 residents (R62) observed to be transferred unsafely in a standing lift. Findings include: R62's face sheet dated 3/13/21, identified [DIAGNOSES REDACTED]. R62's annual minimum data set ((MDS) dated [DATE], identified R62 with severe impaired cognition, extensive assistance needed with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. R62's care area assessment summary (CAA) dated 2/25/21, identified falls triggered due to balance impairment, non-ambulatory, all transfers are not steady and only able to stabilize with human assistance. Potential for falls r/t (related to) impaired mobility secondary [MEDICAL CONDITION](stroke) with left sided [MEDICAL CONDITION], weakness, medications, incontinence, and [DIAGNOSES REDACTED]. R62's care plan dated 2/15/21, identified physical mobility as a problem r/t weakness, pain, medications, and impaired mobility secondary [MEDICAL CONDITION] left-sided [MEDICAL CONDITION] affecting left dominant side, pain, [MEDICAL CONDITION], and medications. Goal identified as upon therapy completion, R62 will require partial/moderate assist with sit to stand, chair/chair-to bed transfer and toilet transfer. Approaches included assist of 2 with stand-up lift for transfers, A2 (assist of 2) for bed mobility. Bilateral grab bars to bed to assist with bed mobility and transfers. Monitor for safety, PRN (as needed) PT/OT (physical /occupational therapy) as ordered, encourage participation as able, monitor for changes in mobility. During an observation on 3/10/21, at 8:01 a.m. R62 sat on edge of bed. Nursing assistant (NA)-F placed sit-to-stand lift in front of R62. NA-H placed R62's hands on the padded handles, positioned lift belt around her upper body, placed feet on the foot plate lower legs into the shin pad, and secured the shin straps around R62's lower legs. NA-F lifted R62 off the bed with the sit-to-stand lift. R62 held onto padded handles and NA-F wheeled her into the bathroom and lowered her down onto the toilet. At 8:07 a.m. NA-F raised R62 up off the toilet with the sit-to-stand lift. R62 struggled to hold herself up and started to loose strength and sat downward and backwards while attached to the sit-to-stand lift. R62 stated it hurts it hurts I am going to fall. R62's arms and elbows raised upwards as she tried to hold herself up. NA-H stated many times stand up honey and stand up (R62). Facility staff did not physically assist R62. R62 could not support herself and hung from the stand lift with her bottom positioned lower than her knees. R62's eyes started to get big and R62 said I cannot stand, it hurts it hurts! R62's bottom remained lower than her knees, staff applied the brief and pulled up her pants as R62 let go of her left hand from the gripper and stated I cannot . I cannot stand and sat further down while attached to the stand lift. NA-H placed R62's hand back onto the gripper and stated you really need to hang on here. NA-F and NA-H rushed R62 out of the bathroom and bumped R62's left elbow on the doorway. R62 stated ouch and NA-F quickly pushed R62 to the wheel chair (w/c) located in her room. NA-F lowered R62 down onto the w/c, released shin straps from lower legs, removed loop straps from the lift, and belt from R62's upper body. During a subsequent observation on 3/10/21, at 9:23 a.m. R62 requested to go to bathroom. NA-H pushed a sit-to-stand lift and licensed practical nurse (LPN)-G pushed R62 in w/c into her room. NA-H placed the sit-to-stand lift in front of R62 (the same lift used on the previous observation). LPN-G fastened the shin straps around R39's lower legs and top harness around her upper body and tightened the loose strap. NA-H and LPN-D attached the first set of harness loops to the sit-to-stand lift. R62's arms and shoulders went upwards and she stated ouch ouch. LPN-D stated the lift arm needed to be lowered down more. NA-H lowered the lift arm down. LPN-D attached the second set of harness loops to the sit-to-stand lift and placed R62's hands on the padded handles. NA-H raised R62 up to a standing position. R62 held herself up through the transfer to the bathroom and until NA-H lowered her onto the toilet. LPN-D exited the room and NA-F entered the room. At 9:30 a.m. NA-H placed R62's hands on padded handles and instructed F62 to hold on tight. NA-F wiped R62's perineal area from front to back. NA-F encouraged R62 to use her legs. R62 slowly lowered herself downwards in a sitting position still attached to the sit-to-stand lift and stated I can't hold on. NA-F placed a clean brief on her and pulled up her pants quickly as resident sat lower and her bottom hung just above her knees. NA-F stated hold on (R62). R62 then attempted to stand. R62's bottom continued to hang down just above her knees while staff quickly wheeled/rushed her from the bathroom to her w/c located in her room. R62's bottom touched the wheelchair seat. NA-F grabbed hold of the R62's pants and lifted her bottom up onto the w/c seat. NA-H lowered her down onto the w/c. Staff removed the loops from the sit-to-stand lift, shin pad straps, the top harness around R62's upper body, and placed a lap blanket across her. During an interview on 3/10/21, at 11:43 a.m. NA-G stated R62 sometimes held on to the padded handles when she used the stand lift but it depended on how she was doing in the morning. NA-G indicated she had informed a staff nurse R62 did not transfer safely at times. NA-G did not identify she reported the previous unsafe transfer observed on 3/10/21, at 8:01 a.m. During an interview on 3/10/21, at 11:58 a.m. NA-F indicated she charted R62 transfers had been unsafe and worse since she had a stroke and COVID the last two months. NA-F stated she's unaware of any assessment that had been done. NA-F indicated R62 let go of the padded handles and lost her strength in her legs during the transfer that morning. NA-F stated she was really afraid she was going to fall. NA-F also indicated R62 should have been lowered back onto the toilet to prevent a fall. NA-F indicated R62 should have been transferred back to the w/c a different way instead to help prevent a fall. R62's medical record lacked any evidence R62's mechanical lift transfer had been reassessed with [REDACTED]. During an interview on 3/10/21, at 12:47 p.m. NA-H stated the R62's transfer with the sit-to-stand lift earlier today was nerve racking. R62 should have been placed back onto the toilet to prevent a fall and then staff figure out what to do from there. NA-H indicated the staff nurse LPN-B was notified. During an interview on 3/10/21, at 3:19 p.m. RN-C stated the nursing assistant 24 hour report sheets are used by staff to communicate to each other and the staff nurse reviews them to assure the information was passed on. R62 used the sit-to-stand lift and when it was unsafe staff should have placed her back onto the toilet and used a 4 point lift instead to safely transfer. Those 2 transfers on 3/10/21 were not safe and when staff saw it the first time they should have used the Hoyer lift the next time. RN-C identified PT and OT had not re-evaluated R62. RN-C indicated she had not been informed of the unsafe transfers. During an interview on 3/10/21, at 3:41 p.m. LPN-B stated staff informed her R62's transfer the morning of 3/10/21, was difficult from the bathroom to the w/c. LPN-B indicated she informed staff they should have used the sit-to-stand lift. LPN-B also indicated there was some miscommunication with staff. LPN-B indicated R62 should have been lowered back onto the toilet when she let go of the padded handles. LPN-B stated R62 has had many events lately such as COVID, hospitalization , and the unexpected death of her son. LPN-B stated it is unsafe for R62 to use the sit-to-stand lift and when staff saw it was not safe the first time they should have used the 4 point (total lift) next time. During an interview on 3/11/21, at 8:15 a.m. PT-D indicated R62 had just been re-evaluated for transfers (3/11/21), following concerns related to unsafe transfer on 3/10/21). R62 stood 1 1/2 minutes then her bottom started to sink and put it back up to stand another 30 seconds for a total of 2 minutes. PT-D identified R62 held on to the paddled handles during the transfer. PT-D stated R62 could use the 2 point sit-to-stand lift but if unable R62 would benefit from the use of the 4 point (total lift). During an interview on 3/11/21, at 8:20 a.m. occupational therapist (OT)-E stated R62 was able to stand 4 minutes in December (2020) and January (2021). R62 stood up, pivoted and transferred with a walker January (2021). OT-E also stated R62 would vary on her ability to stand depending on the day. OT-E indicated staff should be aware and know when it is unsafe to transfer R62 with the sit-to-stand lift and use the 4 point lift instead. OT-E stated we expect staff to report issues if they noticed a change in a resident. During a follow-up interview on 3/11/21, at 8:50 a.m. NA-G stated R62 had the same difficulty with a transfer about one week ago. NA-G indicated yesterday (3/10/21) was the second time R62 have trouble with a transfer. NA-G stated I told another staff member one week ago R62 let go of the padded handles while standing in the lift. During a follow-up interview on 03/11/21 at 9:41 a.m. NA-F indicated the beginning of January 2021, R62 pivoted once she stood up without the sit-to-stand lift and the beginning of February 2021, R62 used only the sit-to-stand lift. NA-F identified R62 let go many times of the paddled handles during the sit-to-stand transfer on 3/10/21. NA-F stated she worried R62 would fall and should have indicated this on the nursing assistant 24 hour report sheet for that day. NA-F indicated immediately after the sit-to-stand transfer with R62 on 3/10/21 at 8:01 a.m., she notified LPN-B. NA-F stated LPN-B asked if the stand up lift was used and NA-F replied yes. NA-F indicated LPN-B did not recommend anything different be done regarding the transfer. The facility policy Sit-to-Stand revised 1/3/20, identified residents who use a sit-to-stand lift must be able to bear some of their weight. Position the resident's arms on the outside of the harness and place their hands on the padded handles. Take the hand control and stand beside the resident. Press the up button until there is slight tension on the harness loops. Perform safety check.

Based on observation, interview and document review, the facility failed to ensure call light was within reach for 1 of 1 (R36) residents reviewed for reasonable accommodations. Findings include: R36's face sheet dated 3/11/21, included [DIAGNOSES REDACTED]. R36's quarterly minimum data set ((MDS) dated [DATE], indicated moderate cognitive impairment, able to understand others, make himself understood, and express his needs/wants. R36 was independent with bed mobility, transfers, dressing, ambulation with walker, and set up with food. R36 required assistance with grooming, toileting, and bathing. Review of R36's care plan dated 04/25/2017, indicated potential for falls related to history of falls, weakness, impaired mobility, incontinence, impaired cognition, medications and [DIAGNOSES REDACTED]. Call light was to be accessible and within reach whenever resident is was in own room. On 03/09/21, at 10:39 a.m. R36 stated he couldn't find his call light in his room. During an observation on 03/09/21, at 10:43 a.m. call light box was located on the floor between the bed and wall. No corded call light was found in the room. During an observation on 03/09/21, at 03:20 p.m. R36 call light box remained on the floor between the bed and wall. No corded call light was found in the room. During observation and interview on 03/10/21, at 09:40 a.m. call light box remained on the floor. R36 stated he could not find his call light. On 03/10/21, at 10:34 a.m. nursing assistant (NA)-C confirmed call light on the floor between wall and bed. She stated the call light holder is zip tied to the far bed rail and sometimes the call light box slips off the holder. NA-C confirmed it was the only call light R36 has. Further, she confirmed it was normal for him to sit in his room with the door shut. NA-C stated call light should be in reach at all times. On 03/10/21, at 10:45 a.m. licensed practical nurse (LPN)-C stated the call light should not be on floor, nor placed on the far side of bed and R36 should have an additional one with a cord coming from the wall. LPN-C placed the call light box on his desk. Her expectations were for call light to be in reach at all times. During observation and interview on 03/10/21, at 02:08 p.m. the call light box was located on far bed rail and there was no call light with cord on the wall. R36 stated he is not sure why it is back on the bed rail. On 03/11/21, at 09:44 a.m. LPN-C confirmed the call light box was back on R36's bed rail and there was no call light on the wall. On 03/11/21, at 10:38 a.m. director of nursing (DON) stated call lights must be in reach at all times. The facility policy with subject: Call Lights, dated 12/9/19, indicated the call light must be accessible to the resident at all times when in resident room. Secure the call light to stay within access of the resident.

Based on observation, interview and document review the facility failed to ensure residents had meal time requests fulfilled for 1 of 2 resident (R43) who requested an extra portion of meat at breakfast. Findings include: R43's undated face sheet identified [DIAGNOSES REDACTED]. R43's significant change minimum (MDS) data set [DATE], identified severe cognitive impairment and was dependent on one assist with transfers and bed mobility. R43's nutritional assessment dated [DATE], indicated R43's weight is 96.4 lbs., received 4 ounces house supplements twice daily, 440 kilocalorie and 12 grams of protein daily with an average food intake of 50-100%; no changes were recommended but were to continue to monitor due to risk related to variable intake and history of significant weight loss. R43's care plan dated 2/23/21, nutritional/fluid intake appears inadequate to meet nutrition needs as evidenced by variable food/fluid intake and significant weight loss with intervention of regular diet, nutritional supplements twice daily, and monitor for high nutritional risk choices. On the morning of 3/9/21, a review of the facility's menu identified sausage as the breakfast meat being offered to the facility residents. During observation on 3/9/21, at 9:30 a.m. R43 asked dietary aide (DA)-A for an extra piece of sausage. DA-A stated that the kitchen only sends up one serving of meat per resident and she did not have any left. In an interview on 3/10/21, at 9:19 a.m. nursing assistant (NA)-A stated that all residents have the right to ask for seconds and if it wasn't in their diet they would discuss risk verse benefits, however they have the right to have what they want. NA-A stated they are monitoring R43's weight and stated if R43 asked for more meat she should have received it. During interview on 3/10/21, at 9:21 a.m. DA-B stated that if a resident asked for extra food and she didn't have extra, she would call either the kitchen or another unit to see if they had extra meat. DA-B stated R43 should have received the extra piece of meat. In an interview on 3/10/21, at 1:39 p.m. trained medication aide (TMA)-A stated they are monitoring R43 for weight loss and she is currently getting nutritional supplements. TMA-A stated if R43 requested more protein at a meal, she should have received, it as it is good for her muscle strength, weight management, and she usually doesn't eat much. During interview on 3/10/21, at 2:03 p.m. registered nurses (RN)-B stated R43 had weekly weights to monitor weight management. RN-B stated it is important for R43 to have protein in her diet to protect her fragile skin and bone healing as she had a previous humerus fracture. RN-B further stated the staff should have called down and got her extra meat if that is what she requested. An interview on 3/11/21, at 9:38 a.m. Food service director stated any resident who requested extra protein should of received it, as staff are allowed to call down to either the kitchen or another unit to obtain more. Food service director added, that it was not ok for a resident to not get this request met, as this was their home. During interview on 3/11/21, at 10:53 a.m. DA-A stated she could have called down to the kitchen to get more sausage or to ask another co-worker if they had extra, but stated that she just didn't. DA-A stated that they are monitoring R43 for past weight loss and it would be beneficial for her to have the extra protein. In a further interview on 3/10/21, at 2:30 p.m. RN-A stated any resident should receive seconds for meals as this is their home and we try to accommodate their needs. RN-A stated if a resident requested extras, they should call the kitchen to see if they are able to send up more. R43 had a fractured humerus and is currently being monitored for weight loss. Policy??

Based on observation, interview and document review, the facility failed to ensure a clean and comfortable living environment that were free from urine odors for 1 of 1 (R26) resident reviewed for environmental concerns. Findings include: R26's face sheet dated 3/11/21, included [DIAGNOSES REDACTED]. R26's significant change of status minimum data set ((MDS) dated [DATE], indicated she was able to understand others and usually make herself understood. R26 required extensive assistance with bed mobility, transfers, dressing, locomotion, eating, bathing, and grooming. Wheelchair was used for mobility. R26's BIMS (cognitive assessment) was not scored. R26's care plan dated 08/09/2018, indicated alteration in bladder elimination due to [DIAGNOSES REDACTED]. R26 had impaired mobility, and cognition, and was weak/frail. Catheter care will be performed per facility protocol. Staff to empty Foley bag every shift. During observation on 03/09/21, at 4:18 p.m. R26's room and bathroom had a very strong urine odor. During observation on 03/10/21, at 9:02 a.m. R26's room and bathroom continued to have a strong urine odor. During observation and interview on 03/10/21, at 09:16 a.m. nursing assistant (NA)-E confirmed strong urine odor in R26's room. She stated the night shift washed out leg bags and kept them in the TV cabinet. NA-E stated R26's urine drainage bag was left open and leaked onto the floor two times on the night shift over the last week or two. NA-E stated she reported it but nothing had happened. Further, NA-E confirmed a new air freshener was placed in R26's room. On 03/10/21, at 09:34 a.m. Licensed Practical Nurse (LPN)-B confirmed strong urine odor in R26's room. During observation and interview on 03/10/21, at 09:42 a.m. (LPN)-C confirmed strong urine odor in R26's room. She confirmed R26 had a catheter bag and wondered if staff possibly had dribbled it on the floor when they emptied it, stated it could be splash over. LPN-B was standing nearby and stated R26's urine had spilled on the floor last week on night shift. LPN-C confirmed air freshener in R26's room and stated it is not allowed in facility, it was a scent free facility. LPN-C removed the air freshener and stated she would contact housekeeping to clean the floor. On 03/10/21, at 10:10 a.m. Housekeeper (H)-B stated she was not sure when R26's room was cleaned last and confirmed the urine odor. H-B stated Maintenance (M)-A was her supervisor and he had the log of when the rooms were cleaned last. She stated she would have another housekeeper come to clean R26's room as soon as possible. She stated she did not receive any communication about R26's room needing any special attention due to odor. During observation on 03/10/21, at 10:37 a.m. housekeeping staff mopped R26's room. During observation on 03/10/21, at 02:07 p.m. R26's room remained odorous of urine. On 03/11/21, at 09:30 a.m. M-A stated every resident room was cleaned weekly and as needed. He stated if there was an area that needed extra attention, any staff person could put in a work order, or just mention it as they walked by. Work orders were done through computer or iPhone app. M-A stated for cleaning urine areas, they used Clorox Disinfecting Bio Stain and Odor to spot clean or oxy clean/shampooing product for carpet cleaning. He stated for hard surface floors they would use the heavy duty floor cleaner machine, and use Diversey cleaning product. M-A stated no work order had been put in for R26's room to address the floor or urine odor. He stated M-B operates the floor cleaner. During observation and interview on 03/11/21, at 09:39 a.m. LPN-C stated she believed urine odor was coming from the TV stand, where the rinsed leg bags had been stored until the end of last year (R26 no longer required leg bags since she started on hospice in December). She had called R26's daughter today and received permission to remove the stand and replace it with a new one. After further discussion with LPN-C the observation was made that the urine odor remained even after the stand replacement. LPN-C then discussed the urine spillage on the floor, and stated the mopping should take care of that, and if it didn't, then the floor would have to be replaced. On 03/11/21, at 10:38 a.m. director of nursing (DON) stated if urine odor was found in a resident room, staff was to investigate and find the source, making sure it was not a hygienic issue. DON went on to state regarding R26's, they had believed the urine odor had been coming from R26's TV stand, stating she could not imagine it would be coming from anywhere else. DON confirmed that there was a urine spill in R26's room previously. She stated R26's room was deep cleaned twice since the spill with a specialized floor cleaner and had just confirmed this with M-A. DON stated she was not certain when this was done and was not sure it was in the computer. She stated M-B was the one that did the floor care, staff did spot cleaning, and housekeeping mopped weekly. DON confirmed work orders were done in the computer by any staff. No work order was able to be provided upon request. The facility policy with subject Cleaning a resident room, dated 12/20, indicated resident rooms will be cleaned per facility determined schedule. Further, the resident rooms are to be dry dusted and mopped Monday through Friday, and every bathroom was to be cleaned thoroughly and damp mopped daily.

Based on observation, interview and document review, the facility failed to ensure open vials of [MEDICATION NAME] identified as expired, were discarded according to manufactuers recommendations. This had the potential to affect the 15 residents whom were admitted after the [MEDICATION NAME] had expired. Findings include: During observation on [DATE], at 10:46 a.m. with licensed practical nurse (LPN)-A noted there were two open vials: 1st vial was opened [DATE]- lot 7 4014 which had a manufacturer's expiration date of ,[DATE] 2nd vial was opened [DATE]- lot 7 60 4014 which had a manufacturer's expiration date of ,[DATE]. During interview on [DATE], at 10:46 a.m. LPN-A stated she thinks the vials are only good for 30 days but was not sure, adding she would call the pharmacy to find out. LPN-A stated she would go off the expiration date on the vial. LPN-A stated they are not currently administering TB tests on their floor at this time, but they may be using it on other floors. LPN-A then called the pharmacy and verified TB vials are only good for 30 days after being expired and stated she will dispose of these vials immediately. During interview on [DATE], at 11:10 a.m. LPN-B stated if she would give a TB test she would go off of the expiration date on the vial. LPN-B stated she would get the TB solution from 1st floor. During interview on [DATE], at 11:20 a.m. LPN-C stated they are still conducting [MEDICATION NAME] testing (TB) on the 2nd floor, but stated due to resident receiving the covid vaccination it is contraindicated at this time. LPN-C stated TB vials should be discarded after 30 days from opening as the medication is less effective after 30 days from opening. LPN-C stated they get all of their TB solution from down stairs on 1st floor. LPN-C stated no residents had recieved the TB test in the last 3 weeks from these vials. Form provided by LPN-C in regards to medication vial openings. A & E pharmacy-medication and expiration guidelines undated, [MEDICATION NAME] PPD, refrigerated expires 30 days after first use. [MEDICAL CONDITION] screening and prevention dated [DATE], indicated All new admissions will receive a 2-step [MEDICATION NAME] skin test or a one time TB blood test unless contraindicated.

Based on observation, interview, and record review the facility failed to ensure functional call lights for 1 of 11 Residents (R34) whom resided in the dementia unit. Findings include: R34's quarterly Minimum Data Set ((MDS) dated [DATE], identified moderately impaired cognition, total dependence with transfers, extensive assistance with personal hygiene, toilet use, dressing, locomotion on and off the unit, and bed mobility, always incontinent of bladder and frequently incontinent of bowel. Further the MDS identified the following [DIAGNOSES REDACTED]. During an observation on 3/08/21, at 6:02 p.m. R34's call light did not function when checked. During an interview on 3/08/21, at 6:22 p.m. R34 stated she placed the call light on when she needed help with something and eventually the staff answered it. During an interview on 3/8/21, at 6:24 p.m. trained medication assistant (TMA)-C stated staff laid the the soft touch call light on R34's chest and she pushed it when she needed help. TMA-C pushed the soft touch call light and nothing happened. TMA-C verified the call light did not function properly. TMA-C stated maintenance was responsible to fix the call lights. CMA-A reported these findings immediately to the licensed practical nurse (LPN)-D. During an observation on 3/8/21, at 6:30 p.m. LPN-D entered R34's room and pressed the soft touch call light. LPN-D verified the call light functioned properly however it turned off when the connection of the cord was moved around. LPN-D stated maintenance checked the call lights frequently. LPN-D also stated a call light maintenance report would be completed. During an observation on 3/09/21, at 08:49 a.m. the surveyor checked call light and verified it functioned properly. During an interview on 03/11/21, at 3:34 p.m. plant operations director (POD) stated he received an alert on a call light when batteries were low. POD also stated work orders received weekly are completed by staff when a call light did not function due to either a bad cord or a malfunctioning soft touch call light. POD verified R34's call light was a soft touch call light and POD would not know it did not function unless staff informed him. POD stated he received a maintenance report on R34's soft touch call light. POD failed to get 34's call light to function, removed it, and replaced it with a new one. During an interview on 03/11/21, at 3:44 p.m. director of nursing (DON) stated a call light report indicated staff tried the call light many times and it worked however, there is not way to immediately know when it did not work. Review of facility policy titled Call Lights last reviewed on 12/19/19 identified if call light is not working properly, notify maintenance immediately and provide alternative call light if indicated.

Based on interview and document review, the facility failed to ensure laboratory results were adequately monitored and acted upon to ensure therapeutic dosing of anticoagulant medication to prevent embolism in 1 of 3 residents (R1) reviewed for unnecessary medication use. These findings constituted an immediate jeopardy (IJ) situation for R1. However, the facility had taken appropriate action(s) to correct the identified non-compliance and, as a result, the findings are being issued as past non-compliance. The IJ began on [DATE], when R1's drawn international normalized ratio (INR; a laboratory test used to determine how long it takes blood to clot) laboratory results were not acted upon by the nursing or provider staff resulting in the omission of therapeutic dosing of anticoagulant medication which contributed to subsequent hospitalization for acute stroke and death. The administrator, director of nursing (DON) and director of SNF clinical services (DCS) were notified of the IJ for R1 on [DATE], at 4:35 p.m. However, the facility had implemented several action(s) including auditing other residents on blood thinning medication to ensure therapeutic dosing and appropriate monitoring was in place; revising facility processes to ensure INR laboratory results were promptly identified and acted upon by nursing and/or provider staff; and, implementing verbal and electronic education to ensure staff competency in these processes. As a result, the IJ was removed and the identified non-compliance was corrected as of [DATE]. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment, required extensive assistance with her activities of daily living (ADLs), and have no impairment(s) or limitations in upper and lower extremity range of motion (ROM). Further, the MDS identified R1 had [MEDICAL CONDITION], heart failure and high blood pressure; and consumed anticoagulant medication for six out of the seven days in the look-back period. On [DATE], at 2:43 p.m. R1's family member (FM)-A was interviewed and explained R1 had lived at the facility's attached assisted living and was generally pretty healthy prior to admitting to the nursing home for rehabilitation services after she sustained a fall. R1's intention was then to return back to the assisted living. FM-A stated R1 had a long-standing history of [MEDICAL CONDITION] (an irregular, often rapid heart rate that commonly causes poor blood flow and increases the risk for clotting and embolism) and, as a result, consumed [MEDICATION NAME] (a blood thinning medication) to reduce her risk of stroke. However, on [DATE], the nursing home had contacted her and voiced R1 was demonstrating stroke-like symptoms and FM-A directed them to send R1 to the hospital right away. FM-A stated she met R1 in the emergency room (ED) and the ED physician asked her, Why did they (the nursing home) stop her [MEDICATION NAME]? FM-A answered she was not sure, so the physician attempted to contact the nursing home without success. FM-A stated R1 was subsequently diagnosed with [REDACTED]. Shortly afterwards, FM-A was at the nursing home visiting R1 when the director of nursing (DON) and another female approached her and voiced they wanted to talk about something. The DON then explained to FM-A there had been a technical error and R1 had not received any [MEDICATION NAME] for the past several weeks while at the nursing home. FM-A stated the DON voiced the error was the nursing home's fault; however, FM-A then became very upset and demanded they leave R1's room. FM-A stated R1 continued to decline and finally died while at the nursing home. FM-A expressed the entire situation and loss of R1 made her just furious and she questioned why the nursing home had abruptly stopped giving R1 the needed medication as you'd think they (the nursing home) would question it when someone who was taking [MEDICATION NAME] abruptly stopped. FM-A again voiced being livid about the lack of monitoring which contributed to such an error voicing she felt she could have had several more years to enjoy R1, but the nursing home's error resulted in her death. FM-A added, They killed my (R1)! R1's care plan, revised [DATE], identified R1's care needs while at the nursing home. The section labeled, Diagnosis, outlined R1 had long-standing [MEDICAL CONDITION], listed as her primary [DIAGNOSES REDACTED]. However, the provided copy of the care plan lacked any specific problem statements, goals or intervention(s) pertaining to R1's use of anticoagulation medication(s) despite having these [DIAGNOSES REDACTED]. R1's Interagency Transfer Form, dated [DATE], identified R1's past medical history (PMH) included long-term use of anticoagulant therapy, [MEDICAL CONDITION] and history of ischemic stroke. The form listed R1's medication(s) for discharge from the hospital to the nursing home with directions, Continue these medications . The medications included [MEDICATION NAME] with directions, Take as directed. If you are unsure how to take this medication, talk to your nurse or doctor . Take 2.5 mg (milligrams) Monday, Wednesday, and Friday and 5 mg all other days. The form identified R1 as being hospitalized for [REDACTED]. will be transferred to TCU (Elim Home Transitional Care Unit) for ongoing physical therapy, with a section labeled, Follow-Up Appointment Instructions, directing to follow-up with the nursing home physician along with dictation which read, Have INR rechecked in 7 days (on [DATE]) for further ([MEDICATION NAME]) dosing. Further, a corresponding (Elim) Physician order [REDACTED].*Copied from signed hospital MD orders (and) labs per MD/NP recommendations. The order(s) were signed by health unit coordinator (HUC)-A. R1's subsequent Fairview Health Services laboratory results, dated [DATE], identified R1 had the ordered INR drawn and completed. The test identified a reference range (a set of values with upper and lower limits of a lab test based on a group of otherwise healthy people) of 0.86 to 1.14 with no posted units of measurement. R1's test result was recorded as, 3.63, which the test identified as, Out of Range. There was no visible markings or dictation present on the recorded lab results which identified they had been reviewed by R1's nursing staff or physician. R1's Medication Administration Record [REDACTED]. R1 was recorded as having been given [MEDICATION NAME], in accordance with the Interagency Transfer Form (dated [DATE]) directions, from [DATE] to [DATE]. The MAR indicated [REDACTED]. R1's medical record identified the following additional progress note(s) and hospital records: On [DATE], a progress note identified R1 admitted to the nursing home from the acute care hospital due to a fall with resulted foot sprain. The note read, Resident plans to do rehabilitation therapy for strengthening and return to prior living situation. Please see chart for past medical Hx (history). On [DATE], a skilled charting note was recorded which identified R1 had a primary [DIAGNOSES REDACTED]. The note recorded R1 as adjusting well to the nursing home environment and progressing towards her goal(s). On [DATE], a progress note identified it was day seven (7) of R1's admission to the nursing home. A section outlined as, Clinical Monitoring, read, (R1) has no recent lab works. Compliant in taking all oral medications. On [DATE], a progress note outlined R1 was afebrile and was progressing towards her goal(s). The note read, On [MEDICATION NAME] ([MEDICATION NAME]) once a day. On [DATE], a progress note identified R1 presented with stroke symptoms as she was unable to speak or respond, had facial drooping and was unable to move her left arm. R1's eyes were recorded as being unresponsive to light and her blood pressure was recorded as ,[DATE] mmHg (normal results ,[DATE] to ,[DATE] mmHg). The on-call provider was notified along with FM-A. R1 was transported to the hospital via emergency medical service (EMS). R1's corresponding (Hospital) Admission History & Physical, dated [DATE], identified R1 presented with a history of [MEDICAL CONDITION] and stroke. R1 was identified as having a long segment occlusion of the right internal carotid artery (ICA) from the neck to the terminus with low attenuation changes in the brain in the right middle carotid artery (MCA) distribution which resulted in severe deficits upon presentation. The report continued, presented to the ED (emergency department) tonight due to left sided weakness and [MEDICAL CONDITION] (language disorder sometimes resulted from stroke) that started acutely . (had) been on [MEDICATION NAME] ([MEDICATION NAME]) in the past but this was apparently stopped earlier this week. She was taken to North Memorial by Air Care. A Neurology Consultation, dated [DATE], was included which identified R1's symptoms presented suddenly and have been severe. The report continued, She had been on [MEDICATION NAME] in the past, but this was discontinued. There was an initial report that she was on Eliquis (an anticoagulant medication), however, it was confirmed that she is not . In the emergency center, INR was 1.0 . (CT) showed evidence of a large right MCA acute stroke. A palliative care assessment was recorded which identified R1 was now unable to engage in meaningful conversation and would likely not regain functional use of her upper and lower extremities; so a decision was made to focus on comfort-based care. On [DATE], a progress note identified R1 returned to the nursing home with . Acute ischemic right internal carotid artery stroke. R1 was admitted on hospice care. R1's corresponding Death in Facility MDS, dated [DATE], identified R1 expired on [DATE]. R1's medical record was reviewed and lacked evidence which demonstrated R1's completed INR monitoring (dated [DATE]) had been reviewed, assessed, acted upon or forwarded to the provider for action and further [MEDICATION NAME] dosing. Further, there were no recorded note(s) which clarified R1's [MEDICATION NAME] consumption despite R1's MAR indicated [REDACTED]. Further, the record lacked indication the abrupt omission of [MEDICATION NAME] from R1's medication regimen had been assessed and acted upon for clarification by the nursing staff despite R1's past medical history being significant for [MEDICAL CONDITION] and R1 having a documented longstanding use of anticoagulant medication. When interviewed on [DATE], at 11:50 a.m. trained medication aide (TMA)-A stated she passed medications, including [MEDICATION NAME], for the unit R1 resided on and recalled her stay at the nursing home. R1 admitted for rehabilitation and was not on comfort cares when she first came in early October. TMA-A explained she was aware of an incident involving R1's [MEDICATION NAME] happened where the order(s) to continue providing it didn't transfer somehow which resulted in R1 not receiving the medication for a period of time. TMA-A stated R1 was a newer resident to the unit when the incident happened, and voiced typically when someone stopped a high risk medication, like [MEDICATION NAME], abruptly the staff would question it. TMA-A stated she could not recall if she ever provided R1 any [MEDICATION NAME] throughout her admission and voiced she felt since R1 was new and not a full time resident; the staff just didn't question her [MEDICATION NAME] being stopped abruptly like they normally would have. TMA-A stated she was aware R1 had been hospitalized after having a stroke adding R1 didn't talk anymore and was paralyzed when she returned from the hospital. TMA-A explained, since the incident, they had received some education and added additional step(s) in the facility's MAR indicated [REDACTED]. TMA-A stated some residents used to have these second alerts set-up and some did not adding she was not aware why some had it and some didn't, however, affirmed all residents taking anticoagulation medication now had them and visually demonstrated these alert(s) to the surveyor for confirmation. TMA-A verified, to her knowledge, R1 did not have this second alert present when the incident happened on [DATE]. When interviewed on [DATE], at 12:06 p.m. health unit coordinator (HUC)-A verified she had transcribed R1's hospital admission order(s) using the Interagency Transfer Form (see above) upon her admission to the nursing home on [DATE]. R1 admitted with orders for daily [MEDICATION NAME] which was to continue until the next INR was done and further dosing orders were received. HUC-A stated she counted out the seven (7) days, as directed in the admission orders [REDACTED]. HUC-A explained when an INR was drawn and completed, the results were sent to a provider inbox along with the facility's EMR (electronic medical record) where they get uploaded and the provider would then write new orders for a resident's [MEDICATION NAME] dosing. HUC-A verified R1's ordered INR was drawn, as directed, on [DATE], and the results were received by the facility on the same day; however, she was unaware if the results had been sent or communicated to the provider for further orders adding, I don't know. HUC-A expressed the unit team leads were responsible to ensure all received lab results, including INRs, were addressed and acted upon; however, in R1's incident, the provider never reviewed the results so no new [MEDICATION NAME] dosing orders were written. This resulted in the medication essentially being discontinued and R1 receiving no anticoagulation therapy from [DATE] through her hospitalization on [DATE] (10 days). HUC-A stated the facility learned of the incident and immediately started to conduct audits of other residents to ensure they all had the needed anticoagulation in place. The facility then revised their process for INR laboratory monitoring to include printing out hard copies of the INRs and providing them directly to the team lead(s) for review and action, before they are uploaded back into the EMR system. HUC-A stated she felt this was a better system than what was in place previously to help ensure laboratory results were not missed in the future. When interviewed on [DATE], at 1:03 p.m. licensed practical nurse (LPN)-B explained the process used by the facility to ensure laboratory monitoring was completed. The ordered lab(s) were placed on a calendar to be tracked and drawn; the results then would be followed up on by the team lead or provider. LPN-B voiced they felt the provider whom ordered the laboratory monitoring was ultimately responsible to ensure they were addressed, but added nursing should also be checking to ensure action on them as a courtesy. LPN-B stated they were aware an incident had occurred involving R1 and her [MEDICATION NAME] where there had been no follow up on R1's drawn INR which caused no further [MEDICATION NAME] dosing orders to be written. LPN-B expressed they were not exactly sure what had caused the error; however, recalled the team lead was not here when the incident happened and the results had somehow been sent to the original Hospitalist who ordered the [MEDICATION NAME], and not the nursing home provider, which may have contributed to the error. However, since the incident happened, all ordered laboratory monitoring, including INRs, were being printed and provided to each units' team lead who now is responsible to sign and date every single lab to ensure it's acted upon and addressed. The lab(s) were then scanned back into the EMR. LPN-B stated the lack of [MEDICATION NAME] dosing for R1 probably could have been avoided, in hindsight, and the new systems in place should prevent future similar errors. On [DATE], at 1:37 p.m. team lead registered nurse (RN)-A and team lead licensed practical nurse (LPN)-C were interviewed. R1 admitted in early [DATE], and her goals were for restorative therapies and to then return to her prior living arrangements. R1's admission orders [REDACTED]. The INR was then drawn, as ordered, on [DATE], and the results were sent to the hospital provider along with being placed in the nursing home's resident message queue in the EMR system. RN-A and LPN-C verified R1's results were available to the nursing home despite being sent to the hospital provider; however, added follow-up on the laboratory results got missed and no further [MEDICATION NAME] dosing orders were written or provided as nobody addressed it as the results were received on the afternoon of [DATE], and left in the queue until the HUC returned after the weekend. The HUC then saw the results and thought they had already been acted upon, so they moved them from the queue to R1's formal EMR, despite them never being sent to the provider for dosing orders. LPN-C voiced the error was kind of a fluke she felt; however, they had reached out to the medical director who was working with IT (information technology) to resolve any issues on the hospital's end which could have contributed to the wrong provider being notified of the laboratory results. They felt several factors, including any potential IT issues with the hospital system, contributed to missed laboratory results including an ongoing rotation of pool nurses who likely would not have known to check various places for the laboratory results, and several of the team leads were extremely new. LPN-C and RN-A both voiced the lack of laboratory result monitoring and subsequent error was absolutely avoidable if someone would have checked the EMR system timely and added, We own it. LPN-C explained they learned of the error after R1 had been hospitalized for [REDACTED]. This resulted in immediate action to audit other residents and then to fix the issues which they felt contributed to it. This included revision of the process for INR monitoring by having the HUC staff members print out hard copies of each INR and provide them directly to the team lead(s) for action and follow-up. They also began immediate education on this process to the direct care staff which continued to this day on a shift-to-shift basis until everyone was educated. LPN-C voiced the whole incident and ultimate death of R1 was a sad situation all the way around and expressed it was important to ensure completed laboratory monitoring results are addressed and acted upon as labs are ordered for a reason and INR monitoring was needed to ensure anticoagulation medications are working properly and to reduce the risk of blood clots which could lead to a stroke and death as a result. When interviewed on [DATE], at 2:08 p.m. nurse practitioner (NP)-A verified R1 had admitted to the nursing home for rehabilitation and was planning to return to her assisted living upon discharge. NP-A explained she was normally the person who managed residents' INR results, and subsequent dosing orders, and proceeded to recall R1's incident. R1 was to have an ordered INR drawn and completed on [DATE], but for whatever reason the results did not get sent to her inbox to be addressed which caused no further dosing orders to be written. This lead to about a week later when R11 was then hospitalized for [REDACTED]. NP-A and the nursing home first learned of the missed laboratory results and subsequent [MEDICATION NAME] dosing when they received paperwork from the hospital prior to her return which directed R1's [MEDICATION NAME] had been discontinued for some unknown reason which lead them to investigate. NP-A voiced a series of events may have contributed to the lack of laboratory result monitoring, including the lack of provider presence within the facility for the past weeks due to the COVID-19 pandemic restrictions and R1 being a new patient to the nursing home. However, NP-A acknowledged the nursing home and herself were responsible to ensure all laboratory monitoring gets acted upon and addressed, and expressed if the nursing home had contacted her about the results with no subsequent orders she would have addressed it. NP-A continued and voiced her heart just dropped when she learned the [MEDICATION NAME] was never re-dosed and ordered for R1 after the [DATE] INR results were posted. NP-A reiterated R1 was at very high risk for subsequent stroke given her medical history and the lack of [MEDICATION NAME], while possibly not preventing a stroke in it's entirety, likely contributed to the severity of the stroke and R1's subsequent death given how long she went without it. Further, NP-A voiced since the incident happened, the nursing home had taken quick action to identify and correct contributing issues including revising their laboratory monitoring process and having the medical director work with Fairview and IT to get a better notification system implemented when laboratory results get posted. On [DATE], at 2:52 p.m. the director of nursing (DON) and administrator were interviewed. The DON verified the incident happened as outlined by RN-A and LPN-C and expressed the drawn INR results had been sent to the wrong provider, in addition to the nursing home, which resulted in them not being acted upon or addressed and caused no further [MEDICATION NAME] orders to be written for R1 after [DATE]. The DON stated the facility learned of the missed results, and subsequent lack of [MEDICATION NAME] dosing, when the hospital sent back information for R1's re-admission to the nursing home which identified R1's [MEDICATION NAME] had been stopped for an unknown reason. They immediately started to investigate the situation and develop ways to prevent recurrence which included auditing other residents with current anticoagulation orders to ensure therapeutic dosing; working with Fairview IT to develop a separate Elim Pool for all laboratory results to be directed into from the laboratory; revising their in-house process to include printing out hard copies of INR order(s) to ensure they are witnessed and acted upon by the team lead(s). The DON voiced education on all these items had already began and remained in progress through verbal and electronic methods. Further, the DON expressed she did not feel the incident was avoidable in this situation, however, added the entire situation, including R1's stroke and subsequent death, was really unfortunate and a terrible circumstance. A provided undated Verification of Investigation (VOI) outlined the facility's completed investigation into the incident involving R1 and the missed INR results. The detail listed outlined, INR ordered on ,[DATE]. INR drawn. (NP-A) did not write follow up orders to continue anticoagulation therapy. ,[DATE]: (R1's) assessment showed signs of stroke. Verbal orders obtained to send resident to hospital . confirmed to [MEDICAL CONDITION]/p (status [REDACTED]. Resident returning to Elim, from hospital [DATE]. A series of interviews were listed which included HUC-A, RN-A, NP-A and the medical director and the incident was reviewed in detail. The conclusion outlined, Cassia policy was reviewed and verified to be followed by Elim Staff. This was a misfortunate (sic) event that happened due to unforeseeable circumstances. Plan and processes put into place within hours to prevent similar events from happening again. These included, but were not limited to, a review of the [MEDICATION NAME] & INR policies; having team lead and medical record staff member(s) review the applicable policies; updating NP-A and R1's primary care physician on the incident; having INR results printed and provided directly to the team lead(s) for action and orders prior to being scanned back into the EMR; and, medical record staff members printing a EMR report of the whole facility' lab draws on given lab day(s) to ensure NP action and follow-up. When interviewed on [DATE], at 9:45 a.m. the consulting pharmacist (CP)-A stated methods of INR monitoring, and subsequent dosing of [MEDICATION NAME], vary a little bit from facility to facility. CP-A explained the facility typically stopped the dosing just prior to an INR draw, and the results were then sent to the provider for subsequent dosing to be ordered; however, CP-A stated he was unaware what their process was at that point to ensure completed results were addressed and acted upon. CP-A voiced he was aware of the error and missed INR results for R1 and stated he did feel some process improvements came as a result of the error. CP-A explained, typically, after someone is off [MEDICATION NAME] a repeat INR is done within a day or two to help determine subsequent dosing needs. The standard goal of [MEDICATION NAME] therapy was to keep an INR between two (2.00) and three (3.00) to reduce the risk of clotting and stroke; and someone off [MEDICATION NAME] could fall below that therapeutic range within four and seven days. CP-A voiced anything under two (2.00) would increase the risk of clotting in someone with [MEDICAL CONDITION]. A provided Cassia [MEDICATION NAME] and INR Procedure policy, reviewed [DATE], identified the licensed nurse was responsible for it's implementation. The policy directed several steps to ensure all [MEDICATION NAME] and INR order(s) were transcribed and followed which included: - Residents taking [MEDICATION NAME] would have Resident take [MEDICATION NAME] placed in their administration notes on the electronic Medication Administration Record [REDACTED] - Residents would have an order for [REDACTED].>- HUC or nurse to transcribe order into computer by deleting any [MEDICATION NAME] orders that are no longer current and adding the new order for [MEDICATION NAME]; - [MEDICATION NAME] orders are scheduled to be administered on the evening shift; - HUC or nurse will add INR to EMR lab order. INR will be entered as an AM order; - Nurse checking / verifying order will follow the above steps to assure their done; - Each change of shift, it will be the responsibility of each nurse to check that INRs have been obtained for the day; - Night shift runs the lab-due report which will indicate who is due for an INR; and, - When an INR has been obtained, physician has been contacted and new order has been obtained, the results will be documented in the INR order under the task in the EMR. The past non-compliance IJ which began on [DATE], was removed prior to the abbreviated survey due to multiple action(s) taken by the facility to correct the identified non-compliance. These actions included beginning a root cause analysis of the incident, auditing other residents currently taking anticoagulation medication to ensure therapeutic dosing and developing and implementing several stop-gap actions to reduce the risk of recurrence to R1 or others. A series of other residents with current orders for anticoagulation therapy were reviewed which identified these action(s) had been successfully implemented; and provided education roster(s) identified education to persons involved with laboratory monitoring at the nursing home had been conducted. As a result, the IJ was removed and non-compliance corrected as of [DATE].

Based on interview and document review, the facility failed to ensure allegations of abuse were appropriately reported to the required person(s) and agencies, investigated and adequate protection provided to ensure freedom from abuse for 3 of 6 residents (R9, R10, R11) whose allegations were reviewed. These findings constituted an immediate jeopardy (IJ) situation which had potential to affect 16 of 16 residents who resided on the Rum River Place secured memory unit at the time of the survey as TMA-A continued to work despite allegations of abuse towards residents. The IJ began on 6/27/20, when an employee (trained medication aide (TMA)-A) was witnessed with her hands grasped around R9's wrists while voicing to the resident, You're not going to hit me again. We're not doing this tonight! Following the incident, no formal re-education was completed for TMA-A and no subsequent audits or monitoring of her care was implemented to ensure residents remained free of abuse. On approximately 7/1/20, a second incident was witnessed and reported to the unit manager regarding TMA-A where she had been witnessed yelling and being mean to a different resident in the locked memory care unit. This allegation was not acted upon, reported or investigated and TMA-A continued to work unsupervised with no protection plan(s) being implemented to ensure all residents on the locked unit remained safe and free of abuse by TMA-A. The administrator (via telephone), director of nursing (DON) and registered nurse (RN)-A were notified of the IJ on 7/17/20, at 4:26 p.m. The IJ was removed on 7/18/ 20, at 5:25 p.m. when the facility successfully implemented a removal plan; however, non-compliance remained at a pattern scope with potential for more than minimal harm which is not immediate jeopardy (Level E). Findings include: A submitted initial State agency (SA) report, dated 6/27/20, identified an allegation of physical abuse regarding R9 which read, Conduct intended to produce pain/injury or rough handling. The report identified on 6/27/20, at 7:40 p.m. an incident happened in the hallway of the locked memory care unit which included, [R9] was attempting to walk another resident . staff intervened and [R9] was upset about being distracted and attempted to hit [TMA-A]. [TMA-A] grabbed the resident's wrist and stated, 'you need to stay out here.' Another staff reported that [TMA-A] said, 'We are not doing this tonight.' The report identified the supervisor was notified and TMA-A was sent home until further investigation could be completed. A corresponding undated Verification of Investigation (VOI) report identified the facility completed an investigation into the allegation submitted to the SA on 6/27/20. The report outlined, [R9] was attempting to walk another resident and verbalized intent to assist with toileting, staff intervened and [R9] was upset about being distracted and attempted to hit [TMA-A]. [TMA-A] grabbed [R9's] wrist and stated, 'you need to stay out here.' Another staff reported that [TMA-A] said, 'we are not doing this tonight. The report identified the supervisor was notified of the incident and TMA-A was sent home pending further investigation. R9 expressed feeling safe at the nursing home; however, when questioned if she was afraid of anyone at the nursing home, R9 was recorded as, . she shrugged her shoulders and said 'I just ignore them' and started chuckling. The administrator, DON, social worker, physician and SA were all notified of the incident, and a series of witness statements were listed which included statements from multiple staff members including nursing assistant (NA)-A, NA-B, and TMA-A. NA-A's recorded interview described TMA-A as being witnessed with a grip on [R9's] wrist and she was pulling her aggressively, and [R9] almost tripped. NA-A instructed TMA-A to be gentle to which TMA-A responded, I am so done, as she threw her hands up in the air. NA-A described R9 immediately following the incident as, She seemed scared. Further, the report concluded with an, Investigation Summary, which outlined TMA-A had intercepted R9's attempt to strike her which . was interpreted as rough behavior on [TMA-A's] part by another staff member who intervened . The DON then re-educated TMA-A on customer service and professional communication. The submitted SA investigation (5-Day Report), dated 7/3/20, was reviewed and identified R9's care plan was reviewed and followed, along with the facility policy which was listed as, . followed, and no changes were made after the incident occurred. The facility's completed investigation was outlined which reflected the VOI detail(s) in large, and an additional form was attached which demonstrated TMA-A had been provided with a verbal disciplinary action along with education on customer service and professional behavior. The form was signed by the DON on 6/29/20, and TMA-A was listed as having verbally acknowledged the form through a telephone call on 6/29/20. The space provided for the administrator to sign the form was left blank and unsigned or dated. There was no evidence in the completed VOI or subsequent SA investigation demonstrating TMA-A had been formally re-educated on the facility's abuse policies and procedures including what constitutes abuse or any education on understanding behavioral symptoms of residents which could increase the risk of abuse and how to respond. A provided resident listing, dated 7/16/20, identified a total of 16 residents resided on the Rum River Unit (locked memory care unit) including R9, R10 and R11. R9's annual Minimum Data Set (MDS), dated [DATE], identified R9 had severe cognitive impairment; however, demonstrated no delusions or physical behavioral symptoms (i.e. hitting, kicking). On 7/17/20, at 9:50 a.m. R9 was interviewed in her room. R9 voiced she was not sure how long she had lived at the nursing home and just replied, No, when asked if she had any concerns with staff treatment or her care. On 7/17/20, at 10:52 a.m. nursing assistant (NA)-A was interviewed and stated she had worked with TMA-A on the evening of 6/27/20, when she stayed late to help put residents to bed. NA-A explained R9 was a resident who frequently wandered into a specific resident' room to use their bathroom and needed to be re-directed; however, at approximately 7:30 p.m. NA-A stated she had come out of a resident room and witnessed TMA-A's hands grasped and squeezing around R9's wrists as R9 seemed to struggle to free herself from TMA-A's grasp by shaking and pulling back. NA-A stated she immediately told TMA-A to let go of R9, however, TMA-A did not and continued to grasp R9's wrists, so NA-A quickly tossed the linens in her hands into a resident room and returned to R9 and TMA-A who remained in the hallway. TMA-A then released R9's wrists and yelled, I'm so done as she walked away from R9. NA-A proceeded to help R9 to use a bathroom on the opposite end of the unit and R9 was upset immediately following the incident, R9 even voiced she thought TMA-A had left bruising on her. NA-A completed R9's cares and then reported the allegation and incident to the working supervisor who subsequently reported it to the DON. NA-A voiced TMA-A was not allowed to complete her shift the night of the incident involving R9 as she was sent home; however, expressed significant concern as TMA-A had subsequently returned to work on the dementia unit on an unsupervised basis. NA-A expressed following TMA-A's return to work, a second incident had happened where TMA-A had potentially abused residents. NA-A stated she knew R11 had expressed concern to a homemaker (HMK)-A that she (R11) had observed TMA-A to place her hands on and shout at another resident (R10) in the memory care unit just a few days after the incident with R9 on 6/27/20. NA-A stated, to her knowledge, HMK-A and R11 did report these concerns to the registered nurse unit manager (RN)-B; however, added she was concerned as, I don't know if they even looked into that much. NA-A stated she had known TMA-A to be very aggressive at times with residents with her tone of voice; however, had never witnessed her be physically abusive with residents until the incident on 6/27/20, adding, I saw what I saw. Further, NA-A reiterated she was concerned TMA-A would continue to potentially abuse residents on the locked memory care unit as TMA-A continued to work, as of that day (7/17/20), on an unsupervised basis for eight hours of the night [shift]. R11's quarterly MDS, dated [DATE], identified R11 had severe cognitive impairment; however, demonstrated no delusions or hallucinations. When interviewed on 7/17/20, at 11:25 a.m. R11 stated she had lived at the nursing home for approximately four years as she needed help with her diabetes management. R11 stated she had no concerns about the way staff treated her; however, expressed she had recently seen a female staff member (TMA-A) abusing a resident in a wheelchair. R11 described TMA-A's actions as grabbing her and pushing her while holding her arms and wrists up to the surveyor. R11 described TMA-A as loud while she helped people and voiced she, herself, had never had an issue with TMA-A; however, added the other people [residents] they're not talking [due to cognitive impairment]. R11 reiterated the incident she had observed between a resident and TMA-A as something she felt was not nice and not right. R11 expressed she told a staff member about the incident; however, was not able to remember who, but added she reported TMA-A to them as someone who was mean and screams at people. On 7/17/20, at 1:47 p.m. HMK-A was interviewed and verified R11 had reported a concern to her approximately two weeks ago which alleged TMA-A had grabbed another resident. HMK-A described R11's reported concern to her as TMA-A was yelling at this other resident and took her arm and pulled her. HMK-A stated she told R11 they needed to go and report the incident to the unit manager and described R11 as upset by it [the incident], as she was talking very fast while reporting it and almost manic and not breathing between words. HMK-A explained R11 was fearful of retaliation by TMA-A and told HMK-A she [didn't] want her [TMA-A] mad at me. HMK-A verified the incident witnessed and reported to her by R11 was reported to the unit manager (RN-B); however, she was unsure of specific follow-up which had been completed as there had already been a different incident reported pertaining to TMA-A around the same time frame. Further, HMK-A stated she had never personally witnessed TMA-A to be physically abusive to a resident; however, had witnessed her to become impatient with residents before and seem a little frustrated while providing direction or cares to them. On 7/17/20, at 2:02 p.m. TMA-A was interviewed and stated her current employment was full time at the nursing home. TMA-A started working at the nursing home in January 2020, and typically worked during the overnight hours. TMA-A described the incident from 6/27/20, which involved R9. TMA-A had stepped in front of R9 to re-direct her which caused R9 to get upset and attempt to hit out at TMA-A. TMA-A verified she then grabbed R9's arm to stop her and said, You're not going to hit me. We're not doing this today. At the same time, another staff member had walked out of a room and observed the interaction while directing TMA-A, Oh my God, you need to be nice. TMA-A stated she didn't feel she had grabbed R9 with a closed hand around her wrists, however, said it was more like she grabbed her arm and pushed it down. TMA-A stated she could not recall anymore specifics from the event; however, added since it had happened she had been spoken to by the DON on things like mannerisms and professionalism. TMA-A added she thought the DON had also discussed with her the various acts, including placing hands on a resident like the incident on 6/27/20 outlined, could constitute abuse and would not be acceptable. TMA-A denied any further incidents with residents on the memory care unit and voiced she continued to work alone on the memory care unit on the overnight shift. TMA-A stated she was not aware of being placed on any formal buddy-systems for cares or monitoring of the care she provided, adding she had just worked last on 7/15/20, and was scheduled to work again in the coming days. When interviewed on 7/17/20, at 2:29 p.m. registered nurse (RN)-D stated they typically work on the overnight shift and verified working full-time with TMA-A adding, She's my TMA. RN-D acknowledged they were aware of an incident involving R9 and TMA-A which had occurred in the past weeks; however, did not witness it or recall specifics. RN-D stated they had not been instructed or directed to do any monitoring or observing of TMA-A's cares or demeanor while at work. RN-D verified TMA-A is left alone for her job most of the time while working as they were often on a different unit adding, Most days she works alone. On 7/17/20, at 2:33 p.m. RN-B and the DON were interviewed and expressed the facility's administrator was off campus on vacation at the time of the survey. The DON described her understanding of the incident involving TMA-A and R9 on 6/27/20, as a situation where R9 was trying to walk another resident in the hallway and TMA-A attempted to intervene which caused R9 to react. TMA-A then placed her hands around her [R9] wrists to prevent her from striking out. NA-A had walked out of a room in the middle of the incident and observed the grabbing of the wrists and so she reported it to the supervisor, TMA-A was sent home, and the incident report was filed to the SA. The DON stated she was unsure of the exact manner or specifics regarding TMA-A's hands and the subsequent grip she had around R9's wrists (i.e. open hand pushing down on the wrists or a closed fist around the wrists) as she did not question it at the time with the staff members; however, voiced such actions could constitute abuse depending on how the resident is grabbed and how aggressive the overall situation was at the moment. The DON explained they interviewed TMA-A regarding the 6/27/20, incident as part of their overall investigation, and TMA-A felt her actions were not abusive. The DON verbalized she told TMA-A her actions could be perceived as abusive and then had a lengthy conversation with TMA-A on professionalism and customer service as a result of the incident on 6/27/20; however, she did not complete or assign her any formal Relias (computerized healthcare training) courses on abuse, vulnerable adult (VA) or dementia-related policies and procedures. The DON verified TMA-A returned to work on 7/1/20, on an unsupervised basis with no formal audits or monitoring of her care being completed or implemented. RN-B recalled R9 had voiced being scared immediately following the incident on 6/27/20. As part of the investigation, RN-B had attempted to interview other residents on the locked memory care unit she felt would be able to cognitively respond which included R11. RN-B stated R11 did not initially report any concerns about TMA-A; however, within a couple days following their discussion, R11 and HMK-A approached her and reported a second allegation of abuse involving TMA-A and a different resident (R10). RN-B stated she felt the initial discussion with R11, as part of the 6/27/20, incident follow-up, had planted a seed in R11's mind which caused her to report the second allegation as R11 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An undated, untitled copy of the taken notes was provided. The notes identified TMA-A's name at the top along with various one-line sentences which included: Always pulling [R10] - come here, Just happened a couple of days ago, She's mean, She's nice to me, Yells-too aggressive. Threatens them, and, [R11] pulled [HMK-A's] arm to demo - quite agressively [sic]. The interview continued and RN-B stated she would not consider R10 or R11 to be a credible historian (despite having selected R11 to interview as part of the 6/27/20 incident), but added things R11 had reported in the past seemed to always [have] a basis of truth. When questioned how the second allegation was handled and investigated, RN-B stated she did not immediately report the allegation to the administrator or DON as she did not feel it was credible as it's coming from [R11], that's why. RN-B stated she placed no formal monitoring of TMA-A's cares, nor did she complete any re-education with TMA-A as part of the second allegation and verified, as of 7/17/20, TMA-A remained working unsupervised on the night shift with the resident population on the Rum River Unit. The DON stated this was the first time I am hearing of the second event [allegation] and voiced, had she and the administrator been told of it, she would have reported it as an allegation of abuse and investigated it as such in accordance with their abuse prevention policy. RN-B and the DON expressed that, to their knowledge, the facility's administrator had no knowledge of the second allegation being reported to RN-B. A provided Vulnerable Adult Report / Tracking Log, dated 10/17/19 to 7/16/20, identified all facility reported incidents (FRI) to the State agency. The listing lacked evidence R11's allegation of abuse pertaining to TMA-A was reported to the State agency. TMA-A's undated training transcript identified TMA-A was hired at the nursing home on 2/20/20. A course named, Abuse & Neglect Self-Paced, was listed as being completed on 2/20/20. A second course with the same name was listed which was not completed; however, listed a 'Due Date' of 7/31/20. There was no evidence on TMA-A's transcript or any other provided documentation demonstrating TMA-A had been formally re-educated on the definitions of abuse, nor subsequent strategies to handle behaviors from cognitively impaired residents after the allegation of abuse was reported and investigated, ending on 7/3/20. Further, there were several classes listed, including Alzheimer's Disease and Related Disorders: Behavior Management, which had listed 'due dates' prior to 7/1/20; however, the classes were not completed and no completion date was identified. In addition, there was no evidence provided during the survey demonstrating TMA-A had been placed on any formal monitoring upon her return to work to ensure she completed therapeutic approaches for the residents and did not engage in potentially abusive behavior(s) towards them despite multiple allegations of abuse being reported pertaining to her. A provided Schedule dated 7/1/20 to 7/31/20, identified TMA-A had worked from 6:45 p.m. to 7:15 a.m. on the following days: 7/1/20, 7/6/20, 7/7/20, 7/10/20, 7/11/20, 7/12/20, and 7/15/20. Further, the schedule outlined TMA-A continued to be scheduled for the same shift hours on 7/20/20, 7/21/20, 7/24/20 and 7/29/20. The facility's Vulnerable Adult - MN policy, revised 10/31/19, identified all staff members must report suspected or alleged abuse immediately and added, The administrator is responsible for the implementation of the policy. The policy outlined residents have a right to be free from verbal and physical abuse and all residents of the facility were considered vulnerable adults. The policy directed, Each employee is responsible to report suspected/alleged violations of mistreatment . immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury ., and, The Administrator will be notified immediately. The policy listed a series of sections which were meant to address and prevent allegations of abuse. A section labeled, Prevention/Protection, identified all staff were trained to understand the facility' abuse prohibition plan along with identify inappropriate behaviors (i.e. rough handling, derogatory language) and added, If a staff member at any time displays suspect or inappropriate behavior, the supervisor must intervene and take appropriate action. A section labeled, Resident Protection During Investigation, was listed which directed to provide immediate safety of the resident(s) upon identification by completing actions which included, but were not limited to, removing the resident from the alleged perpetrator (AP) care or suspending them. Further, the policy directed all reports of suspected or alleged abuse would be . promptly and thoroughly investigated, which included collecting data around the incident, a physical examination of the resident(s) for signs of abuse and interviews with other residents and staff members. The policy directed to document the results of the investigation and log the incident on a facility Event Summary. The IJ which began on 6/27/20, was removed on 7/18/20, at 5:25 p.m. when the facility successfully implemented a removal plan which included removing the AP from resident care, reporting and beginning the investigation of R11's allegation in accordance with their facility's policy, and educating staff members on the reporting process to ensure all allegations made by residents were reported to the administrator and SA. On 7/18/20, from 4:14 p.m. to 5:13 p.m. interview(s) were completed with direct care and management staff to ensure these items had been successfully implemented.

Based on interview, observation and document review the facility failed to ensure all employees were being actively screened (other employees verifying temperature readings during the screening process) for the prevention and potential transmission of [MEDICAL CONDITION] (COVID-19), in accordance with the Centers for Disease Control (CDC) guidelines. This had the potential to affect all 92 residents currently residing in the facility at the time of the COVID-19 survey. Findings Include: A Centers for Medicare and Medicaid (CMS) COVID-19 Long-Term Care Facility Guidance, dated 4/2/20, identified procedures to be implemented to reduce the risk of COVID-19 transmission in a long-term care setting. This included, . every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked. On 7/17/20, at approximately 8:55 a.m. survey team entered facility through the main doors. At that time, survey staff observed three facility employees self screening with no verification of their temperature or COVID screening questions with another employee before entering the facility despite an employee being present at the screening table at the time (employee was screening survey staff). When interviewed on 7/17/20, at 11:49 a.m. dietary aide (DA-A) stated when arriving to work she answered questions and took her own temperature. DA-A said, There is always someone there to make sure you are doing the screening. DA-A stated she did not know of anyone needing to check my temperature. DA-A stated again she self-administered her own temperature and documented the results in the symptoms section of the screening process. When interviewed on 7/17/20, at 1:29 p.m. the director of nursing (DON) stated at the screening table there was always to be someone around to assist with the screening process. DON explained the screening process consisted of answering questions about symptoms and taking temperature. DON stated temperature monitoring was having someone else look at the temperature to verify result. DON stated there was a schedule for helping employees screen and someone was to be at the screening area to assist with all screening to verify information. DON stated she was not aware of employees not verifying temperatures. DON further explained employees had been educated on the screening process which included showing another employee verifying temperature results. Policy entitled COVID-19 Phase 2-All SNFs and all CO sites states, healthcare workers will complete a symptom screening form, including having their temperature checked .these forms will be reviewed by a facility designee prior to reporting to the resident care area.

Based on interview and document review, the facility failed to ensure allegation(s) of potential physical abuse and/or neglect were thoroughly investigated and addressed for 2 of 6 residents (R11, R6) whose allegations were reviewed. This had potential to affect 16 of 16 residents identified to reside on the Rum River Unit (locked memory care unit). Findings include: A provided resident listing, dated 7/16/20, identified a total of 16 residents resided on the Rum River Unit (locked memory care unit) including R11. R11's quarterly MDS, dated [DATE], identified R11 had severe cognitive impairment; however, demonstrated no delusions or hallucinations. When interviewed on 7/17/20, at 11:25 a.m. R11 stated she had lived at the nursing home for approximately four years as she needed help with her diabetes management. R11 expressed she had recently seen a female staff member (TMA-A) abusing a resident in a wheelchair by grabbing her and pushing her. R11 described TMA-A as loud while she helped people and voiced she, herself, had never had an issue with TMA-A; however, added the other people [residents] they're not talking [ due to cognitive impairment]. R11 reiterated the incident she had observed between a resident and TMA-A as something she felt was not nice and not right. R11 expressed she told a staff member about the incident; however, was not able to remember who, but added she reported TMA-A to them as someone who was mean and screams at people. On 7/17/20, at 1:47 p.m. HMK-A was interviewed and verified R11 had reported a concern to her approximately two weeks ago which alleged TMA-A had grabbed another resident. HMK-A described R11's reported concern to her as TMA-A was yelling at this other resident and took her arm and pulled her. HMK-A stated she told R11 they needed to go and report the incident to the unit manager and described R11 as upset by it [the incident], as she was talking very fast while reporting it and almost manic and not breathing between words. HMK-A explained R11 was fearful of retaliation by TMA-A and told HMK-A she [didn't] want her [TMA-A] mad at me. HMK-A verified the incident witnessed and reported to her by R11 was reported to the unit manager (RN-B); however, she was unsure of specific follow-up which had been completed as there had already been a different incident reported pertaining to TMA-A around the same time frame. Further, HMK-A stated she had never personally witnessed TMA-A to be physically abusive to a resident; however, had witnessed her become impatient with residents before and seem a little frustrated while providing direction or cares to them. On 7/17/20, at 2:33 p.m. RN-B and the director of nursing (DON) were interviewed and expressed the facility' administrator was off campus on vacation at the time of the survey. RN-B explained she had interviewed R11 as part of a different allegation; however, within a couple days following their discussion, R11 and HMK-A approached her and reported a second allegation of abuse involving the same staff member and a different resident. RN-B stated she could not recall specifics of the second allegation HMK-A and R11 had shared with her; however, recalled she had taken notes about it on a personal note-pad when the allegation was reported to her. An undated, untitled copy of the taken notes was provided. The notes identified TMA-A's name at the top along with various one-line sentences which included: Always pulling [R10] - come here, Just happened a couple of days ago, She's mean, She's nice to me, Yells-too aggressive. Threatens them, and, [R11] pulled [HMK-A's] arm to demo - quite agressively [sic]. RN-B stated she would not consider R11 to be a credible historian, but added things R11 had reported in the past seemed to always [have] a basis of truth. When questioned how the second allegation was handled and investigated, RN-B stated she did not immediately report the allegation to the administrator or DON as she didn't feel it was credible. The DON stated this was the first time I am hearing of the second event [allegation] and voiced, had she and the administrator been told of it, she would have investigated it as an allegation of abuse in accordance with their abuse prevention policy. RN-B and the DON expressed that, to their knowledge, the facility' administrator had no knowledge of the second allegation being reported to RN-B. A provided Vulnerable Adult Report / Tracking Log, dated 10/17/19 to 7/16/20, identified all facility reported incidents (FRI) to the State agency. The listing lacked evidence R11's allegation of abuse pertaining to TMA-A she voiced to RN-B had been reported or investigated. Further, no documented evidence was provided during the survey demonstrating it had been investigated. A completed Nursing Home Incident Reporting - Incident Report Summary , printed 7/16/20, identified the facility had submitted a report to the State agency (SA) on 11/14/19, involving R6. The report outlined an allegation of, Emotional or Mental Abuse, and described an incident where it had been identified a nursing assistant (NA) was potentially transferring R6 inappropriately and not in accordance with her care plan. The NA was re-educated, however, it was alleged the NA went back into R6's room at a later date and voiced, Thanks a lot. I might be losing my job because of you. This caused R6 to become upset and cry. A corresponding undated Verification of Investigation (VOI) form identified the 11/14/19 incident involving the NA and R6. The report identified R6 was interviewed and expressed concern for possibly costing [the NA] her job because she had told the [night] supervisor that [the NA] always transferred her in the 2 pt [point] lift by herself. The report identified the administrator and SA were notified of the allegation. A section labeled, Witnesses ., was provided which included interviews from another staff member and the NA involved. A section labeled, Investigation Summary, identified the completed investigation timeline for the allegation along with a plan which included reviewing the StandUp Lift policy with the NA, providing immediate re-education to the NA and reviewing R6's care plan. However, the report and subsequent summary lacked any evidence other resident interviews were completed to help determine potential other allegations of neglect aside from R6; nor did it list any procedures or steps taken demonstrating the NA identified would be monitored or audited to ensure they were implementing care plans correctly to prevent harm or injury to residents. A completed SA investigation (5-Day), dated 11/18/19, identified the investigation was submitted to the SA which outlined the facility' completed investigation along with the identical plan which was listed on the VOI Form. This completed investigation lacked any evidence other resident interviews were completed to help determine potential other allegations of neglect aside from R6; nor did it list any procedures or steps taken demonstrating the NA identified would be monitored or audited to ensure they were implementing care plans correctly to prevent harm or injury to residents. R6's quarterly Minimum Data Set (MDS), dated [DATE], identified R6 had intact cognition and required extensive assistance for transfers. When interviewed on 7/16/20, at 3:07 p.m. R6 recalled the incident from 11/14/19, and denied being upset or fearful of injury while being cared for at the nursing home. R6 stated since the incident, staff had consistently been using two people to transfer her. On 7/17/20, at 10:39 a.m. the director of nursing (DON) was interviewed regarding R6's allegation on 11/14/19. The DON acknowledged the lack of evidence in the investigation summary, and corresponding VOI Form, demonstrating if other residents had been interviewed; or if the NA was placed under any formal audits or monitoring upon the investigation completion to ensure care plans were being followed. The DON voiced she would speak to the unit manager and follow-up. A subsequent interview was held with the DON on 7/17/20, at 12:35 p.m. and she voiced investigation(s) typically included other resident interviews to help determine the scope of the allegation and see if additional allegations are identified. The DON expressed these interviews are done using an audit tool, and provided some completed Customer Service Audits for a total of three other residents which were used as part of their investigation in to R6's allegation. However, all of these provided audits were dated 11/22/19 (four days after the investigation was completed and submitted to the SA). The DON stated she was not aware why they were done after the investigation was completed and the NA identified had already returned to work. Further, the DON verified R6 was to have two people present for transfers per her care plan which was in-effect at the time of the incident on 11/14/19. The NA was re-educated; however, there was no documented evidence she could find demonstrating any subsequent monitoring or audits had been completed of the NA's care since to ensure care plans were being followed. The facility' Vulnerable Adult - MN policy, revised 10/31/19, identified all staff members must report suspected or alleged abuse immediately and added, The administrator is responsible for the implementation of the policy. The policy directed all reports of suspected or alleged abuse would be . promptly and thoroughly investigated, which included collecting data around the incident, a physical examination of the resident(s) for signs of abuse and interviews with other residents and staff members. The policy directed, Document the results of the investigation, and log the incident on a facility Event Summary.

Based on interview and document review, the facility failed to ensure triggered Care Area Assessments (CAAs) on a significant change in status Minimum Data Set (MDS) were completed to ensure a comprehensive resident assessment for 1 of 2 residents (R1) reviewed for dementia care and services. Findings include: The Centers for Medicare & Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2018, identified the RAI helps nursing home staff gather information on each resident to help ensure care plans are developed and revised. The manual outlined, under Chapter 4: Care Area Assessment (CAA) Process and Care Planning, the RAI consisted of three components which includes the MDS, the CAAs, and the RAI Utilization Guidelines. The manual identified CAAs were required to be completed for OBRA comprehensive assessments (i.e. admission, annual, significant change in status, or significant correction of a prior comprehensive). R1's significant change in status MDS, dated [DATE], identified R1 had anxiety disorder and depression along with both short and long-term memory impairment. The MDS identified R1 consumed daily anti-anxiety and anti-depressant medications, and demonstrated other behavioral symptoms not directed at others (i.e. hitting or scratching self, public sexual acts, disruptive sounds) 1 to 3 times during the look-back period. Further, under Section V of the MDS, the triggered CAA(s) to be completed were identified with included, 02. Cognitive Loss/Dementia, and, 09. Behavioral Symptoms. Both of these triggered CAA(s) had dictation present which read, See CAA summary. R1's medical record was reviewed and lacked evidence the triggered CAA(s) for R1's cognition and behavioral symptoms had been completed. Further, R1's CAAs Summary listing, printed 7/17/20, identified a red colored ! next to each of the CAA(s) which had triggered for the assessment along with a corresponding green colored checkmark under the column titled, Completed. However, despite both the cognition and behavioral symptoms CAA(s) being identified as triggered; there was no green colored checkmark next to them identifying them as completed. When interviewed on 7/20/20, at 10:28 a.m. registered nurse (RN)-C verified she was the RN who completed and signed R1's MDS dated [DATE]. RN-C stated she had reviewed R1's medical record and was unable to find evidence the triggered CAA(s) had been completed. RN-C explained the facility' social services department was responsible to complete those assigned CAAs, and added she had once in awhile noticed they were not getting done. RN-C stated she sends e-mails to persons when they need to be completed, however, does not typically follow-back to ensure they get done. RN-C expressed the facility had not reviewed their processes or done any education to ensure CAAs are completed before the MDS' are submitted since R1's MDS was completed, and added it was important to ensure CAAs are being done as they're part of the whole assessment. A facility' policy on CAA(s) completion was requested; however, none was received.

Based on interview and document review, the facility failed to ensure an allegation of potential physical abuse was reported to the administrator and State agency (SA) within two hours, as required, for 1 of 6 residents (R11) whose allegations were reviewed. Findings include: R11's quarterly MDS, dated [DATE], identified R11 had severe cognitive impairment; however, demonstrated no delusions or hallucinations. When interviewed on 7/17/20, at 11:25 a.m. R11 stated she had lived at the nursing home for approximately four years as she needed help with her diabetes management. R11 stated she had no concerns about the way staff treated her; however, expressed she had recently seen a female staff member (TMA-A) abusing a resident in a wheelchair. R11 described TMA-A's actions as grabbing her and pushing her while holding her arms and wrists up to the surveyor. R11 described TMA-A as loud while she helped people and voiced she, herself, had never had an issue with TMA-A; however, added the other people [residents] they're not talking [ due to cognitive impairment]. R11 reiterated the incident she had observed between a resident and TMA-A as something she felt was not nice and not right. R11 expressed she told a staff member about the incident; however, was not able to remember who, but added she reported TMA-A to them as someone who was mean and screams at people. On 7/17/20, at 1:47 p.m. HMK-A was interviewed and verified R11 had reported a concern to her approximately two weeks ago which alleged TMA-A had grabbed another resident. HMK-A described R11's reported concern to her as TMA-A was yelling at this other resident and took her arm and pulled her. HMK-A stated she told R11 they needed to go and report the incident to the unit manager and described R11 as upset by it [the incident], as she was talking very fast while reporting it and almost manic and not breathing between words. HMK-A explained R11 was fearful of retaliation by TMA-A and told HMK-A she [didn't] want her [TMA-A] mad at me. HMK-A verified the incident witnessed and reported to her by R11 was reported to the unit manager (RN-B); however, she was unsure of specific follow-up which had been completed as there had already been a different incident reported pertaining to TMA-A around the same time frame. A provided Vulnerable Adult Report / Tracking Log, dated 10/17/19 to 7/16/20, identified all facility reported incidents (FRI) to the State agency. The listing lacked evidence R11's allegation of abuse pertaining to TMA-A she voiced to RN-B had been reported. Further, R11's medical record lacked any evidence the allegation had been reported to the administrator and/or SA since being voiced to HMK-A and RN-B On 7/17/20, at 2:33 p.m. RN-B and the director of nursing (DON) were interviewed and expressed the facility' administrator was off campus on vacation at the time of the survey. RN-B explained she had interviewed R11 as part of a different allegation; however, within a couple days following their discussion, R11 and HMK-A approached her and reported a second allegation of abuse involving the same staff member and a different resident. RN-B stated she could not recall specifics of the second allegation HMK-A and R11 had shared with her; however, recalled she had taken notes about it on a personal note-pad when the allegation was reported to her. An undated, untitled copy of the taken notes was provided. The notes identified TMA-A's name at the top along with various one-line sentences which included: Always pulling [R10] - come here, Just happened a couple of days ago, She's mean, She's nice to me, Yells-too aggressive. Threatens them, and, [R11] pulled [HMK-A's] arm to demo - quite agressively [sic]. RN-B stated she would not consider R11 to be a credible historian, but added things R11 had reported in the past seemed to always [have] a basis of truth. When questioned how the second allegation was handled and investigated, RN-B stated she did not immediately report the allegation to the administrator or DON as she didn't feel it was credible as it's coming from [R11], that's why. The DON stated this was the first time I am hearing of the second event [allegation] and voiced, had she and the administrator been told of it, she would have reported it as an allegation of abuse in accordance with their abuse prevention policy. RN-B and the DON expressed that, to their knowledge, the facility' administrator had no knowledge of the second allegation being reported to RN-B. The facility' Vulnerable Adult - MN policy, revised 10/31/19, identified all staff members must report suspected or alleged abuse immediately and added, The administrator is responsible for the implementation of the policy. The policy outlined residents have a right to be free from verbal and physical abuse and all residents of the facility were considered vulnerable adults. The policy directed, Each employee is responsible to report suspected/alleged violations of mistreatment . immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury ., and, The Administrator will be notified immediately.

Based on interview and document review, the facility failed to ensure precautions and appropriate supervision was provided to reduce the risk of accidents or injuries for 1 of 1 residents (R5) reviewed who had severe cognitive impairment and was sent to a medical appointment off campus unsupervised. Findings include: A Common Entry Point Intake Form, dated [DATE], identified a concern received by the State agency (SA) regarding R5. The report outlined R5 had been brought to an off campus medical appointment with no supervision and was unable to explain why he was there to the staff or physician even asking, . how much the vet bill would cost him. R5 had a listed guardian who had expressed to facility' staff he was unable to attend the appointment, so he was waiting to hear if it had been re-scheduled. The report outlined concern as sending R5 to the appointment with nobody present could be unsafe. R5's admission Minimum Data Set (MDS), dated [DATE], identified R5 had severe cognitive impairment and required extensive assistance with transfers. Further, the MDS identified R5 had sustained a fall with a fracture within the past six months. R5's undated 48 Hour Initial Plan of Care identified R5 was orientated to self and experienced hallucinations with handwritten dictation present reading, Thinks something is there, Has conversations no one there (sic). Further, the care plan identified R5 had a history of [REDACTED]. R5's Referral Form, dated [DATE], identified R5 had an appointment at 3:00 p.m. that day with a physician off campus at the clinic. A section labeled, Nurse Notes/Reason For Referral, was provided which did not list any reasons for the visit to the physician or notes to be addressed; however, merely listed the nursing home' health unit coordinator (HUC) and registered nurse unit manager (RN)-B's name(s) and a telephone number. The physician signed the note on [DATE] and provided dictation which read, Labs, and, T Bone Marrow Biopsy. R5 was diagnosed with [REDACTED]. There was no recorded directions, including level of assistance and any precautions for R5, to ensure he remained safe while off campus at the appointment. R5's corresponding Fairview Geriatric Services note, dated [DATE], identified R5 had been seen for an episodic care visit with pancytopenia listed as the main concern. The note outlined R5, came to follow up with labs that were done on (R5) today. Spoke with the nurse manager to find out what and why labs. (R5) saw (physician) and was at the appointment alone. Not clear why he was there, (R5) did not know and family did not go with. The note identified R5 as up in a wheelchair and sitting out in the commons area adding, Will respond to simple questions but with his memory loss, staff anticipate much of his needs. The note listed several orders for R5 which included diuretic medication, laboratory monitoring and reeducation of antipsychotic medication dosing. R5's progress note(s) identified the following recorded entries: On [DATE], R5 admitted to the nursing home. R5 was recorded as not knowing the place or time upon admission. On [DATE], a SLUMs test (cognition test) was administered to R5. He scored ,[DATE] which the note outlined, . this indicates dementia. On [DATE], the laboratory called and reported a critical lab value for R5's platelets and hemoglobin. The physician was notified of these. There were no recorded progress notes from the appointment R5 had with the hematology clinic on [DATE]; and R5 expired on [DATE]. R5's medical record was reviewed and lacked evidence the facility had arranged family or staff to accompany R5 to his medical appointment on [DATE], despite being identified with severe cognitive impairment and a history of wandering and falls. Further, the record lacked evidence the facility had communicated to the clinic staff on needed levels of assistance or any needed safety precautions to ensure R5 was kept safe and free of accidents if he needed to be transferred, use the restroom, or attempted to leave the clinic unsupervised. When interviewed on [DATE], at 11:22 a.m. nursing assistant (NA)-A stated she recalled R5 residing on the Rum River Unit (locked memory care unit) and described him as forgetful, but easily re-directable. NA-A explained when a resident on the unit has an appointment, the staff bring the resident and a prepared envelope down to the van driver and send them. NA-A stated there typically was not a staff member or family present when they bring the resident down to the van adding, I don't believe so. NA-A expressed she was not sure why residents from the unit were sent to appointments unsupervised and added, That's a good question. Further, NA-A stated R5 used to often verbalize he wanted to go home and she could see R5 becoming confused at the appointment and wondering why he isn't home and wanting to go home then trying to leave the clinic. On [DATE], at 11:45 a.m. HUC-A was interviewed and verified she made the appointments for the residents residing on the Rum River Unit. HUC-A explained depending on a residents cognition they will call family and set-up appointments with them to ensure someone meets them at the site. HUC-A voiced she did not make the decision on who did or did not need to be accompanied to appointments, as that was the unit manager' responsibility. HUC-A stated she typically makes a note on the resident's appointment card regarding if family is meeting someone or not, however, these are not saved or placed in the medical record. Further, HUC-A stated there had not been any revisions or re-education completed with her since R5 resided on the unit adding she was unaware of an incident where R5 had been sent to a medical appointment unsupervised. HUC-A voiced someone should be present so they are supervised. When interviewed on [DATE], at 12:09 p.m. the HandiVan driver (HVD) stated he picks residents up from the nursing home and typically is given an envelope which he provides to the reception desk at the clinic or hospital. He expressed his service was basically a desk to desk service, and someone from the clinic takes over after he checks them in. HVD voiced family, at times, will meet residents from the nursing home at the clinic; however, it was only maybe ,[DATE] (percent) of the time. HVD verified he does not remain with the person while they're at the clinic, and if no family is present, he leaves then let's the resident see the physician. HVD stated he recalled a hair memory of the incident with R5 and, from what he could recall, thought he dropped him off at the clinic on [DATE], and R5's son or responsible party was not there so he brought him inside, but did not remain with him. Further, HVD stated since the incident with R5, he had never been contacted by the nursing home to discuss the situation or revise any procedures to ensure residents are met by family or kept safe when left unsupervised at the clinic. On [DATE], at 1:25 p.m. registered nurse unit manager (RN)-B was interviewed. RN-B explained family was always able to attend appointments with residents; however, added a lot of the times they do go alone. RN-B voiced the HandiVan driver(s) typically waited for the residents at the clinic to her understanding, and added once they're checked in to the clinic appointments, the resident' safety and care planning becomes the clinic's responsibility and not the nursing homes. RN-B stated there were some residents on the locked memory care unit she would hesitate to send alone to appointments, and voiced while the HUC and her do speak about residents and appointments, there was no formal system to decide who needs supervision and who doesn't for appointments. RN-B added, It's not our policy to make sure somebody's with them. RN-B then reviewed R5's incident from [DATE]. RN-B explained R5 had dementia and could self-propel in his wheelchair. RN-B added, at times, she recalled R5 as someone who did become confused and search for people to take him to various places. RN-B stated R5 was a resident who probably should have had family or a staff member present with him at off campus appointments as he would likely not give the physician accurate information on his condition(s). RN-B stated she didn't think much, if any, information on activities of daily living (ADL) assistance or supervision interventions (i.e. to prevent falls or elopements) were sent with residents on appointments adding, We don't do a whole lot of that kind of stuff. RN-B recalled R5's [DATE] appointment and stated the clinic had contacted her via telephone when he arrived and she remembered them being upset and questioning why R5 was at the clinic. When questioned on her follow-up actions to ensure a similar situation like R5's incident on [DATE] did not reoccur, RN-B stated she did probably nothing; however, in hindsight, should have brought the clinic' concerns to someone's attention so they could review their system for sending people to appointments and make sure they're supervised appropriately. On [DATE], at 2:26 p.m. the director of nursing (DON) and RN-B were interviewed. The DON voiced the nursing home's responsibility was to setup the appointment and arrange transportation and she cannot verify if anyone from the nursing home contacts family to ensure they will be attending with the resident or not. DON added, I assume they would, and she felt that was occurring. RN-B and the DON verified they had not reviewed their systems or procedures for sending residents to appointments and ensuring care is coordinated and supervision is provided. The DON voiced she didn't know this was a thing and had we known she would have acted on it and maybe put something in place. A facility policy on supervision of residents while at appointments was not provided.

Based on interview and document review, the facility failed to ensure care was appropriately coordinated with an outside hematology clinic to reduce the risk of delayed treatment for 1 of 1 residents (R5) reviewed with cognitive impairment and who was sent to a medical appointment unsupervised causing confusion on the reason(s) and course of treatment to be provided. Findings include: A Common Entry Point Intake Form, dated [DATE], identified a concern received by the State agency (SA) regarding R5. The report outlined R5 had been brought to an off campus medical appointment with no supervision and was unable to explain why he was there to the staff or physician even asking, . how much the vet bill would cost him. R5 had a listed guardian who had expressed to facility' staff he was unable to attend the appointment, so he was waiting to hear if it had been re-scheduled. The report outlined, Due to not having any decision maker available and with him, however, other labs weren't a possibility as (R5) was unable to give consent. R5's admission Minimum Data Set (MDS), dated [DATE], identified R5 had severe cognitive impairment, several medical [DIAGNOSES REDACTED]. R5's Referral Form, dated [DATE], identified R5 had an appointment at 3:00 p.m. that day with a physician off campus at the clinic. A section labeled, Nurse Notes/Reason For Referral, was provided which did not list any reasons for the visit to the physician or notes to be addressed; however, merely listed the nursing home' health unit coordinator (HUC) and registered nurse unit manager (RN)-B's name(s) and a telephone number. The physician signed the note on [DATE] and provided dictation which read, Labs, and, T Bone Marrow Biopsy. R5 was diagnosed with [REDACTED]. R5's corresponding Fairview Geriatric Services note, dated [DATE], identified R5 had been seen for an episodic care visit with pancytopenia listed as the main concern. The note outlined R5, came to follow up with labs that were done on (R5) today. Spoke with the nurse manager to find out what and why labs. (R5) saw (physician) and was at the appointment alone. Not clear why he was there, (R5) did not know and family did not go with. Has known Pancytopenia and so labs done per orders. Nursing already sent them on to the oncologist office or at least spoke with them about the results and so that is where part of the information came from of (R5) being there alone. The note identified R5 as up in a wheelchair and sitting out in the commons area adding, Will respond to simple questions but with his memory loss, staff anticipate much of his needs. The note listed several orders for R5 which included diuretic medication, laboratory monitoring and reeducation of antipsychotic medication dosing. R5's progress note(s) identified the following recorded entries: On [DATE], R5 admitted to the nursing home. R5 was recorded as not knowing the place or time upon admission. On [DATE], a SLUMs test (cognition test) was administered to R5. He scored ,[DATE] which the note outlined, . this indicates dementia. On [DATE], the laboratory called and reported a critical lab value for R5's platelets and hemoglobin. The physician was notified of these. There were no recorded progress notes from the appointment R5 had with the hematology clinic on [DATE]; and R5 expired on [DATE]. R5's medical record was reviewed and lacked evidence the facility had sent or provided the outside hematology clinic with adequate information or guidance to facilitate care and prevent delays in treatment pertaining to R5's appointment on [DATE]; despite R5 having known cognitive impairment. Further, there was no evidence in the record demonstrating R5's family had been contact and agreed to meet R5 at the appointment to help facilitate communication and treatment with the clinic on the facility's behalf. During interview on [DATE], at 11:22 a.m. nursing assistant (NA)-A stated she recalled R5 residing on the Rum River Unit (locked memory care unit) and described him as forgetful, but easily re-directable. NA-A explained when a resident on the unit has an appointment, the staff bring the resident and a prepared envelope down to the van driver and send them. NA-A stated there typically was not a staff member or family present when they bring the resident down to the van adding, I don't believe so. NA-A expressed she was not sure why residents from the unit were sent to appointments unsupervised and added, That's a good question. Further, NA-A stated HUC-A makes appointments for the residents on the Rum River Unit. When interviewed on [DATE], at 11:31 a.m. licensed practical nurse (LPN)-A explained the process for getting residents on the Rum River Unit to their appointments. LPN-A stated sometimes the family will take them, otherwise they go to off campus appointments using a HandiVan service which the HUC will arrange. LPN-A verified staff members do not routinely attend appointments with cognitively impaired residents and stated someone from the nursing home should be contacting family prior to the appointment to ensure someone is going to be there; however, LPN-A acknowledged she (didn't) know if that actually happens. LPN-A voiced she could vaguely remember an episode in the past where a resident had been sent to an appointment and did not know why they were there when they arrived. LPN-A stated she could not recall any revisions or re-education being completed since that incident; however, expressed it was important to ensure someone was with residents at their appointments to advocate for them and ensure accurate reporting is provided to the physicians. On [DATE], at 11:45 a.m. HUC-A was interviewed and verified she made the appointments for the residents residing on the Rum River Unit. HUC-A explained depending on (a resident's) cognitivity they will call family and set-up appointments with them to ensure someone meets them at the site. HUC-A voiced she did not make the decision on who did or did not need to be accompanied to appointments, as that was the unit manager' responsibility. HUC-A stated she typically makes a note on the resident's appointment card regarding if family is meeting someone or not, however, these are not saved or placed in the medical record. Further, HUC-A stated there had not been any revisions or re-education completed with her since R5 resided on the unit adding she was unaware of an incident where R5 had been sent to a medical appointment unsupervised. HUC-A voiced someone should be present so they are supervised. When interviewed on [DATE], at 12:09 p.m. the HandiVan driver (HVD) stated he picks residents up from the nursing home and typically is given an envelope which he provides to the reception desk at the clinic or hospital. He expressed his service was basically a desk to desk service, and someone from the clinic takes over after he checks them in. HVD voiced family, at times, will meet residents from the nursing home at the clinic; however, it was only maybe ,[DATE] (percent) of the time. HVD stated he recalled a hair memory of the incident with R5 and, from what he could recall, thought he dropped him off at the clinic on [DATE], and R5's son or responsible party was not there so he brought him inside, but did not remain with him. Further, HVD stated since the incident with R5, he had never been contacted by the nursing home to discuss the situation or revise any procedures to ensure residents are met by family or kept safe when left unsupervised at the clinic. On [DATE], at 1:25 p.m. registered nurse unit manager (RN)-B was interviewed. RN-B explained family was always able to attend appointments with residents; however, added a lot of the times they do go alone. RN-B voiced the HandiVan driver(s) typically waited for the residents at the clinic to her understanding, and added once they're checked in to the clinic appointments, the resident' safety and care planning becomes the clinic's responsibility and not the nursing homes. RN-B stated there were some residents on the locked memory care unit she would hesitate to send alone to appointments, and voiced while the HUC and her do speak about residents and appointments, there was no formal system to decide who needs supervision and who doesn't for appointments. RN-B added, It's not our policy to make sure somebody's with them. RN-B then reviewed R5's incident from [DATE]. RN-B explained R5 had dementia and could self-propel in his wheelchair. RN-B stated R5 was a resident who probably should have had family or a staff member present with him at off campus appointments as he would likely not give the physician accurate information on his condition(s). RN-B recalled R5's [DATE] appointment and stated the clinic had contacted her via telephone when he arrived and she remembered them being upset and questioning why R5 was at the clinic. RN-B stated clinic's calling and not having adequate information or having situations where the resident is unable to provide the necessary input for the physician had happened before; however, RN-B felt it was very rarely. When questioned on her follow-up actions to ensure a similar situation like R5's incident on [DATE] did not reoccur, RN-B stated she did probably nothing; however, in hindsight, should have brought the clinic' concerns to someone's attention so they could review their system for sending people to appointments. On [DATE], at 2:26 p.m. the director of nursing (DON) and RN-B were interviewed. The DON voiced the nursing home's responsibility was to setup the appointment and arrange transportation and she cannot verify if anyone from the nursing home contacts family to ensure they will be attending with the resident or not. DON added, I assume they would, and she felt that was occurring. The DON stated she felt the incident with R5 on [DATE] happened due to miscommunication between the physician office and R5's family as the nursing home did our part and arranged the transportation for R5. RN-B and the DON verified they had not reviewed their systems or procedures for sending residents to appointments and ensuring care is coordinated and needed information relayed to the providers. The DON voiced she didn't know this was a thing and had we known she would have acted on it and maybe put something in place. A facility policy on coordination of care with outside providers was not provided.

Based on observation, interview and document review, the facility failed to ensure signs and symptoms of urinary tract infection [MEDICAL CONDITION] were assessed, acted upon and treated timely for 1 of 1 resident (R41) reviewed for change of condition. This resulted in actual harm for R41 whose UTI was left untreated at the facility causing subsequent hospitalization for [MEDICAL CONDITION]. In addition, the facility failed to ensure a developed skin rash was monitored on a routine basis to ensure healing and intervention efficacy for 1 of 2 residents (R297) reviewed for non-pressure skin conditions; and failed to comprehensively assess and develop interventions to promote good posture in the wheelchair for 1 of 1 resident (R17) observed to have poor wheelchair positioning. Findings include: R41's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R41 had intact cognition, required extensive assistance with activities of daily living (ADL's), and had several medical [DIAGNOSES REDACTED]. Further, R41 was identified as needing intermittent catheterization (insertion of a sterile tube into the bladder to allow it to drain) and as incontinent of bowel and bladder. R41's care plan dated 3/1/19, identified R41 had an alteration in bladder status related to a history of UTIs, CKD, and impaired mobility. The care plan directed staff to monitor for changes in elimination as needed and administer medication as ordered. On 2/7/19, interventions were added which directed staff to observe for changes in urinary signs and symptoms, and to collect a specimen for urine analysis and urine culture (UA/UC) as needed per guidelines. In addition, the care plan indicated staff were to notify the provider and follow up on labs as needed. The care plan also included R41's POLST (physician's orders [REDACTED]. On 3/4/19, at 10:06 a.m. R41 was observed laying in bed in her room periodically yelling out, help. R41 was unable to verbalize her needs when questioned, but stated she felt pretty good. On 3/6/19, at 12:40 p.m. family member (FM)-A stated R41 required increased levels of care and often called out help, especially when she was experiencing pain or back spasms. FM-A stated R41 had an episode in (MONTH) 2019, where she had been exhibiting symptoms of increased lethargy, lack of appetite, and calling out for help more. FM-A said she had been notified R41 seemed to be declining, and was being taken to the emergency room (ER) for evaluation. At the ER, FM-A was informed by ER staff, R41 had a UTI which had been diagnosed while at the nursing home but was not treated. FM-A stated the physician in the ER was not sure why treatment had not been initiated at the nursing home for the UTI as the UA had been completed and was positive for infection, while R41 was at the nursing home. FM-A expressed concern with the UTI not being treated in a timely manner while R41 was at the nursing home, describing R41 as pretty fragile. FM-A stated an untreated infection could do her (R41) in. In addition, FM-A stated the nursing home had previously addressed the possibility of hospice for R41. FM-A said she'd chosen to respect R41's request for implementation of interventions and R41's desire to remain a Full Code. R41's progress note(s) were reviewed and identified the following entries: On 1/15/19 at 4:36 p.m., R41 had a post void residual (PVR; a scan completed to asses the amount of urine left in the bladder after elimination) checked indicating she had 833 milliliters (ml) of urine in her bladder, and the staff would attempt to address it after supper. There were no further notes to identify what interventions had been taken to relieve the PVR. On 1/16/19 at 6:41 a.m., notes indicated a PVR was checked and there was 300 ml. The documentation did not address any follow through for the prior PVR of 833 ml. A subsequent note on 1/16/19, R41 was recorded as having pain with repositioning. On 1/17/19, documentation included MDS: Resident incontinent of both B/B (bowel and bladder). There was no information regarding PVR, or any other symptoms of concerns with the resident's B/B included in the note. On 1/18/19 at 12:01 p.m., registered nurse (RN)-A documented a progress note indicating R41 was calling out help repeatedly. R41 was offered assistance to transfer and reposition, warm blankets, food and drink and one to one interventions, all of which were ineffective. R41 had a bladder scan of greater than 300 ml earlier in the week, and a recheck of a PVR was 654 ml, and the geriatric nurse practitioner (GNP) was updated. A subsequent note on 1/18/19, at 3:58 p.m. identified R41 was straight cathed and a urine specimen (UA) was sent to the laboratory to rule out a UTI with symptoms recorded as low back pain, suprapubic pain, blood tinged urine, and residual urine. R41's progress note(s) from 1/18/19 to 1/23/19, lacked any recorded evidence the collected and sent UA was addressed or followed up on to ensure results were reviewed, and/or any required treatment was initiated. On 1/23/19 at 5:55 p.m., the progress notes indicated R41 was calling out for help periodically. Further, the note included, Resident was more lethargic than normal and requesting to go to bed. Resident also refused meals. On 1/24/19 at 5:58 p.m., the progress notes indicated R41 continued to be more lethargic than usual, and was spending more time in her bed and eating less. The note indicated teh nurse had discussed this with the resident who admitted to feeling depressed, but was unable to determine a frequency. A subsequent entry on 1/24/19 at 6:47 p.m., identified twice daily temperature monitoring would be implemented related to her increased fatigue and lethargy. There was still no documentation related to follow up on the UA sent off for evaluation on 1/18/19. No progress notes were recorded for 1/25/19 or 1/26/19. R41's next progress note entry was dated 1/27/19 at 2:25 p.m., and included, Resident (res) did not yell out this shift. No behavioral concerns noted. On 1/28/19 at 3:15 p.m., the progress note included: Res started running a temp of 100.2 this afternoon. HR (heart rate) 115 and BP (blood pressure) 106/57. Res O2 (oxygen) sats (saturation) 89% on RA (room air). The note indicated oxygen had been applied via a nasal cannula and the GNP was called to provide an update. The note further indicated, Asked res if she would like to be eval by hospital, res was unable to verbalize consent as she kept closing her eyes when asked a question. Called res' dtr (daughter)(name of daughter), obtained consent to transfer res to hospital. 911 called for transport. A progress note documented on 1/29/19 at 5:09 a.m., indicated R41 was admitted to the hospital for a UTI [MEDICAL CONDITION] (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), was being treated with intravenous (IV) antibiotics and fluids, and was expected to be hospitalized for [REDACTED]. R41's medical record was reviewed and lacked evidence R41 had been comprehensively assessed to determine the presence of potential infection until 1/28/19, when she developed an elevated temperature and elevated heart rate, despite progress notes from 1/23/19, indicating R41 was having increased lethargy and was refusing meals. Further, the record lacked any evidence the UA obtained on 1/18/19, had been acted upon prior to her being sent to the hospital on [DATE]. R41's Emergency Department (ED) note dated 1/28/19, identified R41 presented to the ED with concerns of fever and lethargy along with a temperature at the nursing home of 102 F. R41 was recorded as being unsure of her whereabouts and only able to answer 'yes and no' questions. The report indicated R41 was diagnosed with [REDACTED]. R41's initial lactic acid reading was 2.7 at 4:30 p.m. in the ED (normal range is 0.7-2.0 millimoles per litre). R41's ED arrival temperature was recorded as 100.3 F and her heart rate was rapid with a rate over 100. R41's CRP (C-reactive protein) was elevated at 101.0 millimoles per litre (elevated levels show potential infection and [MEDICAL CONDITION] conditions). In addition, the report identified, Upon review of her chart it was discovered that she had a (UA) completed on 1/18/19 that grew out a positive culture but I do not see evidence that this was adequately treated. Further, the report indicated a chest x-ray was completed to rule out [MEDICAL CONDITION] causes for the fever which was negative, and R41's admission [DIAGNOSES REDACTED]. R41's Fairview Diagnostic Laboratories report setup 1/18/19, identified R41's collected UA on 1/18/19, showed greater than 100,000 colonies of E. Coli. on 1/22/19, which was sensitive to several antibiotics. R41's History and Physical (H&P) from the hospitalization of 1/28/19, identified R41 as having, . a positive urine culture for E. Coli and Aerococcus 6 days ago which has not been treated. R41 was listed as having a known history of UTI's. In addition, R41's Discharge Summary dated 1/31/19, identified R41's discharge [DIAGNOSES REDACTED]. On 3/7/19, at 10:49 a.m. RN-F stated she was unaware a specimen had been sent off for R41 prior to her admission to the hospital. RN-F stated when a specimen was sent off for analysis, the information was passed on during report. RN-F stated if results were negative, no further follow up was indicated. RN-F stated if the initial results were positive, staff would continue to follow until the final results were available and would follow up with the provider as indicated. RN-F stated she had not been provided with any updated processes as to collection of specimens, sending off for analysis, obtaining of results, and provider follow up. RN-F stated the facility protocol was to complete a scan for a post void reference (PVR) if there had been no voiding for 12 hours. RN-F stated if the PVR was greater than 350/360 staff were to complete a straight cath and obtain a urine specimen. RN-F stated it was important to follow up on specimens to assure the resident received treatment if indicated. RN-F stated if residents were not treated properly, they would get worse and require more intensive treatment. RN-F stated if R41 had been treated right away and was started on antibiotics, she may have been able to be treated with oral meds at the nursing home, instead, she Ended up in the hospital with UTI [MEDICAL CONDITION]. On 3/7/19, at 2:16 p.m. GNP-A confirmed a specimen had been sent off per standing orders for R41 while she GNP-A was gone on vacation. At the time it was sent, GNP-A stated she had been unaware of the specimen being obtained, and it was her understanding no one had checked on the results of the specimen. GNP-A stated when results are processed, they are sent in a queue (an order for [REDACTED]. GNP-A stated R41's infection should have been treated when the results were available and had the UTI been treated right away, the hospitalization could probably have been prevented. GNP-A stated for many residents, a temperature of 99.0 F. could be indicative of a fever. On 3/7/19, at 2:47 p.m. RN-A stated a specimen was collected on R41 when a straight catheterization was performed for an increased PVR after an incontinent void. RN-A stated R41 was demonstrating the symptoms of a UTI which included complaints of lower abdominal pain, back pain, blood tinged urine, and [MEDICAL CONDITION]. RN-A stated the specimen was sent to the hospital for processing. RN-A stated although she had the ability to check in the system to see if the results have been processed, this was more of a courtesy to the provider as the GNP's and providers review them. RN-A stated following R41's culture results delay in processing, the facility did review the process with the lab and were informed results were autoscanned to medical records and were scanned into the electronic record. RN-A stated she did not monitor for the culture results as this was the role of the provider. RN-A stated when R41 became symptomatic with a low grade temp of 99-something, RN-A recalled a specimen had been sent and looked for the results. RN-A stated she then called GNP-A and an order was received for transport to ER for evaluation. RN-A stated when R41 presented with a temperature, elevated heart rate, and low blood pressure, she began to [MEDICAL CONDITION] by using critical nursing skills. RN-A stated PVR's were monitored for residents when a change of condition was identified. RN-A stated there was a potential R41 wouldn't have become septic, as she had not displayed any symptoms since 1/18/19 when specimen was gathered. RN-A stated both GNP's had reviewed the culture as evidenced by the time stamp on the report and opted not to treat it, however, RN-A stated she had not initially looked for the culture results until 1/28/19 when R41's symptoms had advanced and she recalled a culture being sent. RN-A stated she did not confer with GNP-A at that time regarding previous review of results. RN-A stated when a specimen was sent, staff were to write the information down and pass it on in report to follow up on this. RN-A stated she had not received additional training as to how specimens were to be tracked in the future. On 3/7/19, at 3:36 p.m. the director of nursing stated she reviewed the culture results when she learned of the delayed treatment for [REDACTED]. Upon following up on the process, the DON stated the results were autofaxed to the facility, as well as being placed in the electronic queue. The DON stated she had provided RN-A with education as to the process of following up on the UA/UC. The DON stated if results were reviewed as positive for growth, but not treated by the provider, it would be her expectation the nurse would contact the provider in follow up for rationale of not treating. The DON stated this event has been reviewed at the QAPI (Quality Assurance and Performance Improvement) Committee and it was her expectation for the nurse managers and health educator present at the meeting to bring the information back to the floor staff. The DON stated there are no standardized methods among the units established for tracking of specimens and the results in place, and stated each unit was responsible for developing their own system. The DON stated she was awaiting follow up from the lab to review the process of routing lab results via autofax A review of the facility Standing Orders for Skilled Nursing Facilities, revised and amended (MONTH) (YEAR), identified the following orders were to be implemented after removing a catheter: Straight catheterize prn (As needed) if a PVR is greater than 250 ml, no voiding in six hours, full bladder on palpation, or if the patient is uncomfortable. The Standing Orders did not identify what the process was for residents who had not recently had a catheter removed. A facility policy Urinary Catheterization-intermittent (straight catheterization) dated 11/14/18 indicated urinary catheterization was to be done per physician orders. The policy identified this process could be performed to drain residual urine which can cause urinary stasis and bladder infection. A policy was requested from the facility for follow up on laboratory work completed but was not available. SKIN MONITORING: R297's quarterly Minimum Data Set ((MDS) dated [DATE], identified R297 had intact cognition, was independent with activities of daily living (ADLs), and had no ulcers, wounds or other skin problems. R297's progress note dated 2/9/19, identified R297 had complained about his swollen legs. The note described, . legs are swollen, rash to legs, (treatment) applied. In addition, R297's Re-Admission Nursing Evaluation completed 2/22/19, identified R297 was returning from the hospital. A body chart was shown on the evaluation which identified R297 had pink blotchy spots to legs, dry feet. On 3/4/19, at 11:39 a.m. R297 was seated on his bedside in his room. R297 did not have any pants on which exposed the skin on his legs. R297's legs had a visible red, blotchy appearing rash going up and down nearly the entire length of his legs. When interviewed at this time, R297 stated he had these marks, while pointing to the blotchy red areas on his legs, and he was not sure what they were or how long they had been present. R297 expressed the areas were not painful. R297 stated he was applying some type of lotion to the area(s), and the staff were quite aware of the areas. However, R297 stated the floor staff weren't too concerned with them and added he was unsure if the areas were being monitored, or what treatment plan was in place to treat the areas. R297's medical record was reviewed and lacked any evidence the developed red, blotchy rash areas were being monitored to ensure healing, treatment efficacy and help prevent potential infection. When interviewed on 3/5/19, at 5:43 p.m. nursing assistant (NA)-G stated she had noticed R297's rash on his legs before and thought it was hives or something, however, R297 had never complained about the rash being painful. Further, NA-G stated she was unaware if any creams or treatments were being applied to the rash by staff or R297 himself. During interview on 3/5/19, at 5:52 p.m. trained medication aide (TMA)-A stated the staff provide R297 with all his medications. TMA-A expressed she had noticed R297's red, blotchy rash earlier; however, did not get a chance to speak with the nurse about it yet. TMA-A reviewed R297's Treatment Administration Record (TAR) and stated there was no treatment(s) or monitoring set up for it. On 3/5/19, at 6:01 p.m. registered nurse (RN)-A was interviewed and explained R297 had the rash when he returned from a hospitalization on [DATE], and he had ben applying some over-the-counter lotion for it at that time. The nurse practitioner had recently addressed it , but no consensus had been reached on a treatment plan for it given R297's extensive medical needs. During subsequent interview on 3/5/19, at 7:12 p.m. RN-A stated she had reviewed R297's medical record and it lacked any ongoing monitoring of the developed rash. RN-A explained developed skin conditions should be monitored daily and tracked using a weekly skin assessment to make sure they don't worsen. POSITIONING: R17's annual Minimum Data Set ((MDS) dated [DATE], identified R17 was cognitively intact and required extensive assistance with cares. In addition, R17's care plan revised 12/17/18, identified R17 wore a self-releasing chest harness when in the wheelchair. R17's progress note dated 3/4/19, R17 had a fall out of her wheelchair when she had leaned too far forward. During observation on 3/4/19, at 8:57 a.m. R17 was observed in the dining room. R17 was bent over with chest almost touching knees while reading the newspaper. R17 was observed to have a harness on the back of the chair, however it was not strapped. During observation on 3/4/19, at 9:21 a.m. R17 was sitting in the dining room, pushed away from the table, her head rested approximately 4 inches from her left knee with her head just above handle of her extended wheel chair brake. R17's left hand rested on her knee, right hand dangled down mid calf. Harness straps were not attached, straps were resting on R17's back. During observation on 3/5/19, at 6:56 p.m. R17 was at the table in an activity leaning to the left, head was rested on left upper arm. Harness was attached to wheelchair, was not strapped into place over R17's shoulders. During observation on 3/6/19, at 8:48 a.m. R17 was at breakfast, wheelchair was approximately ten inches from the table, R17 was bent forward with harness in place. Straps of harness was stretched approximately 10 inches from the back of the wheelchair to R17's shoulders. Left arm was hanging over the edge of the arm of the wheelchair with armpit resting on the arm while eating cut up toast with a fork. When interviewed on 3/7/19, at 1:43 p.m. nursing assistant (NA)-E stated R17 leaned to the left side even when seated in her recliner R17 would lean. When interviewed on 3/7/19, at 1:59 p.m. registered nurse (RN)-B stated R17 frequently leaned forward and to the left, had a harness in place that assisted with wheelchair positioning and was being seen by physical therapy. When interviewed on 3/7/19, at 2:33 p.m. physical therapist (PT)-A stated R17 had previously been seen for postural exercises, R17 was able to self correct positioning after previous therapy. Currenlty R17 was working on exercises for the left hip. PT-A was not aware of change in R17's current ability to self correct position or degree of bending to the left side. A policy regarding wheelchair positioning was requested; however, none was provided.

Based on observation, interview and document review, the facility failed to ensure ongoing physical and verbal behaviors were comprehensively addressed with psychiatric services being sought and/or implemented for 2 of 2 residents (R85, R63) reviewed who demonstrated physical and verbal behaviors causing distress to themselves and others. This resulted in actual, psychosocial harm for R85 who had repeated episodes of distress and anger evidenced by cursing, threatening others and throwing physical objects having potential to cause injury to himself or others that required multiple intramuscular (IM) injections of antipsychotic medication to help alleviate these episodes. Findings include: R72's quarterly Minimum Data Set ((MDS) dated [DATE], identified R72 had intact cognition. On 4/23/18, at 2:59 p.m. R72 was seated in her room with her doorway closed. She was interviewed about her quality of care and quality of life while living in the facility, and expressed there was another resident, R85, who lived on her unit who was terrible and abusive to the other patients. The resident wanders around the unit and goes into other residents' room(s) and people living there shouldn't have to put up with that. R72 explained R85 will purposefully get in others' way and not let them leave the dining room at times, pour water and juices on the floor, and run into people with his wheelchair. This caused R72 and others to feel afraid and intimidated, as some residents were not able to defend themselves and allowing him to do these things was not right. R72 expressed frustration as the staff would often abruptly leave while caring for her (R72) to tend to R85. R72 felt this was neglectful, and added, that is not right. Further, R72 stated the floor staff and administration were aware of these concerns, however, don't do nothing about it. At 3:17 p.m., during the interview with R72, nursing assistant (NA)-C knocked and entered her room to provide fresh water. R72 turned to her and stated, I'm telling (surveyor) about (R85). NA-C verified R72 was speaking about R85 and stated a lot of residents are not happy with R85's behavior. During interview on 4/23/18, at 3:26 p.m. NA-C stated residents' living on the unit will get really upset at R85 because he swears at staff and them, and wanders the hallways in his wheelchair. R85 was a top priority resident, and usually on some type of one to one basis which the other residents become upset about, too, related to his behaviors and believing people are in his room. The staff just try to keep R85 busy with activities and offer him food or drink to help keep him calm, adding staff follow his care plan to the best of (our) ability. NA-C explained R85 does swear at other residents at times, however, she had never seen or heard of him physically hitting another resident. NA-C stated other residents, including R72, will report they are scared of him and ask staff to make sure he's not allowed in their room(s). NA-C expressed she had wondered so many times why R85 is not in a locked memory care setting, or on some behavior management medication. R85's undated Resident Face Sheet identified R85 had several medical diagnosis' including dementia with behavioral disturbance, Wernicke's [MEDICAL CONDITION] (neurological disorder cause by [MEDICATION NAME] deficiency; marked by mental confusion, abnormal eye movements, and unsteady gait), major [MEDICAL CONDITION] with anxiety, [MEDICAL CONDITION] ([MEDICAL CONDITION] disorder), and unspecified [MEDICAL CONDITION]. R85's annual MDS dated [DATE], identified R85 had severe cognitive impairment with disorganized thinking and inattention being present, and displayed physical (i.e. hitting out) and verbal (i.e. threatening others) behavior symptoms. These identified behaviors were marked as not placing R85 at risk for injury, however, they did significantly interfere with his care and place others at significant risk for physical injury according to the MDS. The MDS identified R85 wandered and demonstrated rejection of care with all these behaviors being identified as, Same, versus the previously completed MDS assessment. Further, the MDS indicated R85 received no minutes of psychological therapy. R85's care plan dated 4/25/18, identified R85 remained in the facility for long term placement. R85 had [MEDICAL CONDITION] and tardive dyskinesia related to past use of [MEDICATION NAME] (an antipsychotic medication). R85 was listed as currently using [MEDICATION NAME] (an antidepressant medication) for depression with anxiety. R85 had used this since his original admission back on (YEAR), however, the medication was currently being reduced; with dosing at 10 milligrams (mg) daily on Monday, and 20 mg every other day. The plan listed target behaviors for the medication including wandering, verbally abusive, resistive to care(s), and disinterest in activities; along with non-pharmacological interventions including redirection, one to one supervision, warm blankets, reassurance, and offering snacks/fluids. The care plan identified R85 demonstrated several behaviors including physical and verbal resistance to cares and wandering into other resident' rooms. R85 had a long history of resisting care, and, at times, . becomes physically aggressive and moods are volatile during cares; behaviors include: hitting/kicking/pinching staff, yelling/swearing at staff, bending staff fingers back, grabbing at shower curtain, throws food/fluids . (family) is aware of behaviors but doesn't understand resident's rights to refuse care. Staff and family have been educated. Further, several interventions were listed to help R85 with these identified behaviors including speaking to him face to face, using his family member's (FM)-A name with cares, redirecting him, and conversing with him about his favorite topics such as being a railroad blacksmith. During observation on 4/24/18, at 8:57 a.m. R85 was seated in a high-back wheelchair in the dining room. A TAB alarm system (makes audible noise when pulled to alert staff) was secured to the chair, along with anti-tip bars on the back of his wheelchair. R85 had a covered mug with chocolate milk inside on the counter directly in front of him, however, his eyes were closed and his head was down. Later the same day, at 2:26 p.m. R85 was laying in bed in his room with the lights darkened. During observation on 4/25/18, at 9:35 a.m. R85 was again seated in the dining room in his wheelchair. The unit homemaker (HMK)-A was seated next to him conversing with him about his family, and R85 was smiling during the interaction. HMK-A was assisting him to eat his morning breakfast. Later on, at 12:00 p.m. R85 remained seated in the dining room next to there serving counter in the kitchenette. He continued to converse with HMK-A as she baked. On 4/25/18, at 1:33 p.m. NA-G and NA-H were interviewed regarding R85. They identified R85's behaviors were present on all shifts with early morning and night being the worst. The staff try to provide him with warm blankets, and visit with him to help keep him calm, however, added it all depends on the day he was having. NA-G and NA-H were unable to identify any specific actions or precursors to R85's outbursts. R85's behaviors seemed to be happening more and more lately, including R85 having tried to physically hit another residents on the unit, however, staff intervened. NA-G and NA-H explained R85 had never been seen or sent to psychiatric services to their knowledge as FM-A would not allow it. The facility had discussed moving R85 to the secured memory unit in the past, however, FM-A shot down the idea. NA-H expressed the nurses and administration were aware of R85's behaviors, and were doing small things to help, however, added those don't solve the immediate issue of him being here and the other residents concerns. NA-G and NA-H elaborated and stated most of them (other residents) living on the unit will report to them they don't like him and are scared of him, with some residents, including R72, even keeping their doorways closed as a result of R85's behavior. NA-H stated some residents often voice frustration with R85 as staff have to leave them, and tend to him so often. On 4/23/18 to 4/25/18, all 16 residents on the Sunshine Circle unit were questioned about their care, and if they had any unresolved concerns with anything or anyone in the facility. No additional concerns were voiced pertaining to R85. R85's progress notes were reviewed for the previous six months and identified the following entries: On 12/22/17, R85 was identified as not allowing staff to approach him. R85 was written as yelling, Get the Hell out of here, and get the Hell out of here, I will get my gun and shot (sic) you, do you hear me(?) Resident then placed himself on the floor and scooted himself to the doorway while hitting out and kicking staff. R85 was yelling . get the [***] out of here, repeatedly. The supervisor responded and determined it would be best to call 911 for safety of R85 and the staff. The on-call physician was notified and an order for [REDACTED]. A nurse from the hospital called the facility afterwards for a description of the behavior, however, the hospital nurse identified, He is not allowing any of us to approach him to provide care . A subsequent note dated 12/22/17, identified the facility staff had, . discussed with the ER nurse the possibility of getting a psych eval done. ER Nurse stated that they would first need to rule out any medical issues before a psych eval would be ordered. Writer discussed with the nurse that resident's behaviors have been escalating for a long time and that we are now unable to handle him. ER nurse acknowledged writer and stated that she would update the facility as as soon as she had some news. R85 readmitted to the facility on [DATE], being diagnosed with [REDACTED]. The corresponding hospital Discharge Summary Hospitalist dated 12/26/17, identified R85 was admitted to the hospital for a total of four (4) days. He presented to the hospital with worsening agitation and [MEDICAL CONDITION]; then was admitted with a concern for pneumonia (an infection which inflames air sacs in the lungs). A Hospital Course was listed which identified two medical issues addressed including R85's dementia with behavioral disturbance. R85 was recorded as having, .intermittent episodes of agitated behaviors particularly in the evening. Clinically, he responded well to antipsychotic medications including [MEDICATION NAME] or [MEDICATION NAME]. A set of discharge medication(s) was provided including an order for [REDACTED]. On 1/15/18, Team Care Conference held with FM-A participating via telephone. Discussion held about (R85's) overall care and her questions were answered. (R85) has been stable with his weight this quarter and is eating well . continues to have times when he is more restless and staff intervene (as needed). He also will awaken at night and staff provide him with a snack until he is ready to return to bed . continues to be dependent on staff for all areas of care. (FM-A) assists with decision making (as needed) due to (R85's) level of dementia. (FM-A) visits regularly and is supportive. Vulnerabilities reviewed and SS (social services) to visit and assist PRN. The note lacked any specific information which had been discussed or reviewed with FM-A pertaining to offering or providing psychiatric services to R85, despite being sent to the hospital and requiring IM [MEDICATION NAME]. On 2/1/18, . has been combative the whole shift. Angry at staff yelling '[***] you.' 'You son of a [***] !' ' I'm gonna kick your ass!' Wandering into other residents rooms, unable to redirect, warm blankets not effective, snacks and coffee not effective. Resident was a 1:1 the entire shift. Raising his fists at staff. On 2/22/18, . husband of the resident in room (unknown family member) reported to writer that (R85) swore at him and made a fist at him as he went into the kitchen to get hot water from the coffee machine before supper. The note did not identify where R85 was seated when this incident happened. On 3/22/18, . clearly agitated and continued to holler 'I'm going to get my pistol and [***] ing blow your heads off.' . wheeled self out into common area hollering and waking other residents up . grabbing whatever he could reach at nurses station and throwing it at staff examples include binders, tape dispenser, lotion bottles, etc. Attempting to get stuff off of nurses cart also. Resident attempting to get into other resident's rooms and scaring other residents with his talk of 'killing everyone.' Resident then stood up and grabbed desktop monitor and attempted to throw at writer. Writer called on call and was given order to give 1ml (sic) [MEDICATION NAME] IM from e-kit. Staff moved all items out of his reach. Redirection attempts all unsuccessful. [MEDICATION NAME] IM given at (12:13 a.m.). Resident is currently 1:1 On 3/25/18, . was combative with cares, wandering, yelling at other residents and staff and trying to throw objects at homemaker. Staff was 1:1 with resident, activity and distraction used to calm resident. On 3/28/18, .combative with AM cares. He was swinging and trying to hit staff. He was assisted to the dining room and started wandering around, bumping into furniture and people in the dining room. He was given food and a cup of juice. He threw the juice across the room. Staff assisted him out of the dining room and he was receiving 1:1 activity and distraction with activity assistant. She was walking around the unit with resident and he flipped over a dining room table on (different unit and not populated) dining room, tipped over a large plant and punched activity assistant in the face twice . when staff approached him he would kick and swing at them and if staff attempted to give him anything, he would throw it . GNP (nurse practitioner) called and updated to residents status and gave orders for 3 mg (milligrams) [MEDICATION NAME] (an antipsychotic medication) IM (intramuscular injection). [MEDICATION NAME] was administered at 1030. (Family) was updated. Resident is currently resting in his (wheelchair). On 4/15/18, . restless and self transferring out of (wheelchair) and self propelling into other res room . swearing at res and staff and chasing writer in his (wheelchair) swearing, 'I'm gonna kick your ass' and kicking out is legs with kicking motions. Res swearing at res. On 4/18/18, . argumentative and combative with (morning) cares, un able (sic) to redirect but staff able to complete cares . self propelling into other res (resident) room between meals . On 4/23/18, . has been busy and tried wandering into other resident's rooms. Staff performed 1:1 (one to one) many times through-out the shift. On 4/24/18, . started yelling that he wanted to get into bed while he was sitting in bed. Staff proceeded to lay resident down but resident started to kick and punch out at staff. Resident kicked NAR (nursing assistant registered) in ribs and grabbed NARs hands . R85's Target Behavior Monitoring flow sheet(s) from 1/2018, to 3/31/18, were reviewed. There were two sheets for each month which tracked incidences of wandering, verbally abusive, resistance to cares, and disinterest in activities. These identified the following: January (YEAR): R85 displayed wandering on a daily basis; with redirection and/or one to one being provided on several examples. However, these behaviors were recorded as either unchanged or worsened with these non-pharmacological interventions. R85 displayed being verbally abusive nine times; with redirection and/or one to one being provided. The non-pharmacological interventions were identified as effective only twice of the recorded nine times. R85 displayed resistance to care nine times; with redirection and/or one to one being provided. These interventions were recorded as having no impact on the behavior. Further, R85 displayed no recorded episodes of having disinterest in activities. February (YEAR): R85 displayed wandering on 26 of 28 recorded days; with redirection and/or one to one being provided on several examples. However, all but two episodes of these behaviors were recorded as either unchanged or worsened with these non-pharmacological interventions. R85 displayed being verbally abusive five times; with redirection and/or one to one being provided. The non-pharmacological interventions were identified as either not changing the behavior, or making it worse. R85 displayed resistance to care 15 times; with redirection and/or one to one being provided. These interventions were recorded as having no impact on the behavior, with several instances of making the behavior worse. Further, R85 displayed no recorded episodes of having disinterest in activities. March (YEAR): R85 displayed wandering on 25 of 31 recorded days; with redirection and/or one to one being provided on several examples. However, all but two episodes of these behaviors were recorded as either unchanged or worsened with these non-pharmacological interventions. R85 displayed being verbally abusive 13 times; with redirection and/or one to one being provided. The non-pharmacological interventions were identified as either not changing the behavior, or making it worse on all but three instances. R85 displayed resistance to care 18 times; with redirection and/or one to one being provided. These interventions were recorded as having no impact on the behavior or making the behavior worse on all but three instances. Further, R85 displayed no recorded episodes of having disinterest in activities. R85's Fairview Geriatric Services physician progress notes [REDACTED]. On 4/23/18, R85 was seen by nurse practitioner (NP)-A for an annual evaluation. R85 was identified to have dementia associated with alcoholism and behavioral disturbance, along with [DIAGNOSES REDACTED], [MEDICAL CONDITION] and [MEDICAL CONDITION]. R85 was listed as having severe cognitive impairment, along with volatile behaviors including combative with cares, punching staff, tipping over furniture, swearing, and wanders into other residents' rooms (many residents are afraid of him (due to) volatile violent-at-times behaviors.) R85 was seen by neurology prior who lowered his [MEDICATION NAME] level and started him on [MEDICATION NAME] (an anticonvulsant medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) adding, Family has been very adamant in the past about no anti-psychotics as patient had a bad reaction to [MEDICATION NAME] in the past and was over-sedated, hyponatremic. A listing of current medications was provided which including dosing for: - [MEDICATION NAME] 10 mg every Monday; 20 mg all other days, - [MEDICATION NAME] (an anticonvulsant) 100 mg every bedtime (started 4/12/18), - [MEDICATION NAME] 50 mg twice a day, - [MEDICATION NAME] 5 mg every bedtime, - [MEDICATION NAME] (used to treat dementia) 5 mg twice a day, - [MEDICATION NAME] [MEDICATION]) 25 mg every morning, and, - [MEDICATION NAME] 50 mg every evening. The note identified NP-A had .communicated with the appropriate disciplines involved with the Plan of Care, and R85's goal for care was to be comfortable and functioning at the top of his ability. A section labeled, Assessment/Plan was provided which explained each of R85's pertinent diagnosis' along with the current treatments. The [DIAGNOSES REDACTED]. Have started [MEDICATION NAME] for possible pain-related [MEDICAL CONDITION] which may be causing behaviors. If this is more helpful in the future, will again try [MEDICATION NAME] taper as [MEDICATION NAME] was originally prescribed for ETOH (alcohol) withdrawal [MEDICAL CONDITION] and patient was not had any [MEDICAL CONDITION] nor is currently drinking ETOH. A [DIAGNOSES REDACTED].will not GDR at this time as patient has history of significant behaviors. On 3/30/18, a Non-Face to Face Prolonged Service note was completed by NP-A. The note indicated the facility nursing staff had reported R85 displayed behaviors including being combative with care, wandering in his wheelchair, yelling at other residents and staff, and trying to throw objects at the staff. The note added, Staff often 1:1 this patient for his safety and the safety of the other residents. The note reviewed the behavioral episode on 3/22/18, which required use of [MEDICATION NAME] IM and updating FM-A who was upset with it's use. NP-A explained a work up was completed each time R85 demonstrated behaviors needing [MEDICATION NAME] to be given, however, nothing had been identified medically. NP-A dictated she had a discussion with FM-A regarding use of IM [MEDICATION NAME] being a last resort, however, added patient, staff and other resident safety must be highest priority, and if no IM [MEDICATION NAME] was allowed, R85 would need to be discharged to the ER. Further, the note directed FM-A, .voiced disappointment in patient's health status, and NP-A addressed having to potentially discuss medication use again if R85's behaviors .were happening often and he was needing frequent IM [MEDICATION NAME] dosing. On 2/23/18, R85 was seen by NP-A for a routine visit. The note had dictation was identified, Nursing recently reported that patient has been doing better with addition of [MEDICATION NAME] however then yesterday (2/22/18) he threatened another resident's family member. Other residents have reported being afraid of him as he will sometimes wheel himself around the unit and into other people's rooms. An Assessment/Plan was listed which included, Recent increase in meds (addition of [MEDICATION NAME]) so not appropriate for GDR of meds at this time, especially in setting of threatening other resident's family members and threatening other residents with his presence in their space. Will monitor for ability to GDR in future. On 2/8/18, R85 was seen for an episodic care visit at the nursing home. R85 was being treated for [REDACTED]. an increase in behaviors, however, at baseline R85 was listed as combative with cares, restless, having racing thoughts, anxiety with speech, and routinely entering other resident' rooms to the point they are either upset with him of scared that he will come in when they do not want him there. These behaviors were described by staff as not redirectable, with additional dictation provided as, Regardless, other tenants are reportedly still upset and scared. A plan was listed which included restarting [MEDICATION NAME] as Neurology recommended with notation, Could think about possibility of [MEDICATION NAME] (an anti-anxiety medication) as (FM-A) has been reluctant to start any medication that may lead to sedation for patient. On 1/8/18, R85 was seen for an episodic care visit at the nursing home. R85 was identified as not tolerating having a nasal cannula placed for his oxygen, with varying saturation levels from 83-91% on room air. The record indicated nursing had noted, patient has been lethargic, and remained on [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] and Wernicke-Korsakoff dementia. NP-A updated FM-A with a plan was developed to draw laboratory values for monitoring R85 for changes. Further, NP-A ordered to discontinue the as-needed [MEDICATION NAME] with notation, was not used, behind the order. An update was added to the note which identified, .have not been able to draw labs d/t combativeness. AVSS and patient less lethargic. Nursing updating that patient did not sleep well the previous night and may be 'catching up' with sleep today. On 12/27/17, R85 was seen following a hospital stay from 12/22/17, to 12/26/17. R85 had been transported to the emergency department (ED) on 12/22/17, with increased agitation and [MEDICAL CONDITION]. He was found to have possible pneumonia (not confirmed), treated with antibiotics and released back to the facility with orders for as needed [MEDICATION NAME] (an anti-psychotic medication) and oxygen. Further, the note identified R85 .responded well to antipsychotics in the hospital, and was followed by Neurology. NP-A provided orders to stop the [MEDICATION NAME] after 14 days and complete a laboratory test, with dictation added reading, Goal for no use of anti-psychotic and PRN can expire on/before stop date. There was no evidence in R85's medical record to demonstrate a psychiatric evaluation had been completed for R85 as requested on 12/22/17, when R85 was hospitalized . The record lacked evidence to demonstrate any assessment or ongoing effort by the facility to contact and implement psychiatric services for R85 despite ongoing, escalating behaviors which were causing distress to other residents in the facility. Further, the record lacked any evidence the facility had counseled or conversed with FM-A regarding having psychiatric services and/or antipsychotic medication initiated despite being identified as having responded successfully to them while hospitalized from [DATE] to 12/26/17. On 4/26/18, at 9:53 a.m. registered nurse (RN)-B and RN-C were interviewed regarding R85's care on the unit. R85 admitted from an assisted living and had always lived on the Sunshine Circle unit. He had several medical [DIAGNOSES REDACTED]. RN-B and RN-C both stated they were unaware other residents were voicing concern and fear about R85. They had just been informed yesterday about these issues when the surveyor had discussed it with other staff, however, RN-B stated she had visited with several residents on the unit that morning and all expressed they felt safe and voiced no concerns with their care or R85 being on the unit. RN-C explained R85's care was very individualized and he had never hurt anybody we are aware of. R85 was never placed in the facility's locked dementia unit as he is not an elopement risk, nor did his behaviors match the other residents already living on the locked dementia unit. RN-C stated several things were being done to help reduce R85's behaviors including having the floor staff follow an extensive non-pharmacological list of interventions, having him seen by Neurology when hospitalized , and having the Ombudsman present for a care conference back in (MONTH) (YEAR). R85 had only been hospitalized for [REDACTED]. RN-B and RN-C stated everyone sees the notes recorded in the computer and are aware of his behaviors. When questioned about following up on these issues sooner, as NP-A identified them in progress note(s) in (MONTH) (YEAR), RN-C expressed they had not seen those comments in the record until yesterday when reviewing R85's care and services. RN-C stated R85 had required [MEDICATION NAME] IM to be given three times in the past six months due to behaviors which were not able to be controlled or calmed. FM-A was not supportive of giving these type of medications though, as they were fearful it would cause R85 to become lethargic. RN-B and RN-C explained NP-A had many conversations with FM-A, however, they continue to not want R85 on medications for his behavior. RN-B and RN-C both expressed the NA staff should have alerted someone to the other resident' comments about being scared and fearful of R85 adding, They never came to us and said that. RN-B stated the psychiatric evaluation referenced in the progress note dated 12/22/17, was not completed as the hospital did not follow through with it. RN-B stated she felt R85 did need that done though, however, did not pursue it any further after his return as his behaviors had improved at the time, and the staff were just updating NP-A with their concerns since then. RN-B explained in the Fall of (YEAR), FM-A had contacted staff about possibly discharging R85 to another care venue, however, then changed their mind. A meeting was set-up with FM-A, staff and the Ombudsman around the same time, and again, different placement was offered, however, FM-A did not want that. RN-C stated she thought NP-A had offered psychiatric services for R85 to FM-A before, however, they had never seen him yet to her knowledge. RN-C reviewed R85's medical record and verified it lacked evidence R85 had ever been consulted or screened by in-house or outside psychiatric services. RN-C expressed she felt a psychiatric evaluation and/or services would be beneficial. Further, RN-B expressed aloud, (I) don't like the idea other residents are scared of him, and RN-C added staff needed to look at the issues and concerns, then just do the nursing process, and try to find a solution. On 4/26/18, at 10:48 a.m. NP-A and RN-B were interviewed. NP-A stated she had been involved with R85's care since (MONTH) (YEAR), and expressed from that day on, R85 had been the same with lots of behaviors. FM-A was very adamant they did not want some care(s) or medications as prior to admission, R85 had a history of [REDACTED]. NP-A explained each time R85 has a violent outburst, a complete work up is completed including looking at his sleeping, pain and bowels, however, family was still pretty resistant to medication management for R85's behaviors. R85's behaviors, at times, have required IM injections to help alleviate, and NP-A expressed these ''repeated behaviors'' need to have more in place versus just treating as needed with IM injections each time. NP-A stated R85 had some concerns with potential [MEDICAL CONDITION] or [MEDICAL CONDITION] awhile prior, and went to Neurology for these concerns, however, not much was done aside from beginning a [MEDICATION NAME] taper (reduction) and starting [MEDICATION NAME] to manage the [MEDICAL CONDITION] risk. NP-A explained the completed note(s) which spoke to residents being 'afraid' of R85 (dated 2/23/18), and stated she had a couple residents report they do not come out of their rooms a lot and keep (their) doors shut, because of R85 and his behavior. NP-A did not provide specific residents who voiced these concerns, however, added nobody had reported these concerns recently. NP-A thought she had forwarded these reported concerns to RN-B in the past, however, RN-B stated she had not heard them. RN-B explained R85 was not on a formal one to one currently, however, staff were just watching him closely. RN-B stated a formal one to one was not suitable in the facility as they were busy and had other things to do. NP-A reviewed the rationale for completing a GDR for R85's [MEDICATION NAME], despite continued and potentially worsening behaviors, and explained it was being done because a GDR hadn't been attempted in a really long time and she figured to try it and if nothing changed, it was not needed. NP-A stated she had offered in-house psychiatric services to FM-A before, however, they were declined. NP-A was not sure if outside psychiatric services, including a behavioral health in-patient stay, had ever been offered. NP-A was not sure if it would be helpful of not. NP-A explained she did not feel they were out of treatment options for R85 while at the facility, more so just limited due to FM-A's adamant refusals with certain care avenues. The plan now for R85, was to see how he handled the [MEDICATION NAME] GDR. If he fai (TRUNCATED)

Based on document review and interview, the facility failed to provide adequate supervision and care planned interventions to ensure the safety of 3 of 10 (R3, R2, and R4) female residents reviewed when another reisdent (R1) was able to inappropriately touch and/or expose himself to the female residents. The lack of staff supervision and interventions for R1's behavior caused actual harm to R2. Findings include: Review of R1's medical record revealed R1's [DIAGNOSES REDACTED]. Review of R1's care plan dated 10/17/2016, revealed R1 was independent with bed mobility, transfers, and ambulation. R1 had severe cognitive impairment with poor short and long term memory. R1 required family to assist with all decision making. The care plan indicated R1 had a history of [REDACTED]. Staff were to separate R1 from other residents when R1 became upset, allow time for R1 to calm down, and provide distractions as needed. R1 resided in a secured unit. Review of R3's medical record revealed R3's [DIAGNOSES REDACTED]. R3 required assistance from one to two staff to complete all activities of daily living and used a wheelchair for mobility. R3 resided in a secured unit. A progress note for R1 dated 11/13/2016, at 6:10 a.m. stated, the day shift reported that R1 was in his room with his pants pulled down with R3 also in his room. Staff separated the residents. An interview with nursing assistant (NA)-A on 12/1/2016, at 4:26 p.m. established on 11/13/2016, R1's room door was closed. NA-A entered the room and discovered R1 standing in front of R3 who was in a wheelchair, pulling up his pants. R3 was fully clothed. NA-A said R1 went into the bathroom and shut the door. NA-A immediately removed R3 from R1's room. NA-A reported the incident to the charge nurse. Review of R1's care plan updated 11/13/2016, stated R1 had exhibited sexually inappropriate behaviors. Staff were to monitor R1 for sexually inappropriate behavior. The care plan did not identify how frequent or what type of supervision staff were to provide for R1. Review of R1's care plan updated 11/16/2016, directed staff to monitor R1 for sexually inappropriate behavior toward female residents and intervene as needed. The care plan indicated R1 was not to be alone in a room with female residents. Staff were to allow R1 privacy in his room to masturbate. The care plan did not identify how frequent staff were to supervise R1 with other female residents. Review of R1's progress note dated 11/16/2016, established family consented to a psychology referral for R1. Review of R2's medical record revealed R2's [DIAGNOSES REDACTED]. Review of R2's care plan dated 11/15/2016, indicated R2 had severe cognitive impairment with an inability to communicate her needs and required others to make all of her decisions. R2 was dependent on others to complete all of her activities of daily living and utilized a wheelchair for all mobility. R2 resided in the secured unit. A progress note dated 11/18/2016, at 3:24 p.m. stated R1 was observed fondling R2's breasts in a public area on the unit. When approached, R1 immediately removed his hands from R2' breasts. Although R1's care plan directed staff to monitor R1 for sexually inappropriate behaviors, R1 was able to inappropriately touch R2. A progress note for R2 dated 11/18/2016, at 3:56 p.m. stated, R1 was noted to be caressing R2's breasts. R2 did not react to it. Interview with trained medication aide (TMA)-B on 12/1/2016, at 3:10 p.m. established on 11/18/2016, after lunch, she witnessed R1 standing behind R2 who was in her wheelchair in the living room. R1 was rubbing R2's breast underneath R2's shirt skin to skin. When approached R1 raised up his hands and denied touching R2's breasts. TMA-B pulled down R2's shirt and removed her from the area placing her in front of the nurse station. R2 made no verbal or physical response to the interaction. The incident was reported to the unit manager. There were no changes made to R1's care plan following the incident with R2. Review of R1's medical record established a psychologist visited with R1 on 11/19/2016. The progress note indicated R1 had difficulty answering questions with noticeable memory deficits. R1 did not plan or remember the sexually inappropriate behaviors but likely recognized the behaviors were not appropriate when they occurred. The psychologist recommendations to staff included detailed documentation of the inappropriate interactions including R1's clothing, location, staff and residents present, and time of day of the incidents to assist in determining a pattern. Additional interventions were recommended however, there were no changes made to R1's care plan or increased supervision of R1. A progress note for R1 dated 11/19/2016, at 2:11 p.m. stated staff observed R1 fondling R2's breasts in a common area. When approached R1 stopped and raised his hands to stretch. R1 denied touching R2's breast. Despite care planned interventions to monitor R1 for sexually inappropriate behaviors, R1 was near R2 and touched R2's breasts. A progress note for R2 dated 11/19/2016, at 2:23 p.m. stated R1 was witnessed fondling R2's breasts. Staff intervened and separated the residents. Staff asked R2 what happened and R2 immediately laughed but later began crying stating she was scared and wanted to leave. There was no change to R1's care plan following of R1 touching R2's breasts on 11/19/2016. Review of R4's medical record established R4's [DIAGNOSES REDACTED]. Review of R4's care plan dated 7/5/2016, revealed R4 required staff to anticipate her needs and R4 required the assistance of others to make all of her decisions. R4 resided in a secured unit. A progress note for R1 dated 11/20/2016, at 11:37 a.m. stated R1 was observed fondling R4's breasts. A progress note for R4 dated 11/20/2016, at 5:42 p.m. stated R1 was touching R4's right breast in the dayroom. R1 and R4 were sitting next to each other. Staff intervened and separated R1 and R4. Despite care planned interventions to monitor R1, he was allowed to sit next to R4 and touch her breasts. Interview with RN-C on 12/2/2016, at 10:41 a.m. revealed she witnessed R1 touch R4's breast near the day room on 11/20/2016. Prior to lunch R1 and R4 were sitting next to each other when R1 reached across and appeared to put one hand on R4's breast. Following the incident staff added an alarm to R1's door that entered the hall. The alarm was activated at night to alert staff of R1 leaving his room. In addition, an additional staff was added to the schedule to monitor for R1's whereabouts. RN-C contacted a behavioral unit for possible alternate placement for R1. Although an alarm was added to R1's room door on 11/20/2016, and activated at night, the incidents between R1, R2, R3, and R4 all occurred during the day. In addition, the extra staff was not care planned or provided a frequency or type of supervision for R1. Review of R1's progress note dated 11/21/2016, at 2:10 p.m. established R1 was evaluated by his practitioner for the inappropriate sexual behaviors. The practitioner placed R1 on Depakote (anti-seizure medication), at 125 milligrams (mg) three times a day for two days. The Depakote would be increased to 250 mg twice a day on 11/24/2016. The rational for the Depakote was for inappropriate behavior/sexual advances with target behaviors of touching/groping female residents. The facility failed to implement additional non-pharmacological interventions including increased supervision recommended by the psychologist on 11/19/2016, prior to starting the medications. Review of R1's care plan with a revision date of 11/22/2016, revealed the facility added a staff person to provide one to one staff to monitor R1 between 8:00 a.m. and 8:00 p.m. In addition, alarms were added to R1's room and bathroom door set to alarm at night. Interview with the RN unit manager (UM) on 12/1/2016, at 1:42 p.m. established staff reported R1's inappropriate sexual contacts with female residents. Staff were verbally told to monitor R1 for the behaviors but the care plan was updated at an unknown time. Not until R2's family came into the unit on 11/22/2016, and expressed concern that R1 remained on the unit did staff add one to one monitoring of R1. Interview with the director of nursing (DON) on 12/12/2016, at 4:36 p.m. established the facility determined R1's sexually inappropriate actions were not willful. In addition, the DON stated she didn't feel R1's actions resulted in physical or mental injury to R2, R3, and R4. The DON said R1's care plan was updated when appropriate in order to intervene with R1's new onset of behaviors. Review of the facility's policy and procedure titled Vulnerable Adult Abuse Prohibition with a revision date of 11/2016, stated, all residents of the facility were considered vulnerable adults. The interdisciplinary team (IDT) evaluated the vulnerability of every resident and developed interventions included in the plan of care. The facility would identify residents whose history could render them at risk for abusing other residents and develop interventions to prevent occurrences. In addition, facility staff would monitor for triggers and reassess the interventions on a regular basis. The policy stated instances of abuse of all residents even those in a coma, cause physical harm, or pain, or mental anguish.