Every finding on record at Essentia Health Grace Home

Based on observation, interview and document review, the facility failed to assesses and develop interventions for residents at risk for elopement (leave the facility without staff knowledge) for 1 of 3 residents (R1) reviewed for elopement. Further, the facility failed to test wanderguard (tags that alarm when a resident elopes) tags per manufacturer's recommendations for 3 of 3 residents (R1, R2, and R3) reviewed for elopement. Findings include: R1 R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively impaired and had diagnoses which included dementia, arthritis, and anxiety disorder. Identified R1 required extensive assistance with activities of daily living (ADL's) which include toileting, and dressing. Identified R1 was able to ambulate independently and wandered. Identified wandering was worse since last assessment. R1's care plan revised 6/23/25, identified R1 had behavioral symptoms present related to dementia with psychotic and behavioral disturbances. Identified R1 wandered and paced throughout the facility daily. Identified R1 had an elopement from the facility on 6/23/25. Identified consulting to find a possible visual barrier to aid in redirection of wandering behavior and promote safety, altered 15 second time frame to 30 seconds for door egress, red banner with magnets that say STOP-DO NOT ENTER placed on door. Directed staff to check wanderguard placement daily. Care plan lacked direction on how often to check the battery of wanderguard tags. Care plan further lacked documentation of exit seeking behaviors which included pounding on the doors and standing at the exit doors. Further lacked interventions for R1 during exit seeking behaviors. R1's elopement risk assessment dated [DATE], identified R1 had a history of wandering and was at risk for elopement. R2 R2's annual MDS dated [DATE], identified R2 was cognitively impaired and had diagnoses which included dementia, anemia, and anxiety disorder. Identified R2 required extensive assistance with ADL's which included transfers, toileting, and dressing. Identified R2 required a wheelchair and wandered. R2's care plan revised 5/15/25, identified R2 had behavioral symptoms with a history of physical and verbal behaviors towards others related to dementia. Identified R2 wandered daily. Identified when resident became agitated or had increased anxiety, staff were to offer objects of comfort such as stuffed animals and/or baby dolls. Attempt to provide diversion activities of resident's desired choices such as cards, music therapy of gospel music or classic country music, or 1:1 visits with reminiscing about fond memories or previous enjoyable events. Offer snacks and fluids as I enjoy sweets. Directed staff to check wander guard placement daily. Care plan lacked direction on how often to check the battery of wander guard tags. R2's elopement risk assessment dated [DATE], identified R2 had a history of wandering and was at risk for elopement. R3 R3's significant change MDS dated [DATE], identified R3 was cognitively impaired and had diagnoses which included dementia, anemia, and hypertension (elevated blood pressure). Identified R3 required extensive assistance with ADL's which include transfers, toileting, and dressing. Identified R3 wandered and R3's wandering was worse since last assessment. R3's care plan revised 6/11/25, identified R3 had behavioral symptoms with a history of physical and verbal behaviors towards others related to dementia. Identified R3 wandered and had a history of elopement and attempts at elopement. Identified behavioral symptoms with a history of physical and verbal behaviors towards others related to dementia. Identified R3 had periods of increased irritability towards others including verbal and physical behaviors. R3 may do better with individual activity verse group settings based on my mood at that time. When R3 was fixated on leaving, attempt redirection and distraction. R3 likes watching TV. In the past, calling my daughter and letting me speak to her seems to be effective in lessening anxiety and/or behaviors at that time. Approach: Encourage activity, watching TV in room, phone calls with family during periods of increased anxiety or behavior Approach: May need to re-approach or try alternative staff if having increased signs of anxiety, anger, irritability, or other physical or verbal behavioral symptoms towards others. Care plan directed staff to check wanderguard placement daily. Care plan lacked direction on how often to check the battery of wander guard tags. R3's elopement risk assessment dated [DATE], identified R3 had a history of wandering and was at risk for elopement. Review of R1, R2,and R3 treatment administration record (TAR) for the month of June 2025, identified placement of the wanderguard was being monitored every shift. TAR lacked evidence that the battery of R1, R2, and R3 wanderguard tag's were being tested. During an interview on 6/30/25 at 1:07 p.m., wanderguard rep stated the manufacturer expected the facility to be checking the batteries on the wanderguard tags that were placed on residents weekly to ensure proper functioning. Review of facility event report dated 6/23/25 at 12:55 p.m., identified R1 had an elopement from the facility and was found across the street on a porch rearranging the flowers. Identified R1 had elopement attempts in the past and wandered without a purpose and attempted to open doors. Interventions included staff assisted R1 back into the building and maintenance tested the wanderguard system and the door at the location of the elopement. Review of an inter-disciplinary team (IDT) progress note dated 6/25/25 at 1:27 p.m., identified R1 had a wanderguard in place due to elopements out of the building and further elopement attempts. Identified wanderguard continued to be checked for placement every shift, consulting with maintenance to find a barrier to be installed to redirect wandering behavior and promote safety for R1. Progress note lacked documentation of why R1 was attempting to elope from the facility or interventions placed related to the reason R1 was attempting to elope from the facility. Review of a progress noted dated 6/28/25 at 10:25 a.m., identified R1 was able to get through the doors and exited the building taking the DO NOT ENTER banner with her. R1 was intercepted immediately by a kitchen staff member and brought back into the building. Identified a black sheet was hung up and the door knob was removed from the nurses station which R1 had used to get to the north door where she eloped from. Identified R1 had been agitated, angry, aggressive all shift. Progress note lacked documentation of why R1 was attempting to elope from the facility or interventions placed related to the reason R1 was attempting to elope from the facility. During an observation on 6/30/25 at 9:30 a.m., R 1 had a wanderguard on her left ankle and was walking at a fast pace throughout the facility. During an interview on 6/30/25 at 12:57 maintenance (M)-A stated on 6/23/25 at approximately 1:00 p.m., he was mowing the lawn in front of the facility when he noticed R1 walking through the facility parking lot, across the street and onto the porch of a house and began rearranging the flowers MA stated R1 most likely came out through the door on the north side of the building. M-A stated he alerted nursing staff immediately and nursing assistant (NA)-A came outside immediately and assisted R1 back into the building. M-A stated he was unsure if anyone immediately asked R1 why she was outside or if anyone had recently tested the battery in R1's wanderguard tag. During an interview on 6/30/25 at 1:25 M-B stated he was called in to work on 6/28/25, after R1 had entered the nurses station and exited the building out the north door. M-B verified he was the one who checked the battery of the wander guard tags on the residents monthly. MB stated he did not document when he tested the battery of the wander guard tags however, knew they were last tested on [DATE], because he also tested all the doors at the same time monthly. MA-B stated he was unaware of how often the battery of the wander guard tags should have been tested. During an interview on 6/30/25 at 1:31 p.m., dietary aide (DA)-A stated she had been standing outside the door on 6/28/25, when R1 exited the building out of the north door. DA-A stated she immediately brought R1 back into the building. DA-A stated R1 told her that she wanted to go outside to work with the flowers. DA-A stated she had taken R1 outside once after her shift to work with the flowers and was unaware if staff had taken R1 out on a regular basis to work with the flowers. During an interview on 6/30/25 at 3:44 p.m., nursing assistant (NA)-A stated R1 was an elopement risk and had recently had an elopement from the facility. NA-A stated the intervention in R1's care plan was to check the placement of the wanderguard each shift. NA-A stated there were not any interventions in R1's care plan related to exit seeking behaviors. During an interview on 6/30/25 at 3:51 p.m., NA-B stated R1 was an elopement risk and had recently had an elopement from the facility. NA-B stated care planned interventions for R1 was the wanderguard. NA-A stated there were not many interventions in R1's care plan for when R1 was exit seeking. During an interview on 6/30/25 at 3:58 p.m., registered nurse (RN)-A stated R1 had eloped recently from the facility. RN-A stated staff had reviewed R1's elopement during IDT but the interventions were more focused on the door which R1 exited from and IDT had not attempted to find out why R1 was wanting out of the facility. RN-A verified there were very limited interventions in R1's care plan for when R1 was exit seeking. RN-A further stated maintenance staff tested the batteries on the wander guard tags monthly and that she was unsure how often the batteries on the wander guard tags had been tested. During an interview on 7/1/25 at 10:00 a.m., director of nursing (DON) verified R1 had eloped in the past week and was at risk for further elopements. DON stated the main focus was the doors and keeping R1 safe. DON stated staff had not assessed the reason R1 was continuing to want to go outside. DON stated R1's care plan lacked interventions for when R1 was exit seeking. DON stated the policy on elopement should be updated. DON stated the batteries of the wanderguard tags were being tested monthly and she was unaware the manufacturer recommendations were to test the batteries weekly. DON further stated her expectation was that R1 would have had care planned interventions for exit seeking behaviors, elopement policy would have included monitoring and managing residents at risk for elopement and that manufacturer recommendations would have been followed for battery testing on all residents who have a wanderguard. Review of a facility manual titled Accutech Installation dated 1/2012, identified for maximum protection of residents or assets accutech recommended that Tags (Wanderguard) be tested on a weekly basis. Review of a facility policy titled Elopement prevention dated 8/7/24, identified all residents would have been assessed through the admission process and elopement precautions would have been initiated immediately for all residents deemed at high risk for elopement and a plan of preventive action would have been incorporated into the resident's plan of care. Policy lacked information regarding monitoring and managing residents at risk for elopement. Policy lacked direction on how often batteries of wanderguard tags were tested.

Based on observation, interview and document review, the facility failed to ensure care plan interventions were implemented for 1 of 3 resident (R1) reviewed who required the use of a transfer belt during transfers reviewed for falls. R1 sustained harm when staff failed to implement the use of a transfer belt during a transfer to the bathroom. R1 fell , sustained a bilateral nasal bone fracture, laceration on the forehead, was sent to the emergency department (ED) requiring medical treatment. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. She required substantial/maximal assistance with toileting hygiene, partial/moderate assistance with personal hygiene, upper and lower body dressing, sit to stand, chair/bed-to-chair and toilet transfers, and ambulation up to 50 feet. She used a walker and a wheelchair for mobility. She was frequently incontinent of bladder and always continent of bowel. Her diagnoses included congestive heart failure, renal failure, and arthritis. R1's medications included diuretic (reduces fluid buildup in the body and increases urination) and anticoagulant (decreases the clotting ability of the blood to prevent and treat blood clots such as deep venous thrombosis or pulmonary embolism). No falls identified. R1's care plan dated 1/7/25 identified at risk for falls due to past history of falls with injury, chronic cardiac conditions, history of urinary tract infections (UTIs), occasional vasovagal (vagus nerve is the largest nerve in the body and regulates key functions causing a sudden drop in heart rate, blood pressure, breathing, and digestion and could had caused lightheadedness, nausea, sweatiness, and may faint response). Staff were directed to re-educate her about importance of transfer belt use, safety, and a sign placed in her room for a reminder for a gait belt and a front wheeled walker to aid in safety with mobility. Staff may have used a mechanical lift as needed (PRN) for periods of increased difficulty with transfers. R1's discharge MDS dated [DATE], identified she had one previous fall without injury and one fall with major injury. R1's progress notes from 2/1/25 through 2/6/25, identified: -2/1/25 at 12:35 p.m. nursing assistant (NA) called over radio for assistance in R1's room. Nurse down [sic] and entered room. R1 is halfway out of bathroom and laid face down on the floor with walker underneath her. Noted blood pooling around her head. NAs assisting R1 and applied pressure to head wound. Nurse assessed resident and 911 was called to transport to hospital. Staff kept resident talking until sheriff and emergency medical technicians (EMTs) arrived. R1 place on gurney and went by ambulance to emergency room (ER) at about 1:00 p.m. -2/1/25 at 3:56 p.m. call received from hospital R1 will be kept overnight for observation. -2/2/25 at 1:14 p.m. (recorded as late entry on 2/4/25 at 7:18 a.m.) Vital signs stable. R1 visiting with son and grandson. Band aide intact on forehead. Bruising noted around eyes, nose, and upper lip, and upper lip swollen. Pupils equal and sluggish to react to light. R1 does not have a headache. -2/2/25 at 3:13 p.m. (recorded as a late entry on 2/4/25 at 3:19 p.m.) 72 hours post fall. R1 was alert and oriented and vital signs (VS) within limits 122/63, 89% Sa02, 71, and 18. Answers questions appropriately. Dressing on forehead clean, dry, and intact (CDI). No signs of bleeding. Moves all extremities without a difficulty. Adequate hydration, voiding, and no complaints of pain so far. Sleeping soundly. -2/2/25 at 2:20 p.m. R1 returned from hospital. New orders received and processed. Daughter-in-law returned R1 to facility and was aware of new orders. R1 had a 5 cm forehead laceration which was stitched up and covered with band aid and was to stay in place until provider came across to remove stitches to forehead. Nose broke on both sides, upper lip swollen and black, also bruised around eyes. Had old bruising to knees and shine [sic] from earlier fall. Staff will monitor bruising for changes and due [sic] [NAME] [sic] checks every shift. -2/2/25 at 6:44 p.m. called over to physical therapy to screen R1 for safe transfers. At this time, we are using Hoyer (total lift machine) lift on her due to fall with injuries yesterday and before coming back to nursing home she had a vagal response at local hospital. -2/3/25 at 10:33 a.m. suture removal dated scheduled for Thursday 2/6/25 at 10:00 a.m. Provider will come over to remove sutures from the clinic. -2/3/25 at 1:46 p.m. Interdisciplinary team (IDT) note identified: contributing cause of the fall: history (HX) of vagal responses has been dizzy over past week, no vagal responses over the past several days. R1 was standing up for perineal (peri) cares and fell forward over her walker, she did not feel that she was passing out but a little dizzy and had been declining more over the past month. Post fall concerns: pain and functional limitation. R1 was sent to ER for evaluation and treatment. Action/Plan/interventions implemented to prevent reoccurrence: upon return R1 was placed as a Hoyer for all transfers with two persons assist for bed mobility as well. No further falls. -2/3/25 at 2:28 p.m. Physical Therapy (PT) evaluation completed. Due to increase in vagal episodes, recommend use of the Hoyer assist of two for all transfers. Leave sling under R1 for safety and skin protection of donning/doffing. Discharging occupational therapy (OT) orders as R1 required a Hoyer lift and assist of two for all ADLs as well. Physical therapy (PT) will continue to keep on for an assessment of safety with mobility and if possible, progress to EZ stand based on medical stability. Discussed with resident doing static stand at her walker in front of recliner with assist of two to continue to get weight through her legs and not fully loose strength. Discussed this could be part of a restorative program, and R1 refused to attempt. -2/6/25 at 2:10 p.m. Sutures removed by provider today. R1 stated not feeling well. Vitals are within guidelines. R1's Emergency Department (ED) notes dated 2/1/25 at 1:16 p.m. identified chief complaint: fall. She was a [AGE] year-old female who was being helped up from the toilet and wiped when she fell forward and struck her face and forehead. She denied neck pain and refused a cervical collar (C-collar) (a medical device used to support and immobilize a person's neck). Physical exam identified: her mouth had gingival bleeding along the gingival tooth junction (the area between the tooth surface and gum tissue), pale skin with a complex laceration (a tear in the skin and underlying tissue caused by blunt trauma) to the forehead, and nose appeared deformed from fall. R1's laceration located on forehead, involved the areolar tissue (loose connective tissue found in both the dermis and subcutaneous layers of the skin) and measured 9 centimeters (cm) by 0.5 cm was repaired with sutures. Review of the electrocardiogram (EKG) revealed a left bundle branch block (LBBB) and identified as new since 11/30/23. She was transferred to hospital. R1's computed tomography (the use of x-rays and a computer to create 3D digital images of your organs, bones, and other tissues) (CT) scan dated 2/1/25, identified cannot exclude nondisplaced acute fracture involving the sternum (breastbone located in the central part of the chest and protects your organs and connects other bones and muscles). R1's CT maxillofacial (bones of the face, including orbits, sinuses, jaw, and teeth) without (WO) contrast dated 2/1/25, identified facial blunt trauma, contusion/laceration overlying the frontal bones without underlying fracture, mildly comminuted (a bone that was broken in at least two placed usually after a very forceful event/trauma) and impacted bilateral (both sides) nasal bone fracture. R1's hospital progress notes from 2/1/25 through 2/2/25, identified: -2/1/25 at 12:58 p.m. R1 presented to ER with complaint of while standing with walker and receiving peri care. She was not aware of weakness coming on said she just went down. She was alert and orientated times four. Presented per ambulance on stretcher. -2/2/25 at 2:34 a.m. R1 complained of nausea and a headache rated at 7 out of 10. Zofran 4 milligrams (mg) given at this time. Ice pack given to her for headache. She can have more Tylenol at 4:00 a.m. -2/2/25 at 9:53 a.m. R1 took two steps to sit on commode. While on commode she had a spell where she passed out. She had dry heaves, passed much flatus but not bowel movement. Hoyer lift used to put her back to bed. She woke up while transferring to bed and positioned on her left side with pillow support. -2/2/25 at 1:36 p.m. R1 was discharged back to nursing home via wheelchair. R1's discharge notes from local hospital dated 2/2/25, identified discharge diagnoses: near syncope (fainting or passing out and is a temporary loss of consciousness and muscle tone caused by a decrease in blood flow to the brain), ecchymosis (bruising) face and right lower leg, closed fracture of nasal bone, and forehead laceration. Sutures to be removed in five days. R1' fall risk assessment dated [DATE] identified high risk for falls. R1's physical therapy (PT) evaluation dated 2/3/25 at 2:27 p.m. identified R1 fell face first and landed on her walker while in bathroom with NA. R1 had been having increased vagal response episodes. R1's prior level of function: ambulated in room with assist of one and front wheeled walker, all cares and transfers assist of one, bed mobility assist of two, and wheelchair dependent for all hallway navigation. R1 was identified as fall risk with impaired mobility and gait. Observation of R1 identified posture in recliner: increased leaning to right side and slouched. R1's had generalized weakness, bruised face, and bandage in place over laceration on forehead. R1's current functional status: Hoyer assist of two with all transfers for safety and static (standing without balance loss with use of upper extremities and moderate support from a person) stand in front of recliner to keep strength in her legs with therapy. Discussed with R1 importance of static stand, declined. Reviewed with R1 Hoyer would be used for safety of her and staff due to frequent vagal responses. R1 upset and verbalized understanding. Facility investigation dated 2/4/25, identified R1 was one person assist with use of walker at time of fall. She had complained of episodes of dizziness over the past few weeks and had vagal responses frequently as part of her normal physiological stasis. On this day, she had no complaints of these symptoms. She was in the bathroom with NA-A and rose to be cleaned. NA-A stood behind her, attempted to clean her when she started to lean forward, fell over her walker through the bathroom doorway, landing face first on the floor. NA-A called for help and applied compression to the wound. LPN-A and NA-B entered the room and R1 laid face down with blood on the floor. LPN-A assisted with compression to laceration on forehead to stop bleeding. LPN-A confirmed when she entered R1's room no gait belt was on her. Call placed for transport to ER. CT scans showed fracture to nose. Investigation showed care plan was not followed, and gait belt was not placed on resident by NA caring for her at the time of the incident. During an observation/interview on 2/26/25 at 12:48 a.m. R1 sat in her recliner awake, call light positioned on her lap, blanket covering her legs and feet, fully dressed in shoes on. She had a tan with dark green trim lift sling positioned underneath her. She had a bruise below and above her right eye and on right check area. She stated she had a tendency of passing out and it happened again about three weeks ago while in the bathroom. An NA had taken her to the bathroom with the walker, she used the toilet, stood up, NA reached for some wipes, kind of lost her balance, fell forward onto the floor on top of the walker, and hit her head. She stated it was the worst fall yet, happened so fast, stitches were placed in her forehead, and broke her nose. She was unable to remember if a gait belt was used. Staff had transferred her with a lift machine since she returned from the hospital after the fall and used the bedpan while she laid in bed. During an interview on 2/26/25 at 1:45 p.m. licensed practical nurse (LPN)-A stated R1 was a high risk for falls and staff were expected to use a gait belt when they transferred her. While R1 sat on the toilet, had a history of vagal response, and would go out and faint. On 2/1/125, she arrived in the room and R1 laid face down on the floor with a pool of blood around her head. R1 had injured the center of her forehead when she face planted onto the floor. She called 911, R1 did not go unconscious, talked to staff until EMS arrived 5 to 7 minutes later. Emergency medical services (EMS) turned R1 over and moved her onto the gurney. She noticed R1 had bruising on her forehead, down to cheek bones on both sides of her face with a laceration in the middle of the forehead that required stitches. She had completed vitals and an assessment prior to EMS arrival. Changes were made on R1's care plan after the fall and staff were expected to use the Hoyer lift for all transfers. She had received mandatory education about 5 days ago that included safe resident transfers, mechanical transfers, use of gait belt, and required to take a test. During an interview on 2/26/25 at 2:20 p.m. NA-D stated R1 had vagal responses after having a bowel movement (BM) on the toilet. Our younger staff had not really understood what a vagal response was unless they had witnessed one. R1 was an assist of one, with walker and gait belt for transfers prior to the fall on 2/1/25. R1 was alert and oriented, used the call light, and could make her needs known. Staff were expected to have used a gait belt on R1 especially due to her vagal response. She stated when she arrived to the room R1 laid on the floor, head and upper body were located two feet out from bathroom doorway, face down in a pool of blood underneath the head. R1 had a laceration on the forehead that required stitches, middle of forehead at top of nose did not look right which resulted in a fractured nose. She talked to R1 while she applied cold wash clothes to her face to keep her awake. R1 had not lost consciousness. EMS arrived, moved R1 out of the bathroom, slowly rolled her over, and placed on the stretcher. During an interview on 2/27/25 at 9:02 a.m. physical therapist (PT)-A stated R1 had occasional vagal responses on the toilet and became unconscious. R1 refused further testing and did not want to be transferred out to another facility. Staff were aware of R1's vagal responses for months, were expected to follow care plan, gait belt applied during transfers for safety prior to when R1 lost her balance and could have helped control her movements. An assessment by PT was not completed after the 1/5/25 fall. When R1 refused the use of the gait belt, staff were expected to have placed the gait belt on or notified the charge nurse. A gait belt would have provided a safer transfer. After R1's fall on 2/1/25 a PT evaluation was completed and was deemed safer to transfer R1 with a Hoyer lift and assist of two. R1's care planned was updated after the 2/1/25 fall, R1 may stand assist of two in front of recliner with restorative therapy (PT) only. Staff were expected to use mechanical lift for transfers. During an interview on 2/27/25 at 9:41 a.m. registered nurse quality/safety supervisor (RN)-B stated R1 had a decline in the last month, not herself, less energy, generally not feeling well, and not happy or upbeat. Staff were expected to transfer R1 with assist of one to the bathroom with a gait belt per care plan. There were a few times she transferred R1 and was a bit nervous due to her age and walked bent over. The gait belt would have provided safety for R1 and the staff, may not have prevented R1 from going down, but staff could have grabbed the gait belt when she started to tilt, and guided R1 back to toilet or lowered her onto the floor. There were a couple of staff that did not use gait belts during transfers, provided mandatory education last week to approximately 95% of staff. She started random audits that included: all gait belts checked for damage/fraying, located in each resident room, and whether staff used a gait belt during transfers. During an interview on 2/27/25 at 10:14 a.m. RN-C stated R1 had vagal responses sporadically when she sat on the toilet and started about one year ago. She was unsure of what caused it, family and provider were notified and chose not to pursue any additional testing. R1's vagal responses became more frequent January 2025 and happened while R1 sat in her recliner. Staff were unaware when R1 would have a vagal response and most often happened while on the toilet. R1's care plan was not followed, and a gait belt was not used during the 2/1/25 transfer that resulted in a fall with injury. Staff were expected to use a gait belt with any resident that required partial/moderate or substantial/maximum assist and dependent upon staff assistance for transfers only if the resident walked or pivoted on care plan. R1 transfers were changed to Hoyer lift only with assist of two staff after return to facility from the hospital on 2/2/25. During an interview on 2/27/26 at 11:30 a.m. NA-A stated she aware of R1's vagal responses, last summer became unresponsive while on toilet for approximately one minute, called for help, and safely transferred to her recliner without a fall. She had worked on 2/1/25 when R1 placed call light on, and she responded to it. R1 sat in the recliner, stated she really had to go to the bathroom, removed her blanket, placed walker in front of her, stood up right away, and pushed the walker while she walked alongside her. She did not use a gait belt on R1 for this transfer. Staff were expected to follow the care plan and use a gait belt on any resident that required assistance of one with transfers. She stated completely had forgotten to use a gait belt and would have been important to use when she started to fall, could have lowered her down or redirected her back to the toilet. R1 had refused the use of gait belt in the past and staff were expected to try and distract them, placed gait belt on, and explain the reason it was needed. Gait belts were to be used to keep everyone safe and protected from falls. She had not realized the gait belt was not on R1 until she fell . R1 had a bowel movement on the toilet, stood up, while she stood on R1's left side, started to wipe her bottom when R1 fell forward, face planted on the floor right in front of the toilet. She used walkie and called for help. R1's face started gushing blood, both her and NA-D placed cold towels on her forehead and tried to stop the bleeding. She stayed with R1 and did not lose consciousness, talked to staff until EMS arrived 15 to 20 minutes later. She assisted EMS, rolled R1 over and onto a sheet, and lifted her onto a gurney. She received education from director of nursing (DON) regarding gait belt use, refusal of gait belt, and transfers. During an interview on 2/27/26 at 1:39 p.m. DON stated R1 rushed to get from one place to another. R1 had a history of vagal response for at least 2 1/2 years now. When R1 had vagal responses, staff were expected to have administered a sternal rub and assessment completed by the nurse. NA-A received training when she first started regarding a response to a vagal incident. R1 usually sat down prior to a vagal respond and unaware of what caused them. She had talked to R1 and informed her she felt dizzy a little bit, there was not a vagal response during the 2/1/25 fall. She expected staff to follow the care plan, had access to it on the medical records system on computer tablets, understood it and if they did not should have asked the nurse questions. Staff were expected to use a gait belt with any resident that required the assistance of one to safely provide care. The gait belt helped steady and/or lower the resident to the floor if they have fallen or lost their balance and provided safety for both the resident and the staff. She stated no gait belt was used for the transfer of R1 on 2/1/25 which resulted in a fall with injuries. NA-A could have placed R1 on toilet, grabbed gait belt and applied it prior to the transfer, NA-A did not think about that. R1 sustained a laceration center of forehead and required seven stitches, landed on her nose, and fractured /cracked both sides (not all the way through) bridge of nose, facial bruising across forehead down to eyes and extended down to the checks on both side of the face. DON stated R1's walker most likely helped avoid additional injuries. R1 stayed overnight at hospital for observation and came back the next day to the facility. She confirmed 36 out of 40 staff had received the mandatory education regarding gait belt use, transfers, lift transfers, and completed the required test afterwards. The remaining four staff were as needed staff (PRN) status and would be required to complete the mandatory education prior to the next shift worked. Facility policy Transfer/Gait Belt, use of dated 8/6/19, identified the purpose of a transfer (gait) belt is to provide support to residents that maybe unsteady on their feet. The belt will protect the resident should they become weak or lose their balance when ambulating or transferring. All staff assigned to provide direct care will be expected to use a transfer belt while providing direct care as indicated in care plan. A transfer belt was to be used on a resident that was care planned to be: assist of one or two with transfers and ambulation. Procedure: 1. Review care plan for resident ambulation status. 2. Identify resident and explain who you are and what you are about to do. 3. Wash hands and gather supplies: transfer belt and appropriate footwear. 4. Assist resident to put on appropriate footwear. 5. Fasten transfer belt securely around waist of properly clothed resident. 6. Grasp transfer belt at resident's side using the underhand grasp. 7. Using proper body mechanics, bend your knees while keeping your back straight and assist resident to a standing position. 8. Allow resident to get and maintain a standing balance. Observe for dizziness or weakness. 9. Grab transfer belt at resident's back and walk at side of resident, supporting hand and arm if necessary. 10. Walk resident as indicated on the care plan. 11. Assist resident to sitting position. 12. Report/record procedure, noting resident's tolerance and ability as needed. 13. Transfer belts are in resident room as well as at the nurse's stations and in the medication drawer room (MDR). Facility Care Plan/Care Conference policy dated 8/9/24, identified purpose of care plan was to ensure each resident had an individual plan of care to provide the necessary care to achieve and maintain the highest practicable level of physical, mental, and psychological well-being. Staff providing direct care were responsible for reviewing and understanding the individualized care plan for each resident.

Based on observation, interview and document review, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 3 residents ( R21) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This deficient practice had the potential to affect all 22 residents residing in the facility. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had moderate cognitive impairment and diagnoses which included diabetes mellitus (DM), renal insufficiency, and hypertension (elevated blood pressure). Identified R21 required extensive assistance with activities of daily living (ADL's) which included toileting, transferring, and dressing. R21's care plan revised 12/20/24, indicated R21 had a catheter related to bladder outlet obstruction. Care plan directed staff to assist with emptying catheter every shift. During an observation on 1/13/25 at 11:02 a.m., there was a sign on R21's door that stated Enhanced Barrier Precautions; Everyone must clean their hands, including before entering and when leaving the room. Wear gloves and gown for the following high contact resident activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. In addition, the sign contained a picture of hand sanitizer, a gown, and gloves. There were no gowns located inside or outside R21's room. During an observation on 1/13/25 at 1:01 p.m., occupational therapy assistant (OTA) entered R21's bathroom, sanitized hands, applied gloves and informed R21 she was there to assist her off the toilet. OTA used toilet paper to wipe R21's perineal area, removed gloves, pulled up R21's pants and washed hands. OTA proceeded to walk along side of R21 in to the therapy room. The only PPE OTA wore while assisting R21 off the toilet was gloves. During an observation on 1/13/25 at 2:56 p.m., nursing assistant (NA)-A entered R21's room, sanitized hands, applied a gait belt around R21's waist and walked with R21 to the bathroom while holding on to the gait belt. NA-A applied gloves and pulled R21's pants down as R21 sat down on the toilet. NA-A used toilet paper to wipe R21's perineal area, removed gloves, pulled up R21's pants and washed hands. NA-A walked with R21 to her recliner while holding on to the gait belt. The only PPE NA-A was wearing while assisting R21 on the toilet was gloves. During an interview on 1/13/25 at 3:01 p.m., NA-A verified the only PPE she had used while toileting R21 was gloves. NA-A stated the only time she needed to wear a gown was when she was working with R21's catheter. During an interview on 1/14/25 at 11:42 a.m., OTA verified the only PPE she had used while toileting R21 was gloves. OTA stated her understanding of EBP was that she only needed to wear a gown when she was working with R21's catheter. During an interview on 1/15/25 at 8:30 a.m., infection preventionist (IP) verified R21 had a catheter and was on EBP. IP stated her understanding of EBP had been that staff only needed to wear a gown if they were caring for R21's catheter. IP stated now that she was aware of when a gown should be used, her expectation was that staff would wear a gown when indicated per Centers for Disease Control (CDC) guidance while caring for any resident who was on EBP. During an interview on 1/15/25 at 9:21 a.m., director of nursing (DON) stated her expectation was that PPE would have been readily available to use for any residents in EBP and staff would have worn a gown and gloves while caring for R21. Review of a facility policy titled Standard and Transmission Based Precautions (TBP) revised 11/2/23, identified TBP were special precautions for the care of patients with diseases or conditions of epidemiological significance that are transmitted by contact. Identified gowns were to be worn to protect skin and prevent soiling of clothing during patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or causing soiling of clothing.

Based on observation, interview and document review, the facility failed to ensure professional standards of practice were followed during medication set-up and administration of insulin with a Novolog insulin pen ( rapid-acting insulin, used to improve blood sugar control in people with diabetes mellitus) for 1 of 2 residents (R12) who received insulin without the pen primed according to manufacturer's recommendations. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition and had a diagnosis of diabetes mellitus (DM) and received injections of insulin. R12's care plan revised 12/1/24, identified staff were to administer medications as prescribed. R12's Order Summary Report signed 12/11/24, identified Novolog Flex Pen U-100 inject 5 units Subcutaneously (an injection just under the skin into the fatty tissue) three times daily for DM. During an observation of medication pass on 1/14/25 at 5:30 p.m., registered nurse (RN)-A prepared R12's medication which included her 5:00 p.m., Novolog insulin. RN-A removed the Novolog insulin pen from the medication cart, removed the tip, attached a needle to the end of the pen, dialed the dose to the ordered 5 units, picked up an alcohol wipe, went to R12's room and administered the 5 units of insulin to R12. RN-A then removed the needle from the end of the pen, placed it in the sharps container and sanitized her hands. RN-A did not prime the pen (waste 2 units of insulin to remove the air bubbles) per manufacturer's instructions prior to drawing up the 5 units of insulin. During an interview on 1/14/25 at 5:324 p.m., RN-A verified she had not primed the insulin pen prior to dialing up the 5 units of Novolog for R12 per manufacturer's recommendations. RN-A stated she was aware the insulin pen should have been primed prior to dialing up the insulin to ensure the accurate dosage of insulin was administered. During an interview on 1/15/25 at 9:15 a.m., consultant pharmacist (CP) stated it was important to always prime an insulin pen prior to drawing up the dosage to ensure the residents received the correct dosage of insulin. During an interview on 1/15/25 at 9:23 a.m., director of nursing (DON) stated her expectation was that the insulin pen would have been primed prior to dialing up the insulin dose for R12 to ensure the proper dose of insulin was administered. Review of the Novolog insulin manufacture's package insert dated 2023, identified the need to perform an airshot before each injection to ensure the any air bubbles were removed. The process directed: Attach a new needle, Select a dose of 2 units on the dosage selector, hold the pen with the needle pointing upward, tap the insulin reservoir to move any air bubbles to the top of the reservoir, press the injection button all the way in, and check to see if insulin comes out of the needle tip. Repeat if no insulin comes from the needle, then dial the selector to the ordered insulin dose and administer as ordered. Review of a facility policy titled Medication Administration revised 7/23, identified staff would follow appropriate standards and protocols when administering medications. .

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 2), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 23 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: 4/23/23, 4/29/23, 4/30/23, 5/14/23, 5/20/23, 5/21/23, 5/27/23, 5/28/23, 6/3/23, 6/4/23, 6/10/23, and 6/17/23 for failure to have licensed nurse coverage 24 hours per day. Review of staffing schedules from 4/1/23 thorough 6/30/23, identified the facility had four staff identified to have worked: registered nurse (RN)-A, RN-B, RN-C and licensed practical nurses (LPN)-B on each of the above dates listed. In addition, review of staff's time cards from 4/1/23 through 6/30/23, on the above-mentioned dates identified licensed nursing staff had worked. Review of the facility's staffing schedules and time cards identified a discrepancy with the PBJ report. During an interview on 12/6/23 at 12:49 p.m., director of nursing (DON) verified the information above and confirmed licensed staff had worked on the dates mentioned above. DON indicated the PBJ report was completed through parent company's business office and the information submitted to CMS was inaccurate. A policy related to PBJ was requested however not received.

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators, were labeled, dated and discarded properly .This deficient practice had the potential to affect all 23 residents who were served food from the kitchen. Findings include: On 12/4/23 at 12:05 p.m., during an initial tour of the facility kitchen area with the dietary manager (DM), the following concerns were identified: Refrigerator: -large plastic container 3/4 full of thousand island with black crusty substance around the lid of the dressing opened 4/28/23. -large plastic container half full of Italian dressing opened and not dated. -large plastic container half full of thousand island dressing opened 5/26/23. - large plastic container half full of French dressing opened 8/22/23. -large plastic container of store bought salsa with a black crusty substance around the lid of the container half full opened 10/3/23. -8 slices of angel food cake not dated. During an interview on 12/4/23 at 2:54 PM., DM confirmed the above findings and indicated the residents had recently been served the salsa, angel food cake and french dressing however was unaware of the last time the residents had been served the other dressings. DM stated dressing was only good for 3 months once opened and store bought salsa was only good for one month once opened. DM stated her expectation would have been that all food would have been dated and discarded per food storage guidelines. During an interview on 12/6/23 at 8:29 a.m., registered dietician (RD) indicated it was the responsibility of the DM to oversee the storage of food. RD stated she has worked for the facility for the past six months but had never been to the facility therefore, was unaware of the undated and past dated food in the refrigerator. RD stated she was not sure of how long food was good once opened. During an interview on 12/6/23 at 9:40 a.m., director of nursing DON stated she was unaware of the undated and past dated food in the refrigerator in the kitchen. DON further stated her expectation was that food would have been dated and thrown out per food storage guidelines. Review of a facility policy titled Refrigerator-Freezers, Food Storage revised 11/19/21, indicated to assure the safe storage and management of patient food stored in refrigerator and

Based on observation, interview and document review, the facility failed to ensure staff were completing hand hygiene and using proper personal protective equipment (PPE) according to the Centers for Disease Control (CDC) guidelines during a COVID-19 outbreak in the facility while delivering meal trays to 3 of 3 residents (R14, R17, R7). In addition, the facility failed to ensure proper medication handling for 1 of 3 residents (R15) reviewed for medication administration. Findings include: Review of the CDC guidance dated 5/8/23, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. The guidance identified health care personnel (HCP) who worked with COVID-19 positive residents were expected to follow PPE guidelines that included: mask, gown, gloves and face shield covering the front and sides of the face, during all resident encounters. Healthcare Personnel were also expected to complete proper hand hygiene prior to entering residents rooms, after leaving residents rooms and after removing PPE. MEAL TRAY DELIVERY During an observation on 12/05/23 at 9:03 a.m., R14's room door was closed and R14 had been placed in isolation due to testing positive for COVID-19. A pocket holder had been placed on R14's door which contained all required PPE to enter R14's room. R14's door included signage for current PPE requirements. Dietary Aid (DA)-A delivered breakfast meal trays on a four-wheeled cart to residents. Licensed practical nurse (LPN)-B and DA-A applied PPE prior to entering R14's room. DA-A removed white gown and face shield from pocket door holder and donned PPE. DA-A's white gown was not secured with the recommended ties and sides of gown were noted to flap at the side when DA-A walked. DA-A had not applied gloves prior to entering R14's room. LPN-B knocked on door and entered R14's room and DA-A followed behind. DA-A placed R14's meal tray onto bedside table, asked R14 if he needed anything further, R14 declined any additional needs and DA-A exited R14's room. While standing in hallway outside of R14's room, DA-A removed white gown and disposed in trash bin outside R14's room. DA-A removed face shield and placed back into pocket holder on R14's door. DA-A removed N95 mask and disposed in trash bin outside R14's room. DA-A proceeded down the hallway while pushing a four-wheeled cart and continued to deliver meal trays. DA-A had not completed hand hygiene or obtained another mask after leaving R14's room or prior to entering R17's room who was not in isolation for meal tray delivery. DA-A exited R17's room, did not complete hand hygiene and continued to walk down the hallway pushing the four-wheeled cart to deliver meals. DA-A entered R7's room who was not in isolation to deliver the meal tray without completing hand hygiene. While in R7's room, DA-A applied an N95 mask and was touching all over the outside of the mask attempting to adjust it while leaving R7's room. DA-A had not completed hand hygiene after leaving R7's room. DA-A pushed the four-wheeled cart back into the kitchen. During an interview on 12/5/23 at 2:33 p.m., nursing assistant (NA)-A indicated R14 received limited assistance from staff and was independent with cares. NA-A stated when a resident became COVID-19 positive, they would be placed in isolation in their room for 10 days. When a resident had been confirmed positive, staff were required to place the pocket holder and proper signs on the door. NA-A indicated staff were required to complete hand hygiene and follow the PPE guidelines when they entered or exited the room. During an interview on 12/5/23 at 5:23 p.m., LPN-A confirmed the above findings and indicated R14 was placed in isolation due to testing positive for COVID-19. LPN-A confirmed the facility was currently in a COVID outbreak and staff were expected to wear N95 masks at all times. LPN-A was unaware DA-A had entered other rooms without wearing proper PPE or completing hand hygiene between residents. LPN-A stated her expectations were all staff would follow PPE guidelines and complete hand hygiene between residents. MEDICATION ADMINISTRATION During an observation on 12/6/23 at 7:27 a.m., registered nurse (RN)-A dispensed medications for R15 while standing at the medication cart. RN-A obtained Tylenol 325 milligrams (mg) tablets for R15. While pouring the medication from the bottle into the medication cup, one Tylenol 325 mg tablet fell on to the top of the medication cart. RN-A picked up the Tylenol with an ungloved hand and placed the Tylenol into the medication cup. RN-A delivered the medications to R15's room and R15 took all the medications. During an interview on 12/5/23 at 5:44 p.m., director of nursing (DON) confirmed the above findings and indicated she was unaware of dietary staff not donning a mask or completing hand hygiene after leaving a COVID room. DON stated her expectations were staff were required to wear an N95 mask during a COVID-19 outbreak. In addition, DON stated her expectations were staff to complete hand hygiene prior to entering and upon exiting resident rooms. During a follow-up interview on 12/6/23 at 12:36 p.m., DON was not aware of staff not handling medications with proper care especially picking up a medication with an ungloved hand. DON stated her expectations were nursing staff would properly dispense medications and if a medication were to fall out of the cup and land on the med cart surface, staff would follow the policy to dispose of it. Review of facility policy titled Hand Hygiene reviewed 11/10/23, outlined hand hygiene practices and expectations for healthcare workers, prevent the transmission of microbial pathogens and aid in the reduction of healthcare associated infections. All healthcare workers must perform hand hygiene before entering a patients room, before touching any object or furniture in the patient zone, after patient contact, after touching any object or furniture in the patients environment, before putting on gloves, after removing gloves or other personal protective equipment. Review of facility policy titled Standard and Transmission Based Precautions reviewed 11/2/23, to provide guidance to reduce the risk of transmitting infections among patients/residents, staff and visitors. Gloves should be worn for touching potentially infections materials or soiled surfaces. Wear a gown to protect skin and clothing. Wear a mask and eye protection or a faceshield to protect mucous membranes. Review of facility policy titled Medication Administration revised 7/23, to ensure safe, and accurate administration of medications in a timely manner to all residents as ordered by licensed provider. When a medication was dropped outside of the medication cup they must be wasted/destroyed immediately. Any medication that was dropped must be documented in the medical record.

Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 4 of 4 residents (R2,R3, R4,R19) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 23 residents residing in the facility. Findings include: During a resident council meeting on 12/5/23 at 9:58 a.m., four residents attended. All four residents, R2, R3, R4, R19, confirmed mail was not delivered to the facility on Saturdays and identified they had to wait until Monday to receive their Saturday mail. During an interview on 12/5/23 at 2:04 p.m., activity director (AD) indicated activity staff delivered mail to residents. AD stated they did not deliver mail to residents on Saturday and indicated the post office had not been delivering mail to the facility on Saturdays. During an interview on 12/6/23 at 9:40 a.m., director of nursing (DON) confirmed mail was not delivered to residents on Saturdays and indicated the post office had not been delivering mail to the facility on Saturdays. The facility policy titled Resident Mail dated 10/21 identified the residents had the right to have access to timely mail delivery.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R8 and R21) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Current CDC recommendations 3/15/2023, revealed the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 at age 65 and older, based on shared clinical decision-making, should receive one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Further, adults who received the PCV13 at any age should receive the PCV20 or PPSV23 one year later. Review of R8's facesheet identified R8, age 93 was admitted to the facility on [DATE]. Review of R8's Minnesota Immunization Information Connection (MIIC) undated, identified R 8 had received the PPSV23 on 1/1/2012, and the PCV13 on 8/27/2015. R 8's medical record lacked documentation R8 had been offered or received the PCV20 vaccine. Review of R21's facesheet identified R21, age 88 was admitted to the facility on [DATE]. Review of R21's MIIC undated, identified R21 received the PCV13 on 2/25/2016. R21's medical record lacked documentation R21 had been offered the PCV20 or the PPSV23 vaccine. During an interview on 12/5/23 at 2:20 p.m., infection preventionist (IP) confirmed R8 and R21 had not been offered or received the pneumococcal vaccines as recommended by the CDC. IP stated her expectation was the facility would offer and administer all vaccination per CDC recommendations. During an interview on 12/6/23 at 9:40 a.m., director of nursing (DON) stated she was aware of the CDC recommendation for the pneumococcal vaccination. DON confirmed R8 and R21 had not been offered or received the pneumococcal vaccinations as recommended by the CDC. DON stated her expectation would have been that all residents would have been offered and received all pneumococcal vaccines per Centers For Disease Control (CDC) recommendations. Review of a facility policy titled SNF Vaccination of residents-Influenza, pneumococcal, and Covid -19, revised 6/13/23, indicated pneumococcal vaccinations would be offered and administered to all eligible residents per CDC guidelines.

Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 1 residents( R11) reviewed for activities of daily living (ADL)'s. Findings include: R11's significant change Minimum Data Set (MDS) dated [DATE], identified R11 had severely impaired cognition and had diagnosis which included diabetes Mellitus (DM), dementia, and obsessive-compulsive disorder. Identified R11 required extensive assistance with activities of daily living (ADL's) which included bed mobility, toileting, transfers, and personal hygiene. R11's current care plan last revised 10/1/23, indicated R11 had deficits with ADL's related to dementia. R11 required staff assistance for personal hygiene. R11's comprehensive Care Area assessment dated [DATE], identified R11 required extensive assistance with ADL's. During an observation on 12/4/23 at 1:46 p.m , R11 was lying in bed and had several 1/2 inch long gray facial hair on his cheeks and chin. During an observation on 12/5/23 at 8:50 a.m., R11 was lying in bed and continued to have several 1/2 inch long gray facial hair on his cheeks and chin. During an observation on 12/6/23 at 7:15 a.m., R11 was seated in his recliner in his room and continued to have several 1/2 inch facial hairs on his cheeks and chin. During an observation on 12/6/6/23 at 9:16 a.m., R11 was lying in bed and continued to have several 1/2 inch facial hairs on his cheeks and his chin. During an interview on 12/6/23 at 8:07 a.m. family member (FM)-A stated R11 always shaved every day. FM-A further stated R11 would not like having long facial hair. During an interview on 12/6/23 at 9:30 a.m., nursing assistant (NA)-A stated R11 required staff assistance to shave facial hair. NA-A stated she had not assisted R11 with shaving recently and was unsure of the last time R11 had been shaved. During an interview on 12/6/23 at 9:32 a.m., registered nurse (RN)-A stated R11 required staff assistance to shave facial hair. RN-A verified R11 had several long facial hairs and was unsure the last time R11 had been shaved. RN-A stated her expectation was R11 would have been shaved daily or when facial hair was present. During an interview on 12/6/23 at 9:40 a.m., director of nursing (DON) indicated R11 required staff assistance with shaving. DON stated her expectation was R11 would have been shaved per his preference and facility policy. Review of a facility policy titled SNF: Activities if Daily Living (ADL's) standards of care undated, indicated residents with facial hair would be shaved daily or when hair was visible.

Based on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self administer medications (SAM) for 1 of 1 residents (R23) reviewed for medication administration. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact. Identified R23 had diagnoses which included diabetes mellitus (DM) and renal failure (a condition where the kidneys loose the ability to remove waste). R23's face sheet indicated R23 had diagnoses which included disorder of the brain. Review of R23's electronic health record (EHR) revealed a SAM assessment had not been completed. R23's Physician Order Report dated from 10/24/23 to 12/6/23, directed staff to administer Toprol XL 100 milligrams(mg) one time daily (medication used for high blood pressure), Actos 15 mg one time daily (medication used to treat diabetes), bumetanide 2 mg one time daily (medication used to remove fluid from the body), Certavites 50 one time daily (multi-vitamin), potassium chloride 10 milliequivalents (mEq) two times daily (supplement), stool softener two times daily, Lisinopril 40 mg one time daily (medication used for high blood pressure), and vitamin E 268 mg one time daily (supplement). R23's Medication Administration Record (MAR) dated 11/1/23 to 12/6/23 indicated R23 was taking Toprol XL 100 mg one time daily, Actos 15 mg one time daily, bumetanide 2 mg one time daily, Certavites 50 one time daily, potassium chloride 10 mEq two times daily, stool softener two times daily, Lisinopril 40 mg one time daily, and vitamin E 268 mg one time daily. R23's care plan dated 10/24/23, indicated R23 would have medications administered as prescribed. During an observation on 12/06/23 8:19 a.m., R23 was seated in the dining room at the table with three other residents for breakfast. Registered nurse (RN)-A removed R23's medications from the medication cart and began to dispense R23's medications. RN-A dispensed the medications listed above into the medication cup, closed the computer, walked to the dining room and set the cup of medications down on the table next to R23. RN-A spoke to R23 about the medications and indicated she would bring R23 the remaining medications to R23's room. RN-A walked away from the table, returned to the medication cart and left the medication cup on the table next to R23. RN-A opened the computer and documented R23 took the medications. After RN-A walked away R23 took the medications listed above independently while sitting at the table. During an interview on 12/6/23 at 8:24 a.m., licensed practical nurse (LPN)-A verified R23 was not able to self-administer medications. LPN-A indicated there were no residents within the facility who were able to self-administer medications. During an interview on 12/6/23 at 9:22 a.m., RN-A confirmed R23's medications had been set down on the table for R23 to take. RN-A indicated she did not watch R23 take the medications and did not follow-up to ensure R23 had taken the medications. RN-A confirmed R23 did not have orders for self-administration and RN-A should have stood next to R23 to ensure all medications were taken. During an interview on 12/6/23 at 12:36 p.m., director of nursing (DON) confirmed the above findings and indicated R23 did not have the cognitive ability to self-administer medications. DON stated her expectations were staff remained next to the residents during medication administration and ensure residents had taken all medications as ordered. Facility policy titled Medications: Self-Administration of revised on 10/23/23, the interdisciplinary team (IDT) would determine that it was safe for the resident to self-administer medications. A Physician's order would be obtained. Observations would be completed to assist with determining if the resident was able to safely self-administer medications. Facility policy titled Medication Administration revised on 7/23, licensed and certified personnel were to remain with the resident and ensure that all medications have been taken/swallowed.

Based on interview and document review, the facility failed to ensure an alleged violation of neglect of care were reported timely to the State Agency (SA) for 1 of 1 residents (R1) who had eloped. Findings include A Facility Reported Incident (FRI) submitted to the State Agency on 8/22/22, at 1:30 p.m., alleged caregiver neglect for an incident that had occured on 8/20/22 at approximately 7:20 p.m. The report indicated R1 exited the facility without staff awareness. A neighbor passing by the facility at 7:20 p.m., noted R1 was stuck in a rut in the parking lot and could not get the wheelchair moving. The neighbor brought R1 back to the facility staff. During an interview on 8/25/22, at 1:35 p.m. Licensed Practical Nurse (LPN)-A stated she worked the evening shift on 8/20/22. LPN-A stated at approximately 7:20 p.m. she received a phone call from a neighbor that he was bringing R1 back to the facility after assisting her out of a rut in the parking lot. LPN-A indicated she was unaware of R1 exiting the facility. LPN-A indicated she attempted to report within the two-hour time frame but had difficulties with the Minnesota Department of Health (MDH) online reporting system. LPN-A stated she thought it was strange that she didn't get a submission confirmation email and was notified on 8/22/22 by the Social Service Director that the report had not been submitted to MDH. The Abuse, Neglect, and Vulnerable Adult Policy last revised 5/2021, indicated the facility was to investigate and report any allegations of abuse immediately, but not later than two (2) hours. Further indicated if unable to report on MDH site, alternative contacts information for reporting included an email address and instructions to email a brief description of the incident, outcome, any injuries that occurred, and to also send the email to the administrator, DON, and SSD.

Based on observation, interview and document review, the facility failed to ensure staff were using proper personal protective equipment (PPE) according to the Center for Disease Control (CDC) guidelines during the COVID-19 pandemic while providing care to 3 of 3 residents (R5, R8, R16). Finding include: The CDC COVID Data Tracker indicated Big Stone County community transmission rate was listed as high on 7/7/22. Review of the CDC guidance dated 2/2/22, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic indicated staff working in health care facilities should utilize source control which included a well-fitting facemask. The guidance identified HCP working in counties with substantial or high transmission should also wear eye protection such as goggles or a face shield covering the front and sides of the face, during all resident encounters. On 7/7/22, at 7:19 a.m. registered nurse (RN)-A was observed at the medication cart in the hallway wearing a surgical mask, standard eye glasses and no eye protection over the glasses while she prepared medications. RN-A entered R5's room, stood within a few inches of R5, administered eye drops, insulin and oral medications. RN-A proceeded to face R5, leaned over, donned a gait belt around R5's waist and transferred R5 into a recliner in her room. On 7/7/22, at 7:50 a.m. RN-A entered R16's room wearing a surgical mask, standard eye glasses and no eye protection over the glasses. RN-A stood approximately a few inches away from R16 and administered his insulin. On 7/7/22, at 7:57 a.m. RN-A walked into the activity room continuing to wear a surgical mask, standard eye glasses with no eye protection over the glasses. RN-A walked to where R8 was seated, stood a few inches from R8 and administered his insulin. On 07/7/22, at 8:09 a.m. nursing assistant (NA)-A was observed in the hallway wearing a surgical mask, standard eye glasses with no eye protection over the glasses. NA-A had a hold of R5's gait belt which was around R5's waist and assisted R5 to walk into the dining room and assisted R5 to sit down in a chair. NA-A was noted to be within six inches of R5 while assisting her to walk. On 7/7/22, at 8:14 RN-A entered the dining room wearing a surgical mask, standard eye glasses with no eye protection over the glasses, stood a few inches away from R8 and administered his medications. During an interview on 7/7/22, at 8:16 a.m. RN-A confirmed she had not been wearing eye protection and believed she was not required to wear them. RN-A indicated she had been unaware of the community transmission rate. During an interview on 7/7/22, at 11:17 a.m. infection preventionist (IP) confirmed the community transmission rate was high and staff were expected to wear a surgical mask and eye protection in all resident areas. During an interview on 7/7/22, at 11:45 a.m. director of nursing ( DON) confirmed the community transmission rate was high and stated staff were expected to wear surgical masks and eye protection in all resident areas. During an observation on 7/7/22, at 8:11 a.m. R16 was seated in a recliner in his room when nursing assistant (NA)-A entered R16's room, faced R16, leaned over him and donned a gait belt around his waist. NA-A, who wore a surgical mask, standard eye glasses, and no eye protection over her eye glasses assisted R16 into a standing position while holding onto the gait belt. NA-A, who was approximately 18 inches from R16, stood next to R16 while assisting him to walk to the dining room. NA-A assisted R16 to a table in the dining room and transferred him into a chair. During an interview on 7/7/22, at 8:17 a.m. NA- A indicated she was required to wear a surgical mask for source control for COVID-19. She indicated within the last few days, it was her understanding, she did not have to wear eye protection over her standard eye glasses. NA-A indicated she was unsure of where or who the direction came from. A facility policy updated 2/2/22, indicated it was the policy of the facility to minimize exposures to respiratory pathogens and promptly identify residents with clinical features and an epidemiological risk from COVID-19 and to adhere to federal and State/Local recommendations (which included, for example:Admissions,Visitation, Precautions, Standard, Contact, Droplet and/or Airborne precautions, included the use of eye protection, testing, and vaccination. EH facilities would have followed the CMS recommended core principles of infection prevention. The policy included COVID-19 PPE and source control grid dated 4/7/22, which had indicated during high community transmission rates a face mask and eye protection which included goggles or a face shield which covered the front and sides of the face should have been worn during all resident encounters.

Based on interview and document review, the facility failed to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 2 residents (R1) reviewed for urinary tract infection ([CONDITION(S)]) as part of their antibiotic stewardship program. Findings include: The Center's for Disease Control and Prevention (CDC)'s Core Elements Of Antibiotic Stewardship For Nursing Homes, dated 2015, included recommendations to identify clinical situations which may be driving inappropriate use of antibiotics such as [CONDITION(S)] prophylaxis and implement specific interventions to improve use. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 required limited assistance with dressing, supervision with personal hygiene and was independent with toileting. The MDS identified R1 had frequent urinary incontinence and had received antibiotics seven of the last seven days. R1's quarterly MDS dated [DATE], identified R1 had moderate cognitive impairment, required limited assistance with dressing, personal hygiene and toileting and had frequent urinary incontinence. The MDS indicated R1 had received antibiotics seven of the last seven days. R1's annual Care Area Assessment (CAA) dated 1/17/22, identified R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan revised 7/7/22, identified R1 was at risk for increasing alteration in elimination related to dementia, history of fluctuating levels of urinary incontinence and history of UTIs. The care plan identified R1 was started on a prophylactic antibiotic called [MEDICATION(S)]. R1's care plan indicated R1 was at risk for infection related to problems which included: chronic conditions, advanced age, type II diabetes and history of recurrent UTIs and dementia. R1's care plan identified on 11/22/21, R1's primary care physician (PCP)-A reviewed prophylactic antibiotic use and changed the administration time to be given in the morning due to stomach upset. The care plan indicated on 1/6/22, the provider reviewed antibiotic use and wanted to continue prophylactic antibiotic as previously ordered for recurrent UTIs. Review of R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] tablet 400-80 milligram (mg) 1 tablet oral (by mouth) once a day, Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .- Review of R1's medication administration records (MARs) reviewed from 10/1/21, to 7/7/22, identified the following: -10/1/21, to 10/31/21, R1 received [MEDICATION(S)] daily. -11/1/21, to 12/31/21, R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -1/01/22, to 1/31/22, R1 received [MEDICATION(S)] 1/6/22, to 1/31/22, daily. -2/1/22, to 2/28/22, R1 received [MEDICATION(S)] daily. -3/1/22, t 3/31/22, R1 received [MEDICATION(S)] daily. -4/1/22, to 4/30/22, R1 received [MEDICATION(S)] daily. -5/1/22, to 5/31/22, R1 received [MEDICATION(S)] daily. -6/1/22, to 6/30/22, R1 received [MEDICATION(S)] daily. -7/1/22, to 7/7/22, R1 received [MEDICATION(S)] daily 7/1/22, to 7/6/22. Review of R1's progress notes dated 10/1/21, to 7/7/22, identified the following: -10/3/21- R1's had 2 days [MEDICATION(S)] (antibiotic) remaining and R1's urine was dark yellow. A request was made to PCP-A for an on-going, prophylactic antibiotic for aid in preventing R1's UTIs. -10/4/21-IDPT (interdisciplinary team) reviewed R1 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 received a new order from PCP-A for [MEDICATION(S)] 400/80 mg 1 tablet orally everyday times 90 days and R1's family member was informed. -10/6/21-R1 had completed her course of antibiotics for [CONDITION(S)], and had no symptoms. R1 was prescribed a prophylactic antibiotic to see if it helped with recurrent UTIs and would be evaluated and reviewed with PCP-A for effectiveness in approximately 90 days. -11/22/21, R1 was seen by PCP-A. R1 had intermittent complaints of stomach aches which occurred more often in the afternoon or evening hours. PCP-A suggested to change administration time of [MEDICATION(S)] to morning and give with food. R1's [MEDICATION(S)] was changed to 8:00 a.m. and 10:30 a.m. R1's medical record lacked documentation that a risk verses benefit was completed with resident or family regarding R1's use of prophylactic antibiotic use. Review of R1's Pharmacist Drug Regimen Reviews from 10/22/21, to 7/5/22, identified the following: -10/25/21, R1 placed on antimicrobial prophylaxis related to recurrent urinary tract infection, will monitor. -12/10/21-no comments or recommendations related to R1's antimicrobial prophylaxis use of [MEDICATION(S)] -12/29/21, no comments or recommendations related to R1's antimicrobial prophylaxis use of [MEDICATION(S)] -1/29/22, the note identified R1 would continue antimicrobial prophylaxis at this time. -2/28/22, no comments or recommendations related to R1's antimicrobial prophylaxis use of [MEDICATION(S)] -3/31/22, no comments or recommendations related to R1's antimicrobial prophylaxis use of [MEDICATION(S)] -4/26/21, no comments or recommendations related to R1's antimicrobial prophylaxis use of [MEDICATION(S)] -6/2/22, no comments or recommendations related to R1's antimicrobial prophylaxis use of [MEDICATION(S)] -7/5/22, no comments or recommendations related to R1's antimicrobial prophylaxis use of [MEDICATION(S)] R1's pharmacist drug regimen reviews lacked documentation of review of continued prophylactic antibiotic use. Review of R1' physician visit notes from 10/18/21, to 6/21/22, revealed the following: -10/18/21, R1 seen by PCP-A. R1's medications, treatments and care plan reviewed, no new orders. -11/22/21, R1 seen by PCP-A. R1's note revealed significant changes and concerns included afternoon stomachache. R1's medications, treatments and care plan reviewed, adjust time of the [MEDICATION(S)]. -12/23/21, R1 seen by PCP-A. R1's medications, treatments and care plan reviewed, no new orders. -1/24/22, R1 seen by PCP-A. R1's medications, treatments and care plan reviewed, no new orders. -2/17/22, R1 seen by PCP-A. R1's medications, treatments and care plan reviewed, no new orders. -3/17/22, R1 seen by PCP-A. R1's medications, treatments and care plan reviewed, would try some mild antianxiety medication. -4/13/22, R1 seen by medical director (MD)-A. R1's medications, treatments and care plan reviewed, no new orders. -5/25/22, R1 seen by MD-A. R1's medications, treatments and care plan reviewed, no new orders. -6/21/22, R1 seen by MD-A. R1's medications, treatments and care plan reviewed, no new orders. The notes lacked documentation the risks and benefits of long term antibiotic use had been reviewed and discussed. During an interview on 7/6/22, at 12:57 p.m. registered nurse (RN)-A indicated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A indicated she believed R1 was still receiving prophylactic antibiotics. During a telephone interview on 7/6/22, at 1:26 p.m. pharmacy consultant (PC)-A stated she attended the facility Quality Assurance and Performance Improvement (QAPI) meetings and they reviewed the facility antibiotic stewardship program during those meetings. PC-A indicated prophylactic antibiotic use was appropriate if someone had repeated infections which were severe, they had [CONDITION(S)] (life-threatening response to an infection) or had a hospital stay. PC-A stated her usual practice was to ask the provider again if the antibiotic order was appropriate however confirmed she had not contacted the provider about R1's antibiotic order. PC-A stated she planned to ask about R1's prophylactic antibiotic use a year from the start date which would be October 2022. At 2:35 p.m. during a follow up telephone interview PC-A indicated R1 had repeated UTIs the previous year and [MEDICATION(S)] had been initially prescribed in October 2021. PC-A stated infection preventionist (IP)-A had been tracking antimicrobial (agent that kills microorganisms, including antibiotics) use monthly, and PC-A had recommended to the facility to track the use every six months in order to provide more data to the physician. PC-A stated IP-A had evaluated R1's [MEDICATION(S)] order in January 2022. PC-A confirmed she had not made recommendations to R1's primary care physician to discontinue prophylactic antibiotic use prior to today. PC-A confirmed she would not recommend a facility nurse to request prophylactic antimicrobial medication use for any resident. PC-A confirmed there was potential harm risks with use of antibiotics prophylactically, which included increased resistance to antibiotics, and if an actual infection occurred, current antimicrobial treatment would not fight the infection. During an interview on 7/7/22, at 10:03 a.m. MD-A stated he had recently assumed the role of R1's primary care provider and had seen R1 on rounds. MD-A indicated he believed R1 had been placed on [MEDICATION(S)] prophylactically for reoccurring UTIs however would have to check R1's record. MD-A confirmed it was not the facility's usual practice to order prophylactic antibiotics however believed the benefits may have outweighed the risks for R1. MD-A indicated he could not recall if R1's antibiotic use had been discussed at QAPI meetings. MD-A stated it was a rare incident for R1 to continue to be on [MEDICATION(S)]. MD-A indicated risks of prolonged use of antibiotics could affect kidney function, however if the resident had no UTIs and tolerated the antibiotic, he usually did not change the order. During an interview on 7/6/22, at 2:59 p.m. infection preventionist (IP)-A indicated the facility had an antibiotic stewardship program in place. IP-A stated she could not recall if she had discussed concerns related to R1's continued [MEDICATION(S)] prophylactic use with PCP-A. IP-A stated the usual facility practice was to review prophylactic antibiotic use every six months, because if reviewed monthly, they felt they would not have as much data to present to the physician. IP-A indicated PC-A's role was to consult and provide guidance to their antibiotic stewardship program. IP-A confirmed risks of prolonged prophylactic antibiotic use included antibiotic resistance and [CONDITION(S)] (an infectious bacterium that causes severe diarrhea and inflammation of the colon-C-Diff). During a follow-up interview on 7/7/22, at 10:42 a.m. IP-A indicated she had been informed by PC-A at QAPI meetings the CDC recommended antibiotic prophylactic use should be reviewed every six months. IP-A stated she had not reviewed the actual CDC recommendation to confirm the accuracy of the every six month review. IP-A confirmed she had never discussed risks verses benefits of prolonged antibiotic use with R1 or R1's family. Review of QAPI Meeting minutes dated 4/15/21, identified a discussion related to infection prevention and antibiotic stewardship was to address prophylactic medications every six months verses (vs) one month vs CDC recommendations. To obtain more information (info)/data in relations to the prophylactic. Review of QAPI Meeting minutes dated 7/16/21, identified one resident was on a prophylactic antibiotic for [CONDITION(S)] prevention the past quarter. The minutes indicated the resident had still been currently taking and recommended the provider address prophylactic medications every six months vs one month. During an interview on 7/7/22, at 11:52 a.m. director of nursing (DON) confirmed R1 received prophylactic antibiotics and the usual facility practice was to review prophylactic antibiotic use every six months. The DON indicated she was not aware how often the review was expected in the facility policy. DON stated it was best practice not to use prophylactic antibiotics, due to the risk for a super bug infection and the possibility the resident could develop an infection that became resistant to treatment. The facility policy titled Policy For Antibiotic Stewardship Program reviewed 9/2021, identified widespread use of antibiotics had resulted in an alarming increase in antibiotic-resistant infections and increased risk of [CONDITION(S)] infection and adverse drug reactions. The policy identified the facility would review infections and monitor antibiotic usage patterns on a quarterly basis. The policy further identified that the antibiotic stewardship team (AST) would identify actions to directly impact inappropriate antibiotic use for specific syndromes and prophylactic indications. The policy identified education would be provided for clinical staff, as well as residents and their families on appropriate use of antibiotics.

Based on observation, interview, and document review, the facility failed to ensure the correct diet was served to 3 of 3 residents (R1, R2, R3) reviewed for diet. This resulted in an immediate jeopardy for R1, who was served bite sized fruit larger than ½ inch in size per physician orders which caused R1 to choke and had to be walked to the Emergency Department where R1 self-expelled a piece of fruit 2.7 by 2.0 cm in size. Additionally, R2 and R3 were served food against physician orders. The immediate jeopardy began on 9/9/21, when R1 was served bite sized fruit larger than ½ inch in size per physician orders, which resulted in R1 choking. R1 ate the fruit, and had a choking episode, however, did not require the [MEDICATION(S)] maneuver, due to being able to talk at the time of the incident. The administrator, director of nursing and certified dietary manager were notified of the immediate jeopardy at 3:16 p.m. on 9/17/21. The immediate jeopardy was removed on 9/23/21, at 1:45 p.m. but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included diabetes, dementia and had severe cognitive impairment. Further review of MDS, R1 required extensive assistance of one staff member for most activities of daily living (ADLS) and required supervision after set up for eating. R1's care plan printed 9/17/21, identified R1 was a safety risk due to history of choking and required reminders to alternate bites and fluids while eating. R1's nutrition interventions included supervision by staff for cueing and all foods cut into ½ inch in size bites or smaller. R1's diet order per order summary as of 1/18/21, indicated mechanical soft and cut all food into ½ inch in size bites with staff to encourage alternating food and fluid and to eat slowly. R1's dietary card as of 9/9/21, indicated regular, soft and bite sized foods cut in ½ inch size bites. Review of R1's progress notes: -On 9/9/21, Resident choked on cut up cantaloupe at dinner. States feels like something stuck in throat. Noting poor air exchange. Will send to ER and notify family. - On 9/9/21, Resident returned from hospital and was able to clear obstruction per self. - On 9/10/21, Review of choking episode on 9-9-21. SLP [speech language pathologist] screen requested for swallowing and for appropriate diet textures. - On 9/16/21, Resident seen by speech today new orders recommended for diet change. Will recommend diet of minced and moist and to continue with thin liquids. Review facility report dated 9/9/21, R1 was eating cut up cantaloupe and started to choke. R1 was able to cough up phlegm and some cantaloupe but continued to state some was still stuck in R1's throat. R1 was walked to the emergency room (ER) by facility staff. Review of Emergency Department Provider Notes dated 9/9/21, indicated R1 was brought to the ER due to concern for food obstruction. R1 did present to the ER sounding hoarse and attempting to clear throat. R1 received an X-ray which showed there was a 2.7 cm by 2.0 cm cube-shaped density projecting in the hypopharynx. R1 was able to expel a piece of cantaloupe while in the ER at 2:45 p.m. which a repeat X-ray was completed and showed resolution of foreign body. On 9/16/21, at 1:33 p.m. nursing assistant (NA)-A indicated dietary cook (DC)-A and dietary director (DD) worked in the kitchen during the noon meal on 9/9/21. NA-A indicated she was at the dining room table with R1 on 9/9/21, when R1 began to choke on a piece of cantaloupe. NA-A stated, I could tell something was lodged in her throat by the way she was talking and NA-A called for licensed practical nurse (LPN)-A to respond. NA-A indicated R1 continued to wheeze and was brought over to the ER. In addition, NA-A indicated she was across the table from R1 and I just figured they [dietary] are the ones serving. They served it [cantaloupe] and dished it so it should be right. I would hope that the kitchen would get it right. On 9/16/21, at 1:56 p.m. LPN-A indicated R1 required supervision because she wants to shovel everything in and NA-A was assisting with cues for R1 on 9/9/21, the day of the choking incident. LPN-A indicated R1 had a bowl of cantaloupe cut up she was eating. She can have cantaloupe if it is cut small enough. I don't think it was cut small enough because she got one stuck. LPN-A indicated she was called down to the dining room by NA-A, and LPN-A then noted R1 was coughing and couldn't breathe but was still talking so the [MEDICATION(S)] maneuver was not performed. R1 went back to her room and continued to try to cough it up but was unsuccessful, so R1 was brought to the ER since we couldn't do anything to get it out. On 9/16/21, at 4:02 p.m. NA-B stated R1 required supervision with cues to slow down while eating and her diet order is soft and ½ inch bite sized foods. Further, NA-B indicated the dietary cook will cut up the resident's food if there is a physician's order (i.e. ½ inch bite). NA-B indicated R1 had a choking episode when R1 consumed cantaloupe which it was not soft that day at all and I would say bigger than ½ inch bites. They looked like regular sized bites given to everyone not specifically cut up for her [R1]. On 9/16/21, at 5:01 p.m. when asked about the process for serving and dishing of meal trays, dietary aid (DA)-A indicated the dietary cook (DC) will plate the foods and the dietary aid will deliver the food to the residents in the dining room. Further, DA-A indicated the DC will reference the diet card that is on the tray with the specific resident's diet order while plating the food to ensure appropriate food is dished and then the DA will take the card with the tray and plate of food to the identified resident and check to make sure everything matches up. In addition, DA-A indicated she had heard R1 had a choking incident but was unsure of any other details and confirmed there has been no education since the incident. On 9/16/21, at 5:14 p.m. when asked what the facility's process was for serving meals, DC-A indicated the DC will dish the plate and the aids will pass the plate to the resident. We have cards that tell you what diet for each resident and what mechanically altered foods they need. The cook cuts up the food if they are soft and bite sized prior to going out to the resident. However, DC-A stated, a bite size is about one half inch piece and we just cut it with a knife into small bite sized pieces. It is just eyeball or guess, I guess. They don't have a tool or measuring device to cut things. DC-A confirmed she cut up R1's cantaloupe that day into smaller pieces and DD passed out the cups of fruit and did not ask DC-A which cup was R1's. In addition, DC-A indicated she was not aware that R1 had choked and there has not been any education provided since the beginning of summer. On 9/17/21, at 9:00 a.m. social service designee (SSD) indicated she completed the internal investigation for the report that was made regarding R1's choking incident. SSD indicated she interviewed LPN-A and NA-A on the incident and followed up with the ER as well. SSD indicated monitoring was initiated for R1 upon her return from the ER, to ensure no aspiration was noted after the choking incident. Further, SSD indicated at the time of the incident, R1's care plan was followed for her diet order. SSD confirmed she read the ER provider note dated 9/9/21, and when asked if the 2.7 cm by 2.0 cm piece of cantaloupe that was expelled from R1 at the ER was a ½ inch bite, SSD stated oh yes, it is smaller. However, surveyor and SSD converted the cm into inches, SSD then stated, with that being said, the care plan was not followed. I guess I didn't do the math conversion. In addition, SSD stated there was no education provided to staff and just focused on in report carrying over the importance of diet texture and being aware of what resident's current diets are. On 9/17/21, at 9:16 a.m. when asked what facility's process for serving meals was DD indicated the DC will set up the tray by dishing the food onto the plates and the DC was responsible for mechanically altered textured foods. The food should be cut by the cook for one half inch pieces. We [dietary] don't have a tape measure or ruler it would just be smaller pieces than the rest approximately one half inch in size. Further, DD indicated R1 was prescribed a soft and bite sized diet related to a history of choking. DD indicated NA-A informed him of R1's choking incident on 9/9/21, and it was reported she had multiple pieces in her mouth. R1 was brought to the ER because she felt like there was still another piece she couldn't get up. DD indicated at the time of the incident, R1's care plan was being followed and indicated the food she consumed was bite sized pieces. DD confirmed he had not reviewed the ER provider note from 9/9/21. When surveyor converted 2.7 cm by 2.0 cm was into inches with DD, DD stated it seems that piece would have been slightly larger than what it should have been. In addition, DD indicated since R1's choking incident there was no education provided to dietary staff other than communication sheet that they should be following appropriateness for texture and preferences however, DD confirmed the communication sheet was not specific to R1 or R2's incidents of receiving the wrong diet order. At approximately 10:34 a.m. DD indicated staff were expected to follow the resident's diet cards. On 9/17/21, at 10:39 a.m. director of nursing (DON) indicated SSD completed the investigation after it was reported R1 choked on a piece of cantaloupe. DON indicated the root cause of the incident was related to R1 not chewing the cantaloupe causing her to choke. Further, DON indicated at the time of the incident R1's care plan was being followed. When asked if she reviewed the ER provider note dated 9/9/21, DON stated I never seen the full details of the note until today. I reviewed it all today and I know what you are referring to about the size of the piece that was observed and it was 2.7 cm by 2.0 cm which is larger than a half inch. In addition, DON then confirmed R1's care plan was not being followed at the time of the incident. DON indicated staff are expected to ensure ½ inch pieces are ½ inch pieces and the importance of following resident's diet for the resident's safety. R2's quarterly MDS dated [DATE], indicated R2's diagnoses included stroke and moderately impaired cognitive skills. Further review of MDS, R2 required extensive assist of one staff member for most ADLs which included toileting, hygiene, dressing and required supervision while eating. R2's care plan printed 9/17/21, indicated R2 was independent with eating after set up. Further review of care plan, indicated R2's diet order as of 8/31/21, was regular soft and bite sized foods. R2's diet card in the morning of 9/17/21, identified regular soft and bite sized food. Review of R2's progress notes: -On 8/31/21, during a dietary observation R2 consumed chicken breast cut into bite size pieces and did well. Resident ate 100% of chicken breast 8/26 and 8/27 and bacon for breakfast 8/26. Discusses plan of care with dietary staff for use of plates and offering bacon daily. -On 9/9/21, resident has shown interest in consuming bacon daily at breakfast. -On 9/17/21, at 9:14 a.m. provider updated on resident's increased interest in chicken breast and bacon. SLP orders obtained to eval [evaluate], treat and follow their recommendations for appropriate diet modifications. -On 9/17/21, at 9:17 a.m. left message for hospice to call back for update on SLP new orders. -On 9/17/21, at 9:25 a.m. therapy notified of SLP eval [evaluation] orders. -On 9/17/21, at 9:30 a.m. hospice returned call and okay with SLP orders for diet modifications. On 9/17/21, at 8:40 a.m. R2 was observed sitting in her wheelchair in the doorway of her room with her bedside table in front of her and her breakfast tray on top. R2's tray contained one plate with a pastry cut into small pieces, and a second plate that contained strips of bacon that appeared to be cut in half and crispy. However, R2 was not observed consuming any of the food on her tray at that time. On 9/17/21, at 8:45 a.m. when asked what R2's diet order was, NA-C looked at R2's diet card on breakfast tray and stated, it is regular soft and bite sized. Further, when asked about the crispy bacon on R2's plate, NA-C began to cut up the bacon into bite sized pieces and confirmed bacon was not cut into bite sized pieces and was not soft per physician's orders. In addition, NA-C left the plate of bacon in front of R2 and walked away to assist another resident with their meal. On 9/17/21, at 8:53 a.m. when asked about R2's diet order, DON confirmed R2 requires regular soft and bite sized pieces. Further, DON stated they [dietary] have been doing a trial with her. I believe they have consulted with hospice on the trial. DON indicated dietary staff were aware of the trial but was unsure if the physician was aware or if there was an order to upgrade R2's diet. However, the plate continued to remain on R2's tray table but R2 was not observed eating the crispy bacon. On 9/17/21, at 9:16 a.m. DD indicated R2's diet order was soft and bite sized textured foods. Further, DD stated I have trialed food items with her per her request. At approximately 1:25 p.m. DD stated crispy bacon is not part of her diet. Further, DD indicated the process for upgrading a resident's diet was for the resident to be screened by a speech language pathologist (SLP) prior to giving the resident any food out of their diet order. DD confirmed that prior observation of R2 receiving the wrong diet order for breakfast on 9/17/21, there had been no communication with R2's hospice staff, physician, or SLP. In addition, DD stated he expected staff to complete a screen form for SLP to evaluate the resident prior to providing the resident with the food due to risk of swallowing and chewing difficulties. On 9/17/21, at 12:59 p.m. DON indicated during the incident observed on 9/17/21, R2's diet order was regular soft and bite sized solids and confirmed the bacon that was served today was not following her diet. Further, DON indicated staff were expected to follow the facility policy which is to complete a request for a therapy screen and follow the recommendations prior to giving them against their [resident's] diet orders On 9/17/21, at 1:09 p.m. SLP indicated she was notified on 9/17/21, by facility staff, who requested a speech evaluation for R2, due to R2 requesting bacon which was not part of her soft and bite sized diet. R3's quarterly MDS dated [DATE], indicated R3 had diagnoses which included diabetes, dementia and moderate cognitive impairment. Further review of MDS, indicated R3 was independent with ADLS and eating after setting up only. R3's care plan printed 9/17/21, indicated R3 receives a therapeutic diet due to diagnoses of chronic heart failure and diabetes with interventions that included canned fruit ok, independent with eating in main dining room and minced and moist textured food. Review of R3's dietary card printed on 9/17/21, indicated R3's diet order was minced and moist textures and disliked cantaloupe. On 9/16/21, at 1:33 a.m. NA-A indicated on 9/9/21, which was the same day R1 had a choking episode, when she was picking up room trays after the noon meal, she observed R3 was served a cup of cut up cantaloupe and noted on R3's diet card it indicated R3 was minced and moist textured foods. NA-B indicated the cantaloupe appeared to not be consumed by R3 due to R3 disliking cantaloupe NA-B notified DD immediately after discovering R3 was served the wrong texture diet. NA-B stated to DD this is the exact reason [R1] is in the ER. On 9/16/21, at 4:02 p.m. NA-B indicated R2 was served cantaloupe that was not minced and moist on 9/9/21. NA-B indicated she reported it to the DD with NA-A immediately. On 9/17/21, at 9:16 a.m. DD indicated he was aware R3 received cut up cantaloupe on 9/9/21. Further, DD stated R3's diet was ordered as minced and moist and was approved to have toast and canned fruit. DD indicated he was unsure who gave R3 the cup of cut up cantaloupe on 9/9/21, but indicated he addressed it to the staff that the care plan was not followed and R3 should have received a cup of canned fruit instead. Review of facility policy titled Notification and Documentation of Nutritional Cares dated 6/19, indicated Nursing and Dietary Staff will monitor for nutritional changes. Recommended changes to diet plan will be assessed by completing a Screen to Therapies. Documentation of changes will be made in Progress notes and/or screenings and these changes will be addressed in residents care plan. The immediate jeopardy that began on 9/17/21, at 3:16 p.m. was removed on 9/23/21, at 1:45 p.m. when it was verified by observation, interview and document review the facility reviewed and implemented new dietary policies on accuracy of diet ordered and production and the facility trained dietary aids and nursing staff on the need to ensure dietary tickets were checked prior to a resident being served food. Implementations included: -Staff education was provided to dietary staff and nursing staff via video on diet orders and mechanically altered diet types. Staff were to complete a competency quiz as well. -Policy titled Accuracy of Diet Ordered and Production was reviewed. -Process developed for dishing and serving meals. -Audits were completed on compliance of current diet order. -Residents who received a mechanically altered diet were reviewed and dietary cards were reviewed to ensure accuracy with physician's orders. -Residents who received a mechanically altered diet were evaluated by a speech language pathologist and modifications were made to diets as needed.

Based on observation, interview, and document review the facility failed to ensure hand hygiene was completed during medication administration for 4 of 9 residents (R1, R5, R16, R19) observed during medication administration. During an observation on 5/24/21, registered nurse (RN)-D prepared medications, locked the medication cart, and walked down the hallway. RN-B assisted another resident in the room next to R19 with a transfer to bed using a walker, exited the room, and did not sanitize her hands. RN-D then entered R19's room, handed her a mug while she held onto the handle and administered medications. RN-D placed the call light closer to R19 and as she left the room sanitized her hands. During observations of medication administration on 5/26/21, by licensed practical nurse (LPN)-A identified: -At 7:30 a.m. LPN-A approached medication cart, unlocked the cart, and removed a [MEDICATION(S)] patch from the locked box. LPN-A entered R16's room removed the old patch from R16's left side of her upper back, folded the [MEDICATION(S)] around it, and held it in her hand. LPN-A applied a new patch to R16's upper middle back. LPN-A exited R16's room, walked down the hallway to a locked room and disposed of the [MEDICATION(S)] patch. LPN-A walked back to the medication cart, unlocked it, grabbed the oximeter, locked the cart, and did not sanitize her hands prior to preparation of medications and entering R16 's room, and after exiting R16's room and application and disposal of a [MEDICATION(S)] patch. -At 7:40 a.m. LPN-A entered R5's room, held her hand while she applied the oximeter. LPN-A removed the oximeter, exited R 5's room, unlocked the medication cart, and placed it back in the cart. LPN-A prepared R5's medications, opened a capsule with her bare hands and poured the contents into a pill cup. LPN-A did not sanitize her hands after exiting R5's room and prior to preparation of medications. -At 9:30 a.m. LPN-A entered R1's room (a shared room with R2), washed her hands, took R1's vitals, placed [MEDICATION(S)] medication in nebulizer cup, attached mask to tubing, placed the strap around R1' s head with mask over her nose and mouth, and turned machine on. LPN-A exited the room without sanitizing her hands, walked down the hallway, and opened the medication cart. LPN-A removed R2's hearing aids from medication cart, locked the cart, and re-entered R2's room. LPN-A placed R2's hearing aid into her left ear and exited the room without sanitizing her hands. LPN-A unlocked the medication cart, replaced the battery in the other hearing aid then locked the cart. LPN-A re-entered the residents' room, touched R1's mask with her hand to see if medication had been administered then went over to R2 and placed the right hearing aid into her ear. Without sanitizing her hands, LPN-A went back over to R1 and removed the mask from her face with both hands. LPN-A offered R1 a drink of water and then listened to her lung sounds with the stethoscope. LPN-A removed the mask from the tubing and ran water over it in the bathroom, dried her hands without sanitizing them, then pushed the vitals machine down the hallway to the nurse's station. During an interview on 5/26/21, at 8:40 a.m. RN-A confirmed staff are expected to sanitize their hands in between residents during medication administration for infection control. During an interview on 5/26/21, at 12:22 p.m. LPN-A stated it was important to sanitize hands in between any residents to help prevent infection and to help avoid cross contamination. LPN-A also stated she may have sanitized her hands but did not remember if she did during medication administration. During an interview on 5/26/21, at 2:05 p.m. director of nursing (DON) stated staff are expected to complete hand hygiene in between each resident for infection control. Facility policy last revised 4/2021, titled Handwashing/Hand Hygiene identified this facility considered hand hygiene the primary means to prevent the spread of infections. All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, patients, and visitors. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents/patients. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION(S)] or [MEDICATION(S)] maybe used for all the following situations: before preparing or handling medications, and after contact with objects (e.g., medical equipment) in the immediate vicinity of resident/patient. Facility policy undated, titled Medication Administration identified handwashing or sanitizing must be completed before each resident med pass.

Based on observation, interview and document review, the facility failed to ensure resident records that contained private, medical, and personal information were not accessible to unauthorized personnel for 6 of 9 residents (R1, R5, R14, R15, R16, R18). This had the potential to affect all 23 residents whose records were stored electronically and unsecured by staff. Findings include: Observation on 5/26/21, at 7:30 a.m. during a medication pass, identified licensed practical nurse (LPN)-A left the computer screen located on top of the medication cart open and did not lock the screen when she entered R16's room to administer medications and then down a hallway to dispose of a [MEDICATION(S)] patch. LPN-A returned to the computer after nine minutes. Private confidential resident information would have been able to be viewed by all passers-by in the hallway. Observation on 5/26/21, at 7:40 a.m. during a medication pass, identified LPN-A left the computer screen located on the medication cart open and did not lock the screen when she entered R5's room to obtain a heart rate and returned back to the medication cart after two minutes. Staff members walked by the open computer screen. LPN-A prepared R5's medications, left the computer screen open and did not lock the screen when she entered R5's room again to administer the medications. LPN-A returned to the computer after nine minutes. A staff member walked by the medication cart at that time. Private confidential information would have been able to be viewed by passers-by in the hallway. Observation on 5/26/21, at 7:50 a.m. during a medication pass, identified licensed practical nurse (LPN)-A left the computer screen located on the medication cart open and did not lock the screen when she entered R18's room to administer medications. LPN-A returned to the computer after 5 minutes. Private confidential information would have been able to be viewed by passers-by in the hallway. Observation on 5/26/21, at 8:00 a.m. during a medication pass, licensed practical nurse (LPN)-A left the computer screen open located on top of the medication cart and did not lock the screen when she entered R14's room to administer medications. LPN-A returned to the computer after 5 minutes. Private confidential information would have been able to be viewed by passers-by in the hallway. LPN-A completed her documentation, walked away from medication cart, left the computer screen open, and did not lock the screen. Observation on 5/26/21, at 8:15 a.m. during a medication pass LPN-A left the computer screen open located on top of the medication cart and did not lock the screen when she walked away to administer medications in the dining room to R15. Private confidential information would have been able to be viewed by passers-by in the hallway Observation on 5/26/21, at 9:30 a.m. during a medication pass LPN-A arrived at the medication cart and the computer screen remained open and had not been locked. LPN-A left the computer screen located on top of the medication cart open and did not lock the screen when she walked down the hallway and entered R1's room to administer medications. LPN-A returned to the medication cart two times and the computer screen remained opened and unlocked. LPN-A returned to the computer after 15 minutes. Private confidential information would have been able to be viewed by passers-by in the hallway. LPN-A completed her documentation and prior to waking away left the computer screen open and did not lock the screen. During an interview on 5/26/21, at 8:40 a.m. RN-A stated it would be standard practice after using the computer and prior to walking away to either log off or close the computer screen. RN-A also indicated anyone that walked by could see the resident's personal information and this would be a HIPAA (Health Insurance Portability and Accountability Act) violation. During an interview on 5/26/21, at 12:22 p.m. LPN-A stated staff are expected to shut the computer screen or log out to protect the resident's personal information and so it can not be seen by others. LPN-A also indicated when staff are not standing in front of the screen they should protect the information on it in case someone happens to walk by and see it. During an interview on 5/26/21, at 2:05 p.m. director of nursing (DON) verified the computer screen should be closed, minimized or covered prior to walking away from the cart to administer medications. DON stated privacy is then provided for the resident. Review of a Facility policy undated, titled Medication Administration identified during medication administration all personal protected health information must be hidden on medication cart when not in immediate attendance. On 5/26/21, at 2:10 p.m. a request for a facility HIPAA policy/procedure and it was not provided.

Based on interview and document review, the facility failed to ensure incidents of potential abuse were immediately reported to the Administrator and failed to immediately report to the State Agency (SA), no later than 2 hours after knowledge of the allegation of abuse, for 1 of 3 residents (R123) reviewed for allegations of abuse. Findings include: R123's significant change Minimum Data Set (MDS) dated [DATE], identified R123 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R123's MDS identified R123 was independent with most activities of daily living (ADL) and needed assist to transfer for bathing. R123's MDS identified no behaviors. R123's care plan revised 10/29/19, identified R123 was independent with all ADL's except required help with transfer only for bathing. R123's care plan further identified R123 had potential for physical and verbal abuse by others and infliction of abuse on other vulnerable adults. R123's care plan interventions included to move R123 away from others that would harm her and to document all incidents of potential or actual abuse at the time of occurrence. R123's SA report submitted from the facility on 12/17/21, at 2:35 p.m. identified on 12/15/21, at 5:00 a.m. R123 was crying and stated to the night shift nurse that her husband was very rude and hurtful verbally to her. -The report was submitted 57.5 hours after R123 reported the allegation of abuse to the night nurse. Review of R123's progress notes from 12/15/21, to 12/16/21, identified the following: -12/15/19, at 5:00 a.m. R123 was crying tonight, stated she just could not take it anymore and indicated she was done with her spouse being very rude and hurtful tonight. Staff attempted intervention, but spouse began yelling at staff and refused staff to get near him. -12/15/19, 2:20 p.m. R123's spouse was awake and verbally abusive to staff for much of the night. R123 was crying during the night and again that morning and stated she just could not put up with him anymore, he knew he was being awful and did it on purpose. -12/16/19, at 8:03 a.m. R123 asked to have breakfast in her room, and stated she did not want to sit next to her spouse. -12/16/19, at 12:40 p.m. staff discussed current room and dining room seating with R123. R123 indicated she would stay where she was at. R123 stated she was from old school, you marry for better or worse and she had put up with it for [AGE] years and did not need help from anyone. R123 indicated she would take care of her spouse in her own time, in her own way. -12/16/18, at 1:04 p.m. altercation with her spouse, R123 was struck with a closed fist once in the forehead, arm and chest. Two staff present immediately intervened, and R123 was removed from her room. R123 was on the phone with family at the time of the altercation. -12/16/21, at 1:30 p.m. R123 was interviewed with director of nursing (DON) and social services (SS) present. R123 was very upset and angry with her spouse, crying and calling him names and hitting her hand on the table top in anger and frustration. R123 was told she would be immediately moved to a different room and table away from her spouse. R123's family was here also and talked with staff, and R123 wanted to go home with family. -12/16/21, at 2:15 p.m. R123 went home with family on therapeutic leave, R123 packed her belongings while spouse was out of the room. -1/02/2020 11:09 a.m. R123's family called to let facility know R123 would not be returning to facility and would be living with family. On 5/26/21, at 12:14 a.m. licensed practical nurse (LPN)-A indicated R123 could not remain in the same room at the facility with her spouse due to he put his hands on her, and R123 had went home with family. LPN-A stated that R123 and her spouse had had verbal altercations prior and it was escalating, so R123 left the facility with her family. On 5/27/21, at 8:54 a.m. LPN-B indicated she remembered the night of the incident, R123 was crying and had reached her limit of her spouse being rude, but had not witnessed anything. LPN-B stated she had documented the incident in R123's progress notes and passed the information on in report. LPN-B indicated she did not remember notifying the administrator of the incident or filling a vulnerable adult (VA) report, but indicated if she had it would have been documented in R123's progress notes. LPN-B stated she remembered they had discussed the incident and R123 had left the facility to live with her family after that. On 5/27/21, at 10:41 a.m. director of nursing (DON) confirmed the allegation of abuse was submitted late and she would have expected the incident would have been reported to the administrator and SA immediately after it was reported to staff. DON indicated their process to report incidents at the facility were to text or call the administrator or herself, who would then notify the administrator. On 5/27/21, at 10:58 a.m. Administrator indicated it was her expectation for staff to notify her if they were submitting a VA report by phone or text as outlined in the facility policy. Administrator indicated she was aware of altercations between R123 and her spouse, but could not recall when she was specifically notified of the incidents. Administrator confirmed she would expect staff to follow the facility policy. The facility policy titled Abuse Neglect And Vulnerable Adult revised 5/21, identified abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The policy further identified reporting would be made immediately no later than 2 hours after the allegation was made if the events that cause the allegation involved abuse, to the administrator of the facility and to other officials, including the SA.

Based on interview and document review the facility failed to ensure the Medicare A beneficiaries received the skilled nursing facility advanced beneficiary notice (SNFABN) form for 3 of 3 residents (R126, R17, R4) remaining in the facility. Findings Include: R126 R126's skilled nursing facility (SNF) Beneficiary Protection Notification Review form completed by the facility identified R126's Medicare Part A Skilled services Episode Start date was 2/23/21, and last covered day of part A service was 3/10/21. R126's form further identified the SNFABN form was not provided due to the CMS form was provided for Medicare Part A discharge. R17 R17's SNF Beneficiary Protection Notification Review form completed by the facility identified R17's Medicare Part A Skilled services Episode Start date was 3/26/21, and last covered day of part A service was 4/14/21. R17's form further identified the SNFABN form was not provided due to the CMS form was provided for Medicare Part A discharge. R4 R4's SNF Beneficiary Protection Notification Review form completed by the facility identified R4's Medicare Part A Skilled services Episode Start date was 3/19/21, and last covered day of part A service was 3/25/21. R4's form further identified the SNFABN form was not provided due to the CMS form was provided for Medicare Part A encounter. On 5/26/21, at 8:10 a.m. social service designee (SSD)-A confirmed she completed the facility beneficiary forms for the facility. SSD-A confirmed R126's last covered day of part Medicare part A coverage was 3/10/21, and R126 remained in the facility. SSD-A confirmed R17's last covered day of Medicare part A coverage was 4/14/21, and R17 remained in the facility. SSD-A confirmed R4's last covered day of Medicare part A coverage was 3/25/21, and R4 remained in the facility. SSD-A confirmed she had not provided R126, R17 or R4 a SNFABN form, and had not provided the SNFABN form for any residents in the past. SSD-A indicated she was new to the responsibility of providing beneficiary notification forms to residents and was not aware the SNFABN form needed to be provided. On 5/26/21, at 8:32 a.m. director of nursing confirmed SSD was responsible to complete beneficiary forms. DON indicated she expected the residents would be provided the correct forms, whether the residents remained in the facility, or were discharged . The facility policy titled Beneficiary Notifications, undated, identified the facility would provide the appropriate Medicare notification to each beneficiary and/or their authorized representative of their Medicare benefit and any changes regarding their Medicare benefit. The policy further identified a SNFABN letter would be given to the beneficiary and/or their authorized representative before an extended service or items were furnished, reduced or terminated when the SNF believed that Medicare would not pay for or would not continue to pay for extended care services that the SNF furnished and that a physician ordered. The policy also identified the SNFABN letter would be provided to the beneficiary and/ or their authorized representative so they could decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. The policy identified the SNFABN letter would be given when the resident had skilled benefit days remained, they would be discharged from Part A services, and would continue living in the facility.

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 1 of 3 residents (R1) observed who needed feeding assistance. Findings include: R1's Quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severely impaired cognition and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 required extensive assistance with bed mobility, transfers, dressing, eating, and toileting. R1's care plan last updated on 1/17/17, identified R1 had activities of daily living (ADL's) self- care deficit R/T (related to) Alzheimer's disease and dementia. The care plan instructed staff to provide extensive assist with eating. The care plan identified R1 needed a lot of cues and encouragement as she had a difficult time staying on task and was easily distracted. The care plan indicated R1 rarely made her self understood or understood others due to unclear speech R/T to her dementia. During an observation on 5/24/21, at 5:30 p.m. nursing assistant (NA)-B sat next to R1 in the main dining room at a table. NA-B gave R1 a spoon full of apple sauce and used the spoon to scrape off the apple sauce from the side of her mouth then fed it back to R1. NA-B gave R1 another spoon full of apple sauce and again scraped the apple sauce from the side of her mouth with a spoon then fed it back to R1. During an observation on 5/26/21, at 8:23 a.m. NA-A sat next to R1 in the main dining room at a table. NA-A gave R1 a spoon full of oatmeal and scraped off the oatmeal from the side of her mouth with a spoon and fed it to back her. NA-A gave R1 another spoon full of oatmeal and again scraped the access from the side of her mouth then fed it back to R1. During an interview on 5/26/21, at 8:45 a.m. NA-A stated she scraped the access food off R1's face with the spoon rather than letting it run down her face. NA-A indicated that was not the appropriate way to clean off her face and she should have used a napkin to wipe it off. NA-A stated this would not make the resident feel good and it could have affected her dignity. During an interview on 5/26/21, at 2:05 p.m. director of nursing (DON) stated the staff should have used a napkin to remove the access from the face rather than a spoon. During a telephone interview on 5/27/21, at 9:45 a.m. R1's family member (F)-A stated R1 was unable to tell you how she felt due to her declining condition health and dementia. F-A indicated during a meal when food was scraped off her face and fed back to her it would had really bothered her R1. F-A stated he thought that would had bothered anyone during a meal. On 5/26/21, at 2:15 p.m. a request was made for information on dignity and dining observation policy and procedures. DON stated they did not have a policy.

Based on observation, interview and document review, the facility failed to accurately assess, identify and monitor facility acquired pressure ulcers for 2 of 2 residents (R8, R27) who were observed for pressure ulcer care. This deficient practice resulted in actual harm for R8 who initially had an open area caused by shearing (occurs when layers of skin rubs against each other or when the skin remains stationary and the underlying tissue moves and stretches and tears underlying capillaries and blood vessel causing tissue damage) identified to the right buttocks which worsened to an unstageable pressure ulcer (observed full-thickness skin and tissue loss in which the extent of the damage cannot be confirmed due to the wound bed obscured with slough or eschar). Findings include: R8's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R8 had [DIAGNOSES REDACTED]. The MDS identified R8 had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADL's) which included bed mobility, transfers, dressing, toileting, personal hygiene, bathing and limited assistance with eating. The MDS further indicated R8 was at risk for developing pressure ulcers and had no current pressure ulcers identified. The MDS revealed the following interventions were in place to prevent pressure ulcers which included pressure reducing device for chair and a turning and repositioning program. The MDS identified R8 had no weight loss and received a mechanically altered diet for meals. The MDS further identified R8 was frequently incontinent of bladder and always incontinent of bowel. R8's annual Care Area Assessment (CAA) dated 9/5/18, indicated R8 required assistance with ADL's due to progressing [MEDICAL CONDITION] and dementia. The CAA revealed R8 was at risk for developing pressure ulcers due to immobility and the need to be repositioned by staff. The CAA identified R8 had no current skin issues at the time of the assessment. The CAA further indicated R8 was at risk for weight and fluid changes due to intake and abnormal labs. The CAA further identified R8 was at nutritional risk due to [MEDICAL CONDITION] with heart failure, acute kidney failure, dementia and [MEDICAL CONDITION] (quivering or irregular heartbeat). The CAA indicated R8 was to be toileted three times a day on the commode utilizing the mechanical lift to transfer, provide the bedpan as needed and to provide incontinence care as needed. R8's care plan revised 5/14/19, revealed R8 required extensive to total assistance with ADL's which included bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and bathing. The care plan indicated R8 required supervision with set-up for eating tasks. The care plan identified R8 had an open area to her right buttock as a result of shearing. The care plan instructed staff to apply a [MEDICATION NAME] dressing to the open area and to change the dressing every three days or more often if needed. The care plan further instructed staff to encourage and assist with every two hour repositioning while seated and every three hours when laying in bed. The care plan indicated staff would monitor for skin breakdown and report to the nurse if breakdown occurred. The care plan instructed staff to encourage R8 to consume a well balanced diet as well as consume all fluids offered at meal times. The care plan identified the resident was to use a geo matt (a therapeutic overlay mattress to aid in prevention and treatment of [REDACTED]. R8's care plan instructed staff to toilet R8 three times a day on the commode utilizing the mechanical lift to transfer, provide the bedpan as needed and to provide incontinence care as needed. On 5/14/19, at 1:00 p.m. nursing assistant (NA)-B and occupational therapy assistant (OTA)-C placed sling for a mechanical lift behind R8's back and looped it under her legs while she was seated in the wheelchair with plans to lay R8 down in bed. Once the loops of the sling had been applied to the mechanical lift, NA-B operated the lift to transfer R8 out of the wheelchair and lowered her into her bed while OTA-C guided R8 in the sling. At 1:09 p.m. NA-B and OTA-C turned R8 to the left side in bed and removed an incontinent brief. A square [MEDICATION NAME] dressing was noted to R8's right lower buttocks area and was intact with a quarter sized area of dark brown drainage noted on the dressing. NA-B cleansed perineal area and proceeded to apply a new brief to R8. NA-B and OTA-C positioned R8 on the left side and placed a pillow behind the right side to keep R8 on the left side. NA-B provided call light to R8 and covered her up with blankets. NA-B and OTA-C completed hand hygiene after removing gloves. On 5/14/19, at 1:58 p.m. registered nurse (RN)-A assessed [MEDICATION NAME] dressing noted on R8's right lower buttocks and noted there was a quarter sized area of dark brown drainage in the center of the dressing that was visible however had not soaked through. RN-A stated the dressing had just been changed the day before and indicated she would not be changing it at that time. On 5/14/19, at 3:30 p.m. R8 was noted to be seated on a pressure reducing cushion in a wheelchair in the dayroom attending a music activity. On 5/15/19, at 7:47 a.m. R8 was noted to be laying in bed on her back as NA-A and NA-C provided morning cares to R8. At 7:50 a.m. NA-C removed the front of the soiled brief and proceeded to cleanse R8's front perineal area. NA-C and NA-A positioned R8 on the right side and removed the brief completely and provided perineal cares to her back side. A [MEDICATION NAME] dressing to right lower buttocks was noted to be intact with the quarter sized area of dark brown drainage present. At 7:56 p.m. NA-C placed a new brief under R8 and with assistance from NA-A, applied the brief while turning R8 from side to side in the bed. NA-A and NA-C applied pants and placed sling for the mechanical lift under R8 while turning R8 from side to side. At 8:01 a.m. NA-A operated the lift and NA-C guided R8 into the wheelchair on top of the wheelchair cushion. NA-A and NA-C removed the sling and positioned R8 in an upright properly aligned position in the wheelchair. NA-A proceeded to remove R8's nightgown, cleansed chest and applied deodorant to R8's underarms. At 8:04 a.m. NA-A applied bra and hook of bra scratched right arm near R8's elbow which resulted in a skin tear. NA-A immediately provided pressure to stop the bleeding and asked for assistance from nursing staff. At 8:08 a.m. RN-A entered R8's room and assessed the skin tear and stated she would obtain dressings to treat the skin tear and would return. At 8:10 a.m. director of nursing (DON) entered the room and stated she would return shortly with supplies to treat the skin tear. At 8:14 a.m. NA-A proceeded to apply R8's shirt and glasses. At 8:16 a.m. DON returned to room with supplies, applied gloves and placed a cold washcloth to the skin tear that had bled slightly. DON indicated the measurements of the skin tear were 5 cm long and 0.7 cm in width. DON proceeded to cleanse the wound with normal saline and applied three steri strips to the skin tear after using a cotton-tip applicator to realign the skin together. DON placed a dressing over the skin tear and wrapped the arm with kling wrap. At 8:21 a.m. NA-A provided oral cares to R8 and brushed her hair. DON and NA-A completed hand hygiene after cares and NA-A brought R8 to the dining room for breakfast. On 5/15/19, at 1:21 p.m. RN-A and Infection Control Coordinator (ICC)-F were both present in R8's room during a dressing change to her right buttocks area. RN-A and ICC-F positioned R8 on the left side. RN-A removed old [MEDICATION NAME] dressing from right buttocks and indicated the dressing had a little bit of dark brown drainage present. RN-A stated most of the wound bed had yellow slough present and additionally had a 0.25 cm dark brown area to the proximal area of the wound bed. RN-A measured the wound and indicated the width of the wound was 2 cm and the length of the wound was 2.5 cm. RN-A statedd there was about 0.1 cm depth to the wound. RN-A confirmed the wound had worsened since she had seen it last as there had been no yellow slough present in the wound bed when she'd last assessed the wound. RN-A was not able to recall the date she had last seen the wound. RN-A stated she would classify the wound as a stage two pressure ulcer due to the depth of the wound and ICC-F concurred. RN-A applied clean gloves, cleansed the wound with normal saline and applied a new [MEDICATION NAME] dressing. RN-A removed her gloves and completed hand hygiene. RN-A stated the wound had been caused by friction from a sling and as a result staff identified it as an abrasion. Review of R8's Braden scale (tool used to determine risk for pressure ulcer development) dated 11/19/18, indicated R8 was at risk for developing pressure ulcers due to the following risk factors: slightly limited sensory perception, moisture, chairfast, slightly limited with mobility and had a potential problem with friction and shearing. The Braden scale revealed R8 had the additional risk factors which included cardiovascular disease, chronic incontinence, diabetes, and [MEDICAL CONDITION] disease. The Braden further indicated R8 required extensive assistance with bed mobility, required the use of a mechanical lift for transfers and was always incontinent of bowel. Review of R8's Braden scale dated 2/16/19, indicated R8 was at moderate risk for developing pressure ulcers due to the following risk factors: slightly limited sensory perception, was often moist, chairfast, slightly limited mobility and a problem with friction and shearing. The Braden scale revealed R8 had additional risk factors which included cardiovascular disease, chronic incontinence and cognitive impairment. The Braden scale further indicated R8 required extensive assistance with bed mobility, required the use of a mechanical lift and was always incontinent of bowel. The medical record lacked any additional Braden scale assessments completed after 2/16/19. Review of R8's Skin Integrity Event for 4/8/19, revealed the following: -R8 developed a skin tear to her right buttocks that was noted to be shallow and measured 0.5 centimeters (cm.). The wound had a small amount of bleeding and had smooth wound edges. It was unknown how the wound developed. The wound was cleansed with soap and water and a [MEDICATION NAME] dressing was applied to it after R8's bath. The event indicated the physician and family had been notified. Review of the interdisciplinary progress notes from the electronic health record (EHR) from 4/8- 5/16/19, revealed the following: - 4/8/19, R8 was noted to have an open area to her buttocks that measured 0.5 (cm). Nurse planned to apply [MEDICATION NAME] (a foam absorbent dressing used to treat acute and chronic ulcers and wounds) after R8 had received morning bath. - 4/9/19, Interdisciplinary Team (IDT) reviewed R8's wound to the buttocks and identified the wound as shearing. The note further indicated treatment would be administered as ordered and Ammens powder (a powder utilized for minor skin irritations) would be applied to keep the area dry and to prevent breakdown. The note identified a ROHO cushion (a cushion used for pressure relief) would be utilized in R8's wheelchair and staff would monitor the wound daily and document at least weekly until healed. - 4/13/19, 0.5 cm raw area noted to R8's right buttock as well as another 0.5 cm. located 1 cm laterally to the initial area. R8 had a large loose foul-smelling bowel movement (BM) and bowel medications were not administered as a result. Nursing staff applied a new [MEDICATION NAME] dressing to the right buttock area. -4/14/19, R8 had a large loose foul-smelling BM and dressing had been changed again as a result. The note indicated the inferior (older) area measured 1 x 1 cm and the superior (new) area measured 0.8 x 0.8 cm. -4/20/19, R8's dressing had been soiled again and nursing staff cleansed the area and applied a new dressing. Nursing staff noted the area appeared to be increasing in size and would ask the director of nursing (DON) to assess the area. - 4/23/19, R8's dressing had been changed on 4/22/19, and 4/23/19, due to large loose BM's. The lower open area had been noted to be very superficial and nearly healed. The upper open area had been noted to be approximately 2 cm in diameter with four spots covering and about 1/3 of the wound barely through the skin and superficial. -4/27/19, dressing changed to R8's right buttock after R8 had a large BM. The area was noted to be 2 x 2 cm and the area was 100% blanchable (area returns to normal skin color when pressure is applied and removed). -5/1/19, R8's dressing to her right buttock was noted to be all curled up. Nursing staff removed the old dressing and applied a new [MEDICATION NAME] dressing. R8's area had no drainage, had clean edges and was noted to be dark red in color. - 5/3/19, R8's dressing was noted to be coming off and a new [MEDICATION NAME] dressing was applied. No drainage or any signs of change had been noted to the wound. - 5/5/19, R8 was noted to continue to have a 2 cm x 2 cm open area that was dressed with a [MEDICATION NAME] dressing. The wound had no drainage and the dark red area had clean edges. R8 was noted to have had recurrent incontinent BM's. - 5/6/19, OT (occupational therapy) staff evaluated R8 for positioning needs and instructed staff to position R8 on the left side. The note further indicated the ROHO cushion (pressure relieving cushion) was not holding air and OT staff were checking with vendors for other cushion options. - 5/7/19, [MEDICATION NAME] dressing completed to R8's right buttock due to soiled. Area noted to be slightly more shallow and lighter pink in color. - 5/8/19, OT staff provided education to nursing staff on proper use of the hygiene sling. The progress note further indicated the DM (dietary manager) was aware of the skin concern and nutrition had been addressed. - 5/9/19, dressing change completed to R8's right buttock due to soiled. Area noted to have had slow healing. - 5/10/19, dressing change completed to R8's right buttock and noted to have a round area that measured 1.5 cm in the center and superficial skin noted to be missing in 1 cm border of the wound. The center area had been noted to be pink in color. - 5/11/19, R8's old dressing had been removed and was noted to be soiled and difficult to remove. The area was noted to be 3.0 cm. x 3.0 cm, had an odor and was noted to be moist. -5/12/19, the dressing to R8's right buttock shearing area was removed and a new [MEDICATION NAME] dressing had been applied. -5/15/19, [MEDICATION NAME] dressing changed to R8's right buttock. Nursing staff indicated a small to moderate amount of tan colored drainage was noted on the old dressing and no odor had been detected. The open area measured 2 cm in width by 2.5 cm in length. The nursing staff further indicated darker pink tissue surrounded the wound and the entire wound measured, which included the open wound and the surrounding dark pink tissue 3 cm. The color of the majority of the wound bed was light yellow in color and the proximal area of the open wound had a 0.25 cm dark red-brown area. The progress notes lacked documentation of staging of the pressure ulcer or the presence of yellow slough in R8's pressure ulcer. During interview on 5/14/19, at 1:25 p.m. NA-B stated R8 required extensive to total assist with all ADL's except for eating which she required limited assistance with. NA-B stated R8 had a shearing to her right buttocks from her old lift sling and OTA-C assisted with determining best positioning practices as well as suggesting the use of the hygiene sling in an attempt to prevent further shearing. NA-B stated licensed nurses were notified by NA's when skin issues develop and skin was checked every day by NAs during morning cares. On 5/15/19, at 11:21 a.m. OTA-C stated occupational therapy staff received an order to evaluate and make recommendations for pressure relieving devices for R8 to use as well as suggesting positioning strategies. OTA-C confirmed R8 had been changed to a hygiene sling to prevent further shearing from occurring. OTA-C stated OT staff provided education to nursing staff on proper use of slings as well as proper positioning for R8. On 5/15/19, at 11:46 a.m. NA-C stated R8 required extensive assist with ADL's and minimal assistance with eating tasks. NA-C indicated R8 had been changed from the old lift sling to a hygiene sling due to the old one causing irritation to her skin. NA-C further stated the sore on her right buttocks developed from the use of the old sling. Review of R8's current physician orders [REDACTED]. - 4/8/19, general nursing order to change dressing weekly on bath day and as needed and document the condition of dressing under results. - 5/15/19, Vicair cushion for wheelchair. Review of R8's treatment administration record (TAR) for (MONTH) 2019, revealed the following: - an order on 4/8/19, Ammens Powder- apply light dusting of Ammens Powder to bottom to aide in keeping area dry and prevent breakdown. - an order on 5/14/19, to change the dressing weekly on R8's bath day and as needed. Additionally, the nursing staff were to document the condition of the dressing under result in the EHR, monitor daily and chart under event at least weekly on Sundays and as needed. Review of R8's physician progress notes [REDACTED]. - 3/19/19, the physician progress notes [REDACTED]. The progress note lacked any documentation of any skin issues. - 4/24/19, the progress note indicated R8 had no complaints except for feeling tired. The progress note identified an increase of [MEDICATION NAME] to 5 milligrams (mg) (prescribed for high blood pressure) and to check labs with the next lab draw. The progress note lacked any documentation of any pressure ulcers or wounds. - 5/14/19, the progress note lacked documentation of weight loss or a plan to address weight loss. However, there was an addendum note indicating nursing staff had informed the primary physician (MD)-E of R8's gluteal ulcer being treated and the progress toward healing. According to the note, the physician indicated the ulcer had developed due to shear or maceration due to friction, seat position and exposure to urine. -5/15/19, an addendum to the 5/14/19, progress note indicated MD-E had assessed the ulcer and determined the ulcer was the size of a quarter and had shallow pale superficial slough. However, the note did not include any physician assessment of the resident's nutritional status, weight loss, or any plans to address the weight loss. The note indicated the nursing staff believed the ulcer developed from shear or maceration due to friction, seat position and exposure to urine. Further review of R8's progress notes of the EHR revealed the resident had experienced a significant weight loss: 11/13/18, 200.5 pounds (lbs.) 12/13/18, 196 lbs. 1/13/19, 193 lbs. 2/13/19, 188.3 lbs. 3/12/19, 188.8 lbs. 4/15/19, 183.9 lbs. 5/13/19, 180.4 lbs. 5/15/19, RD-D documented she had been notified R8 had an open wound to her right buttocks that measured 2 cm by 2.5 cm with a total width of 3 cm. RD-D also identified R8's weight of 180.4 pounds which equaled an additional 2% weight loss in 30 days, 5% weight loss in 90 days and 9% weight loss in 180 days. The RD-D note indicated R8's meal intakes continued to be variable, and indicated breakfast was where R8 had the best intake 76-100% , while lunch and supper meals ranged from 25% to 75%. RD-D recommended a trial of 4 ounces of ensure at lunch and supper meals to provide additional protein, calories and fluids. Additionally, staff were to offer protein-rich food/fluids and offer favorite foods to improve intakes. The note identified goals of stabilizing weight, improve skin integrity, supplement acceptance, improve meal intakes to be equal to or greater than 75% and the RD-D planned to follow-up at the next site visit. Review of R8's Medication Administration Record [REDACTED]. Review of R8's treatment administration record (TAR) for (MONTH) 2019, also failed to indicate any nutritional supplement order or implementation. On 5/15/19, at 1:46 p.m. registered nurse manager (RN)-A confirmed R8 had not been receiving any supplements. On 5/15/19, at 2:35 p.m. DD-B stated weights were reviewed on a weekly basis and if a resident had not been eating well or experienced an unwanted weight loss, offering high caloric foods would be one of the first interventions to implement. DD-B also stated high protein supplements would be implemented for residents who had pressure ulcers or wounds to promote healing. DD-B confirmed RD-D had not seen R8 during her last site visit on 4/24/19 and further confirmed he was not aware R8 had a pressure ulcer. DD-B further confirmed R8 had not been receiving nutritional supplements. On 5/16/19, at 10:07 a.m. during a phone interview with RD-D, RD-D stated she worked closely with DD-B to monitor nutritional concerns and further stated she made onsite visits on a monthly basis. RD-D explained for any needs that developed inbetween her visits, DD-B would email or call her on the telephone. RD-D stated she would expect to be notified within 48 hours if any resident developed a pressure ulcer or had a significant weight loss. RD-D confirmed she had first been notified by DD-B of R8's pressure ulcer and significant weight loss on 5/15/19, and would have expected to have been notified earlier for both. RD-D stated she'd reviewed R8's EHR at 5:56 p.m. on 5/15/19, to determine intakes and weight loss had occurred. RD-D confirmed R8 had experienced a significant weight loss in the past six months. Further, RD-D made recommendations for a supplement at the lunch and supper meals, and encouraging high caloric foods to promote wound healing and to prevent further weight loss. RD-D stated she planned on evaluating R8 in person during her next onsite visit which she planned to do within the next couple of weeks. On 5/15/19, at 1:46 p.m. nurse manager (NM)-A stated the process for skin care involved the nurses assessing the pressure ulcers and wounds and determining if the pressure ulcer was blanchable or not. NM-A further stated if the pressure ulcer had been determined to be caused by friction or shearing the staff identified it as an abrasion. NM-A indicated R8's pressure ulcer had been caused by shearing from her incontinence brief. NM-A stated she was not aware R8's pressure ulcer had yellow slough present and would have had to assess it herself to determine that. NM-A stated the expectation was for nursing staff to utilize the E-Z Graph Wound Assessment Worksheet at least weekly and document in the events and progress notes of the EHR. NM-A stated it was expected nursing staff would comment on whether the pressure ulcer was improving or not at least weekly. Review of R8's E-Z Graph Wound Assessment Worksheet dated 5/11/19, indicated R8 had a wound to the Butt - R (right) side. The worksheet indicated a length of 3.0 cm, width of 3.0 cm and a depth of 0.5 cm. The worksheet indicated the presence of an odor and eschar/slough present. The worksheet had a hand drawn diagram of an irregular shaped circle with an inner circle with a line from it indicating yellow. To the right of the hand drawn diagram was the handwritten words Soft and Moist. The worksheet provided space to document wound base, drainage amount, drainage type, periwound appearance, age of wound, pain present, and wound status however, these areas were left blank. No further E-Z Graph Wound Assessment Worksheet were provided for R8. On 5/16/19, at 12:55 p.m. primary physician (MD)-E indicated he expected, and the facility normally, would contact him immediately via fax when a wound or pressure ulcer developed on a resident. MD-E confirmed he assessed R8's pressure ulcer on 5/15/19, and R8 had a pressure ulcer to her right lower buttocks that was unstageable due to the wound bed covered in slough. MD-E stated he planned to continue current treatment and interventions and expected the pressure ulcer would heal. On 5/16/19, at 2:02 p.m. the director of nursing (DON) stated R8 had a significant weight loss as identified in R8's EHR and verified RD-D had implemented new interventions on 5/15/19. The DON also stated the expectation for identifying, monitoring and treating a pressure ulcer or wound involved the nursing staff completing an event form, updating the care plan, and documenting the appearance of the pressure ulcer or wound at least weekly. The DON stated it was expected the pressure ulcer documentation would include the location of the wound, the measurements of the wound, if there was drainage or odor present, any signs or symptoms of infection, if there was pain present and a thorough description of the wound. The DON explained R8's pressure ulcer started as a shearing abrasion from the incontinent brief or sling utilized with the mechanical lift and verified the pressure ulcer had worsened to an unstageable pressure ulcer which had yellow slough present. The DON stated licensed nursing staff recently watched a webinar in (MONTH) 2019, regarding pressure ulcer prevention and repositioning requirements. R27's quarterly MDS dated [DATE], indicated moderate cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R27 required extensive assistance from 2 staff with activities of daily living (ADL)s including bed mobility, transferring, toileting, dressing and personal hygiene. R27's annual care area assessment (CAA) dated 1/25/19, revealed R27 was cognitively impaired, and indicated at risk for pressure ulcers but had no skin issues. In addition, the CAA identified R27 required staff assistance with ADLs including dressing the lower body. The CAA indicated R27 was at risk for skin breakdown related to advanced aging, [MEDICAL CONDITION] and thin fragile skin. R27's current care plan described various interventions and instructions for self care deficits, and required assistance with all ADLs. In addition, the care plan addressed R27's risk for skin breakdown on her feet related to structural problems, needing assist with ADL's, [DIAGNOSES REDACTED]. During an interview on 5/13/19, at 1:47 p.m. R27 stated she had a sore toe and indicated staff were aware and had been applying salve to the area, but indicated it was not helping. A review of R27's active Medication Administration Record [REDACTED]. Review of R27's progress notes reviewed from 3/5-5/14/19, lacked any documentation of skin issues or interventions utilized. In addition, a nursing progress note dated 3/16/19, at 7:00 p.m. indicated R27 had a reddened area on second toe on the right foot and indicated she also had rubbing from her shoes on her left foot, that she wore toe sleeves and indicated staff would make sure she was wearing the toe sleeves. R27's electronic Medication Administration Record [REDACTED]. Review of a podiatry consult on 3/5/19, did not address any reports of redness or irritation of her feet/toes or use of the toe sleeve to reduce friction or rubbing during the visit and indicated no skin concerns were noted at the time of the visit. On 5/14/19, 2:41 p.m. R27 was seated in her room with her feet elevated in a recliner chair. R27 was wearing black diabetic shoes and had tan compression socks on bilateral lower extremities with tan Geri sleeves (protective sleeves) on both lower legs under her pants. On 5/15/19, at 7:16 a.m. Nursing Assistant (NA)-C stated she looked at all residents' skin head to toe with morning and bedtime cares. NA-C stated if she observed any changes or issues with a resident's skin she would notify the nurse right away. NA-C stated R27 had redness on the left second toe and indicated it was not new for R27 and staff were putting a foam toe sleeve on R27's toe to separate the toes and prevent rubbing in her shoes. On 5/16/19, at 8:39 a.m. NA-D stated she checked the resident's skin every day with morning and evening cares, and indicated the bath aide completed a head to toe skin assessment on each resident's bath day and would report any concerns to the nurse. NA-D stated NAs do not document the skin issues, but report them to the nurse so a skin assessment/documentation could be completed. NA-D stated if there were any skin issues or interventions they would be care planned and on the eTAR so nursing staff could monitor and document on the area. NA-D stated she had cared for R27 and observed redness on her toes which she had made nursing staff aware of. NA-D said nursing was monitoring the areas and were applying padding to the reddened toes with morning cares. On 5/16/19, at 8:52 a.m. NA-E stated she would look at the resident's skin when she is providing cares in the morning and evenings, checking them over head to toe. NA-E stated if there are any issues such as bruising, redness, or anything different she would report it to the nurse. NA-E stated the process for reporting a skin issue was to complete a Stop N Watch (alert). NA-E stated if a resident had Diabetes or other skin issues she would pay close attention to their feet. NA-E stated the nurse would then assess the skin issue and complete the documenting and tracking until resolved. NA-E stated she had worked with R27 and stated staff look at her skin and feet with cares. NA-E also explained staff help R27 apply stockings and remove them every day and indicated they look at feet and legs at that time. NA-E stated she had observed redness on R27's left second toe and had reported the concern to the nurse several months ago. NA-E stated they apply toe cushion wraps as an intervention, and stated R27's toes did not look any different than they had for the last couple of months. On 5/16/19, at 10:30 a.m. registered nurse (RN)-A stated the process for routine skin monitoring was to complete the licensed nurse data collection (LNDC) weekly assessment for all the residents which included questions regarding skin condition. RN-A stated the bath aide and NAs looked at the residents' skin during daily cares and notify nursing if there are any changes in skin integrity. RN-A stated she looked at the resident's skin head to toe each week for the LNDC and indicated she thought that was the facility policy. RN-A stated R27 was at risk for skin breakdown due to history of hammer toes, and stated they get red and sore. RN-A verified there was no monitoring for this issue currently in place. In addition, RN-A stated she was not aware of any current skin issues with R27, and reviewed the most current temporary care plan in the resident's chart and verified monitoring of the redness on her toes was not in temporary care plan. RN-A stated the care plan instructed staff to monitor any changes in skin and report to nursing, but indicated the care plan lacked anything specific about monitoring R27's feet or toes, or effectiveness of the use of R27's toe sleeves. RN-A verif (TRUNCATED)

Based on observation, interview and document review, the facility failed to complete accurate and ongoing nutritional assessment for 1 of 2 residents (R8) reviewed for nutrition. R8 sustained harm when the facility failed to accurately and timely assess nutritional status, address risk factors for impaired nutritional status, and implement approaches to maintain acceptable nutritional parameters for R8 who experienced a clinically severe weight loss of over 10% in six months. Findings include: R8's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R8 had [DIAGNOSES REDACTED]. The MDS identified R8 had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADL's) which included bed mobility, transfers, dressing, toileting, personal hygiene, bathing and limited assistance with eating tasks. The MDS indicated R8 was at risk for developing pressure ulcers and had no current pressure ulcers identified. The MDS revealed the following interventions were in place to prevent pressure ulcers which included pressure reducing device for chair and a turning and repositioning program. The MDS identified R8 had no weight loss and received a mechanically altered diet for meals. R8's annual Care Area Assessment (CAA) dated 9/5/18, indicated R8 required assistance with ADL's due to progressing Alzheimer's Dementia. The CAA revealed R8 was at risk for developing pressure ulcers due to immobility and the need to be repositioned by staff. The CAA identified R8 had no current skin issues at the time of the assessment. The CAA indicated R8 was at risk for weight and fluid changes due to intake and abnormal labs. The CAA further identified R8 was at nutritional risk due to [MEDICAL CONDITION] with heart failure, acute kidney failure, dementia and [MEDICAL CONDITION] (quivering or irregular heartbeat). R8's care plan revised 5/14/19, revealed R8 required extensive to total assistance with ADL's which included bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and bathing. The care plan indicated R8 required supervision with set-up for eating tasks and staff were to monitor the resident's need for increased assistance. The care plan identified R8 had an open area to her right buttock as a result of shearing. The care plan instructed staff to encourage R8 to consume a well balanced diet as well as consume all fluids offered at meal times. The care plan identified R8 was on a regular diet with nectar thin liquids and R8 was to be seated at the supervision table due to occasionally required increased assistance with eating tasks from staff. The care plan further instructed staff to monitor and record intake and to report any significant changes to the physician and family. On 5/14/19, at 12:20 p.m. R8 was observed to be seated in her wheelchair at the dining room table being assisted by nursing assistant (NA)-B to eat her lunch. R8 consumed one half of her sherbet and one fourth of her hotdish. R8 drank all of her apple juice. On 5/15/19, at 8:42 a.m. NA-A wheeled R8 to the dining room and placed her at the dining room table. R8 was provided her breakfast tray consisting of a banana, toast, scrambled eggs and yogurt as well as two glasses of juice. R8 was noted to be leaning to her left in her wheelchair. R8 was provided a fork by NA-A and attempted to feed herself bites of her banana with difficulty. At 8:46 a.m. NA-A sat down next to R8 and attempted to position R8 in a more upright position in her wheelchair. R8 proceeded to feed herself her breakfast slowly with cueing and occasional assistance from NA-A with placing food on her fork and guiding it to R8's mouth. At 9:20 a.m. R8 continued to drink her juices and was no longer eating anymore of her food. R8 consumed all of her banana, half a slice of toast and a couple bites of the yogurt and eggs. On 5/15/19, at 11:14 a.m. R8 was seated in her wheelchair at the dining room table waiting for lunch to be served. At 12:15 p.m. R8 was brought back to her room due to complaints of nausea. R8 had not eaten her lunch as a result of the nausea. Review of R8's weight record from the electronic health record (EHR) were reviewed from 11/13/18, to 5/13/19 and included: 11/13/18, 200.5 pounds (lbs.) 12/13/18, 196 lbs. 1/13/19, 193 lbs. 2/13/19, 188.3 lbs. 3/12/19, 188.8 lbs. 4/15/19, 183.9 lbs. 5/13/19, 180.4 lbs. Review of R8's 2/19/19, nutritional screening revealed R8's weight was noted to be 190.2 lbs., this compared to 192.9 lbs. 30 days prior and 201.5 lbs. 180 days prior. The screening indicated R8's usual body weight was 190- 200 lbs. The screening further indicated R8 had swallowing problems and utilized adaptive equipment. The screening identified R8's usual intake was 51%- 75% and she typically consumed under 1000 milliliters (ml.) of fluids. The screening further identified R8's skin as intact, and indicated the team should continue the current plan of care. Review of progress notes from 3/20-5/15/19, revealed the following: 3/20/19, registered dietician (RD)-D noted R8's weight was 188.3 lbs. and R8 had experienced a significant weight loss of 21 lbs. (10%) in 180 days. The note indicated R8 may benefit from a gradual weight loss to reduce stress on organs and joints. The note further indicated R8's meal intakes varied from 25% to 100%. The note identified R8 required encouragement and indicated staff would continue to monitor weights, intakes and plan of care for significant changes. 4/10/19, dietary director (DD)-B noted R8's weight was 185 pounds which equaled a 3.6% weight loss in 30 days and a 10.1% weight loss in 180 days. The note identified R8's intakes varied from 25% to 100% per meal. The note indicated the plan to continue to monitor and to refer to RD-D at the next site visit. 5/2/19, DD-B noted R8's weight was 181.6 pounds which equaled a 19 pound weight loss in 180 days. The note indicated R8's intake varied by meal. Further, the note indicated R8 required cueing to dine as needed, and indicated R8 may require more assistance with eating. The note indicated staff would continue to monitor and the RD-D would see R8 at next site visit. 5/15/19, RD-D stated she had been notified R8 had an open wound to her right buttocks that measured 2 cm by 2.5 cm with a total width of 3 cm. RD-D also identified R8's weight of 180.4 pounds which equaled an additional 2% weight loss in 30 days, 5% weight loss in 90 days and 9% weight loss in 180 days. RD-D indicated R8's meal intakes continued to be variable, and indicated breakfast was where R8 had the best intake 76-100% , while lunch and supper meals ranged from 25% to 75%. RD-D recommended a trial of 4 ounces of ensure at lunch and supper meals to provide additional protein, calories and fluids. Additionally, staff were to offer protein-rich food/fluids and offer favorite foods to improve intakes. The note identified goals of stabilizing weight, improve skin integrity, supplement acceptance, improve meal intakes to be equal to or greater than 75% and the RD-D planned to follow-up at the next site visit. Review of the physician's progress notes in the electronic health record (EHR) were reviewed from 2/22-5/15/19, revealing the following: 2/22/19, the progress note lacked documentation regarding R8's weight loss or a plan to address weight loss. 3/15/19, the progress note lacked documentation regarding R8's weight loss or a plan to address weight loss. 4/24/19, the progress note lacked documentation regarding R8's weight loss or a plan to address weight loss. 5/14/19, the progress note lacked documentation of weight loss or a plan to address weight loss. However, there was an addendum note indicating nursing staff had informed the primary physician (MD)-E of R8's gluteal ulcer being treated and the progress toward healing. According to the note, the physician indicated the ulcer had developed due to shear or maceration due to friction, seat position and exposure to urine. 5/15/19, an addendum to the 5/14/19, progress note indicated MD-E had assessed the ulcer and determined the ulcer was the size of a quarter and had shallow pale superficial slough. However, the note did not include any physician assessment of the resident's nutritional status, weight loss, or any plans to address the weight loss. Review of R8's signed physician orders [REDACTED]. Additionally, there were general orders dated 6/28/17, regarding nutritional supplement per RD-D or DD-B recommendation, noted. Review of R8's Medication Administration Record [REDACTED]. Review of R8's treatment administration record (TAR) for (MONTH) 2019, also failed to indicate any nutritional supplement order or implementation. On 5/15/19, at 8:36 a.m. NA-A stated R8 could feed herself with cueing but did occasionally require assistance from staff with eating. NA-A further indicated R8 had a fair appetite but had experienced weight loss. NA-A wasn't sure how much weight R8 had lost. On 5/15/19, at 11:46 a.m. NA-C stated R8 required assistance with eating at times, and often refused meals at noontime. NA-C stated R8 had experienced a weight loss but did not receive nutritional supplements. NA-C wasn't sure how much weight R8 had lost. On 5/15/19, at 1:46 p.m. registered nurse manager (RN)-A stated DD-B monitored the weights for all residents, and would start new nutritional interventions if a resident required it due to weight loss. RN-A stated she wasn't sure if R8 had experienced a weight loss or not, and reviewed the weights in R8's EHR to determine if a weight loss had occurred. Upon review of R8's records, RN-A confirmed R8 had experienced a significant weight loss. RN-A again stated DD-B, and RD-D, managed weight loss concerns for all residents. RN-A also confirmed R8 had not been receiving any supplements for the weight loss. On 5/15/19, at 2:35 p.m. DD-B stated weights were reviewed on a weekly basis and if a resident had not been eating well or experienced an unwanted weight loss, offering high caloric foods would be one of the first interventions to implement. DD-B also stated nutritional supplements would be offered to promote stabilization of weight or weight gain. Further, a referral to RD-D would be initiated, and she would see the resident in person during her monthly visits. DD-B stated when a resident triggered a significant weight loss of 5% or more in 30 days, or 10% or more in 180 days, RD-D would be notified via phone or email instead of waiting for the monthly visit. DD-B also stated high protein supplements would be implemented for residents who had pressure ulcers or wounds to promote healing. DD-B confirmed RD-D had not seen R8 during her last site visit on 4/24/19 and further confirmed he was not aware R8 had a pressure ulcer. DD-B further confirmed R8 had not been receiving nutritional supplements. On 5/16/19, at 10:07 a.m. during a phone interview with RD-D, RD-D stated she worked closely with DD-B to monitor nutritional concerns and further stated she made onsite visits on a monthly basis. RD-D explained for any needs that developed inbetween her visits, DD-B would email or call her on the telephone. RD-D stated she would expect to be notified within 48 hours if any resident developed a pressure ulcer or had a significant weight loss. RD-D confirmed she had first been notified by DD-B of R8's pressure ulcer and significant weight loss on 5/15/19, and would have expected to have been notified earlier for both. RD-D stated she'd reviewed R8's EHR at 5:56 p.m. on 5/15/19, to determine intakes and weight loss had occurred. RD-D confirmed R8 had experienced a significant weight loss in the past six months. Further, RD-D made recommendations for a supplement at the lunch and supper meals, and encouraging high caloric foods to promote wound healing and to prevent further weight loss. RD-D stated she planned on evaluating R8 in person during her next onsite visit which she planned to do within the next couple of weeks. On 5/16/19, at 2:02 p.m. the director of nursing (DON) stated DD-B and RD-D monitor all residents for weight loss and provided recommendations for interventions to promote weight stabilization and/or weight gain. The DON stated it was expected a significant weight loss of 5% or more in 30 days, or 10% or more in 180 days would be addressed with new interventions which included supplements. The DON also stated R8 had a significant weight loss as identified in R8's EHR and verified RD-D had implemented new interventions on 5/15/19. Review of facility's 5/18 policy, Nutritional Care, indicated RD-D would initially assess residents during a monthly in house visit to facility, and at least annually, or when there had been a significant change in condition or as nutritional needs changed. The policy further indicated assessments would cover dietary needs of residents and any recommended changes as a resident's condition changed. The policy identified DD-B would monitor weights, intakes, labs and recommended changes to diet plans as needed. Further, the policy identified DD-B would refer high nutritional risk residents to RD-D for nutritional assessment and recommendations as needed. The policy instructed staff to document changes in the progress notes and/or screening and the changes would also be addressed in the care plan. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2018, identified Section K: Swallowing/Nutritional Status to be completed with an intent to assess the many conditions that cold affect the resident's ability to maintain adequate nutrition and hydration. Under K0300: Weight Loss Planning for Care: - Weight loss may be an important indicator of a change in the resident's health status or environment. - If significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication (e.g. diuretics), or changed fluid volume status. - Weight loss should be monitored on a continuing basis; weight loss should be assessed and care planned at the time of detection and not delayed until the next MDS assessment.

Based on observation, interview, and record review the facility failed to ensure all residents residing in the facility attained or maintained their highest practicable mental, physical, and psychosocial well being for 4 of 7 residents (R3, R36, R28, R34) in the facility. R3 had sustained psychosocial harm related to the facility's lack of adequate assessment and implementation of appropriate interventions to manage the behavioral symptoms of R36. Findings include: The facility's failure to adequately assess and develop appropriate interventions to address R36's continued behavioral symptoms had resulted in ongoing psychosocial issues for multiple residents residing in the facility. R3 verbalized recurrent and decreased quality of life including a disturbed sleep cycle related to R36's ongoing behavioral symptoms and had sustained psychosocial harm. On 12/15/10 at 7:00 a.m., LPN-A stated R3 had reported being woken up during the night and early morning hours by R36 hollering in the facility. At 7:24 a.m., LPN-A stated R36 hollers "daily" and swears at residents and staff. She stated other residents in the facility have complained about R36's yelling. Most recently another resident had indicated the hollering done by R36 was disturbing and stated, "I just wish he would lose his voice." LPN-A stated she felt the repeated hollering by R36 was "frightening" to other residents in the facility who were unable to voice their distress. She indicated there have been been multiple occasions, most recently "last Sunday," when staff removed R36 from the dining room due to multiple residents complaining about the noise and yelling "shut up." At 8:03 a.m., LPN-A indicated "last Sunday" R3 had reported she was unable to sleep the prior night due to R36 yelling. R3 reported she had been sleeping most of the day to catch up on sleep from the previous night. LPN-A stated she had to wake up R3 twice to administer her 5:00 p.m. medications to her. R3's [DIAGNOSES REDACTED]. The 12/9/10, 5 day Medicare Minimum Data Set (MDS) indicated cognitive deficits in memory recall requiring verbal cueing. The MDS also indicated R3 had trouble falling or staying asleep, and feeling tired or having little energy on 7-11 of the last 14 days. In addition, the MDS indicated R3 complained of frequent pain that limited the ability to sleep at night as well as limited her day to day activities. The 10/27/10, current plan of care identified difficulty falling asleep or staying asleep with the intervention of ascertaining the cause and attempt to reduce or eliminate it, and make sure resident's sleep environment is as quiet and conducive to sleep as possible. The 12/10/10, current physician orders [REDACTED]. The 12/10/10, physician orders [REDACTED]. Review of the 10/11/10, physician "Nursing Home Visit Note" indicated R3 complained of sleep disturbance stating help with Ambien; however, requested more improvement. The 11/5/10, physician "Nursing Home Visit Note" indicated a complaint of sleep disturbance and stated some help with the use of Ambien (hypnotic); however, requested more improvement. The 12/3/10, physician "Nursing Home Visit Note" indicated R3 had a complaint of sleep disturbance with help from the Ambien, however, requested more improvement. The 9/18/10, 5:00 a.m. interdisciplinary team (IDT) note indicated R3 received scheduled Ambien earlier in the evening, however, R3 stated she had not slept well at all. the 9/19/10, 5:00 a.m. IDT note indicated R3 received scheduled Ambien earlier in the evening, however, stated "I think I fell asleep for about 10 minutes." The 9/20/10, 5:00 a.m. IDT note indicated R3 received scheduled Ambien earlier in the evening, however, stated she had not slept all night. In addition, R3 also stated she was going to "kill" another resident because of his yelling. The 9/25/10, 2:30 a.m. and 3:40 a.m. IDT note indicated inability to sleep due to another resident yelling. The 10/22/10, IDT note indicated R3 received Ambien for insomnia, and Trazodone for sleep. The 12/8/10, IDT note indicated R3 received Ambien, and Trazodone for sleep disturbance, insomnia. On 12/13/10, at 6:19 p.m. R3 stated R36 screamed all night and sometimes all day and added, it was "making her crazy." R3 stated "what sleep" when asked if this disrupted her sleep pattern. R3 also stated that she would fall asleep in the middle of the day, right in the middle of things when kept up at night due to the screaming. R3 verified she was unable to sleep due to the disruption 5 nights a week. In addition, R3 stated she had informed staff, the director of nursing, and the social worker regarding this stating she was informed to "be patient" and "we will look into this." On 12/14/10, at 8:10 a.m. R3 stated R36 yelled during the night; however, stated "not that bad." On 12/15/10, at 7:25 a.m. R3 stated she had not slept well during the night due to R36's continual yelling. On 12/16/10, at 8:40 a.m. R3 stated she had slept "so-so" due to R36 yelling intermittently throughout the night. In addition, R3 stated she "might live a little longer without that disruption." On 12/15/10, at 7:03 a.m. NA-A stated "a lot" of residents are complaining about R36 screaming and yelling out. In addition, NA-A stated staff attempt to move R36 away from other residents; however, added R36 "screams even louder." NA-A also verified R36 screams and yells out on a daily basis, all hours of the day and night effecting other residents' sleep. At 7:14 a.m. NA-B stated R36 was "upsetting to other residents." NA-B verified R36 yells out and stated it was hard on the other residents. NA-B added, "It upsets their sleep, especially (R3), as she complained about it." At 7:20 a.m. NA-C verified R36 hollers a lot and upsets a lot of residents. In addition, NA-C verified R36 kept other residents awake during the night and they have trouble getting back to sleep. NA-C also stated the other residents have complained to staff about this. At 7:24 a.m. R3 stated R36 hollers on and off throughout the night. R3 stated R36's hollering made her angry and "madder than a wet dog." R3 also stated the continual hollering was "emotionally frustrating." R3 also verified receiving daily hypnotics because of R36's hollering. At 8:24 a.m. R28 verified R36 hollered all day and all night and stated, "He hollers so loud it wakes me up about every night." R28 also stated he felt "draggy" during the day due to lack of sleep. At 12:29 p.m. R34 stated she had removed her hearing aides and "let him holler." At 12:45 p.m. the director of nursing (DON) verified R36's continual yelling was "annoying" to R3 and added R3 had sleep problems and, "This is not helping her." In addition, the DON indicated the psychosocial needs of the other residents that are being disrupted by R36 were being managed by having the nurses talk to those residents affected by it. At 1:24 p.m. the licensed social worker (LSW) verified other residents' well being, including their rest and meal times, was disrupted by the disturbance. The LSW also verified the disruption can last 4-5 hours at a time and stated it could be a constant disruption. The LSW also verified the disruption was very upsetting to R3 and stated R3 had informed him of her sleep pattern disturbance due to this. The LSW added, R3 was most affected by it due to her room location. The LSW also stated he did not know what to do for the residents that are affected by this disruption. R36's [DIAGNOSES REDACTED]. The 10/5/10, quarterly MDS indicated R36 was incorrect with the temporal mental status questions. The MDS also indicated R36 had daily behaviors of disruptive sounds and verbal behavior symptoms that occurred 4-6 days a week. The 2/11/10, Psychosocial Resident Assessment Protocol (RAP) indicated R36 had increasing daily disruptive behavior. The RAP also indicated R36 was verbally abusive and socially inappropriate in his remarks to staff, and occasionally to other residents or family. The RAP also indicated R36 hollered out loudly and repeatedly all hours of the day and night. In addition, the RAP indicated this behavior was very disturbing and upsetting, and sometimes frightening to other residents. The RAP went on to state R36 gets easily annoyed and angry with staff, other residents, and family. The 2/12/10, Cognitive RAP indicated R36 "gets easily annoyed with staff and others." The RAP also indicated R36 hollered out a lot of the time and was very disturbing to other residents. The 2/12/10, Behavioral RAP indicated R36 hollered out at all times of the day and night and was very disruptive to other residents to the point of causing other residents to have behaviors or requiring other residents to take more medications to help them with their sleep or increased anxiety. The 2/10/10 through 12/10/10, daily "Behavior Monitoring" forms revealed disruptive behaviors occurring multiple times per day. The 10/14/10, current plan of care identified episodes of inappropriate behavior which was not easily altered. The listed intervention was to inform the resident that the behavior was inappropriate. The plan of care also identified the potential for physical and verbal abuse by others and the potential to afflict abuse on other vulnerable adults. The listed interventions included removing R36 away from other residents that could harm him, or when R36 could harm others. Staff was also directed to keep R36 a discreet distance from the other residents and to informally monitor for abuse. The 1/24/09, Social Service Note indicated R36's shouting was disruptive to other residents, visitors, and staff. In addition, the note indicated some residents get irritated and have complained they can even hear him when their doors are closed. The 9/7/09, Social Service Note indicated R36 was in open conflict with severe impatience with staff and other residents repeatedly throughout the day and night. In addition, the note indicated R36's repertoire of behaviors and mood are extremely annoying to and sometimes frightening to other residents who are within 150 feet of his room, even when his door and their doors were closed. The note also indicated R36's yelling can be heard as far away as the south nurse's station. Also, the note indicated it was the worker's opinion that R36's behavior was becoming more than the facility was equipped to handle. The 11/22/09, Social Service Note indicated R36's behavioral outbursts were getting to the point that other residents were becoming annoyed with him because of the yelling, vulgarity, and anger, and the behavior was disturbing their peace, rest, and sense of security. The 2/6/10, Social Service Note indicated R36 was frequently verbally abusive and social inappropriate in his remarks to staff and occasionally other residents or family. R36 hollered out loudly and repeatedly which is very disturbing and upsetting, and sometimes frightening, to other residents. The note also indicated R36 got easily annoyed and angry with staff and other residents, and family. The 6/1/10, IDT note identified the facility had increased in the number of complaints from other residents related to R36 yelling out at various times of the day and night. The 6/5/10, 6:30 a.m. IDT note indicated R36 yelled out during the night and was disruptive to the other residents. The 5:00 p.m. IDT note indicated R36 continued to yell throughout the day and night for the past two days. The 6/7/10, 6:30 a.m. note indicated R36 yelled out several times during the night. The 4:00 p.m. IDT note indicated R36's son was informed of the other residents complaining about the frequent night time hollering out. The 6/28/10, Southern Minnesota Community Support Services, Linking Elderly Supports (LES) form indicated R36 was disruptive to his peers. The form also indicated recommendations for medication changes for the disruptive, inappropriate behaviors. The 7/10/10, "Southern Community Support Services" form indicated R36 was referred to the Linking Elderly Supports (LES) program related to increased hollering out, delusions, hallucinations, and disturbing peers which has increased behaviors in other residents. The previous LES form dated 6/15/10, also indicated R36 disturbed his peers. The 7/15/10, physician "Nursing Home Visit Note" indicated R36 had an anger problem and agitated depression. The 7/22/10, 6:30 a.m. IDT note indicated R36 had been yelling out periodically all night which was very disruptive to the other residents. The 7/27/10, night shift IDT note indicated R36 yelled out randomly during the night with inability to redirect the behavior. The note also indicated the behavior was disruptive to the other residents "who were trying to sleep." The 7/27/10, 9:00 p.m. IDT note indicated R36 yelled out during the day and evening shifts and when attempts made to redirect, R36 yelled out louder. The 7/31/10, 4:30 a.m. IDT note indicated R36 yelled out all night. The 8/2/10, 8:30 p.m. IDT note indicated R36 was very angry, yelling and swearing at everyone. The 8/13/10, PM IDT note indicated R36 was very disruptive in the dining room yelling at staff and other residents. The note also indicated the behavior was very disturbing and upsetting to the other residents. The 8/17/10, PM note indicated R36 yelled many times this shift. The 9/4/10, 6:30 a.m. IDT note indicated R36 was swearing and yelling out. The 9/12/10, 9:30 p.m. IDT note indicated R36 yelled out from 6:30 p.m. until 9:30 p.m. with no requests or needs. The 9/19/10, 4:00 a.m. IDT note indicated R36 was yelling out periodically during the night The 9/28/10, 2:00 a.m. IDT note indicated R36 yelled out multiple times and denied any needs when asked, stating "nothing." The 10/3/10, 1:30 a.m. IDT note indicated R36 yelled and called out most of the night. The 3:15 p.m. note indicated R36 had done "a lot of yelling" this shift. The 10/4/10, IDT review note indicated R36 was verbally loud and yelling at staff and others and at times just yells or screams for no reason and directed at no one. The 10/11/10, "Care Conference Summary" indicated behavior problems such as yelling out, disturbing other residents. The 10/14/10, 10:00 a.m. note indicated R36 had continual yelling for two hours with staff inability to redirect. The 10/18/10, p.m. IDT note indicated R36's yelling continued to increases without ability to redirect. The 10/21/10, physician "Nursing Home Visit Note" indicated R36 had been "more of a behavior" problem indicating the physician did not have a solution to the behavior and indicated the need to continue to monitor the behavior. The 10/23/10, p.m. IDT note indicated R36 hollered out and was disruptive to the other residents and indicated those behaviors created anxiety in residents on the south end where his voice carries. The 10/28/10, PM IDT note indicated R36 hollered out constantly from 2:00 p.m. until 6:50 p.m. which disturbed many other residents whom expressed great aggravation and frustration to staff when he yells. An additional 10/28/10 PM IDT note also indicated R36 was very disruptive all shift, yelling and calling out very frequently. The note also indicated R36 had to be removed from the dining room for yelling. In addition, the note indicated other residents were openly discussing R36's behaviors and later were yelling from the their rooms for R36 to "shut up." The note also indicated when redirection was attempted R36 "yelled all the more." The 11/3/10, 1:30 p.m. IDT note indicated R36 continued to yell out loud and denied needs when asked and then would resume yelling after attempts made to meet needs. The 11/5/10, night shift IDT note indicated R36 yelled out and continued to yell out after attempts made by staff to redirect. The 11/11/10, 1:30 a.m. IDT note indicated R36 was yelling loudly and was very disruptive with other residents complaining of inability to sleep due to the disruptive behavior. The 3:00 a.m. IDT note indicated R36 continued to yell out and was very disruptive to the other residents. The 11/11/10, PM shift IDT note indicated between 3:00-4:00 p.m. R36 obsessively yelled out and while in the dining room for the supper meal R36 was habitually yelling out "clearly" disturbing the other residents. R36 continued to yell out until assisted to bed at 7:00 p.m. The 11/13/10, 5:00 p.m. IDT note indicated R36 was yelling since 2:00 p.m. The 5:30 p.m. note indicated R36 was extremely disruptive to other residents due to yelling out constantly. In addition, the note indicated other residents voiced many complaints about how the yelling was offending an interfering. The 11/18/10, physician "Nursing Home Visit Note" indicated R36's behavior of yelling out and acting up had worsened. Medications changes were made. The 11/18/10, 11:00 a.m. IDT note indicated staff reported R36's behaviors over the past three days had increased alternating sleeping or awake and yelling with no requests to address. The 12:15 p.m. note indicated R36 was yelling at another (unidentified) resident by swearing at them. The note also indicated the other residents was very upset about this. The 11/21/10, PM IDT note indicated R36 was yelling in the north day room causing three residents who were in there watching TV to leave. The 11/28/10, PM IDT note indicated R36 was yelling and swearing in the dining room during supper with the inability to redirect. The 11/30/10, "Data Collection/Assessment" form for pain indicated R36 continued to call out frequently with recommendations being made to manage those behaviors. The 12/5/10, PM IDT note indicated R36 was continually yelling out "help me" and "get me out." The 12/10/10, 4:30 a.m. IDT note indicated R36 yelled throughout the night denying any needs. The note also indicated after attempts were made to redirect the resident, R36 continued to yell loudly disturbing everyone. The 6:30 p.m. IDT note indicated R36 was persistently yelling in the dining room and continued to yell after relocated. The 12/10/10, 8:45 p.m. IDT note indicated R36 yelled continuously for no reason at all. The note also indicated R36 was removed from the dining room due to the disruptive behaviors that caused the other residents to tell him to "shut up." The 12/12/10, 8:00 p.m. IDT note indicated R36 was "very rude and nasty" all shift and upsetting to all the residents on the north end of the facility. The 12/13/10, "Nursing Data Collection" form indicated R36 had become more hostile, possibly related to recent medication changes and indicated R36 "rarely" sat awake and quiet. The behavioral section of the form indicated verbal behavioral symptoms such as screaming and cursing at others occurred on a daily basis. The 12/13/10, 9:00 p.m. late entry IDT note for 12/13/10 10:15 a.m. indicated R36 had increased aggressive comments that were more hostile in nature. A medication change was ordered at this time by the physician. The 12/14/10, 10:44 a.m. IDT note indicated R36's behaviors and interventions were reviewed. The note also indicated the LES consultant stated they felt they were at the "end of the road" and agreed that referral to a behavioral unit was appropriate. In addition, the note suggested allowing R36 to eat supper in the north day room to prevent retaliation remarks from the other residents. The 12/14/10, 4:30 p.m. IDT note indicated the family would discuss R36's behaviors and options with the primary physicians the following day. On 12/14/10, at 2:25 p.m. R36 was observed in bed, snoring. At 3:00 p.m. R36 was observed sitting in his wheelchair quiet, appearing to be sleeping. On 12/15/10, at 7:09 a.m. R36 was observed in his wheelchair near the dining room. R36 appeared to be sleeping. On 12/15/10, at 12:15 p.m. R36 was observed in his wheelchair in the north day room. R36 was observed to holler out with a loud tone. Staff intervened and assisted R36 to his room. A short time later R36 was observed in his bed appearing to be sleeping. At 2:00 p.m. R36 was observed seated in his wheelchair yelling out. Staff intervened and assisted R36 back to his room and assisted him to bed. R36 was intermittently observed sleeping in his bed or wheelchair throughout the day. On 12/16/10, at 8:40 a.m. R36 was observed dressed, sleeping on top of his bed covers. On 12/15/10, at 7:03 a.m. NA-A verified a lot of residents had complained about R36 screaming. NA-A stated staff try to move him away from other residents and R36 screams even louder. NA-A stated R36 screams and yells out on a daily basis all hours of the day and middle of the night, and this sometimes effects other residents' sleep. At 7:14 a.m. NA-B verified R36 was upsetting to other residents and stated, "They don't care for the yelling" and added, "It is hard on them." At 7:20 a.m. NA-C stated R36 hollered a lot and upset a lot of the other residents. NA-C also verified R36 kept other residents awake at night due to the yelling and they had difficulty falling back asleep. NA-C stated the other residents had complained to staff about this. On 12/15/10, at 12:45 p.m. the DON verified R36's behaviors had fluctuated since admission to the facility. She stated R36 was a lifetime community member and added the facility "had been up against that from the start." She indicated R36 "hated" moving to the nursing home. In addition, the DON verified informing the family and physician of the escalating disruptive behaviors and stated both did not want R36 transferred to another facility, rather, they agreed to the in house LES consultation review. The DON went on to state R36's behaviors was managed with medication. She added the Senior Behavioral Unit was contacted regarding a transfer there; however, R36's family had declined. The DON verified the LES consultant started in 7/10/10. The DON also indicated R36 was on the Veteran's Home waiting list; however, was #39 on the list for admission. The DON also stated the Veteran's Home had recently informed the facility they would not accept a resident that had disruptive behaviors that affected other residents. The DON indicated LES reviews R36's behaviors by periodic faxes and in house evaluations regarding behavior medications and interventions with medication change recommendations made. The DON stated this past weekend other residents were hollering "shut up" at R36. She verified the staff had informed her R36 had a more hostile "look to him." In addition, the DON verified LES services informed the facility that it was time to look at a potential transfer to a behavioral unit stating they had tried everything. The DON stated the physician was informed of the transfer recommendation; however, the physician declined the transfer stating R36 was from our community and had requested to keep him in the facility until an opening to the Veteran's Home was created. The DON stated the family was also informed of the transfer recommendation; however, also declined a transfer. Medication changes were made after the decision to decline a transfer was made. The DON stated the physician requested to try a medication change first. When asked about the other residents' psychosocial needs, the DON stated we just have the nurses talk to those residents affected. The DON also verified all staff were aware of the disruptive yelling and the affect it had on the other residents. At 1:24 p.m. the LSW indicated R36's behaviors such as shouting, verbal, physical and sexual abuse, had been deteriorating. The LSW stated R36's shouting, yelling, and disturbance at night, at suppertime, and at other times during the day too, had increasingly gotten worse. The LSW stated he had informed the physician of R36's disruption of other residents rest, meals, and the refusal of staff to work extra shifts due to the inability to emotionally handle R36's behaviors. The LSW verified R36 yelling could continue for 4-5 hours at a time and stated it was constant and had continually gotten worse in the last 3-4 months. In addition, the LSW stated the facility can not transfer R36 "anywhere else" and verified there is "nothing we can do." The LSW stated that when other residents ask for additional medication to help them sleep due to the disruption, "They will get it." The LSW also indicated he had informed the physician that the other residents were getting very irritated and yelling back at R36 to "shut up." The LSW stated he did not know what to do with the other residents affected. In addition, the LSW stated recently while in the dining room, another resident yelled at R36 to "shut up" and R36 replied "you can't make me do it." The LSW indicated R36 was "status quo" while the facility attempted to locate assistance with the behavioral problems. He added, if they could get a transfer to a behavioral unit, it would give some respite to the residents and staff. The LSW also indicated staff talk about the disruptive behaviors frequently during the week to decide what to do.