Every finding on record at Essentia Health Homestead

Based on observation, interview and document review, the facility failed to ensure the care plan was followed for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm to R1 when she fell out of bed and sustained a femur (the longest, heaviest, and strongest bone in the human body, located in the upper leg) fracture. Findings include: R1's Resident Face Sheet indicated she was admitted to the facility 3/28/23. Diagnoses included Parkinson's disease, dementia, anxiety and repeated falls. R1's comprehensive Minimum data set (MDS) dated [DATE], identified severely impaired cognition. The MDS indicated R1 was dependent on staff for bed mobility and transfers. R1's John Hopkins Fall Risk Assessment Tool dated 4/30/26, indicated a low risk for falls. R1 care plan dated 5/12/26, identified a risk for falls related to diagnosis of Parkinson's disease, dementia, hallucinations, impaired mobility, weakness and decreased safety awareness. The care plan identified: Fall on 3/28/23. Interventions included: call light and personal items in reach when in room. The care plan further identified an alteration in physical mobility and activities of daily living and indicated she required the use of a mechanical lift for transfers Fall on 8/10/23. Interventions included: low bed with non-slip mat next to bed. Fall on 4/22/26. Fall description indicated R1 rolled out of bed, onto the floor and sustained a femur fracture. Fall interventions included: 30-minute safety checks. Facility Safety Event dated 4/22/26, indicated on 4/22/26, at 7:00 a.m., R1 had a fall from her bed. R1's bed had been raised to working height so staff (nursing assistant (NA-A)) could get R1 ready for the day. NA-A left the room to get assistance from another staff member and when they returned, R1 was observed on the floor. R1's Resident Progress Notes indicated the following: 4/22/26, Writer was called to [R1's] room at 7:00 a.m. Upon entering room, R1 was on the floor on her right side next to the bed. R1 appeared to have rolled out of bed. No visible injury to torso, hips, head or face. 4/22/26, At 7:15 p.m., R1 was crying in bed and stated she hurt. Administered pain medication and R1 fell asleep. 4/23/26 at 8:45 a.m., While providing morning cares, R1 complained of pain with movement of right hip. R1 said ouch, ouch when attempting to reposition. Facial grimacing and guarding noted. R1 was taken to radiology for imaging. 4/23/26, 10:07 a.m., Computed Tomography (CT) scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) returned negative for fracture. 4/24/26, 9:31 a.m., R1 was crying and leaning in her chair in the morning, and stated, I hurt. 4/24/26, 12:54 p.m., Bruise noted to R1's inner right leg, above the knee to the abdomen. Bruise measured 6.6 centimeters (cm) x 5.4 cm. No swelling in bruised area but upper thigh was swollen. Tenderness on palpitation of area. 4/25/26, 1:25 p.m., Writer was called to [R1's] room to assess her right leg. Inner thigh had a large blue/purple bruise covering most of the area. Right thigh appeared swollen and larger than the left. R1 reported pain with movement of knee. 4/25/26, 2:25 p.m., X-ray of R1's right thigh and knee performed. 4/25/26, 3:30 p.m., X-ray indicated displaced (broken bone ends have shifted out of their normal, anatomical alignment) fracture extending from the lower femoral shaft to the metaphysis (section of bone located between the rounded end of the bone and the long, straight shaft). During interview on 5/18/26 at 12:51 p.m., NA-A stated on the morning of 4/22/26, staff had been getting residents up for the day. NA-A stated she got R1 ready and placed the mechanical lift sling underneath her. NA-A left R1's room to get another staff to assist and forgot to put R1's bed back down. R1's bed was about three feet from the floor. NA-A stated for a few days following the fall, R1 had seemed her normal self, then started having pain. NA-A stated following the fall she met with the administrator and the director of nursing (DON) and received education related to following the plan of care and had to complete a packet of training as well as online training. During interview on 5/18/26 at approximately 1:30 p.m., registered nurse (RN)-A stated prior to R1's fall she had not been able to bear weight and had contractures (a permanent or semi-permanent tightening of muscles, tendons, skin, or other soft tissues that cause joints to become stiff and restrict normal movement). RN-A said after R1 fell; she had a CT scan of her pelvis. RN-A said the fracture had not been identified during the CT scan. RN-A stated since the fall, R1had to remain in bed because she was unable to use the mechanical lift due to the fracture. During interview on 5/18/26 at 1:42 p.m., the DON stated NA-A lifted R1's bed to perform cares. When NA-A stepped out to get help, R1 fell out of bed. The DON stated staff received education related to following the care plan. Audits were implemented related to awareness of the care plan, following the care plan and following safety interventions. During interview on 5/18/26 at 2:08 p.m., the medical director (MD) stated R1 had fallen and had a CT performed which showed no fracture. MD said R1 displayed high anxiety and difficulty communicating. A few days after the fall, R1 had increased pain and x-rays showed a fracture. The MD stated the fracture was a result of R1's fall from bed. Facility policy Care Planning - Care Conferences dated 9/15/25, indicated direct care staff are expected to follow the care plan as written to provide consistent, safe, resident centered care. Following the care plan supports the residents' highest practicable level of physical, mental and psychosocial well-being. The Past Noncompliance began on 4/22/26 when NA-A left R1 unattended with her bed raised to working height resulting in R1 falling from the bed and sustaining a femur fracture. The deficient practice was corrected by 4/23/26, after the facility provided education to NA staff related to following the plan of care and developed and implemented audits to ensure care plan compliance, safety interventions and care plan awareness. The education was verified through interview and document review.

Based on observation, interview, and document review, the facility to disinfect a point of care glucose monitor between the use for 2 of 2 residents (R5, R18) who were observed to have their blood glucose checked. Findings include: R5's admission Minimum Data Set, dated [DATE], identified R5 had a diagnosis of diabetes mellitus (DM) and received insulin on a regular basis. R5's care plan dated 4/1/26, identified to monitor blood glucose (sugar) per orders. R5's orders dated 3/10/26, identified to have blood sugar checked three times a day. R18's quarterly MDS dated [DATE], identified R18 had a diagnosis of DM and received insulin on a regular basis. R18's care plan dated 3/5/26, identified to monitor blood sugar per order. R18's orders dated 4/15/26, identified R18 was to have blood sugar checked 4 times a day. During observation on 4/20/26 at 4:37 p.m., registered nurse (RN)-A used the point of care glucose monitor and obtained a blood sugar on R5. RN-A then placed the glucose monitor on R5's overbed table while RN-A administered R5's insulin and other medications. Upon exiting R5's room RN-A placed the glucose monitor on the medication cart and returned to the nurse's station. The glucose monitor remained undisinfected on the medication cart. R18 then approached RN-A and asked to have their blood glucose checked before supper. RN-A sanitized her hands, put gloves on, then reached for the undisinfected glucose monitor and proceeded to obtain R18's blood sugar without disinfecting the glucose monitor. During an interview on 4/20/26 at 4:45 p.m., RN-A stated she only disinfected the glucose monitor at the end of her shift and had not been disinfecting it between residents. During an interview on 4/20/26 at 4:55 p.m., the interim director of nursing (DON) stated glucose monitors were to be cleaned between use with each resident to prevent spread of infections. All nurses were trained when hired on the policy regarding disinfecting glucose monitors. The facility's Cleaning and Disinfecting the Glucose Monitor, dated 1/22/25, identified staff were to clean and disinfect the glucose monitor after each patient use.

Based on observation, interview and document review the facility failed to ensure care planned interventions were implemented to reduce the risk for falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm to R1 who fell from her wheelchair and sustained a fracture, head injury and lacerations to her hand. Findings include:R1's Continuity of Care Document created 4/1/26, indicated she admitted to the facility 1/5/22. R1's diagnosis included aphasia (communication disorder- may affect written and spoken language as well as ability to understand), dysphagia (difficulty swallowing) muscle weakness and dependence on enabling machines and devices for transfers.R1's John Hopkins Fall Risk Assessment Tool dated 1/5/26, indicated a high risk for falls.R1's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated she required substantial/maximal assistance for transfers. The MDS indicated R1 was dependent on staff for transport in a manual wheelchair.R1's care plan dated 3/23/26, identified a problem related to wheelchair transport safety and positioning. The care plan directed staff to ensure R1 was fully positioned and supported in wheelchair prior to transport, verify footrests were in place prior to transport and monitor for leaning, sliding or unsafe positioning. The care plan identified a risk for falls related to diagnosis of traumatic brain injury, aphasia and impaired mobility. Care planned approach dated 9/13/22, directed staff to ensure wheelchair pedals were on at all times.A facility Event Report dated 3/21/26, indicated R1 sustained a fall out of her wheelchair at 7:30 p.m. in her room. No suspected head injury was identified. The report indicated R1 was able to communicate but refused to make a statement. R1's fall was witnessed by staff. The report indicated R1 was being pushed in the wheelchair after her shower, leaned forward in the chair and fell out of it.R1's Progress Notes identified the following:3/22/26 at 1:35 a.m., Writer received call from the emergency department (ED) stating they would be admitting R1 for a thoracic fracture.3/22/26 at 8:26 a.m., Xray result indicated highly suspicious for T12 (12th thoracic vertebra at the base of the mid-back) fracture. 3/22/26 at 9:19 a.m., R1 had an abrasion to her forehead and a bruise to her left knee. R1 also had two lacerations on her right hand. 3/22/26 at 10:22 a.m., R1 had two different areas that she lacerated on her right hand, fourth finger base and sutures intact upon removal of splint. R1's entire hand was black and blue and swollen. R1 had two sutures on the outside and nine on the inside. R1 had pain in the hand.3/22/26 at 3:21 p.m., late entry note for 3/21/26. At 7:30 p.m., after shower, nursing assistant (NA) was wheeling R1 to her room. While going through the doorway, R1 leaned forward and fell out of her wheelchair. Upon assessment, R1 had a laceration on her right hand, a lump on her head and a bruise on her left knee. R1 was transferred to the ED. 3/23/26, ED physician Visit Note; R1 arrived from the facility following a fall out of her wheelchair resulting in abrasions and injury to her forehead, left knee and right hand. According to camera footage, R1 fell out of the wheelchair when she was being transported to her room in the wheelchair. The wheelchair hit the door frame stopping the chair with R1 then falling out of the chair. Assessment indicated a head injury with concussion, left upper mid head abrasion and contusion, T12 fracture and right hand laceration that required repair with sutures.During observation on 3/31/26 at 11:27 a.m., R1 was seated at a table in the dining room. R1 had a bandage on her right hand. Foot pedals were observed on R1's wheelchair.During interview on 3/31/26 at 2:14 p.m., NA-A stated R1 had received a shower and when she transported R1 from the shower room to her room, she had not put the foot pedals on the wheelchair. NA-A stated when she wheeled R1 into her room she hit the doorframe with the right side of the wheelchair. NA-A said R1 had begun to lean forward in the chair and fell onto the floor. NA-A stated she was aware she should have had the foot pedals on the wheelchair but had not put them on since she was only transporting R1 from the shower to her room. NA-A stated, following the incident, she received education related to following the care plan and was required to demonstrate transfers and transports more than once.During interview on 3/31/26 at 2:26 p.m., the director of nursing (DON) stated the care plan had not been followed when R1 had fallen. The DON stated after the incident, education had been completed with NA- A and ongoing audits had been implemented to ensure safe transport and to ensure staff were following the plan of care.Facility policy Activities of Daily Living Standards of Care dated 9/10/25, indicated a plan of care was developed for each resident based on assessment, preferences, choices and standards of care. All staff will be responsible for knowing and following the individual plan of care for each resident. The Past Noncompliance began on 3/21/26 when NA-A was assisting R1 in her wheelchair from the shower room to R1's room without use of foot pedals. R1's wheelchair hit the door frame of R1's room. This caused R1 to fall from her wheelchair which resulted in R1 sustaining a fracture, head injury and lacerations to her hand. The deficient practice was corrected by 3/22/26, after the facility provided education to NA staff related to following the plan of care and developed and implemented audits to ensure care plan compliance and safe wheelchair transfers and transport. The education was verified through interview and document review.

Based on observation, interview and document review, the facility failed to ensure an un-licensed nursing student (NS) was supervised during resident medication administration, including significant medication such as insulin, liquid morphine and other controlled substances. In addition, NS did not possess a nursing license, competencies, or skills set to provide necessary resident nursing services nor other certification required for medication administration. This had the likelihood for a serious adverse outcome and placed 4 of 4 residents (R2, R3, R6, R7) in immediate Jeopardy (IJ). The IJ began on 12/12/25, when the NS was observed administering insulin to a resident without direct supervision by a licensed nurse. The administrator was notified of the immediate jeopardy at 5:05 p.m. on 12/16/25. The immediate jeopardy was removed on 12/17/25, 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: R2's Resident Face Sheet indicated diagnosis of respiratory disease, dementia with mood disturbance, chronic pain and delusions. R2's care plan dated 9/25/25, identified a risk for alteration in comfort related to pain and identified the use of antipsychotic medication and indicated medications per orders. R2's Physician's Order Report dated 12/17/25, identified the following order: -12/26/23, Hydromorphone- schedule II (controlled substance) liquid; 1 milligram (mg)/milliliter (ml). Amount 2 ml's by mouth every hour as needed. Up to 24 times per day. R2's Individual Narcotic Record identified hydromorphone 1 mg/ml. The record indicated the NS administered the medication on 11/10/25. R2's Medication Administration Record (MAR) dated December 2025, indicated the NS administered R hydromorphone 1 mg/ml medication on 12/5/25 and 12/12/25. R6's Resident Face Sheet indicated diagnosis of pain, hypertension, respiratory failure and diabetes. R6's care plan dated 11/26/25, identified altered endocrine function related to type II diabetes. The care plan directed staff to monitor blood glucose per physician orders and monitor signs and symptoms of hypo or hyperglycemia. The care plan further directed staff to administer medications and ordered. R6's Physician Order Report dated 12/17/25, identified the following orders: -3/26/25, hydrocodone- acetaminophen- schedule II tablet 5 mg-325 mg. Amount 1 tab twice daily as needed. -9/9/24, Accuchecks, notify certified nurse practitioner if below 70 readings are noted. -4/3/25, Humolog KwikPen Insulin (insulin lispro) pen; 100 unit/ml; amount eight units subcutaneous (sq) (fatty tissue just under the skin). Give eight units three times daily with meals. -4/4/25, Lantus U-100 Insulin (insulin glargine) solution; 100 unit/ml. Amount 40 units sq. Once daily between 6:00 a.m. and 10:00 a.m. R6's Individual Narcotic Record identified hydrocodone/acetaminophen- schedule II 5mg/ 325mg, one tab as needed. The record indicated NS administered the medication on 11/10/25. R6's Medication Administration Record (MAR) dated December 2025, indicated the NS performed accuchecks and administered medication, including insulin, to R6 on 12/5/25 and 12/12/25. During observation on 12/12/25 at 11:34 am., the NS administered insulin to R6 via insulin pen, unsupervised. When interviewed, the NS stated she was working at the facility as part of an apprenticeship program and said she was still in school. The NS stated, I can do basically almost anything except a select few things. The NS stated she did not perform treatments but passed medications, completed blood glucose checks and gave insulin. NS said she normally checked with the nurse when giving insulin because she was not comfortable with it but acknowledged she had not checked with the nurse when she gave R6's insulin during observation. NS also indicated the program was newer and there were a lot of things that were not clear regarding skills she was allowed to perform. When asked how she knew what skills she could and could not perform, NS said she had a sheet somewhere but did not have it with her. At 12:36 p.m., the NS confirmed she was not a trained medication aide. On 12/12/25 at 12:06 p.m., the NS was observed performing a blood glucose check independently, without supervision. It was noted during all observations of NS medication administration, Registered Nurse (RN)-A was seated in a glass enclosed office, located behind the nurse station, not in sight of NS during her task. R7's Resident Face Sheet indicated diagnosis of Alzheimer's, dementia, anxiety, depression and chronic pain. R7's care plan dated 12/16/25, identified pain and directed staff to administer medications per orders and monitor and record effectiveness. The care plan identified the use of psychotropic medications and directed staff to monitor for effectiveness and adverse consequences. R7's Physician Order Report dated 12/17/25, identified the following medications: -10/23/25, Tramadol- schedule IV tablet 25 mg. Amount: 75 mg by mouth two times daily. -11/12/25, Lorazepam- schedule IV tablet; 0.5 mg by mouth. Can take 0.5 mg every four hours as needed for agitation/anxiety/restlessness. -10/23/25, Morphine concentrate- schedule II solution; 100 mg/5 ml (20mg/ml). Amount 0.5 ml by mouth every hour as needed up to 24 times per day. R7's Individual Narcotic Record identified Morphine 100 mg/ 5 ml. take 1/2 ml every hour as needed. The record indicated the NS administered the morphine twice on 11/17/25 and once on 12/8/25. R7's MAR dated December 2025 indicated the NS administered the morphine medications to R7 on 12/5/25 and 12/12/25. During interview on 12/12/25 at 2:10 p.m., RN-A was asked what duties the NS was able to perform. RN-A pointed to a list taped to a cabinet that indicated the NS could administer medications after competency was verified and said she had not seen the competencies (completed by NS) but said they should have been completed prior to being released to work on the floor. During interview on 12/16/25 at 9:21 a.m., the director of the associate degree programs for the college where the NS was a student, stated the apprenticeship program utilized the Essentia Health intern student guidelines and according to Essentia the student was supposed to be supervised. The director said the student was supposed to be paired with a preceptor and said the NS was assigned to RN-A and two other nurses. The director stated the apprenticeship program was not designed to have the students working as a nurse on the floor without supervision. During interview on 12/16/25 at 2:33 p.m., the administrator stated her understanding of the nurse apprentice was once they had competencies completed, they could treat the students like new nurses on orientation. The administrator further stated she had spoken to the DON who said she had not completed competencies with the NS. The administrated believed NS started at the building around September of 2025, adding she was never on the schedule but could not provide a date as to when NS may have started passing medications unsupervised. During interview on 12/17/25 at 3:02 p.m., RN-A stated she had not been given guidance regarding what the NS was able to with or without supervision. RN-A said she kept asking so the director of nursing posted a list on the cabinet that outlined what tasks the NS could perform after a competency had been completed. RN-A stated she was unable to attend the training to be a preceptor, so she did not believe she had been assigned. RN-A confirmed she was not NS preceptor on 12/12/25 (onsite survey date) and was the only RN on duty. An Essentia Health document titled Nursing Student Guidelines dated 9/2024, indicated medication administration by mouth, sq, intramuscular, inhaled or topical could only be administered under direct supervision. During interview on 12/29/25 at 5:01 p.m., the medical director stated he had concerns about staff working outside the scope of practice and said insulin and controlled substances had a higher risk for negative patient impact and diversion. The immediate jeopardy that began on 12/12/25 was removed on 12/17/25, after the facility implemented a systemic plan that included the following actions: The nurse apprenticeship program was reviewed. Nurse apprentice to receive re-education on program expectations prior to returning to work. All staff responsible for administering medications and/or supervising a nurse apprentice were educated on the [NAME] apprentice program and have reviewed the orientation education agenda. All resident records were reviewed for medication errors.

Based on interview and document review the facility failed to implement a grievance process for 1 of 8 residents reviewed who expressed care concerns to the facility. Findings include: R1's annual Minimum Data Set, dated [DATE], identified intact cognition and diagnosis of fractures, heart disease and dependence on enabling machines. R1's care plan dated 12/18/25, identified an alteration in mobility related to fracture of lumbar spine, weakness and pain. The care plan directed staff to transfer R1 using a mechanical lift. An electronic (e)-mail from R1 to the director of nursing (DON) and administrator dated 11/12/25, indicated the following:R1 wrote, Asking for help with two issues. On 10/12/25, during transfer to the shower chair something went wrong and R1 ended up with a giant and very painful bruise on the inside of his leg. After the incident for approximately two plus weeks, it was too painful to transfer, so other than two times he did not get up for lunch and except for shower days he remained in bed. Recently at 3:00 p.m., R1 asked to transfer from the bed to the recliner and was told staff would be too busy to transfer him back to bed until around 8:00 p.m. R1 wrote that he recently asked five times to be transferred into his recliner for lunch and had been turned down because staff could not fit him in. R1 also identified a concern related to a pillow that was missing from his room that enabled him to sit up straight in his chair. During interview on 12/16/25 at 9:50 a.m., R1 stated he sustained an injury related to a transfer from his bed to a shower chair. R1 said after he recovered from the injury that left him unable to transfer due to the pain, one of the staff told him he had lost his spot and not enough staff were available to help him out of bed. R1 further stated he had concerns related to a pillow that was missing and said he needed to the pillow to remain upright when seated in his chair. R1 said he sent an e-mail to the DON and the administrator expressing concerns about not getting transferred from the bed and also about the pillow. R1 said neither had responded and said it had been very disappointing. R1 said by chance someone from Essentia came by to see him and asked how things were going and he reported the concerns to her. R1 said a few days later someone from therapy came and brought him a pillow and when he asked for a transfer, he was transferred out of bed. During interview on 12/17/25, at 8:44 a.m., Essentia Health care coordinator (CC) stated she had visited with R1 on 11/17/25, and he expressed concerns about wanting to get up during the day, and about a missing pillow. The CC stated she had spoken with the DON about R1's concerns. The CC said R1 sent her an e-mail on 11/19/25, and said nothing had happened so she had reached out to the social worker. The CC said she received another e-mail from R1 on 11/20/25, that the concerns had been taken care of. During interview on 12/17/25 at 2:05 p.m., the administrator stated the facility grievance officer was the DON. The administrator said she had received an e-mail from R1 that had been sent to the DON and herself about transfer times and staff reporting they were too busy and also about the pillow. The administrator said the DON had told her she would handle it. The administrator said the concern should have been written up as a grievance and said she did not know why it had not happened. Facility policy Resident Grievances dated 4/12/24, indicated a resident's right to voice a grievance orally or submit a formal, written grievance or an anonymous grievance. The facility will take prompt efforts to respond to and resolve grievances, including facility acknowledgment of the grievance and actively working toward a resolution. The grievance official or designee may assign the investigation, evaluation and determination of action steps to a member of the interdisciplinary team. The grievance official or designee will oversee the process and review all information and action steps and if needed, will work with the Interdisciplinary team member to formulate a response to the resident or resident representative. The grievance official or a member of the team will communicate the findings and grievance decision to the resident or resident representative. The grievance official or designee will track the grievance through to conclusion.

Based on observation, interview and document review the facility failed to ensure staff utilized the proper sling sizes when performing transfers via mechanical lift for 4 of 5 residents (R1, R2, R4, R5) who utilized a mechanical lift for transfers. Findings include: R1's annual Minimum Data Set, dated [DATE], identified intact cognition and diagnosis of fractures, heart disease, obesity and dependence on enabling machines. R1's care plan dated 12/18/25, identified an alteration in mobility related to fracture of lumbar spine, weakness and pain. The care plan directed staff to transfer R1 using a mechanical lift but lacked evidence of a sling size. R1's Essentia Lift and Move Profile dated 9/20/25 indicated the need for a full body lift, indicated he was not able to lift himself into a standing position and indicated he did not weigh less than 265 pounds (lb.) The assessment indicated sling size LL (purple), 220-350 lbs. R1's care plan dated 10/8/25, identified an alteration in physical mobility related to fracture to lumbar spine with surgical fixation, weakness, pain and medications. The care plan directed staff to assist with transfers using a mechanical lift but lacked evidence of a sling size. R1's Progress Notes identified the following:10/15/25, Bruise noted to R1's right inner thigh measuring 9.7 centimeters (cm) x 5.8 cm. Very dark in color and is swollen enough to see dimples where each piece of hair inserts into the skin. Swelling, hard and approximately the size of a softball. The skin surrounding the contusion was reddish blue/purple and measured 25 cm x 26.5 cm. R1 stated pain rated 3-5 out of 10 resting but increased to 7-9 out of 10 when area was touched. R1 stated it was from the lift sling. Bruise was consistent with where the sling crossed under the right thigh and where it hooked to the machine. R1's records lacked evidence the facility to any further action to reduce the likelihood of another injury such as, assessment of possible sling or lift concerns, or addressing staff training. During interview on 12/16/25 at 9:50 a.m., R1 stated when he was injured during a transfer, and said sometime between the transfer from the bed to the shower chair he ended up getting a bruise on the inside of his right thigh that was gigantic. R1 said it was very painful and said a couple days later a nurse looked at it and called the physician right away to look at it. R1 said the bruise prevented him from getting out of bed for several days. During observation on 12/16/25 at approximately 11:15 a.m., nursing assistant (NA)-A and NA-B prepared to transfer R1 using the mechanical lift. The lift sling applied had royal blue edging (according to the size chart on the assessment indicated XL (308-440lbs.). A sling with orange edges (XXL, 440-550 lbs.) was on the chair next to R1's bed. R2's Resident Face Sheet indicated diagnosis of respiratory disease, dementia with mood disturbance, chronic pain and delusions. R2's Essentia Lift and Move Profile dated 11/15/25, indicated the use of a mechanical lift. The profile did not identify a sling size. R2's care plan dated 9/25/25, identified an alteration in mobility related to obesity, weakness, age and back pain. The care plan directed staff to transfer R2 with a mechanical lift but lacked evidence of a sling size. During observation on 12/16/25, at 11:30 a.m., R2 was seated in a wheelchair. Underneath R2 was a sling with purple edges, size LL according to the sizing chart. R2's weight on 12/12/25 indicated 138 lbs. According to the sizing chart on the lift and move profile 138lbs. indicated a medium sling. R4's Resident Face Sheet indicated diagnosis of Parkinson's disease, dementia, artificial knee joint and osteoarthritis. R4's Essentia Lift and Move Profile dated 11/29/25, indicated the need for a mechanical lift, indicated she was unable to stand and weighed less than 256 lbs. The profile indicated a sling size M (yellow) 121-165 lbs. R4's care plan dated 11/26/25, identified an alteration in physical mobility related to weakness, advanced age, Parkinson's disease and dementia. The care plan indicated the use of a mechanical lift for all transfers but lacked evidence of a sling size. During observation on 12/16/25 at 11:30 a.m., R4 was seated in the dining room in her wheelchair. R4 had a sling underneath her with purple edges (LL) 220-350 lbs. R5's Resident Face Sheet identified diagnosis that included diabetes, heart failure, end stage renal disease and above knee amputation. R5's care plan dated 11/18/25, identified impaired mobility and indicated use of a mechanical lift with amputee sling for all transfers but lacked evidence of a sling size. R5's Essentia Lift and Move Profile dated 10/14/25, indicated the use of a mechanical lift and a [NAME] sling (large) 166-219 lbs. During interview on 12/16/25 at 12:41 p.m., NA-A stated the sling size should be on the care plan. NA-A said they used the purple sling for R2 and said it was a size medium. For R1, they used an orange sling because it was a little bigger and had more padding, and staff used the purple edged sling to transfer R4. NA-A said he did not know where to look to determined what slings should be used and stated R5 also used a mechanical lift with a Yellow (medium) edged sling. During interview on 12/16/25 at 12:55 p.m., the interim director of nursing (DON) stated sling sizes were based on weight. The Interim DON said the lift and move assessment was used to determine size. The interim DON said each resident had their own sling in their rooms. During observation on 12/17/25 at 10:28 a.m., R5 was wheeled into the facility following an appointment. R5 was seated in a wheelchair with a sling with yellow edges underneath him. (Profile indicated Green) During interview on 12/17/25 at 10:34 a.m., the interim DON stated she did not think anyone came up with a root cause related to R1's bruise. The interim DON said the sling did put pressure on the thigh and felt it was an isolated incident but said she was unsure if anyone had assessed to ensure the correct sling size had been used. During interview on 12/17/25 at 1:57 p.m., the quality partner registered nurse (RN) said the facility policy was to follow manufacturers recommendations for proper sling size. The quality partner RN said the potential repercussions of using the incorrect sling included injury to the resident. Facility Lift Program Policy and Guide, updated, indicated all resident care would be provided in a safe, appropriate and timely manner in accordance with the care plan. The care plan team used the Essentia Health Lift Program Guide to determine the means for providing transfer and mobility assistance for residents.

Based on interview and document review the facility failed to report allegations of drug diversion to the state agency (SA) and law enforcement within 24 hours for 4 of 4 residents (R1, R2, R3, R4) reviewed for drug diversion. This had the potential to affect all residents who were prescribed narcotics.Findings include:R1's quarterly Minimum Data Set, dated [DATE], identified R1 was cognitively intact and had diagnoses including quadriplegia and neurogenic bladder. R1 required assistance for activities of daily living (ADL's), had functional limitation in range of motion with bilateral upper and lower extremities and used a motorized wheelchair for locomotion. R1 had almost constant pain which occasionally affect sleep. R1's pain was rated #7 on a 0-10 scale (0=no pain, 10=worst pain) and received scheduled and as needed (PRN) opioid medications for pain.R1's physician orders report dated 6/30/25 through 7/30/25, identified orders for oxycodone 10 mg tablet give 1 tablet orally every 4 hours as needed for pain.R2's significant change MDS dated [DATE] identified R2 had functional limitation in bilateral upper and lower extremities, required staff assistance with all ADLs except eating and diagnoses included chronic osteomyelitis, paraplegia, chronic pain syndrome, and chronic pressure ulcers. R2 had almost constant pain that was rated #8/10. R2's pain frequently affected sleep and interfered with therapy and day-to-day activities, and almost constantly interfered with therapy activities. R2 received scheduled and PRN pain medication. R2's cognition section was not completed on assessment.R2's physicians orders report dated 6/30/25 through 7/30/25, identified orders for morphine immediate release 15 mg tablet give one tablet by mouth every 6 hours as needed for pain.R3's quarterly MDS dated [DATE], identified R3 was cognitively intact, and diagnoses included arthritis, osteoporosis, dementia, bipolar disorder and muscle weakness. R3 refused to ambulate, was independent with manual wheelchair locomotion and required assistance with all other ADL's. R3 had almost constant pain that was rated a #7/10. R3's pain occasionally affected day-to-day activities, rarely affected sleep, and received scheduled and PRN pain medication.R3's physician orders report dated 6/30/25 through 7/30/25, identified orders for oxycodone 5 mg tablet give 2.5 mg (half tablet) orally every 6 hours as needed for pain.R4's quarterly MDS dated [DATE], identified R4 was cognitively intact, and diagnoses included Guillain-Barre syndrome, trigeminal neuralgia, and quadriplegia. R4 had functional limitation in both lower extremities, was independent with ADL's and used a walker and motorized wheelchair for mobility. R4 had almost constant pain that was rated #7/10. R3's pain frequently affected sleep and interfered with therapy and day-to-day activities. R4 received scheduled and PRN pain medication. R4's physician orders report dated 6/30/25 through 7/30/25, identified R4 had orders for pregabalin 150 mg give 1 tablet by mouth three times daily and tramadol 50 mg give 1-2 tablets orally every six hours as needed for painThe facility reported incident submitted to the SA on 7/14/25 at 5:30 p.m., identified the facility found evidence of diversion of narcotic pain medication of one or more residents. A facility provided list identified R1, R2, R3, R4 were including in the list of residents whos medication were divertedOn 7/30/25 at 10:43 a.m., registered nurse (RN)-A stated the narcotic medications are counted by the outgoing and incoming nurse at the start of every shift. RN-A stated on 7/1/25, RN-A worked the morning shift starting at 6:00 a.m. and was counting narcotics with the outgoing nurse who was also alleged perpetrator (LPN-A). When we got to R3's medication, the number of pills left had not matched the narcotic record. LPN-A stated she forgot to write the administrations into the record and proceeded to write in the book. RN-A didn't think anything of it because everyone got busy at times and write the administrations into the record at the end of the shift. Later that morning R3 requested pain medication. RN-A reviewed the narcotic record and couldn't read LPN-A's handwriting. RN-A looked at the MAR and the administration was not signed off. RN-A immediately reported to the DON. RN-A stated there was another resident that complained the oxycodone medication had not tasted bitter like it should when LPN-A gave the medication. On 7/30/25 at 4:19 p.m., DON stated she and the administrator suspected LPN-A may have diverted narcotic pain medication because RN-A reported LPN-A had documented narcotic medication administrations while they were counting out at the end of LPN-A's shift. Later that morning RN-A checked the book to see when the last dose was given and couldn't read LPN-A's writing. The DON stated according to the facility abuse policy suspected drug diversion should be reported to the SA within 24 hours of notification. The DON was uncertain if suspected drug diversion should be reported to local law enforcement (LE). DON stated the incident was not reported to the SA within the required 24-hour timeframe because they didn't want to make an allegation unless they were sure it occurred; however it had not been reported to LE.On 7/30/25 at 5:32 p.m., the administrator stated she was notified of the medication discrepancy regarding LPN-A on 7/1/25 when the DON and administrator decided to investigate LPN-A's narcotic medication administration documentation. The administrator stated according to the facility policy drug diversion allegations should be reported to the SA within 24 hours of notification. The administrator stated a report should have been filed with LE when they were notified of a suspected drug diversion. The allegation was not reported within 24 hours because the administrator and DON wanted to ensure there was evidence supporting the allegations first. The administrator and DON wanted to investigate the incident prior to filing an allegation. The administrator stated the allegation should have been reported to the SA within 24 hours of suspicion and should also have been reported to LE.The facility Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy reviewed 11/24, identified abuse allegations would be reported per Federal and State Law. The facility would ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of residents property, were reported . no later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. In addition, local law enforcement would be notified of any reasonable suspicion of a crime against a resident in the facility. The policy further identifies all reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff would fully cooperate with the local law enforcement designee. The policy failed to identify examples of reportable suspected crimes

Based on interview and document review the facility failed to develop policies and procedures for when to report a suspected crime to law enforcement. This had the potential to affect all residents residing in the facility.Findings include:The facility Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 11/24, identified local law enforcement would be notified of any reasonable suspicion of a crime against a resident in the facility. the policy included reporting a suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated; however, lacked further examples of crimes that should be reported.During interview on 7/30/25 at 4:19 p.m., the director of nursing (DON) stated the facility abuse policy identified allegations of drug diversion should be reported to the state agency within 24 hours of suspicion and should be reported to MN Board of Nursing. The DON did not recall what the policy identified regarding what suspected crimes should be reported or when they should be reported to law enforcement (LE).During interview on 7/30/25 at 5:23 p.m., the administrator stated she was uncertain what crimes should be reported to LE . The facility abuse policy identified allegation of drug diversion should be reported to the state agency within 24 hours of suspicion. The administrator stated the abuse policy was vague and failed to identify examples of crimes that should be reported to LE and the timeframe for reporting those crimes. The administrator stated the policy needed to be reviewed and be more detailed.

Based on interview and document review, the facility failed to accurately submit hours for the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 20 residents residing in the facility. Findings include: The facility's PB&J data for quarter four submitted to CMS for 7/1/24 through 9/30/24, identified the facility was triggered for excessively low weekend staffing, and failed to have licensed nursing coverage 24 hours/day for the following days: 31 out of 31 days during the month of July 2024, 31 out of 31 days during the month of August 2024, and 30 out of 30 days during the month of September 2024. In addition the report identified the facility triggered for no registered nurse (RN) coverage for eight consecutive hours for the following days: 31 out of 31 days during the month of July 2024, 8/1/24, 8/5/24, 8/9/24, 8/15/24, 8/19/24, 8/21/24, 8/23/24, 8/24/24, 8/25/24, 8/26/24, 8/27/24, 8/28/24, 8/29/24, 9/3/24, 9/4/24, 9/6/24, 9/7/24, 9/8/24, 9/20/24, 9/21/24, 9/22/24, 9/24/24, and 9/25/24, The facility payroll and working schedules were reviewed for 7/1/24 through 9/30/24, and identified the following: - There were licensed nursing staff 24 hours/day for all 92 days identified on the PB&J report. - There was RN coverage 8 consecutive hours for all 54 days identified on the PB&J report. During joint interview with director of nursing (DON) and RN-A on 8/27/25 at 6:02 p.m., the DON stated the PB&J data was entered by the administrator. Both the DON and RN-A stated there was always a nurse in the facility. If there was a nurse call-in and they were unable to find a replacement the previous shift would be mandated to stay. On 3/12/25 at 7:39 p.m., the administrator stated the nursing hours were entered by an off-site corporate staff member and the administrator double checked the information by running a report. The administrator stated she knew there was a corporate wide problem regarding how the information was pulled, although did not know how to correct the issue. The administrator stated accurate PB&J information is important because it showed how many, and they type of staff working, and they are working as a corporate agency on correcting the issues. A policy/procedure regarding PBJ data submission was requested but not provided.

Based on interview the facility failed to ensure residents' mail and packages were delivered on Saturdays for 2 of 2 residents (R2, R8) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 20 residents residing in the facility. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was cognitively intact. R2's quarterly MDS dated [DATE], identified R2 was cognitively intact. During an interview on 3/11/25 at 1:10 p.m., at the resident meeting, R8 stated she did not receive mail or packages on Saturdays. R8 stated when packages were set to arrive late Friday or early Saturday, R8 would not receive them until Monday. R2 stated he did not receive mail or packages on Saturdays. R2 stated he received notifications when packages arrive at the facility on Saturday; however, would not receive the packages until Monday. R2 stated mail and packages come in through the main hospital and is sorted there and then delivered to the nursing home. During an interview on 3/12/25 at 2:34 p.m., the activities director (AD) stated when COVID started the mail delivery shifted from being delivered to the nursing home to being delivered to the hospital. The normal process was explained: mail/packages come in through the hospital and are sorted and then placed in the mailroom to be picked up by nursing home staff. When the mailroom is checked by staff on Saturdays there are usually no mail/packages for the nursing home, but AD was not sure if there were staff in the hospital to sort the mail. Any mail/packages delivered on Saturday would have to wait until Monday to be delivered. AD stated she would have to look into mail/packages for the resident on Saturdays, because they deserve to get their mail/packages quickly. An interview was conducted on 3/12/25 at 5:38 p.m., with director of nursing (DON), registered nurse (RN)-A, licensed social worker (LSW), and health unit coordinator (HUC). The HUC stated mail and packages came in through the hospital, they were sorted there and then placed in mailroom for nursing home staff to come down to pick it up. The LSW stated the areas where the was mail and packages were sorted was not staffed on weekends so anything that came in over the weekend would have to wait until Monday to be delivered to the resident. They were not sure if the city was delivering mail on Saturdays. The DON, RN-A, HUC and LSW all stated residents have the right to have received mail on Saturday. The facility's Patient Rights and Responsibilities policy dated 9/5/23, identified residents have the right to promptly receive mail/packages.

Based on observation, interview and document review the facility failed to ensure medications were properly labeled to prevent medication errors for 1 of 7 residents (R11) observed during medication pass. Findings include: R11's quarterly minimum data set (MDS) identified R11 had moderate cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). R11's physician orders report dated 2/12/25 through 3/12/25, identified R11 was to receive anoro ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation - administer 1 puff into the lungs one time a day with a start date of 7/24/24. On 3/12/25 at 7:18 a.m., licensed practical nurse (LPN)-A was observed during a medication pass. LPN-A removed a foil container from a medication cart. Inside the container was an inhaler with R11's name and a label identifying the medication as anoro ellipta 62.5-25 mcg/act LPN-A stated the inhaler belonged to R11 although it did not have a label identifying how the medication should be administered. LPN-A stated most-likely the facility received the inhaler in a box labeled with the residents identifying information and the instructions for use. LPN-A stated the box must have been thrown away. Prior to administering the medication, LPN-A would check the physicians orders for a current order and instructions. LPN-A further stated all medications should have a resident label and instructions from the pharmacy. On 3/12/25 at 1:24 p.m., the director of nursing (DON) stated all medications in the medication cart should have a label that includes the medication name, pharmacy it came from, date of order, expiration date, residents name and the orders/instructions for use. If the label did include all the appropriate information the nurse should remove the medication from the cart, not use the medication and contact the pharmacy right away. The Medication Management policy dated 8/8/24 identified prior to administering a medication staff were to compare the medication and dosage schedule on the medication administration record (MAR) to the medication label and review each for the right patient, right medication, right dose, right time and right route of administration.

Based on interview and document review the facility failed to identify a diagnosis for a medication for 1 of 5 residents (R4) reviewed for unnecessary medications. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had diagnoses of dementia with behavioral disturbance, bi-polar disorder (a chronic mental health condition characterized by significant and persistent shifts in mood), and manic depression. The MDS identified R4 received an antidepressant. R4's order summary report dated 1/15/25, included an order for escitalopram (a medication used to treat depression) 10 milligram (mg) tablet, take 15 mg each morning. The medication order failed to include a diagnosis or indication for use. During an interview on 3/12/25 at 5:23 p.m., registered nurse (RN)-A stated each prescribed medication needed a diagnosis or reason for use. RN-A had entered R4's escitalopram order after a medication change and forgot to put the diagnosis in. During an interview on 3/12/25 at 5:25 p.m., the director of nursing (DON) stated it was expected all medications would include a diagnosis or indication for use. It was important to have the diagnosis or indication of use to ensure R4 had not received the medication unnecessarily. The facility's Medication Order Transcription policy dated 10/17/24, identified medication orders mush include medication, dose, frequency, route, and diagnosis or indication for use.

Based on observation, interview and document review, the facility failed to ensure required nurse staffing information was consistently posted on a daily basis. This had potential to affect all 20 residents, staff, and visitors who may wish to view the information. Findings include: On 3/10/25 at 6:09 p.m., upon entering the unit, the facility nurse staff posting was hanging on a cork board on the wall across from the dining room. The staff posting was dated 3/9/25. The document listed staff scheduled hours per shift for each nursing job class. However, the posting was dated 3/9/25, one day prior. On 3/11/25 at 8:40 a.m., the cork board across from the dining room where the nurse staff posting was hanging the day prior was observed. The same section of the cork board was empty and the nurse staff posting was not hanging on the cork board. On 3/11/25 at 11:55 a.m., the director of nursing (DON) stated the night nurse was responsible for completing the daily staff posting for the following day. The most recent form was completed for 3/9/25, which was removed and another form for 3/10/25 and 3/11/25 were not completed. The DON stated the staff posting was expected to be posted and updated daily. It was important so residents, staff and visitors knew how many staff were working each shift, the hours per shift and their role. The Staffing Nursing Hours policy revised 2/13/24, identified staffing hours would be posted in a prominent place daily, would be clear, readable and easily accessible to residents and visitors. The posting would include the following: facility name, current date, total number and actuall hours worked by RN (not including the DON, assistant DON, or unit managers), licensed practical nurses (LPN) or licensed vocational nurses (as defined under state law), and certified nurse aides (NA), and the resident census.

Based on observation, interview, and record review, the facility failed to ensure that residents dining in the main dining room were given an opportunity to sanitize their hands prior to meal consumption. This deficient practice had the potential to impact all resident who dined in the main dining room. Findings include: During a dinner meal observation on 5/13/24 that started at 5:36 p.m., there were residents seated at five tables in the main dining room waiting for their meals to be delivered. None of the tables had hand sanitizing products on them. During dining observation, there were no observations of staff offering hand sanitization to residents that entered the dining room or to those already seated in the dining room. During a breakfast meal observation on 5/15/24 that started at 7:00 a.m., several residents were seated at tables in the dining room. None of the tables had any hand sanitizing products on them tables. Staff were observed assisting residents with clothing protector application. Staff appropriately sanitized their own hands at the sink between residents and tasks; however, staff did not offer hand sanitization to seated residents or to any additional residents as they entered the dining area for breakfast. During a lunch meal observation on 5/15/24 that started at 11:52 a.m., some residents were already seated at tables in the dining room. There was one pack of hand sanitizing wipes at the largest table in the dining room. Three additional residents entered the dining area. Residents were helped with clothing protectors however there was no observation of staff offering residents the opportunity to sanitize their hand prior to eating. Staff sanitized their own hands at the sink appropriately between residents and tasks. During an interview on 5/15/24 at 12:51 p.m., nursing assistant (NA)-A stated they always offered residents hand hygiene when they were in the resident's room but indicated they had not been offering hand hygiene to residents in the dining room prior to meals. NA-A confirmed they had not offered hand hygiene at the breakfast or lunch meals on 5/15/24. This should be done for infection prevention reasons. During an interview on 5/15/24 at 1:13 p.m., NA-B stated the dining room tables normally had hand sanitizer wipes on them, but there wasn't any, and they were not sure what had happened to them. NA-B stated when they brought a resident to the dining room from their room, they usually asked the resident if they wanted to wash their hands at their sink in their room. NA-E confirmed they had not offered hand sanitization to any of the residents in the dining room prior to meals being served on 5/15/24, and indicated it was important to offer residents hand sanitization prior to meals to prevent germs and infection. During an interview on 5/15/24 12:42 p.m., family member (FM)-A stated they had never seen their family member or other residents offered hand sanitization in the dining room prior to meals. FM-C stated they visited over mealtime about three times a week. During an interview on 5/15/24 at 1:23 p.m., the infection preventionist (IP) stated it was their expectation that residents were offered the opportunity for hand sanitization prior to meals. Resident's hands could be contaminated just from touching surfaces and or from missed handwashing after bathroom use. The IP stated they needed to make sure resident's hands were sanitized prior to food consumption to help prevent the spread of infection and or illness. During an interview on 5/15/24 at 1:41 p.m., the director of nursing (DON) stated they expected staff to give all residents the opportunity for hand sanitization prior to meals either at the sink or with the hand sanitizing wipes that are normally on the dining tables. The DON stated sanitizing wipes should be on all the dining tables and indicated wipes had been requested earlier that day. Proper hand sanitization for residents was needed to prevent the spread of infection and illness. The facility Stand Work: Activates of Daily Living (ADL's) Standards of Care dated 4/12/24, line item 15. Instructed all residents were to be offered hand hygiene prior to meals.

Based on interview and document review, the facility failed to ensure as-needed (PRN) antipsychotic medication use was limited to 14 days or notes from a provider face to face visit to demonstrate medical justification was provided to support ongoing use for 2 of 5 residents (R16, R20) reviewed for unnecessary medication use. Findings include: R16: R16's quarterly Minimum Data Set (MDS), dated [DATE], identified R16 had severe cognitive impairment, consumed antipsychotic medication daily and on an as needed (PRN) basis. R16's diagnoses included Alzheimer's and dementia. R16's most recent Physician Order Report, dated 5/16/24, identified R16's current physician-ordered medications. These included Haldol and Risperdal (both antipsychotic medication) on a PRN basis. The start date for Risperdal was 5/25/23 with no stop date documented. The start date for Haldol was 10/11/23 with no stop date documented. R16's medical record was reviewed and lacked evidence the provider had done every two weeks face to face visits to justify the continued use of PRN antipsychotic medication or had new orders for the PRN antipsychotics every 14 days. During an interview on 5/16/24 at 9:43 a.m., registered nurse (RN)-A stated all antipsychotic medications ordered PRN could only be ordered for 14 days and then needed a provider in person visit with documented medical need to continue the use. Also, the order had to be reordered every 14 days after the provider in person visit. RN-A was unaware who had the responsibility to ensure the visit and reorder were completed. During an interview on 5/16/24 at 10:56 a.m., hospice registered nurse (RN)-B stated the hospice provider does not round every two weeks and only renews antipsychotic medications yearly, unless there is a change to the dose. During an interview on 5/16/24 at 1:20 p.m., the pharmacy consultant (PC) stated all PRN antipsychotics needed to be renewed every 14 days after the provider performed an in person visit and documented medical need for the continued use. During an interview on 5/16/24 at 1:53 p.m., the director of nursing (DON) stated all PRN antipsychotic medication needed to be renewed every 14 days. It was up to the floor nurses who worked the cart to keep track of when that time was up and communicate the need with the provider. Facility Policy Psychotropic Medication last reviewed 11/27/17, indicated PRN antipsychotic medications would be limited to 14 days and would not be renewed unless the provider evaluated the resident for appropriateness of the medication. 47263 R20: R20's admission Minimum Data Set (MDS) dated [DATE], indicated R20 had severe cognitive impairment with a diagnosis of non-Alzheimer's dementia. The MDS indicated R20 received antipsychotics on a regular basis but did not indicate the use of a as needed (PRN) antipsychotic medication. R20's Physician Order Report dated 4/18/24, had the following order for the antipsychotic medication quetiapine, 12.5 mg three times a day PRN, quetiapine 12.5 mg one time a day between 4:00 p.m. and 6:30 p.m., and quetiapine 25 mg one time a day between 7:00 p.m. and 10:00 p.m. R20's Medication Pharmacy Regimen Review dated 4/30/24, stated if a new 14-day order for antipsychotic med is to be written, need examination by md to determine if still needed. R20's electronic medical record (EMR) lacked evidence that a provider had completed in person assessments of R20 every 14 days for the continued use of PRN antipsychotic medication. In addition, there was not a documented provider response to the pharmacist recommendations made on the 4/30/24. During an interview on 5/15/24 at 9:23 a.m., the director of nursing (DON) stated R20 was admitted to the facility with scheduled and PRN quetiapine. The DON pulled up R20's electronic medical record (EMR) and indicated R20 was last seen by a provider on 4/18/24, and had not been evaluated in person since admit for the continued use of PRN quetiapine. The DON indicated the pharmacy medication review recommendations drove when the provider was notified to complete a in person resident assessment and review of PRN antipsychotic medication orders. The facility did not have additional processes in place that ensured in person provider assessments and order discontinuation, or renewal occurred every 14 days for PRN antipsychotic medication. The facility policy Psychotropic Medication dated 11/27/17, indicated PRN antipsychotic medications would be limited to 14 days and would not be renewed unless the provider evaluated the resident for appropriateness of the medication.

Based on observation, interview and document review, the facility failed to comprehensively assess and identify and provide meaningful activities for 3 of 3 residents (R3, R4, R19) who were dependent on staff for activities. Findings include: R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment. R3 was non-ambulatory and required assistance with bed mobility, locomotion, and transfers. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 was unable to voice daily and activity preferences, but preferred listening to music, doing things with groups of people and spending time outdoors. R3's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 8/6/21, identified R3 had significant dementia that affected her daily life and routines. She had decreased safety awareness, she had behaviors in relation to dementia and cognition, as well as cognition does affect her activities of daily living (ADL)'s and interaction with others. R3's goal was for R3 to continue participation in cares, ADL's, activities, and to have relationships with others despite dementia as noted. R3's care plan dated 6/23/21, identified R3 preferred activities that identified with her prior lifestyle. Staff were directed to allow R3 to express feelings and desires, encourage R3 to become involved with/or observe activities, inform R3 of upcoming activities by (for example: provide activity calendar, verbal reminders, escort, encouragement, etc.), provide materials of interest: (for example, magazines, needlework, etc.), and provide setting in which activities were preferred: (for example, own room, day room, etc.). R3's medical record lacked evidence a current activity assessment was conducted to identify meaniningful activities for R3. R3's Population Record for Activities dated 5/1/22 through 5/31/22, identified R3 observed cooking three times, crafts once, resident council once, and dice three times. R3 actively participated in a family/friend visit twice. R3 visited with activity staff/volunteer 23 times and ambulated 23 times, which is an ADL. R3 held her baby doll 7 times. However, the record lacked to identify what R3 did during the activity staff/volunteer visits or the time duration. All other group activities were marked as refusals. R3's Population Record for Activities dated 6/1/22 through 6/30/22, identified R3 observed cooking once and dice once. R3 visited with activity staff/volunteer 24 times, ambulated 24 times, and held her baby doll 15 times. However, the record lacked to identify what R3 did during the activity staff/volunteer visits or the time duration. All other group activities were marked as refusals. R3's Population Record for Activities dated 7/1/22 through 7/31/22, identified R3 observed bingo/jingo once, cooking once, and current events once. R3 had activity staff/volunteer visits 24 times, ambulated 24 times, and held her baby doll 8 times. However, the record lacked to identify what R3 did during the activity staff/volunteer visits or the time duration. All other group activities were marked as refusals. During a continuous observation on 8/2/22, at 10:40 a.m. R3 was wandering in her wheelchair aimlessly throughout the dining room. A dice game was being played in the activity room. R3 was not observed to be offered to participate or observe. - At 11:03 a.m. the dice game was still active in the activity room, but R3 continued to wander. R3 was not offered to participate or observe the activity. - At 11:10 a.m. the activity was over, and the AD was straightening up the activity room. R3 sat in her wheelchair at the entrance of the north hallway, staring at another resident's closed room door. R3 picked up a wet floor sign from the floor, looked it, sat it back down against the wall, then wandered down the hall. - At 11:16 a.m. R3 wandered into room [ROOM NUMBER] and the call light immediately was turned on. - At 11:16 a.m. LPN-B answered the call light and pulled R3's wheelchair out of the room doorway and pointed her in the direction of the nurses' station. R3 immediately began wandering towards the nurses' station and wandered behind the nurses' desk. - At 11:19 a.m. LPN-A shut the chart room door to prevent R3 from entering the room but did not offer R3 anything to do. - At 11:20 a.m. registered nurse (RN)-C assisted R3 from behind the nurses' desk and brought her to the activity room. - At 11:21 a.m. R3 was sitting in her wheelchair at the activity room. The AD was observed to put away nail care utensils and RN-C stated, oh you're doing nail care and further stated R3 could use that too. The AD stated she was just clipping the other female resident's nails and not really doing nail care. The AD did not offer nail care to R3. RN-C left the area. - At 11:23 a.m. RN-C returned to the activity room and again stated to the AD, R3 could have her nails done too. The AD continued to not offer nail care to R3 and went into her office. RN-C left the area. During an observation on 8/2/22, at 3:25 p.m. root beer floats were served in the activity room. There were two residents in attendance. R3 was wandering in her wheelchair and was not observed to be offered to participate or observe the activity. During an interview on 8/3/22, at 10:34 a.m. nursing assistant (NA)-A stated R3 generally just roamed around the facility minding her own thing. NA-A stated, every once in a while, R3 would go to activities depending on what the activity was. R3 liked kickball and stuff like that. NA-A stated she really did not keep track, so was unable to say how often R3 attended activities. During an interview with R3 on 8/3/22, at 11:30 a.m. NA-D stated R3 was very, very busy. R3 was all over the place and staff needed to know where she was and redirect her. NA-A stated R3 probably went to activities one to two times per week but staff tried every day. During an interview on 8/3/22, at 11:53 a.m. licensed practical nurse (LPN)-B stated R3 constantly wandered. R3 sometimes liked hand massages. LPN-B then stated activities should always be offered to R3 and, if she wouldn't stay in the activity, an alternative should be tried. During an interview on 8/3/22, at 2:33 p.m. LPN-A stated R3 was very busy. She sometimes would go to activities, but she did not always participate. R3 liked kickball and nail care. During an interview on 8/3/22, at 2:41 p.m. NA-E stated R3 really did not have the attention span for activities. However, R3 liked her baby doll and would sit and talk to it. During an interview on 8/3/22, at 3:36 p.m. the activity director (AD) stated all activities were documented on the Population Record for Activities for each resident. When a resident was admitted , the activity admission assessments were documented on paper and brought back to the activity office to enter into the electronic medical record. Then, a basic care plan was made for each resident, but the basic care plan would be tweaked as needed. Activities were a lot of the things the resident liked doing or did like doing at one time. R3 would participate in physical activities, like kickball, on good days. Usually, R3 liked to do her own thing. R3 just liked to visit, and liked to be loved, petted, touched, and things like that. R3 did have a baby doll that she liked to hang on to, but the AD had not seen that for a few days. The baby doll was probably in R3's room. - At 3:44 p.m. the AD stated she was unable to locate R3's activity assessment on paper and stated there was not an activity assessment in R3's electronic medical record. The AD further stated she had no idea why R3 did not have a completed activity assessment in her medical record. - At 3:48 p.m. the AD stated R3's activity care plan interventions were generic. Further, R3 had changed since her admission and the interventions did not reflect R3's preferences. The AD did not offer nail care during the observation on 8/2/22, because she just didn't have the time. The AD needed another staff member to assist her with R3's nail care because it was a team effort and the AD usually had nursing do nail care for residents who needed more assistance. The facility was not completing activity participation notes due to COVID because they were doing 1:1 visits with all the residents but wanted to get back into the normal activity program. At that time, the AD stated the ambulation identified on R3's Population Record for Activities indicated R3's toodling or wandering. It meant R3 was out and about. I mean she's moving. The AD stated she did not have any documentation or record that reflected what a staff/volunteer visit consisted of and/or the duration of the visit. R4's quarterly MDS dated [DATE], identified R4 had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was non-ambulatory and required assistance with locomotion, personal hygiene, toileting, dressing, bed mobility and transfers. R4's significant change MDS dated [DATE] identified a staff assessment for activity preferences was conducted. It was identified R4 liked to listen to music and doing things with groups of people. R4's Cognitive Loss/Dementia CAA dated 2/16/22, identified R4 had a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Activities CAA dated 2/16/22, identified R4 had cognitive issues and staff would follow the care plan. R4's care plan dated 11/2/21, identified R4 preferred activities that identified with her prior lifestyle. Staff were directed to allow R4 to express feelings and desires, encourage R4 to become involved with/or observe activities, inform R4 of upcoming activities by (for example: provide activity calendar, verbal reminders, escort, encouragement, etc.), provide materials of interest: (for example, magazines, needlework, etc.), and provide setting in which activities were preferred: (for example, own room, day room, etc.). R4's Essentia Activity assessment dated [DATE], identified R4's date of admission, date of birth and marital status; however, the assessment provided no further information. R4's Population Record for Activities dated 5/1/22 through 5/31/22, identified R4 observed bingo/jingo once, cooking three times, crafts once and parties/special events once. R4 actively participated in visits from staff/volunteer 22 times, ambulation 22 times, walks outside twice, and held her baby doll 4 times. However, the record lacked to identify what R3 did during the activity staff/volunteer visits or the time duration. All other group activities were marked as refusals. R4's Population Record for Activities dated 6/1/22 through 6/30/22, identified R4 observed bingo/jingo twice, crafts twice and dice once. R4 actively participated in family/friend visit three times, and parties/special events twice, staff/volunteer 24 times, ambulation 24 times, walks outside once, and held her baby doll 8 times. However, the record lacked to identify what R3 did during the activity staff/volunteer visits or the time duration. All other group activities were marked as refusals. R4's Population Record for Activities dated 7/1/22 through 7/31/22, identified R4 observed bingo/jingo three times, and dice once. R4 actively participated in cooking twice, family/friend visit twice, grooming/nail care once, physical games once, movies/popcorn/video once, visits with staff/volunteer 24 times, ambulation 24 times, and held her baby doll twice. However, the record lacked to identify what R3 did during the activity staff/volunteer visits or the time duration. All other group activities were marked as refusals. During an observation on 8/2/22, at 12:51 p.m. R4 was lying in bed. R4's room was darkened with no tv or music. During an observation on 8/2/22, at 2:32 p.m. R4 was lying in bed. R4's room was darkened with no tv or music. During an observation son 8/2/22, at 3:25 p.m. R4 was sitting in the recliner in front of the nurses' station. An activity of root beer floats is in the activity room. R4 was not offered a root beer float or to come to the activity room. There were two residents in attendance. During a continuous observation on 8/3/22, at 9:41 a.m. R4 sat in her wheelchair, pedaling with her feet and wandering throughout the dining room and activity room. - At 9:51 a.m. R4 wandered into the activity room window and sat looking out. The AD was telling another resident the resident council meeting was that day and encouraged her to come. However, the AD did not offer the resident council meeting or talk to R4. - At 9:55 a.m. the AD waved at R4 and said hello. R4 smiled and pedaled her wheelchair out of the activity room. The AD did not encourage R4 to stay or remind her of the resident council meeting at 10:15 a.m. - At 9:56 a.m. R4 wandered aimlessly in the dining room. - At 10:03 a.m. the AD assisted R4 back into the activity room for the resident council meeting. However, the AD left the activity room to go resident room to resident room to offer the resident council meeting. - At 10:14 a.m. R4 left the activity room and wandered down the north hallway. Morning snack was being served. - At 10:18 a.m. NA-A brought R4 back to the nurses' station but did not offer the resident council meeting or the morning snack. - At 10:20 a.m. R4 wheeled herself down the north hallway. - At 10:20 a.m. NA-A again brought R4 to the nurses' station but did not offer a snack to R4 nor the resident council meeting. - At 10:22 a.m. R4 sat watching R3 eat her snack of potato chips. NA-D saw R4 watching and asked R4 if she wanted some too. R4 quietly said mmhmm and I'll share. NA-D gave her a bag and stated they were all hers. R4 smiled and giggled. - At 10:24 a.m. R4 wandered into the dining room, eating chips as she went. The AD returned the activity room and assisted R4 into the resident council, then shut the doors. During an interview on 8/3/22, at 10:31 a.m. NA-A stated R4 frequently wandered throughout the facility. R4 would sometimes go to activities but it really depended on what was going on. R4 liked snacks every once in a while but needed encouragement to eat. During an interview on 8/3/22, at 11:41 a.m. NA-D stated R4 would go to activities and sometimes stay there, especially bingo. During an interview on 8/3/22, at 12:19 PM LPN-B stated R4 wandered aimlessly. R4 liked silly videos about animals. R4 would also sit with activities and watch or sometimes she would color. During an interview on 8/3/22, at 2:42 p.m. NA-E stated R4 would not stay in an activity, but she did like her baby doll. During an interview 8/3/22, at 2:52 p.m. NA-C stated R4 would not stay in an activity and R4 like to do her own thing such as wandering. During an interview on 8/3/22, at 3:21 p.m. R4 wheeled herself into the activity room where a dice game was already in play. R4 asked the AD what was going on. The AD did offer to let R4 play and R4 smiled. The AD set up the game pieces in front of R4. - At 3:22 p.m. the AD asked R4 if she could shake the dice and dump it out. R4 did not respond, nor did she take the cup of dice. The AD shook the cup and tossed the dice onto the table in front of R4, then turned over the appropriate card. R4 sat with flacid facial expressions and watched the other residents. - At 3:23 p.m. the AD asked R4 if she wanted to try again, but R4 stated she did not know. The AD again shook the dice for R4. - At 3:26 p.m. R4 picked up the cup, shook it and placed it back down without tossing the dice. R4 looked at the AD expectantly, but the AD did not toss the dice either. R4 slowly backed her wheelchair away from the table. - At 3:27 p.m. R4 wheels back to the table, but the AD no longer offered R4 a turn. The game has completed, and the AD began putting the game away. During an interview on 8/3/22, at 3:36 p.m. AD stated all activities were documented on the Population Record for Activities for each resident. When a resident was admitted , the activity admission assessments were documented on paper and brought back to the activity office to enter into the electronic medical record. Then, a basic care plan was made for each resident, but the basic care plan would be tweaked as needed. Activities were a lot of the things the resident liked doing or did like doing at one time. R4 liked to do her own thing. R4 also had a baby doll that she liked to hang on to. - At 3:44 p.m. the AD stated she was unable to locate R4's Activity Assessment on paper. However, there was an incomplete activity assessment in R4's electronic medical record. - At 3:48 p.m. the AD stated R4's activity care plan interventions were also generic. The AD then stated the facility had not been completing activity participation notes due to COVID because they were doing 1:1 visits with all the residents but wanted to get back into the normal activity program. At that time, the AD stated the ambulation identified on R4's Population Record for Activities indicated R4's toodling or wandering. Additionally, the AD stated she did not have any documentation or record that reflected what a staff/volunteer visit consisted of and/or the duration of the visit. R19's quarterly MDS dated [DATE], identified R19 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 was non-ambulatory and was totally dependent on staff for all care areas. R19's annual MDS dated [DATE], identified a staff activity preference was conducted. It identified R4 liked doing things with groups of people. R19's Activities CAA dated 1/20/22, identified R19's ability to cope with different forms of stimulation had to be re-assessed daily. Participation in group activities varied due to R19's level of comfort. The care area was safe and secure for R19 for all indoor activities. The CAA further identified to see R19's care plan. R19's care plan dated 7/21/21, identified R19 had an alteration in social interaction. Sensory stimulation program of activities required due to being non-verbal. R19 was able to make needs known through facial expression, smiles for happy, grimaces when in pain or unhappy. The care plan directed staff to provide 1:1 visits with activity staff or volunteers a minimum of two times per week with focus on the use of sensory stimulation to facilitate R19's engagement in her environment. R19 was scheduled in group activities to meet her social needs as R19 was able to tolerate. R19 was to get up in room, sunroom or living room as R19 tolerated after lunch. R19 was to use activities related to native culture during 1:1 visits to foster increased quality of life. R19's Population Record for Activities dated 5/1/22 through 5/31/22, identified R19 actively participated in aviary three times, physical games once, visits from staff/volunteer 22 times, and TV 22 times. However, the record lacked to identify what R19 did during the activity staff/volunteer visits or the time duration. R19 refused group activities 39 times and was in bed twice. R19's Population Record for Activities dated 6/1/22 through 6/30/22, identified R19 actively participated in aviary four times, physical games twice, pet visit once, visits from staff/volunteer 24 times, TV 24 times. However, the record lacked to identify what R19 did during the activity staff/volunteer visits or the time duration. R19 refused group activities 30 times and was in bed six times. R19's Population Record for Activities dated 7/1/22 through 7/31/22, identified R19 actively participated in aviary twice, physical games once, visits from staff/volunteer 24 times, TV 24 times. However, the record lacked to identify what R19 did during the activity staff/volunteer visits or the time duration. R19 refused group activities 39 times, was not available twice, and was in bed five times. During an observation on 8/2/22, at 8:37 a.m. R19 was lying in bed with the head of her bed elevated 30 degrees. R19's TV was turned on to a sitcom. During an observation on 8/2/22, at 2:14 p.m. R19 was sitting in her wheelchair in front of her room window. R19's TV was on with a sitcom playing, but R19 was turned away from the TV. During an observation on 8/3/22, at 7:17 a.m. R19 was lying in bed on her left side. R19's room was dark, and the radio was on to country music. During an observation on 8/3/22, at 10:06 a.m. the AD entered R19's room and assisted her to the living room to sit in front of the aviary. No other residents are in the room. The resident council meeting was scheduled in the activity room. During an observation on 8/3/22, at 2:07 p.m. R19 sat in her room in her wheelchair next to the window. R19's call light was pinned to her t-shirt. R19's TV was on behind her. During an interview on 8/3/22, at 11:39 a.m. NA-D stated R19 was hard because she did not have behaviors, but at the same time did. R19 would sometimes holler or moan. R19 was assisted up into her wheelchair three times a day. Sometimes she would stay in her room and sometimes she would go to the bird room. NA-D then stated R19 went to activities every day, but when asked what R19 like to do for activities NA-D stated sometimes R19 liked to watch TV. During an interview on 8/3/22, at 11:53 a.m. LPN-B stated R19 was hard. R19 really did not like group activities but did like to sit in the bird room. LPN-B stated she couldn't speak for everyone, but she offered R19 activities every day. During an interview on 8/3/22, at 2:20 p.m. LPN-A stated R19 really did not like music, and it would make R19 to begin crying. R19 likes to laugh, but R19 would become upset if you talked about her or her situation in front of her. LPN-A then stated R19 can see you, understand what you're saying, but was unable to make that known. During an interview on 8/3/22, at 3:36 p.m. AD stated R19 has been at the facility for many, many years. R19 did not like group activities and usually watched TV, sat in front of her window, or sat in the bird room. The AD was the only staff member in the department. When looking at R19's Population Record for Activities, the AD stated she had no documentation to reflect R19's activity staff visits such as what it involved or how long it was. During an interview on 8/3/22, at 5:34 p.m. the administrator stated she expected all residents to have an adequate activities program that met personal preferences and likes. A facility policy related to activities was requested but not received.

Based on interview and document review the facility failed to ensure written transfer notices were provided to the resident and/or resident representative along with notification to the Long-Term Care Ombudsman (LTCO) following a facility-initiated transfer to the hospital for 1 of 1 resident (R13) reviewed for hospitalization . Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. The MDS identified R13 had two hospitalization s in the look back period. R13's progress notes identified the following: - On 4/10/22, R13 was transferred and admitted to the hospital due to [CONDITION(S)]. - On 5/29/22, R13 was admitted to the hospital due to pain. R13's medical record lacked evidence R13 or the LTCO was provided written notification of any of R13's transfers to the hospital. During an interview on 8/2/22, at 1036 a.m. R13 stated he did not recall received any written documentation when transferred to the hospital. During an interview on 8/3/22, at 9:44 a.m. family member (FM)-A stated they did not recall receiving any written notification of transfer when R13 was hospitalized in April or May of 2022. During an interview on 8/3/22, at 1:59 p.m. director of nursing (DON) stated there was no evidence R13, R13's representative or LTCO was notified in writing of R13's hospital transfers. The DON would have expected both of the notification to be completed and identified in the medical record. The facility's Bed-Hold and Return to Facility Policy dated 6/12/19, identified the facility shall inform and provide in writing to the resident and/or the resident's representative information regarding the transfer, reason for the transfer, in writing in a language and manner they can understand.

Based on interview and document review, the facility failed to develop a person centered comprehensive activity care plan for 2 of 3 residents (R3, R4, and R19) reviewed for activities. Findings include: R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment. R3 was non-ambulatory and required assistance with bed mobility, locomotion, and transfers. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 was unable to voice daily and activity preferences, but preferred listening to music, doing things with groups of people and spending time outdoors. R3's medical record lacked a comprehensive activities care plan. R3's care plan dated 6/23/21, identified R3 preferred activities that identified with her prior lifestyle. Staff were directed to allow R3 to express feelings and desires, encourage R3 to become involved with/or observe activities, inform R3 of upcoming activities by (for example: provide activity calendar, verbal reminders, escort, encouragement, etc.), provide materials of interest: (for example, magazines, needlework, etc.), and provide setting in which activities were preferred: (for example, own room, day room, etc.). R4's quarterly MDS dated [DATE], identified R4 had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was non-ambulatory and required assistance with locomotion, personal hygiene, toileting, dressing, bed mobility and transfers. R4's significant change MDS dated [DATE] identified a staff assessment for activity preferences was conducted. It was identified R4 liked to listen to music and doing things with groups of people. R4's Cognitive Loss/Dementia CAA dated 2/16/22, identified R4 had a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Activities CAA dated 2/16/22, identified R4 had cognitive issues and staff would follow the care plan. R4's care plan dated 11/2/21, identified R4 preferred activities that identified with her prior lifestyle. Staff were directed to allow R4 to express feelings and desires, encourage R4 to become involved with/or observe activities, inform R4 of upcoming activities by (for example: provide activity calendar, verbal reminders, escort, encouragement, etc.), provide materials of interest: (for example, magazines, needlework, etc.), and provide setting in which activities were preferred: (for example, own room, day room, etc.). During an interview on 8/3/22, at 3:36 p.m. the activity director (AD) stated she had been the director a little over two years and was responsible for assessing residents' activity preferences and developing a care plan. The AD stated a paper copy of the activity assessment was collected, brought back to the activity office, and entered into the electronic medical record. A basic care plan was created and tweaked as needed. R3 and R4's care plan interventions were generic without any personalization.

Based on observation, interview and document review, the facility failed to implement care planned fall interventions as directed to minimize the risk for falls for 1 of 1 resident (R3) who was reviewed for accidents. Findings include: R3's Falls Care Area assessment dated [DATE], identified R3 had seven falls in the previous three months: all with no injury. She received an antidepressant daily for depression. R3's mood varied greatly but it was noted she was not trying to stand-up from her wheelchair as much as she was previously. R3's balance was not steady and R3 was only able to stabilize with human assistance for all transfers and sit to stand; R3 was non-ambulatory. R3 was at risk for falls related to her diagnosis of dementia, [CONDITION(S)], wandering, chronic heart failure (CHF), chronic pulmonary embolism, [CONDITION(S)], macular degeneration; impaired mobility, self-transfers, pain, weakness, medications, incontinence, decreased safety awareness and fall history. Staff would continue to encourage R3 to ask for assistance when she needs to get out of bed/wheelchair, etc. Interventions in resident's care plan would focus on fall prevention as well as prevention of an injury in relation to a fall. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified had severe cognitive impairment. R3 was non-ambulatory and required extensive assistance with bed mobility and transfers. R3 had no falls since the last assessment period on 5/2/22. Diagnosis included non-traumatic [CONDITION(S)] and dementia. R3's care plan dated 6/26/21, identified R3 was at risk for falls. Staff were directed to tilt the back of R3's wheelchair seat down when in wheelchair and not eating or transferring During a continuous observation on 8/2/22, at 8:32 a.m. R3 was seated in her wheelchair and wandering the nursing unit. - At 9:14 a.m. R3 moved dining room standard chairs out of her way as she pedaled her wheelchair with her feet. R3 was sitting forward in her wheelchair so there was approximately 6 inches of seat behind her, and her buttocks rested on the edge of the seat. No staff attempted to reposition R3. - At 9:23 a.m. R3 wandered into the activity room. R3 leaned back in her wheelchair so her shoulders rested against the top of her wheelchair back and her buttocks continued to rest on the edge of her seat. R3 rocked her wheelchair back and forth by extending and bending her knees. R3 suddenly sat up and grasped her wheelchair armrests. R3 attempted to lift herself to scoot back in her seat but moved minimally and never lifted her buttocks off the seat. R3 continued to sit at the edge of her seat. - At 9:29 a.m. R3 continued to sit at the edge of her seat cushion and rocked back and forth in the wheelchair. - At 9:31 a.m. R3 attempted reposition herself but made minimal movement, never lifting her buttocks off the seat cushion, and continued to sit at the edge of the seat cushion. - At 9:45 a.m. R3 again attempted to reposition herself but continued to sit at the edge of the seat cushion. - At 9:48 a.m. R3 wheeled toward the exit door and the activity director (AD) came out of her office. The AD did request nursing assistance to help reposition R3 further back into her chair. - At 9:50 a.m. the AD asked R3 if she could scoot back in her wheelchair. The AD held the handles of R3's wheelchair and R3 grasped the wheelchair armrests and attempted to lift herself back but moved minimally. R3 continued to sit at the seat cushion edge. The AD went back into her office and R3 wandered away. The AD did not seek help from nursing staff. - At 9:52 a.m. R3 leaned back into her wheelchair with her shoulders resting at the top of the wheelchair back. R3 was in a reclined position with her head bent forward resting on crumpled bent wheelchair back. The AD exited her office, walked past R3 and left the activity room. - At 10:00 a.m. R3 again leaned back into her wheelchair in a reclined position with her buttocks at the seat cushion edge and her legs out in front of her. - At 10:14 a.m. R3 left the activity room and entered the living room. R3 continued to sit at the seat cushion edge. R3 sat in her wheelchair in the corner of the living room. - At 10:24 a.m. R3 suddenly turned her wheelchair around and wheeled herself out of the living room. nursing assistant (NA)-A assisted to the nurses' station for morning snack. NA-A did not attempt to reposition R3 further back in her chair. - At 10:27 a.m. NA-A gave R3 a bag of chips and an ensure. NA-A looked down at R3, then wheeled R3 into the adjoining hallway and repositioned R3 in her wheelchair. NA-A returned R3 to the nurses' station desk where R3 continued to eat her morning snack. During a continuous observation on 8/3/22, at 9:21 a.m. R3 sat in her wheelchair next to the courtyard exit door. R3 was in an alcove that was near the nurses' station but was not easily visible from the desk. R3 was positioned between the wall and a loveseat. R3 was facing the wall and was seated at the edge of her seat cushion with her knees pointed to toward the loveseat. R3 was grasping the armrest of the loveseat and was looking at the seat of the loveseat. - At 9:36 a.m. R3 sat at the seat cushion edge with approximately 6 inches of seat exposed behind her. - At 10:05 a.m. Licensed practical nurse (LPN)-A was seated at the nurses' station desk but did not offer to reposition R3. - At 10:13 a.m. NA-A served the morning snack. NA- assisted R3 to the nurses' station desk after she assisted R3 into a safe seated position. NA- then gave R3 her morning snack. During an interview on 8/3/22, at 10:34 a.m. NA-A stated R3 wandered frequently. R3 liked to slide to the edge of her seat cushion and staff tilted her wheelchair back to keep in a safe seated position. NA-A stated R3 was not on a specific check schedule but staff were directed to keep an eye on her. If R3 was not in other resident rooms, R3 was good. NA-A stated R3 had been in the alcove by herself approximately 5 minutes that morning but NA-A was doing other things, so you know. During an interview of 8/3/22, at 11:53 a.m. LPN-B stated R3 was very busy. R3 was constantly wandering. R3 needed to be monitored and repositioned so she was in a safe seated position. During an observation on 8/3/22, at 3:07 p.m. the AD walked past R3 while R3 sat at the seat cushion edge, bending down to pick an item off the floor. R3 was sitting in front of the nurses' station desk at the entrance of the dining room. AD did not make any comments to R3, did not request assistance from nursing and continued to the activity room. - At 3:09 PM registered nurse (RN)-A approached R3, grasped her wheelchair handles and asked R3 to scoot back in her wheelchair. R3 grasped her wheelchair armrests and lifted herself back onto the seat cushion after RN- gave verbal cues. Any staff member who saw R3 seated at the seat cushion edge should reposition R3 because she was at risk for falling. During an interview on 8/3/22, at 3:36 p.m. the AD stated R3 looked like she was on the edge of her seat, which is normal for R3. The AD stated she tried to keep an eye on R3 to make sure she was not too close to the seat edge but agreed she had not given any verbal cues to R3 to reposition herself, nor did she ask for nursing assistance. On 8/3/22, at 4:29 p.m. and interview was conducted with RN-B and the director of nursing (DON). R3 could be repositioned one minute and would be back at the edge of her seat cushion two minutes later. The DON then stated the facility was unable to staff to provide R3 with one-to-one monitoring and the staff were only required reposition R3 every two hours. During an interview on 8/3/22, at 5:34 p.m. the administrator stated staff were expected to be aware of R3's location and to always reposition R3 to ensure her and other residents' safety. A policy regarding resident safety as requested but not received.

Based on interview and document review, the facility failed to provide a bed hold notice at the time of transfer for 1 of 1 residents (R13) reviewed for hospitalization . Finding include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. The MDS identified R13 had two hospitalization s in the look back period. R13's progress notes identified the following: - On 4/10/22, R13 was transferred and admitted to the hospital due to [CONDITION(S)]. - On 5/29/22, R13 was admitted to the hospital due to pain. R13's progress notes lacked any discussion with resident or their representative about obtaining a bed hold at the time of transfer. R13's medical record lacked a signed bed hold notice and lacked any evidence a bed hold was provided. During an interview on 8/3/22, at 1:59 p.m. the director of nursing (DON) stated when a resident was sent to the hospital a bed hold would be signed with the resident or their representative to hold the resident's bed until they return. The information of the bed hold would be charted in the resident's chart and a copy of the documents would be kept with the medical record. R13 medical record did not have any evidence R13 was provided a bed hold for the hospital transfers. The facility's Bed-Hold and Return to Facility Policy dated 6/12/19, identified the facility shall inform and provide in writing to the resident and/or the resident's representative the facility's bed hold and return policy and must be written in a language and manner they can understand.

Based on observation, interview and document review, the facility failed to ensure all staff completing self testing were trained and competency tested to ensure COVID-19 outbreak and routine testing was completed according to manufacturers testing instructions. This deficient practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all residents residing in the facility during the COVID-19 Focused Infection Control Survey; including 17 of 21 residents (R17, R5, R1, R2, R3, R4, R6, R15, R9, R10, R7, R11, R12, R14, R8, R16) residents who contracted COVID-19. This resulted in actual harm to R2, R3 and R5 who expired with COVID-19 and R4 and R15 who were hospitalized with COVID-19. In addition, the facility failed to ensure testing rosters were organized and tracked in real time; failed to increase testing frequency of unvaccinated staff per the Centers for Disease Control (CDC) county positivity rate. This had the potential to effect all residents residing in the facility along with staff and visitors. The IJ began on [DATE], when activity director (AD)-A and nursing assistant (NA)-A were observed to complete COVID-19 tests in a manner not consistent with manufacturers recommendations. In addition, the facility failed to ensure all staff responsible for testing were trained and competency tested per manufacturers recommendation to ensure accurate testing. The administrator, director of nursing (DON) and registered nurse (RN)-B were notified of the IJ on [DATE], at 4:35 p.m. The IJ was removed on [DATE], at 10:15 a.m. but noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance People with Certain Medical Conditions dated [DATE], identified older adults were more likely to get seriously ill from COVID-19. More than 80 percent of COVID-19 deaths have occurred in people over the age of 65, and more than 95 percent of COVID-19 deaths have occurred in people older than 45. Further, among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. STAFF TESTING: The CDC guidance Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing dated [DATE], identified proper specimen collection was the most important step in the laboratory diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on [DATE], at 11:15 a.m. the administrator stated the facility entered outbreak testing frequency on [DATE], when a R1 tested positive for COVID-19. In addition, two staff members called in ill on [DATE], with symptoms of COVID-19. The staff members were directed to get tested for COVID-19 and both tested positive. The DON identified 98 percent of the facility residents and 58% of the facility staff were fully vaccinated against COVID-19. Currently nine residents were positive for COVID-19 in the facility, three residents expired, and three residents were currently hospitalized for COVID-19. R17's discharge Minimum Data Set (MDS) dated [DATE], identified R17 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's medical record identified R17 was fully vaccinated. R17's progress notes dated [DATE], identified R17 complained of body aches, headache and cough. R17 tested positive for COVID-19. R5's undated face sheet identified R5 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's medical record identified R5 was fully vaccinated. R5's progress notes identified the following: - [DATE], R5 tested positive for COVID-19 - [DATE], identified R5 expired at the facility. R1's undated face sheet identified R1 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, it was identified R1 was roommates with R5. R1's medical record indicated R1 was fully vaccinated. R1's progress notes dated [DATE], identified R1 had a fever of 99.3 degrees F and was again medicated with Tylenol. R1 went to the dining room for his breakfast, where he became unresponsive at the breakfast table. R1 had low blood pressure and his oxygen saturation level decreased to 78 percent on room air. R1 was transferred to the emergency room for evaluation, where he tested positive for COVID-19. R2's undated face sheet identified R2 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's medical record indicated R2 was not vaccinated for COVID-19. R2's progress notes identified the following: - [DATE], a COVID-19 test was obtained and R2 tested positive for COVID-19. - [DATE], R2 was admitted to the hospital where R2 expired. R3's undated face sheet identified R3 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's medical record identified R3 was not vaccinated for COVID-19. R3's progress notes identified the following: - [DATE], R3 tested positive for COVID-19. - [DATE], R3 had a fever of 102.2 degrees F. and later expired at the facility. R4's undated face sheet identified R4 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's progress notes identified the following: - [DATE], R4 was tested for COVID-19 with positive results. - [DATE], R4 was hospitalized for respiratory symptoms related to COVID-19 and remained hospitalized . R6's undated face sheet identified R6 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's medical record indicated R6 was fully vaccinated for COVID-19. R6's progress notes identified the following:- [DATE], R6 complained of feeling freezing cold. R6 had a cough, body aches and hoarse voice. R6's temp was 101.4 degrees F. and R6's O2 sats decreased to 92 percent. R6 later left the facility to an orthotic appointment to be fitted for shoes, while having symptoms of COVID-19. - [DATE], R6 was tested for COVID-19 with positive results. R15's undated face sheet identified R15 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's medical record identified R15 was fully vaccinated for COVID-19. R15's progress note(s) dated [DATE], identified R15 developed a fever of 101.2 degrees F, had shortness of breath and R15's O2 sats decreased to ,d+[DATE] percent. R15 was tested for COVID-19 with positive results and was hospitalized for pneumonia due to COVID-19. R9's undated face sheet identified R9 was [AGE] years of age. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's medical record indicated R9 was fully vaccinated for COVID-19. R9's progress notes identified the following: - [DATE], R9 had a cough and increase confusion.- [DATE], R9 tested for COVID-19 with positive results. R10's undated face sheet identified R10 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's medical record identified R10 was full vaccinated for COVID-19. R10's progress notes identified the following: - [DATE], R10 had increased coughing episodes and was lethargic (sleepy or fatigued and sluggish). - [DATE], R10 tested for COVID-19 with positive results. R7's undated face sheet identified R7 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's medical record indicated R7 was fully vaccinated for COVID-19. R7's progress note(s) dated [DATE], identified R7 had a cough and tested positive for COVID-19. R11's undated face sheet identified R11 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's progress note dated [DATE], identified R11 tested positive for COVID-19. R12's undated face sheet identified R12 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's medical record identified R12 was fully vaccinated for COVID-19. R12's progress note dated [DATE], identified R12 tested positive for COVID-19. R14's undated face sheet identified R14 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's medical record identified R14 was fully vaccinated for COVID-19. R14's progress note dated [DATE], identified R14 tested positive for COVID-19. R8's undated face sheet identified R8 was [AGE] years of age. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's medical record indicated R8 was fully vaccinated for COVID-19. R8's progress noted dated [DATE], identified R8 tested positive for COVID-19 on [DATE]. R16's undated face sheet identified R16 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's medical record identified R16 was fully vaccinated for COVID-19. R16's progress note dated [DATE], identified R16 tested positive for COVID-19. During observation on [DATE], at 2:18 p.m. AD-A entered the facility COVID-19 testing area, opened a testing vial and put her label on the vial, identifying the test sample was hers. AD-A did not complete hand hygiene prior to testing. AD-A inserted the wooden, long stemmed, cotton swab into their right nostril and swirled the swab in her nostril for 30 seconds, then placed the swab into the labeled vial. AD-A did not swab the other nostril. AD-A placed the cap on the vial and placed the vial into a biohazard bag. AD-A exited the room and delivered the sample to the attached hospital laboratory for processing. AD-A did not complete hand hygiene after testing or prior to delivering her sample to the laboratory. When interviewed on [DATE], at 2:28 p.m. AD-A stated RN-D showed her how to do the COVID-19 test. AD-A only tested on e nostril, as the current practice in the facility was to swab only one nostril and not both. Further, AD-A stated she did not complete hand hygiene prior or after self testing for COVID-19. During observation on [DATE], at 2:56 p.m. NA-A entered the facility COVID-19 testing area, opened a testing vial and a wooden, long stemmed, cotton swab without completing hand hygiene. NA-A swabbed her right nostril for ten seconds, swirling it three or four times inside her nostril, placed the swab into the vial and closed the lid. NA-A failed to swab the other nostril. NA-A wrote her name, date and time on the adhesive label and attached it to the vial. NA-A exited the testing area with her sample and hand delivered the sample to the attached hospital laboratory without completing hand hygiene. When interviewed on [DATE], at 3:05 p.m. NA-A stated she knew how to perform the COVID-19 test from having been swabbed numerous times since the COVID-19 pandemic started. The facility started out having someone else perform the test, but the staff were asked to self test soon after the pandemic began. NA-A stared she did not complete hand hygiene prior or after self testing for COVID-19. During interview on [DATE], at 10:28 a.m. dietary aide (DA)-A stated she tested herself for COVID-19 at the nursing facility test area. Further, DA-A was never trained on the procedure. DA-A just stuck the swab in her nose and stirred it around a few times and put it into the container, then walked the sample over to the hospital laboratory to be processed. During interview on [DATE], at 10:31 a.m. housekeeper (HK)-A stated she tested herself for COVID-19 at the nursing facility test area and was never trained on the procedure. HK-A stated she was tested by another person in the past, so she knew how to complete the test. On [DATE], at 11:18 a.m. the health unit coordinator (HUC)-C stated she tested herself for COVID-19 in the nursing facility test area. HUC-C indicated she was trained by RN-D, who instructed her to insert the cotton swab into one nostril and to swirl it around for ten seconds. RN-D walked her through the procedure and watched her perform the test. During interview on [DATE], at 11:21 a.m. activity aide (AA)-B stated she tested herself for COVID-19 in the nursing facility test area; however, was never trained on the testing procedure. AA-B knew how to perform the test from being tested in the past. During interview on [DATE], at 11:24 a.m. dietary supervisor (DS)-F indicated the facility directed the dietary staff to self test for COVID-19 and bring their sample to the hospital laboratory for processing. One of the facility registered nurses instructed them on how to perform the test and to swab one nostril for fifteen seconds. On [DATE], at 12:01 p.m. the environmental services supervisor (EVS)-E stated he thought staff were instructed on how to self test at some point but was not sure when. They were to insert the cotton swab into their nostril, fairly deeply and swab it around for ten seconds and do the other nostril. Facility staff COVID-19 testing training and competency tests were requested and not received. During interview on [DATE], at 11:16 a.m. the administrator identified facility staff performed self testing for COVID-19. A laboratory employee trained one of the facility's registered nurses, who then taught the rest of the facility staff how to perform the test. The trained registered nurse left the facility after [DATE], and no longer worked at the facility. The administrator was unable to locate any documentation of any training and competency testing for self testing for COVID-19. When interviewed on [DATE], at 12:07 p.m. the medical laboratory supervisor (MLS) identified the procedure for obtaining a sample for a COVID-19 test included: insert the cotton swab just inside the nostril and to swirl it about for fifteen seconds and to repeat on the other nostril with the same swab. MLS was aware the facility staff were self testing; however, the laboratory personnel had not trained the facility staff. MLS indicated the test was only as good as the specimen collected, so there was always a chance the test was not performed correctly and could have inaccurate results. The hospital laboratory procedure How To Collect Your Anterior Nasal Swab Sample For COVID-19 Testing dated [DATE], directed the tester to use hand sanitizer, remove the swab and insert the swab into nostril no more than a half an inch. Slowly twist the swab, rubbing it along the insides of your nostril for fifteen seconds and using the same swab, repeat in the other nostril. Place swab in the supplied vial and use hand sanitizer again. Place vial in a biohazard bag and give the bag to the laboratory. Use the hand sanitizer again. The undated facility policy Essentia Health Long Term Care (SNF/AL) Infection Prevention Interim Policy for Guidance during Pandemic and Suspected or Confirmed Coronavirus (COVID-19), did not identify the process for obtaining COVID-19 testing. The Minnesota Department of Health (MDH) guidance COVID-19 Specimen Collection for Point Prevalance Survey (PPS) dated [DATE], indicated health care providers and other medically trained staff could collect specimens for COVID-19 testing. Staff should be trained and competency evaluated by a registered nurse (RN) or other health care provider. Specimen collection and training should be conducted in accordance with the CDC: Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19. The IJ which began on [DATE], was removed on [DATE], at 10:15 a.m. when it could be verified through observation, interview and document review the facility : Stopped self testing immediately; MLS trained select facility nurses on obtaining COVID-19 tests until staff could be competency tested ; Policies were reviewed and revised to reflect protocols for testing procedures to ensure all staff were tested for COVID-19 in a manner consistent with current standards of practice for conducting COVID-19 tests; Education was provided to all staff on current and updated COVID protocols for staff and would continue for continued outbreak testing; and Completion of testing and training would be tracked, analyzed, and acted on to ensure compliance with routine and outbreak testing. ROUTINE TESTING: On [DATE], at 10:28 a.m. the facility's outbreak testing rosters, staff schedules, call-in forms, and staff workability forms were requested. The DON provided the the requested documents from [DATE] to present. On [DATE], at 11:16 a.m. the facility provided the routine and outbreak testing rosters for [DATE] through [DATE]. The roster provided the following data: site name, site address, site phone number, site fax number, site contact name, site contact email, site type (SNF), ordering provider name and indication for testing: conducting staff testing to meet CMS requirements (routine or outbreak) (Client bill) and date of collection. Staff names were listed, but the roster did not include the staff role, each roster was clipped to a stack of individual printed test results and the names of the staff were highlighted, circled, and/or had indiscriminate marks. The roster dates did not consistently correlate to the test result dates, not every name had a discernible notation to determine if the staff member required testing, nor did every name have printed results. Additionally, the rosters did not provide a consistent manner of tracking to ensure every staff member who required testing fulfilled testing requirements. The Centers for Medicare and Medicaid Services (CMS) COVID-19 [CONDITION(S)] (NAAT) Laboratory 14-Day Test Positivity Rates, by US County provided the following Itasca county positivity rates by the dates below: - On [DATE], the county positivity was 1.8 percent indicating low positivity rate and were required to test monthly. - On [DATE], the county positivity was 2.6 percent indicating low positivity rate and were required to test monthly. - On ,d+[DATE]//21, the county positivity was 5.2 percent indicating low positivity rate and were required to test weekly. - On [DATE], the county positivity was 6.6 percent indicating low positivity rate and were required to test weekly. The facility testing rosters indicated routine testing was last conducted on [DATE]. Outbreak testing began on [DATE], and the facility continued outbreak testing frequency. During interview on [DATE], at 2:33 p.m. the DON stated she was responsible for tracking COVID-19 testing for staff and residents. The facility last conducted routine COVID-19 staff testing on [DATE], until R1 tested positive during an emergency department evaluation on [DATE]. Additionally, two nurses called-in ill on [DATE], and were instructed to get tested . Both nurses tested were tested and had positive results. On [DATE], the facility began outbreak testing of all vaccinated and unvaccinated residents and all staff that entered the nursing home unit. - Upon review of the testing rosters, the DON was unable to determine if all staff members listed were required to test, had refused testing, had worked in the nursing home, or why some test results were not available. The DON was unable to explain the purpose of the roster and was unable to identify which staff completed testing without searching in the electronic test result system for a result. She indicated not everyone listed on the roster worked in the nursing home or was required to test but was unable to identify which staff members did not need to test without looking for a result in the electronic system, nor could she identify if the staff member worked without testing. On [DATE], at 1:42 p.m. the DON stated the facility collected the county positivity rate once a week on Wednesday from the CMS website. If the county positivity rate went above a certain level, testing began that same week. Review of the DON's form Senior Care COVID-19 risk assessment dated [DATE], indicated the county positivity rate was 5.2 percent on [DATE]. The DON stated the facility should have increased routine testing to weekly beginning on [DATE] or [DATE]. We started outbreak testing on the 10th. I guess we delayed. I'm not recalling that I realized we should have increased routine testing the Friday prior. Further, the DON stated the facility could potentially have lessened the impact of the COVID-19 outbreak if they implemented the increased testing as required. Review of the [DATE] nursing schedule identified registered nurse (RN)-C worked an emergency, fill-in shift at the facility. DON stated RN-C was a hospital employee and she did not know her vaccination status; however, hospital employees were not required to be vaccinated until a future date. DON reviewed RN-C's record and indicated she was never tested for COVID-19. During interview on [DATE], at 3:47 p.m. the administrator stated she put trust in her staff to be compliant with testing requirements and followed all facility COVID-19 policies. The undated facility policy Essentia Health Long Term Care (SNF/AL) Infection Prevention Interim Policy for Guidance During Pandemic and Suspected or Confirmed Coronavirus (COVID-19), indicated the facility would identify employees that work at multiple facilities, and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19. Further, the policy directed staff to see COVID-19 Testing Recommendations for Long Term Care Facilities updated [DATE]. The CDC Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated [DATE], identified expanded screening testing of asymptomatic HCP should be as follows: -In nursing homes located in counties with >10% positivity of [CONDITION(S)] tests in the past week, unvaccinated HCP should have a [CONDITION(S)] test twice a week. -If unvaccinated HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). -In nursing homes located in counties with ,d+[DATE]% positivity of [CONDITION(S)] tests in the past week, unvaccinated HCP should have a [CONDITION(S)] test once a week. -In nursing homes located in counties with <5% positivity of [CONDITION(S)] tests in the past week, unvaccinated HCP should have a [CONDITION(S)] test once a month. The Centers for Medicare and Medicaid (CMS) Quality Safety and Oversite (QSO) memo (QSO ,d+[DATE] NH) revised [DATE], directed routine testing of unvaccinated staff was based on the extent of the virus in the community. Facilities used their county positivity rate in the prior week as the trigger for staff testing frequency. The facility must test all unvaccinated staff at the frequency indicated based on the county positivity rate reported in the past week. Facilities monitored their county positivity rate every other week and adjust the frequency of performing staff testing accordingly. - If the county positivity rate increased to a higher level of activity, the facility should begin testing staff at the frequency shown in the table above as soon as the criteria for the higher activity were met. - If the county positivity rate decreased to a lower level of activity, the facility should continue testing staff at the higher frequency level until the county positivity rate has remained at the lower activity level for at least two weeks before reducing testing frequency. Staff with symptoms or signs of COVID-19, vaccinated or not vaccinated, must be tested immediately and are expected to be restricted from the facility pending the results of COVID-19 testing. If COVID-19 is confirmed, staff should follow Centers for Disease Control and Prevention (CDC) guidelines Criteria for Return to Work for Healthcare Personnel with SARSCoV2 Infection.

Based on observation, interview and document review, the facility failed to ensure residents displaying signs and symptoms of COVID-19 were quarantined to their rooms; transmission based precautions initiated and tested per The Centers for Disease Control and Prevention's (CDC) guidance to prevent the spread of COVID-19 for 8 of 21 residents (R17, R5, R1, R2, R4, R6, R9, R10). In addition, the facility failed to ensure staff who displayed signs and symptoms of COVID-19 were removed from the schedule per the the CDC's guidance. This deficient practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all residents residing in the facility during the COVID-19 Focused Infection Control Survey; including 17 residents (R17, R5, R1, R2, R3, R4, R6, R15, R9, R10, R7, R11, R12, R14, R8, R16) who contracted COVID-19. This resulted in actual harm to R2, R3 and R5 who expired with COVID-19 and R4 and R15 who were hospitalized with COVID-19. The IJ began on [DATE], when the facility failed to quarantine and initiate transmission based precautions (TBP) when R17 reported COVID-19 signs and symptoms of aching all over along with a headache; and the facility continued the practice of not quarantining and initiating TBP when R5, R1, R2, R4, R6, R9 and R10 began displaying signs and symptoms of COVID-19. In addition, the facility failed to ensure staff; licensed practical nurse (LPN)- B, nursing assistant (NA)-A and registered nurse (RN)-A reported all signs of symptoms of COVID-19 prior to starting their shifts and did not work with signs and symptoms of COVID-19 until a COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The CDC guidance People with Certain Medical Conditions dated [DATE], identified older adults were more likely to get seriously ill from COVID-19. More than 80 percent of COVID-19 deaths have occurred in people over the age of 65, and more than 95 percent of COVID-19 deaths have occurred in people older than 45. Further, among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. During entrance conference on [DATE], at 10:15 a.m. the director of nursing (DON) stated there were nine residents in the facility with COVID-19, three residents had expired with COVID-19 and three residents were in the hospital with COVID-19. Further, 98 percent of residents were vaccinated and 58 percent of the facility staff were vaccinated. The CDC guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (COVID-19) Spread in Nursing Homes dated [DATE], indicated nursing homes must sustain core infection prevention and control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and healthcare personnel (HCP) to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. People with COVID-19 had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms appeared ,d+[DATE] days after exposure to the virus. Anyone could have mild to severe symptoms and may have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea and/or vomiting, and diarrhea. Anyone with symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test immediately. - Properly managed individuals with suspected or confirmed [CONDITION(S)]-CoV-2 infection or who had contact with someone with suspected or confirmed [CONDITION(S)]-CoV-2 infection: HCP should be excluded from work and should notify occupational health services to arrange for further evaluation. Residents with suspected [CONDITION(S)]-CoV-2 infections should be prioritized for testing, should be cared for by healthcare personnel (HCP) using an N95 or higher-level respirator, eye protection (for example: goggles or a face shield that covers the front and sides of the face) gloves and a gown. Ideally, the resident should be moved to a single-person room with a private bathroom while test results were pending. In general, it was recommended the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. Increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptom, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least three times daily and quickly manage serious infection. Symptomatic Residents: On [DATE], at 12:12 p.m. the resident area was observed. One wing was designated as the COVID-19 wing with the doors to the wing shut. There was a personal protective equipment (PPE) station set up for putting on and removing PPE. All residents were in their rooms and staff currently were wearing appropriate PPE including N95 respirators, eye goggles, gowns and gloves on the unit. R17's discharge Minimum Data Set (MDS) dated [DATE], identified R17 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's medical record identified R17 was fully vaccinated. R17's progress notes identified the following: - [DATE], R17 complained of aching all over and a headache. - [DATE], R17's oxygen saturations (O2 sats) decreased to 90 percent (a average level of oxygen is 95 percent or higher) on room air. R17 had a productive cough, complained of feeling very tired and ate poorly. - [DATE], R17 complained of body aches, headache, and a cough. - [DATE], R17 tested positive for COVID-19. R17's medical record lacked evidence R17 was immediately quarantined and TBP were initiated after displaying COVID-19 symptoms on [DATE]. R5's undated face sheet identified R5 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, it was identified R5 was roommates with R1. R5's medical record identified R5 was fully vaccinated. R5's progress notes identified the following: - [DATE], R5's O2 sats decreased to ,d+[DATE] percent on room air. - [DATE], R5 tested positive for COVID-19 - [DATE], R5 expired at the facility. R5's medical record lacked evidence R5 was immediately quarantined and TBP initiated after displaying symptoms on [DATE]. R1's undated face sheet identified R1 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, it was identified R1 was roommates with R5. R1's medical record indicated R1 was fully vaccinated. R1's progress notes identified the following: - [DATE], R1 had a fever of 100.2 degrees Fahrenheit (F) in the afternoon and was medicated with Tylenol to bring his temperature down. - [DATE], R1 had a fever of 99.3 degrees F and was again medicated with Tylenol. R1 went to the dining room for his breakfast, where he became unresponsive at the breakfast table. R1 had low blood pressure and his O2 sats decreased to 78 percent on room air. R1 was transferred to the emergency room for evaluation, where he tested positive for COVID-19. R1's medical record lacked evidence R1 was immediately quarantined and TBP after displaying symptoms of COVID-19 on [DATE], or when R1's roommate R5 began displaying symptoms of COVID-19 on [DATE]. R2's undated face sheet identified R2 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's medical record indicated R2 was not vaccinated for COVID-19. R2's progress notes identified the following: - [DATE], R2 had a fever of 99.6 degrees Fahrenheit, was coughing and complained of body aches. - [DATE], R2's O2 sats decreased to 94 percent and R2 had a cough. - [DATE], a COVID-19 test was obtained and R2 tested positive for COVID-19. - [DATE], R2 was admitted to the hospital where R2 expired. R2's medical record lacked evidence R2 was immediately quarantined and TBP initiated after displaying symptoms on [DATE]. R3's undated face sheet identified R3 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's medical record identified R3 was not vaccinated for COVID-19. R3's progress notes identified the following: - [DATE], R3 tested positive for COVID-19. - [DATE], R3's O2 sats were fluctuating in the 70 percent range. - [DATE], R3 had a fever of 102.2 degrees F. and later expired at the facility. R4's undated face sheet identified R4 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's progress notes identified the following: - [DATE], R4 was tested for COVID-19 with negative results and remained on the active COVID unit of the facility. - [DATE], R4 was tested for COVID-19 with negative results and remained on the active COVID unit of the facility. - [DATE], R4 had a fever of 99.6 degrees F. and R4's O2 sats decreased to 93 percent. Further R4 complained of discomfort and sore throat. - [DATE], R4 had a cough and complained of sore throat. - [DATE], R4 was tested for COVID-19 with positive results. - [DATE], R4 was hospitalized for respiratory symptoms related to COVID-19 and remained hospitalized . R4's medical record lacked evidence R4 was immediately quarantined and TBP initiated after displaying COVID-19 signs and symptoms on [DATE], and remained on the COVID-19 unit without transmission based precautions initiated. R6's undated face sheet identified R6 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's medical record indicated R6 was fully vaccinated for COVID-19. R6's progress notes identified the following: - [DATE], R6 complained of pain and headache. - [DATE], R6 complained of feeling freezing cold. R6 had a cough, body aches and hoarse voice. R6's temp was 101.4 degrees F. and R6's O2 sats decreased to 92 percent. R6 later left the facility to an orthotic appointment to be fitted for shoes, while having symptoms of COVID-19. - [DATE], R6 was tested for COVID-19 with positive results. R6's medical record lacked evidence R6 was immediately quarantined and TBP initiated after displaying COVID-19 symptoms on [DATE]. R15's undated face sheet identified R15 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's medical record identified R15 was fully vaccinated for COVID-19. R15's progress note(s) dated [DATE], identified R15 developed a fever of 101.2 degrees F, had shortness of breath and R15's O2 sats decreased to ,d+[DATE] percent. R15 was tested for COVID-19 with positive results and was hospitalized for pneumonia due to COVID-19. R9's undated face sheet identified R9 was [AGE] years of age. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's medical record indicated R9 was fully vaccinated for COVID-19. R9's progress notes identified the following: - [DATE], R9 had a cough and increase confusion. - [DATE], R9 tested for COVID-19 with positive results. R9's medical record lacked evidence R9 was immediately quarantined and TBP initiated after displaying COVID-19 signs and symptoms on [DATE]. R10's undated face sheet identified R10 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's medical record identified R10 was full vaccinated for COVID-19. R10's progress notes identified the following: - [DATE], R10 had increased coughing episodes and was lethargic (sleepy or fatigued and sluggish). - [DATE], R10 tested for COVID-19 with positive results. R10's medical record lacked evidence R10 was immediately quarantined and TBP initiated after displaying COVID-19 signs and symptoms on [DATE]. R7's undated face sheet identified R7 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's medical record indicated R7 was fully vaccinated for COVID-19. R7's progress note(s) dated [DATE], identified R7 had a cough and tested positive for COVID-19. R11's undated face sheet identified R11 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's progress note dated [DATE], identified R11 tested positive for COVID-19. R12's undated face sheet identified R12 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's medical record identified R12 was fully vaccinated for COVID-19. R12's progress note dated [DATE], identified R12 tested positive for COVID-19. R14's undated face sheet identified R14 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's medical record identified R14 was fully vaccinated for COVID-19. R14's progress note dated [DATE], identified R14 tested positive for COVID-19. R8's undated face sheet identified R8 was [AGE] years of age. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's medical record indicated R8 was fully vaccinated for COVID-19. R8's progress noted dated [DATE], identified R8 tested positive for COVID-19 on [DATE]. R16's undated face sheet identified R16 was [AGE] years old. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's medical record identified R16 was fully vaccinated for COVID-19. R16's progress note dated [DATE], identified R16 tested positive for COVID-19. During interview on [DATE], at 11:31 p.m. RN-B stated she was not sure when residents were quarantined and moved to the COVID-19 unit as she was out of the facility until a few days ago. RN-B was aware many residents tested positive for COVID-19 when the facility initiated outbreak testing. On [DATE], at 10:57 a.m. the administrator stated the facility started to do twice a day COVID-19 symptom monitoring after R1 tested positive for COVID-19. Any resident who exhibited symptoms of COVID-19 such as cough, diarrhea or any COVID-19 symptoms would be rapid tested . The administrator indicated residents should have been placed in quarantine and tested when first displaying signs and symptoms of COVID-19. She felt the nurses may have become complacent with the low community spread of COVID-19 and would administer Tylenol to treat the residents symptom of fever, instead of thinking potential COVID-19 symptoms. On [DATE], at 4:15 p.m. LPN-A stated she checked R1's temperature on [DATE], and it was elevated at 100.4 degrees F. R1 complained of cough and runny nose, but LPN-A stated she felt a cough and runny nose were not symptoms of COVID-19. LPN-A did not place R1 in quarantine on transmission based precautions pending a COVID-19 test. Further, R1 went to the dining room for supper the evening of [DATE], and was not quarantined from other residents. LPN-A stated if a resident became ill on her shift, she would assess them, if LPN-A could not bring the temperature down with Tylenol or symptoms were severe, she would either notify the physician or send the resident to the emergency room . LPN-A had never initiated transmission-based precautions for any resident and did not know the process for testing a resident for COVID-19. On [DATE], at 5:47 p.m. an interview was conducted with the DON and RN-B. It was not the facility's practice to quarantine, initiate TBP and test residents for COVID-19 unless there was a strong suspicion of COVID-19 or a cluster of symptoms. The facility would not conduct testing unless the resident had one or two severe symptoms that lasted more than 24 hours. The facility's practice prior to their outbreak on [DATE], was to administer Tylenol for a fever or headache and cough syrup for a resident with a cough. The facility was not placing residents on quarantine and initiating transmission based precautions when residents were displaying potential COVID-19 symptoms such as a fever or cough until after receiving a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The undated facility policy Essentia Health Long Term Care (SNF/AL) Infection Prevention Interim Policy for Guidance during Pandemic and Suspected or Confirmed Coronavirus (COVID-19), identified prompt detection, triage and isolation of potentially infected residents was required. A resident with known or suspected COVID-19 , immediate infection prevention and control measures need to be put in to place. Residents should have contact and droplet precautions intiated. The policy had several links embedded into the document; however, did not identify symptoms of COVID-19 and when to quarantine and intiate TBP, until testing could be completed. Symptomatic Staff: The Centers for Medicare and Medicaid (CMS) Quality Safety and Oversite (QSO) memo QSO-,d+[DATE]-NH revised [DATE], directed staff with symptoms or signs of COVID-19, vaccinated or not vaccinated, must be tested immediately and are expected to be restricted from the facility pending the results of COVID-19 testing. If COVID-19 is confirmed, staff should follow Centers for Disease Control and Prevention (CDC) guidelines Criteria for Return to Work for Healthcare Personnel with SARSCoV2 Infection. The CDC guidance Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2 updated [DATE], indicated healthcare personnel (HCP) with even mild symptoms of COVID-19 should be prioritized for [CONDITION(S)] testing with approved nucleic acid or [MEDICATION(S)] detection assays. When a clinician decides that testing a person for [CONDITION(S)]-CoV-2 is indicated, negative results from at least one FDA Emergency Use Authorized COVID-19 [CONDITION(S)] test indicates that the person most likely does not have an active [CONDITION(S)]-CoV-2 infection at the time the sample was collected. A second test for [CONDITION(S)]-CoV-2 RNA may be performed at the discretion of the evaluating clinician, particularly when a higher level of clinical suspicion for [CONDITION(S)]-CoV-2 infection exists. If the second test is positive, consultation with an infectious disease expert should be considered to resolve the discrepant results. For healthcare personnel who were suspected of having COVID-19 but following evaluation another diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .A symptom-based strategy for determining when HCP with [CONDITION(S)]-CoV-2 infection could return to work is preferred in most clinical situations. - The criteria for the symptom-based strategy are: HCP with mild to moderate illness who are not moderately to severely immunocompromised: - At least 10 days have passed since symptoms first appeared and - At least 24 hours have passed since last fever without the use of fever-reducing medications and - Symptoms (e.g., cough, shortness of breath) have improved - HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: -At least 10 days have passed since the date of their first positive [CONDITION(S)] diagnostic test. - HCP with severe to critical illness or who are moderately to severely immunocompromised: - At least 10 days and up to 20 days have passed since symptoms first appeared and - At least 24 hours have passed since last fever without the use of fever-reducing medications and - Symptoms (e.g., cough, shortness of breath) have improved - Consider consultation with infection control experts During interview on [DATE], at 2:33 p.m. the DON stated she was responsible for COVID-19 routine and outbreak testing for staff and residents, but registered nurse (RN)-B was taking over the infection prevention program overall. The facility conducted routine COVID-19 staff testing on [DATE], and had no positive results. However, R1 was the first resident who tested positive, when R1 was transferred to the emergency department on [DATE]. Additionally, two nurses called-in ill on [DATE], and were instructed to get tested as well due to a high-risk exposure. Both nurses tested , and the test results were positive. On [DATE], the facility began outbreak testing of all vaccinated and unvaccinated residents and staff that entered the nursing home unit. On [DATE], at 10:47 a.m. the outbreak testing rosters, county positivity rate and staff work schedules dated [DATE] to [DATE], were reviewed with the DON who stated the facility had approximately twenty staff members and nine of those were positive for COVID-19; however, some staff met the CDC criteria to return to work. The DON identified the facility process for a confirmed COVID-19 staff member as: the staff member was removed from the work schedule and the staff member was instructed to call an offsite corporate workability call center for determination of work status. Once a workability assessment was completed, the DON received the staff member's workability form which identified the date the staff member was allowed to return to work. Additionally, if a staff member reported symptoms of COVID-19, the staff member was instructed to call an offsite corporate workability call center. An assessment was conducted and a COVID-19 test was obtained. The staff member was not allowed to work until instructed. The following was reviewed with the DON: - LPN-B's COVID Employee Tracking (workability) form dated [DATE], indicated the following: -Date of COVID-19 positive test: [DATE] -Employee symptom onset: [DATE] -Last day worked: [DATE] -Work restrictions start date: [DATE] -Work restriction end date: [DATE] -Return to work date: [DATE] - LPN-B's [CONDITION(S)]-CoV-2 RNA (COVID-19), Molecular Detection laboratory report dated [DATE], identified the test was positive for COVID-19. The specimen was collected [DATE] and results were identified on [DATE]. - LPN-B's workability form dated [DATE], indicated LPN-B returned to work on [DATE], and LPN-B reported she was symptomatic on [DATE]. During interview on [DATE] at 2:33 p.m., the DON stated she was unaware LPN-B reported symptoms beginning [DATE]; however, LPN-B's onsite daily active screenings dated [DATE], [DATE] and [DATE], indicated LPN-B reported no symptoms nor had displayed any fever. According to the facility schedules LPN-B worked in the facility on [DATE], [DATE] and [DATE] and was not removed from work until she tested positive on [DATE]. During interview on [DATE], at 2:57 p.m. LPN-B stated she tested positive for COVID-19 on [DATE], during outbreak testing. LPN-B worked on [DATE] and [DATE], but was unsure if she worked [DATE]. When LPN-B spoke with workability, she told them her symptoms started on [DATE], when she had a sore throat, sniffles and a weird cough; therefore, workability told LPN-B she was able to return to work on [DATE]. Further, LPN-B answered no to all screening questions, indicating she had no signs or symptoms of COVID-19, prior to all her shifts because she could not tell if it was allergies or not. Further workability told her that was perfectly ok that she did not report her symptoms earlier. On [DATE], at 3:03 p.m. the offsite corporate workability phone line was called and the staff member who answered the call declined to identify herself. She stated all staff were educated on the signs/symptoms of COVID-19 and were to report any symptoms. All symptomatic staff were to be tested prior to returning to work even if the staff member was unsure if the symptoms were related to allergies. Symptomatic staff were instructed to call ahead for testing prior to working their shift and not report to work even if testing was required daily. If positive, staff were instructed to isolate at home for ten to twenty days depending on the individual situation. Symptomatic individuals were instructed to quarantine at home for fourteen days depending on the individual situation. During interview on [DATE], at 9:41 a.m. LPN-C stated all staff must screen themselves upon entry to the building at the front door. Their temperature was taken and the staff answered screening questions and, based on their answers, they were allowed entry. Staff were not allowed to work if they were symptomatic and were instructed to contact workability. Additionally, any symptoms including sniffles must be addressed by workability before the staff member was allowed to work. During interview on [DATE], at 10:55 a.m. RN-F stated she was collecting staff test samples that day. However, staff were screened prior to entry into the building. The Health Unit Coordinator (HUC) or the charge nurse obtained the staff member's temperature and the staff member self answered the screening questions by filling out the screening tracking form. If a staff member reported symptoms, the HUC would have the charge nurse assess the staff member and the staff member would be instructed to call workability. However, RN-F stated symptoms would need to be new onset. For example, if a staff member had allergies, they would have symptoms all the time. If there was any doubt, the staff member called workability. Additionally, the staff member was instructed to go home until they were instructed to return to work. During interview on [DATE], at 10:25 a.m. the administrator stated any staff member who exhibited symptoms during onsite daily screening or tested positive for COVID-19 during routine or outbreak testing were instructed to contact workability. During the workability call, the staff member was assessed for symptoms and was removed from the work schedule for at least 10 days no matter what; however, some staff were kept away longer if they continued to exhibit symptoms or if there were other health considerations. The workability forms were then emailed to the staff member's supervisor. For the nursing home, the nursing staff workability forms were sent to the DON, while ancillary departments which serviced the nursing home such as laundry, dietary, or maintenance were departments of the hospital and received their own workability forms. Therefore, no one in the nursing home reviewed all workability forms for employee's reporting symptoms or return to work status. For example, the administrator stated, in the spring months, she tested negative for COVID but was instructed to stay home from work for 14 days due to a cough and that was the process they should follow. Because of this, the process for staff to call workability applied to all reports of illness; however, the administrator was unsure of any process to ensure a staff member called workability, it's more of a verbal communication. The facility Employee Call-in Book, identified the following call ins: -[DATE], NA-A called-in ill stating I don't feel good, and I won't be in. No further symptoms were documented. -[DATE], RN-A called-in ill due to a headache. No further symptoms were documented, or information provided. - [DATE], NA-G called-in ill due to headache. No further symptoms were documented, or information provided. During interview on [DATE], at 11:24 a.m. the administrator stated no workability assessments were completed for the three staff members NA-A, RN-A and NA-G who called-in ill as identified by the Employee Call- In Book. Further, there was no follow up on their symptoms as required, to ensure the signs and symptoms were not COVID-19 related. NA-A returned to work on [DATE]. RN-A returned to work on [DATE], and continued to work [DATE], [DATE], [DATE] and [DATE]. On [DATE], RN-A was identified to test positive for COVID-19 during outbreak testing. NA-G returned to work on [DATE]. Further, all three staff members should have called the workability call center for an assessment to determine their work status prior to reporting for work. On [DATE], at 2:00 p.m. the medical laboratory supervisor (MLS) stated the facility procedure to call workability applied to any staff member who missed shifts due to illness; however, if the call in was related to a possible COVID-19 symptom the staff needed to be tested the day they called in or at least before they returned to work. Further, if a staff member had not called workability and had returned to work, they would be instructed to call, and a rapid test would be obtained. On [DATE], at 2:25 p.m. NA-A stated she had called in on [DATE], due to a fever and sore throat but she didn't call the corporate workability call center. Instead, she went to [MEDICATION(S)] and purchased a quick test on her own, which she reported was negative. NA-A stated she sent a photo of the negative test to the DON and returned to work on [DATE]. During the interview NA-A removed her eye protection and rubbed her eyes with her hand. NA-A' s face was flushed, and her eyes and surrounding skin were reddened and irritated. NA-A stated she had nasal congestion, and had mattery eyes and spoke in a harsh voice. NA-A stated she had allergies. However, she answered no to all the screening questions prior to her shift even though she was instructed these were possible symptoms of COVID-19. NA-A stated I should have answered yes on the screening questions but stated the nurses were aware of her symptoms and instructed her to keep her mask on. -At 2:35 p.m. RN-A and licensed practical nurse (LPN)-C were notified by the survey team of the need to assess NA-A because she was displaying symptoms of possibly COVID-19. RN-A and LPN-C stated they were unaware of NA-A having symptoms; however, RN-A turned to LPN-C and stated, if it's only allergies, but LPN-C replied any staff member who was showing symptoms should be pulled from the floor and the DON should be notified. Further, NA-A was tested during outbreak testing, but those results would not be available for possibly two days and NA-A required a negative rapid test to return to work. -At 2:37 p.m. RN-A called the DON to notify of NA-A's symptoms. RN-A did not assess or speak with NA-A prior to the call. NA-A was instructed to go to the DON's office. -At 2:38 p.m. NA-A left the unit and met the DON in the administrative hallway. NA-A was instructed to take a seat in the beauty shop where testing was conducted. NA-A sat in the beauty chair, removed her eye protection and surgical mask, but continued to wear an N95. -At 3:06 p.m. the DON instructed NA-A to go home because the lab was able to use the previously collected swab to conduct a rapid PCR test. The results were expected to be available in approximately one hour, but NA-A was instructed to not return to the facility until she was notified to do so. During interview on [DATE], at 3:09 p.m. the DON stated she was unable to recall if NA-A sent her photos of a non-facility test on [DATE]. Additionally, the health unit coordinator (HUC) screened NA-A for symptoms prior to her shift on [DATE], and NA-A responded no to all the questions regarding symptoms, even though she had congestion, itchy watery eyes, and harsh voice, but the DON assumed she had allergies. When asked if a nurse would be notified to assess a symptomatic staff member during the screening process, the DON shrugged her shoulders and stated the HUC asked the questions, and the staff responded. Upon review of the facility policy regarding symptomatic staff members, the DON stated symptomatic staff members should be t

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning in accordance with the care plan for 2 of 6 resident (R3, R22) identified as at risk for the development of pressure sores. This failure resulted in actual harm for R3 due to the development of a recurrent pressure ulcer. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R3 required extensive to total assistance of staff for personal hygiene and was identified at risk for the development of pressure ulcers. R3's Pressure Ulcer Care Area Assessment (CAA) dated 11/23/18, only included: Med DX (medical diagnosis). The CAA did not contain an analysis of R3's skin condition. R3's Tissue Tolerance Assessment (skin perfusion test) dated 5/7/19, indicated R3 had no reddened areas after after sitting or lying for three hours. R3's Braden Scale (an assessment of pressure sore risk) dated 5/8/19, indicated R3 was at high risk for the development of pressure ulcers. R3's Care Plan dated 8/28/18, indicated R3 had a stage two pressure ulcer (partial loss of skin) on the coccyx and directed staff to reposition R3 every two hours. On 5/15/19, at 7:07 a.m. R3 was observed in the dining room, seated in a wheelchair. Continuous observations were conducted until 9:50 a.m. - At 7:23 a.m. R3 remained in the dining room seated in the wheelchair. R3 was asleep. - At 8:20 a.m. R3 began to drink a nutritional supplement. - At 8:54 a.m. nursing assistant (NA)-D asked R3 if she wanted anything else to eat. - At 9:15 a.m. NA-D wheeled R3 out of the dining room and into the living room. - At 9:20 a.m. NA-F wheeled R3 from the living room to her room and asked if she would like to use the restroom. R3 refused. - At 9:30 a.m. when asked, NA-F stated she had assisted R3 out of bed at 6:50 a.m. and had not provided assistance with repositioning since that time. - At 9:31 a.m. licensed practical nurse (LPN)-A stated R3 had a history of [REDACTED]. LPN-A stated the area was very fragile and she did not know if the area was currently open or not but due to R3's incontinence/moisture on her skin, R3 was at risk for open areas. - At 9:50 a.m. NA-F and the director of nurses (DON) transferred R3 from the wheelchair to bed via a full body mechanical lift. R3's wheelchair was equipped with a pressure redistribution cushion. - At 9:55 a.m. NA-F rolled R3 onto her side and removed the incontinence brief. R3's coccyx had an open area and a small amount of serosanguineous (blood/serum) drainage was noted on the brief. NA-F stated R3's coccyx was open when she had assisted R3 out of bed at 6:50 a.m. and the open area was not covered with a dressing at that time, nor had she notified the nurse the wound dressing was missing. (R3 had not been assisted with repositioning for three hours and five minutes). - At 10:00 a.m. registered nurse (RN)-A and the DON cleansed the wound and reported the wound measured 0.7 centimeters (cm) by 0.5 cm x 0.1 cm deep. The wound edges were noted to be jagged surrounded by pink skin. In addtion, R3 was noted to have a 1.5 cm x 1 cm macerated area on the right buttocks. The wound was covered with a [MEDICATION NAME] AG (foam) dressing. The DON stated when the staff had noted the wound dressing was off during morning cares, it should have been reported to the nurse so the dressing could be replaced. The aforementioned wound measurements were documented in R3's progress notes. R3's Skin Integrity Events (wound documentation) dated 4/28/19, indicated R3 was noted to have a pressure ulcer on her coccyx area. The wound measured 0.7 cm x 0.1 cm and was identified as superficial. The interventions implemented were to monitor the skin daily, encourage R3 to allow incontinence cares timely, encourage nourishment and refer to physican for evaluation. R3's Progress Note dated 5/9/19, at 2:02 p.m. indicated the nurse practioner (NP) had evaluated R3's coccyx. The NP indicated the wound was to be washed with soap and water, dried, and a [MEDICATION NAME] AG dressing applied every other other day. R3 was to be repositioned every two hours and offloaded to ensure R3 was not sitting all day. On 5/15/19, at 11:25 a.m. RN-A stated R3 was to be repositioned every two hours as directed by the care plan. RN-A stated R3's coccyx area opened and closed frequently. Upon comparison of the documentation from 4/28/19, to the 5/15/19 measurements, RN-A stated R3's wound had increased in size. RN-A confirmed R3 had not received assistance with repositioning as directed by the care plan, and should have been. On 5/15/19, at 12:47 p.m. the DON verified R3 was to be repositioned every two hours as directed by the care plan. The DON also stated R3's coccyx had been identified as closed on 4/26/19, however it had reopened on 4/28/19. Since that time, the wound had increased from a superficial wound to a wound with depth, the area of the wound was larger and R3 had developed a second macerated area on her buttocks. The DON confirmed R3's coccyx pressure ulcer had worsened. R22's quarterly MDS dated [DATE], indicated R22's [DIAGNOSES REDACTED]. The MDS indicated R22 had significant cognitive impairment and needed extensive assistance with ADL's. He was unable to ambulate and required a full body mechanical lift for transfers. R22 was always incontinent of bladder and bowel and required assistance with all toileting and repositioning. R22's Pressure Ulcer CAA dated, 12/13/18, indicated R22 was at high risk for skin breakdown related to his poor mobility, incontinence, behaviors and his reliance on staff for all ADL's. R22's Activity of Daily Living (ADL) CAA dated, 12/13/18, indicated he was dependent on staff for mobility and required extensive assistance with all ADL's. R22's care plan last reviewed/revised on 5/10/19, indicated R22 had a stage 1 pressure ulcer (redness of the skin that does not blanch when pressed upon) on his coccyx, measuring 6 centimeters (cm) x 5 cm, related to refusing to offload (any measure to eliminate abnormal pressure points to promote healing or prevent ulcers). The problem start date was 5/10/19. The care plan directed staff to implement interventions which included but were not limited to: -Avoid friction and shear forces during transfer and position changes -Conduct a systematic skin inspection weekly. Report any signs of further skin breakdown -Keep clean and dry as possible. Minimize skin exposure to moisture. -Keep resident off pressure injury site. -Provide incontinence care after each incontinent episode. -Turn and reposition every 2 hours. -Use therapeutic cushion for pressure reduction when resident is in chair. The undated, nursing assistant's care sheet indicated R22 required full assistance with ADLs and directed staff to provide side to side repositioning assistance every two hours and offload after breakfast and lunch for 1 hour. R22's Progress Note dated 5/9/19, indicated R22 had a stage 1 pressure injury on coccyx that measured 6.0 cm x 5.0 cm. The area surrounding is dark pink and blanchable. Sacral Mep ([MEDICATION NAME]) boarder (sic) (bordered foam dressing) applied, resident to be offloaded every day after breakfast and after lunch 1 hour each time. Resident to be repositioned side to side every 2 hours during the night. Will update nurse practitioner and physician. R22's Skin Assessment Progress Note dated 5/15/19, indicated R22 had a stage 1 pressure injury to his coccyx. Areas are blanchable at this time. A large [MEDICATION NAME] border was placed over the area due to other open areas. A new cushion placed on resident's wheelchair. Resident denies any discomfort with new cushion. Will monitor. On 5/14/19, at 5:32 p.m. staff were observed to transfer R22 into his wheelchair via the full body mechanical lift. Continuous observations continued until 8:24 p.m. - At 5:44 p.m. R22 remained seated in the wheelchair, at the dining room table with his eyes closed and his head flexed back. R22 remained seated in the wheelchair, at the dining table, consuming the meal until 6:48 p.m. at which time was assisted into the activity area to play bingo. R22 remained in the activity until 7:32 p.m. when the activity director assisted R22 to the nurses station to wait for his medication. - At 8:01 p.m. R22 remained at the nurses station and was heard to say he would like to go to his room and get washed up. - At 8:08 p.m. nursing assistant (NA)-K assisted R22 to his room. Once in the room, NA-A entered and both NAs proceeded to assist R22 with washing up while seated in the wheelchair. - At 8:24 p.m. NA-K and NA-A transferred R22 into his bed via the full body lift. The NA's provided incontinence care and confirmed R22's brief was wet. R22's coccyx and entire buttocks area were noted to be a deep red color with scattered open areas throughout. The skin on the right buttock was macerated and excoriated with bleeding noted in scattered areas. NA-A confirmed R22 had not been repositioned for two hours and 52 minutes. NA-A stated R22 should be repositioned every two hours but you don't mess with bingo. -At 8:37 p.m. the director of nursing (DON) confirmed R22 coccyx and buttocks were dark red and inflamed as described. On 5/15/19, at 7:43 a.m. the DON was observed in R22's room providing wound care. R22's skin was observed to continue to be reddened over entire coccyx and buttocks. However, DON stated R22's coccyx and buttocks were less inflamed than had been when he was assisted into bed the previous night and confirmed the redness had improved and was not as dark after being positioned off the areas overnight. -At 7:56 a.m. R22 was observed seated in the wheelchair while being assisted into the dining room for breakfast. Continuous observations of R22 continued until 11:30 a.m. - At 8:52 a.m. R22 remained in the dining room finishing his breakfast, seated in the wheelchair. - At 9:11 a.m. R22 hollered out when am I going to get my pills and he was taken to his room. He was told the nurse would be there in a minute. R22 was not offered or provided offloading or repositioning assistance. The call light was positioned within R22's reach. The TV was turned on. - At 9:18 a.m. licensed practical nurse (LPN)-A entered R22's room, administered his medications and left. - At 9:36 a.m. LPN-A entered R22's room and administered his eye drops and left the room. R22 remained seated in the wheelchair, watching TV. - At 9:43 a.m. NA-F entered the room to pass fresh water and left the room. NA-F had not offered nor provided R22 offloading or repositioning assistance. R22 remained in the wheelchair, watching TV until 10:13 a.m. at which time he was assisted out into the hall and given a drink from snack cart and assisted to the resident council meeting in the activity room. R22 remained in the activity area until 11:30 a.m. at which time the activities had ended and R22 remained in the wheelchair. - At 11:32 a.m. the surveyor intervened and requested NA-D reposition R22. -At 2:25 p.m. NA-A confirmed R22 had been sitting without repositioning for greater than three hours. NA-A stated we did ask R22 to reposition and toilet before he went to activities but he had refused. On 5/16/19 at 10:17 a.m. the DON verified R22 should have been repositioned as directed by the care plan and confirmed staff had not been documenting R22's refusal to lie down to off load. DON agreed interventions to treat the pressure ulcer were not being implemented. The Comprehensive Care Plan policy dated 1/1/19, indicated each resident was to receive necessary care as identified on the individualized care plan. The Skin Care Management policy dated 2/19/19, directed the staff to identify and assess resident whose clinical conditions increase the risk for impaired skin integrity, and pressure injury: to implement preventative measures; and to provide appropriate treatment modalities for injury according to injury standards of care.

Based on observation, interview and document review, the facility failed to provide ambulation services as directed in order to prevent the decline in ambulation abilities for 1 of 3 residents (R2) observed to have declined in the ability to ambulate. The lack of the provision of ambulation services resulted in actual harm for R2 due to the inability to ambulate. In addition, the facility failed to provide range of motion services as directed in order to maintain range of motion (ROM) abilities for 3 of 3 residents (R8, R21 and R1) who had a restorative program. Finding include: R2's annual Minimum Data Set ((MDS) dated [DATE], indicated R2 had [DIAGNOSES REDACTED]. The MDS indicated R2 had severe cognitive impairment and required extensive assist of one staff for all activities of daily living. The MDS indicated R2 did not have the ability to ambulate. R2's quarterly MDS dated [DATE], indicated R2 did not have the ability to ambulate. R2's quarterly MDS dated [DATE], indicated R2 had the ability to ambulate with extensive assistance of one staff. R2's Falls Care Area Assessment (CAA) dated 2/9/18, indicated R2 had impaired balance during transitions for sitting to standing. The CAA did not identify R2's ability to ambulate. R2's care plan dated 2/19/17, indicated R2 had limitations in physical mobility and directed the staff to transfer to assist R2 with a walker and gait belt while transferring. The plan also directed the staff to provide R2 with assistance with a walking program. R2 was to ambulate up to twenty feet with a front wheeled walker and two staff twice a On 4/11/18, at 12:34 p.m. nursing assistant (NA)-C was observed wheeling R2 out of the dining room. Shortly there-after, R2 was observed resting in bed. NA-C stated she had transferred R2 to the bed by herself. On 4/11/18, at 5:00 p.m. family member (FM)-A stated he/she could not recall the last time R2 had been ambulated. - At 5:48 a.m. NA-D assisted to transfer R2 from the bed to her wheelchair. R2 was able to sit on the edge of the bed and maintain her seated balanced. NA-D applied a transfer belt and cued R2 to stand. R2 was not observed to be able to bear weight on her legs as NA-D lifted R2 and transferred her from the bed to the wheelchair. - At 5:52 p.m. NA-D stated R2 had not been able to walk for the past few months. NA-D stated she had reported R2's inability to ambulate to the nurses but was unsure of any further interventions. Review of the Restorative Nursing Flows sheets revealed the following information: R2 was to ambulate up to 50 feet with a front wheeled walked and two staff members with the wheelchair to follow. The restorative program was to implemented twice a day. - (MONTH) (YEAR), R2 ambulated between 5 - 50 feet on 55 of 60 opportunities. - (MONTH) (YEAR), R2 ambulated between 5-20 feet on 24 of 60 occasions. The back of the restorative flow sheet indicated R2 had refused to participate in the program on 7 occlusions and had stated concerns such as legs sore, legs hurt and toes and I can't do it. - (MONTH) (YEAR), R2 ambulated 2 - 20 feet on 15 of 62 occasions. The back of the restorative flow sheet indicated R2 had refused on five occasions with rational such as to weak, no, or took one step. - (MONTH) (YEAR), R2, ambulated 5-10 feet on 19 of 62 opportunities. The back of the restorative flow sheet indicated on 4 occasions R2 was too weak. - (MONTH) (YEAR), R2 ambulated 5- 50 feet on 19 of 60 opportunities. The back of the restorative flow sheet indicated R2 hard time standing, wasn't able to stand, too weak and not moving feet. - (MONTH) (YEAR), R2 ambulated 5 feet on on 8 of 62 opportunities. The back of the restorative flow sheet indicated on 16 occasions, R2 was too weak, ill, said no and wouldn't stand up. - (MONTH) (YEAR), R2 ambulated five feet on 1 of 30 opportunities. The back of the restorative flow sheet included three entities of documentation which stated: too weak, no, and I can't I'm too weak. - (MONTH) (YEAR), R2 ambulated 5-10 feet on 2 of 62 opportunities. The back of the sheet indicated on three occasions, R2 was unable to stand up. - (MONTH) (YEAR), R2 ambulated 5 feet on 1 of 62 opportunities. The back of the sheet included two entire which indicated R2 can't walk . - (MONTH) (YEAR), R2 had not participated in the ambulation program. The back of the sheet indicated R2 did not have the ability to stand upon her feet. - (MONTH) (YEAR), R2 ambulated five feet on 3/8/17. R2 had not participated in the program at any other time. The back of the flow sheet indicated R2 can't stand long enough to walk, too weak and wont stand. - (MONTH) (YEAR), R2 did not participate in the program. Review of the progress notes from 5/1/2017 - 4/11/18, lacked documentation related to R2's ability to ambulate. R2's clinical record lacked a therapy assessment. On 4/12/18, at 10:05 a.m. the director of nurses (DON) stated the facility had identified concerns with the restorative program. The DON stated the restorative program was to be reviewed monthly to ensure the residents were able to participate in the goals as directed. The DON reviewed R2's clinical record and confirmed R2's record did not contain documentation related to R2's inability to ambulate. The DON stated she could not recall the last time R2 was able to ambulate and R2's care plan had not been followed. On 4/12/18, at 12:42 p.m. registered nurse (RN)-A stated she was unaware R2 was on an ambulation program because R2 did not have the ability to ambulate. -At 12:51 p.m. NA-C and RN-A attempted to stand R2 in her room. R2 was unable to bear weight as NA-C transferred R2 to bed. NA-C stated R2 did not have any limitations in her range of motion, however, she was unable to bear weight and ambulate. -At 4:01 p.m. the DON reported she had reviewed R2's clinical record and confirmed the record lacked documentation related to R2's ability to ambulate. The DON stated R2 should have been reassessed when R2's ability to ambulate had declined, however, a re-assessment had not been completed. A policy related to ambulation was requested and none was provided. R8 had not received assistance with range of motion (ROM) as directed by the care plan. R8's quarterly MDS dated [DATE], indicated R8 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R8 required extensive assistance of two staff for bed mobility, extensive assist of one staff for transfers, dressing and personal hygiene. The assessment indicated R8 had no impairments in ROM of the upper extremities. R8's Activities of Daily Living Care Area Assessment (CAA) dated 8/8/17, indicated R8 required stand by assist of one with activities of daily living, and required simple verbal cues and encouragement. R8's care plan dated 11/14/17, directed staff to provide upper extremity exercises with yellow Thera-band (elastic resistance band) two times per week. It also directed the staff to walk with R8 2-3 times a week with stand by assist and a front wheeled walker and to provide many cues for completion. On 4/12/18, at 7:50 a.m. NA-C and the DON were observed to assist R8 with morning cares. R8 was observed to be able to move his arms in order to put his shirt on, however, R8 was not able to move his left arm higher than the level of his chest. -At 12:58 p.m. NA-C stated R8 participated in a restorative program during the evening shift. NA-C stated there had not been a change in his ability to dress. R8's Restorative Nursing Flowsheet directed staff to provide: -Lower extremity stretches 2 to 3 times per side with a 30 second hold to be completed three times per week. -Walk with resident with stand by assist and a front wheeled walker for a distance of at least 100 feet 2-3 times per week. -Upper extremity restorative program with a yellow Thera- band two times per week. Review of R8's Restorative Nursing Flowsheets revealed the following information: - (MONTH) (YEAR) - upper extremity ROM flowsheet was blank. - (MONTH) (YEAR) - upper extremity ROM flowsheet was blank. - (MONTH) (YEAR) - restorative flowsheet was unavailable for review. - (MONTH) (YEAR) - upper extremity ROM flowsheet was blank. - (MONTH) 1 - 13, (YEAR) - upper extremity ROM flowsheet was blank. -At 1:00 p.m. NA- C and RN-A assisted R8 to ambulate 80 feet with a front wheeled walker. R8's gait was steady as he walked from the nurse's station to his room. Once in his room, R8 was observed to lift his arm. R8 was not able to fully extend his arms over his head, but was able to lift his hands to the level of his head. NA-C stated R8's ROM in in his arms had not changed. -At 1:15 p.m. RN-A stated R8 had not had a change in his ROM in the upper extremities. RN-A stated the ROM program was to be completed as directed by the care plan. RN-A stated the NA's were to complete the programs, however, the flowsheets were not reviewed by any of the nursing staff for completion. -At 2:30 p.m. DON confirmed R8 had not received assistance with ROM as directed by the care plan. The DON stated the facility had identified a lack of oversight with the restorative nursing program and the quality assurance (QAPI) program was working on it. RN-A would be assigned to review the restorative program. R21 had not received assistance with ROM as directed by the plan of care. R21's quarterly MDS dated [DATE], indicated R21 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R21 required extensive assistance of one staff for transfers, dressing, personal hygiene and extensive assistance of two staff for bed mobility. The MDS also indicated no impairment for upper extremities. R21's Occupational Therapy Evaluation and Treatment Plan dated 3/27/18, indicated R21 had limitations in the upper extremities and was to continue with the ROM as directed. R21's care plan dated 3/22/18, directed the staff to perform active range of motion or passive range of motion as resident tolerated three times a week in accordance with the restorative nursing flowsheet. The Restorative Nursing Flow sheet directed the staff to assist R21 with upper extremity exercises with a green or red Thera-band two times a week each extremity ex for 10-15 minutes. Review of the Restorative Nursing Flowsheets dated (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed the flowsheets were blank. On 4/12/18, at 7:14 a.m. NA-C provided morning cares for R21. NA-C assisted R21 to apply a clean T-shirt and he was only able to lift left arm to chest level. -At 7:40 a.m. NA-C was asked about R21's restorative program and indicated no I don't do anything with him. We used to but he has (had a cognitive) declined so much that he cannot follow directions anymore. -At 10:06 a.m. the DON stated R21 was to receive assistance with ROM as directed by the care plan. The restorative program was to be reviewed monthly, however, this had not been completed. -At 1:38 p.m. NA-A stated the NA's did not have the time to provide assistance with ROM for R21. NA-A confirmed he had a program but it was not completed. -At 1:40 p.m. NA-C stated she had not provided ROM for R21 for a while and indicated R21 did not have the ability to follow directions due to cognitive decline. -At 1:51 p.m. licensed practical nurse (LPN)-A stated it was very difficulty to find the time to complete the restorative program. LPN-A felt the facility was adequately staffed, but the restorative program did not always get done. -At 1:54 p.m. RN-A stated R21 should have received assistance with ROM as directed by the care plan. R1 was to receive ROM services which was not provided as directed. R1's quarterly MDS dated [DATE], indicated R1 had severe cognitive impairment, required extensive assist of two staff for bed mobility, transfers and toileting, and one staff assist for locomotion in the wheelchair. R1 did not ambulate, had poor balance and limited functional range of motion of the upper and lower extremities. R1's Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 4/27/17, indicated R1's [DIAGNOSES REDACTED]. The CAA indicated R1 had impaired bilateral ROM to upper and lower extremities, and required one to two staff assistance for ADLs and transferred with a mechanical standing lift. A restorative exercise program of passive range of motion (PROM) three times weekly which R1 occasionally refused but staff continued to offer and encouraged R1 to participate as she was willing. R1's care plan dated 2/5/18, indicated ADL/mobility impairment due to [MEDICAL CONDITION], joint contracture, and [MEDICAL CONDITION]. The plan indicated R1 was to perform PROM exercises three times weekly to reduce the extent of the contracture and reduce pain. R1 had a history of [REDACTED]. R1's restorative nursing documentation form for (MONTH) (YEAR), located in the Homestead Restorative charting book revealed a directive to PROM to the right upper extremity and attempt left upper extremity and lower extremities bilaterally three times a week with five repetitions. The charting book also contained pictures of exercises to be provided to R1 by occupational therapy and physical therapy. Review of R1's restorative nursing forms for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed a daily directive to provide ROM three times weekly. The restorative nursing forms lacked evidence the program was provided three times per week as directed. The exercises were as follows: -The Personal Exercise Program sheet dated 3/3/16, indicated R1 was to perform six separate lower extremity exercises, five repetitions each exercise, three times per week. -The Hip Abduction and Adduction Caregiver PROM sheet dated 12/24/15, (unchanged since implementation) directed the staff to provide hip abduction and adduction exercises five repetitions each three times a week and the Hip and Knee Extension and Flexion Caregiver PROM section directed the staff to provide hip/knee extension/flexion exercises five repetitions each, three times a week. -The Ankle Dorsiflexion PROM Caregiver sheet directed staff to perform ankle exercises five repetitions each foot, three times a week. The Ankle Inversion and Eversion PROM Caregiver section directed staff to provide inversion and eversion exercises each ankle, five repetitions each, three times a week. On 4/11/18, from 3:38 p.m. until 5:30 p.m. R1 was observed laying in her bed, awake and looking around her room. At 5:40 p.m. NA-A and NA-C were observed to provide personal cares. No exercises were provided or offered during this observation. NA- A stated the nurses were responsible to provide ROM services to R1. R1's Restorative Nursing Flowsheets' revealed the following: -4/1/18-4/30/18, indicated ROM services were provided for 4 of 6 opportunities. -3/1/18-3/31/18, indicated ROM services were provided 7 of 15 opportunities. -2/1/18-2/18/18, indicated ROM services were provided 8 of 12 opportunities. -1/1/18-1/31/18, indicated ROM services were provided 5 of 15 opportunities. -12/1/18-12/31/18, indicated ROM services were provided 7 of 15 opportunities. On 4/11/18, at 06:19 p.m. LPN-A stated the nurses were responsible to provide R1 PROM whenever we could and it did not matter which shift it was provided on as long as it was provided. On 4/12/18, at 12:23 p.m. RN-A stated there were no set days for R1 to receive PROM services and it could be provided on any shift, as long as it was completed three times a week and was documented on the Restorative Nursing Flowsheet. -At 12:52 p.m. LPN-A stated some days it got very busy in which R1 had not received her ROM three times per week. LPN-A stated the facility no longer had a restorative aide and staff had expressed the need for a restorative aide, however, were told the facility was adequately staffed. LPN-A stated she had tried very hard to complete R1's ROM services but confirmed it was not always provided as directed. -At 12:58 p.m. RN-A stated R1's last physical therapy assessment was completed 7/17, and she had RN-A stated staff are so busy it is hard to complete the restorative program for R1 and other residents. RN-A stated she was recently assigned the ROM services oversight and was new to this area of practice. RN-A stated she would develop a plan to ensure R1 received her ROM services, as directed. RN-A confirmed R1 was to be provided ROM services three times a week which was not provided as directed. The Care Planning and Care Conferences policy dated 1/1/18, indicated each resident was to have a care plan so that he/she would be able to receive the care necessary to enable him/her to achieve and/ or maintain the highest practical physical mental and psychical well-being. The facility Restorative Nursing policy reviewed 2/19/18, indicated residents are to be given the appropriate treatment and services to maintain or improve his/her abilities as indicated by the resident's care plan. Restorative Nursing is a nursing intervention utilized to achieve this goal.

Based on observation, interview and document review, the facility failed to conduct a comprehensive assessment of pain, and failed to implement interventions in an attempt to manage chronic pain for 3 of 3 residents (R25, R6, R11) reviewed who experienced pain. Failure to alleviate pain resulted in actual harm for R25, R6 and R11. In addition, the facility failed to provide wheelchair positioning for 1 of 1 resident (R31) who had improper wheelchair positioning. Findings include: R25 was experiencing moderate to severe pain on a regular basis despite receiving narcotic pain medications and without adequate assessment of the pain. In addition, non-pharmacological interventions were not implemented to help alleviate pain. R25's significant change MDS dated [DATE], indicated R25 was cognitively impaired, understood others, had the ability to make self-understood and was able to express ideas and wants both verbally and non-verbally. The MDS indicated R25 required supervision with walking and dressing and was independent with eating. The MDS also indicated R25 received scheduled pain medication, received non-medical interventions, and had pain occasionally. The MDS identified [DIAGNOSES REDACTED]. The 7/24/2014, Pain Care Assessment (CAA) indicated R25 had arthritis and pain varied. R25's care plan last revised 8/5/14, indicated R25 rated her pain on a scale of 1-10 and as needed (PRN) medications may be given if indicated. Interventions indicated R25 was to participate in ambulation and exercises to decrease pain. No other pharmalogical interventions were addressed. The 6/12/2014, Pain Data Collection Assessment summary indicated R25 utilized a scheduled [MEDICATION NAME] (narcotic medication) patch 25 micrograms (mcg) which was to be changed every 72 hours and [MEDICATION NAME] 5/325 (narcotic medication to treat moderate to severe pain) milligrams (mg) PRN which was taken daily 4 out of 5 days. The assessment further indicated R25 had pain related to childhood [MEDICAL CONDITION] arthritis, R25 participated in activities, ambulated to the toilet and also ambulated with staff. The assessment indicated the medication regimen was adequate for pain management and that staff should continue current care plan. The 6/25/14, therapy progress note indicated R25 was doing very well although ambulation distance varied due to pain in her legs, back, hands and neck from arthritis pain and directed the continuation of ambulation as tolerated. The 8/12/14, physician order [REDACTED]. one tablet every four hours PRN. The 9/2/2014, physician order [REDACTED]. The electronic Medication Administration Record [REDACTED]. The 9/15/14, physician note indicated R25 stated her legs hurt and indicated R25 had 2 plus [MEDICAL CONDITION] bilaterally which she'd had for a long time. The note indicated the [MEDICAL CONDITION] was a little worse and more uncomfortable for her. The note also indicated R25 had severe deforming [MEDICAL CONDITION] arthritis. The physician's plan indicated R25 had not previously utilized diuretics, that the elevation of her legs was not taking care of the [MEDICAL CONDITION], and that it had become symptomatic for her. Plan to get a baseline BMP (basic metabolic panel- lab work) and another one on Friday and start her on [MEDICATION NAME] (diuretic) 10 mg every day and to monitor weights. The 9/24/14, nurse progress note by licensed practical nurse (LPN)-B indicated R25 had complained of severe left leg pain in the p.m. (evening), and that PRN [MEDICATION NAME] 5/325 had been given at 4:40 p.m. and 10:30 p.m., with minimal relief after the 1st dose. The progress note indicated the nurse had noted R25's left leg was very swollen, from foot to hip. The record lacked documentation of the effectiveness of the 2nd dose of the PRN that had been given to R25. The 10/2/2014, physician's orders [REDACTED]. [MEDICATION NAME] doses if needed. Do not exceed 3000 mg ([MEDICATION NAME]) total in 24 hours. The EMAR dated 9/2/14-10/2/14 revealed the following: -R25's PRN [MEDICATION NAME] had been used every day on average of 3 times a day and was up to 5 times in one day, with a total of 93 doses administered. -PRN [MEDICATION NAME] was given for bilateral pain for lower extremity discomfort. -R25's PRN pain medication was effective 17 out of the 93 doses, "somewhat effective" 10 out of the 93 doses, not effective 1 out of the 93 doses, and 55 out of the 93 doses the effectiveness was lacking on the medical record. During interview on 9/30/2014, at 7:42 p.m. R25 stated she had discomfort in both of her legs. Review of the EMAR indicated on 10/1/14, at 1:57 a.m. PRN [MEDICATION NAME] 5/325 mg. one tablet was given due to left leg and right and left heel pain. Documentation on effectiveness was lacking. During interview on 10/1/2014, at 7:05 a.m. R25 was observed lying in bed moaning "oh my leg hurts." Surveyor asked her if she had told anybody and she stated, "No, they know and all staff are busy." At 7:15 a.m. R25 stated both of her legs hurt, "they are hard as a rock, just feel them." At that time R25 removed her covers and showed the surveyor her legs that appeared shiny and firm to the touch. At 7:45 a.m. nursing assistant (NA)-D was observed assisting R25 wash up for the day. R25 stated her groin/crotch area was swelled up and so tight. At 7:50 a.m. R25 stated as she transferred from toilet to wheelchair, "oh my knees hurt." NA-D stated, "Oh that darn arthritis." NA-D handed her a pair of slacks and R25 started to put on the pants with NA-D's assistance. R25 stated, "ouch" then stated the pants were too tight. NA-D offered her 3 different pair of pants due to each pair being too tight. R25 moaned in discomfort as she attempted to put on each pair of pants. R25 stated, "My legs are bad." R25 added, "Oh it hurts me." NA-D stated at that time (8:00 a.m.) R25 usually dresses herself but that morning she needed help getting out of bed because of her leg discomfort. NA-D was not observed to notify the nurse of the pain. At 8:15 a.m. R25 stated her legs hurt and added, "They don't stop hurting." NA-D wheeled her to the dining room. On 10/1/14, at 8:27 a.m. LPN-A gave R25 PRN [MEDICATION NAME] 5/325 mg. for pain. R25 rated her pain at an 8. At 8:50 a.m. R25 had finished eating her breakfast and at 9:00 a.m. R25 asked RN-A for a pain pill. LPN-A stated she gave her a pain pill 25 minutes ago and RN-A stated she should give the pain pill a while to work because she had just had her breakfast. At 11:25 a.m. NA-D stated R25 always had pain in her legs. NA-D stated it did not make a difference if she had taken a pain medication or not, R25 was always in pain. At 12:55 p.m. R25 stated,"(the pain pills) helped this morning for about two hours." R25 added, "They (her legs) hurt, they hurt, they hurt!" At 1:05 p.m. R25 told the director of nursing (DON) her legs hurt. At 1:07 p.m. LPN-A gave PRN [MEDICATION NAME] 5/325 mg. tablet for pain in her legs, rating the pain at a 9. On 10/1/14, at 1:07 p.m. LPN-A stated staff can tell if R25's pain pills were effective or not, staff don't ask R25 if the PRN pain pills were effective because that was "like planting in her the need for another pain pill." LPN-A stated staff wait for her to ask for another pain pill. LPN-A stated NA-D did not inform her that R25's legs hurt on the morning of 10/1/14. LPN-A stated NA-D should have reported to her and R25 should have had a pain pill before getting out of bed. LPN-A added, "It has been very crazy around here." LPN-A stated R25 did not receive the PRN [MEDICATION NAME] for breakthrough pain probably due to the staff did not want R25 to exceed the recommended amount of 3000 mg, since [MEDICATION NAME] also has [MEDICATION NAME]. On 10/2/14, at 9:30 a.m. LPN-B stated R25 was doing terrible with her pain management for her legs. LPN-B stated the medications did not seem to help. LPN-B stated she had not been giving R25 the PRN [MEDICATION NAME] for break through pain and did not know why they did not give it. On 10/2/14, at 9:30 a.m. registered nurse (RN)-B stated NA-D should have contacted LPN-A regarding R25's pain and before starting a.m. cares. RN-B verified R25 had used PRN [MEDICATION NAME] 2-3 times a day and she questioned if it should be given on a regular basis. RN-B stated the physician would be contacted and verified the break through PRN [MEDICATION NAME] should be given as directed by the physician. RN-B stated the staff could be doing some monitoring of R25's pain on a daily basis for the effectiveness of her current pain medications. RN-B added if staff were reporting that R25's pain was terribly managed, the information needed to be relayed to the DON. On 10/2/14, at 11:20 a.m. LPN-B stated R25's PRN [MEDICATION NAME] usually was effective for a while but then R25 would state, "Old Arthur hurts." LPN-B stated last night LPN-D gave R25 a PRN [MEDICATION NAME] around 2:00 a.m. and then 2 hours later R25 was asking for another pain medication, however, did not give her anything. LPN-B stated due to the fact R25 was on the bumped up dose of [MEDICATION NAME], staff were concerned about her being a fall risk because she did get up by herself. On 10/2/14, at 11:55 a.m. the DON and RN consultant were interviewed. The DON stated the break through PRN [MEDICATION NAME] needed to be implemented as directed by the doctor. On 10/2/14, at 2:30 p.m. RN-B provided the surveyor with a physician order [REDACTED]. R6 was experiencing chronic pain on daily basis which affected her ability to participate in activities of daily living, without adequate assessment of the pain and/or efficacy of the narcotic medication. In addition, non-pharmacological interventions were not implemented to help alleviate pain. R6's annual MDS dated [DATE], indicated R6 had intact cognition and required extensive staff assistance for all activities of daily living. The MDS also indicated during the annual assessment period, R6 had reported her pain level at a 5 on a 0 to 10 pain scale. The assessment indicated the pain limited R6's ability to participate in day to day activities. R6's Pain CAA dated 3/13/14, indicated R6 voiced complaints of leg pain daily. R6 was on scheduled pain medications and received PRN medication for break through pain. R6's pain was attributed to [MEDICAL CONDITION], muscle dystrophy and muscle spasms. The CAA also indicated staff assisted her to take frequent rest periods throughout the day and to keep the physician informed of the pain management program. R6's quarterly MDS dated [DATE], also indicated R6 had intact cognition, required extensive staff assistance with all activities of daily living and was unable to ambulate. The MDS indicated R6 had [DIAGNOSES REDACTED]. The MDS also indicated R6 suffered from frequent pain which prevented her from participating in daily activities. During the assessment period, R6 had reported her pain to be at a 6 on a 0-10 pain scale. R6's care plan dated 6/4/14, identified an alteration in comfort related to numbness/tingling in the hands secondary to carpal tunnel syndrome and muscle [DIAGNOSES REDACTED] secondary to [MEDICAL CONDITION]. The plan directed staff to anticipate her needs and respond in a timely manner. The care plan did not direct staff on how to minimize potential leg pain and it did not include non-pharmacological interventions to minimize R6's pain. The physician note dated 7/3/14, indicated R6's biggest problem was related to pain control. The note also indicated at that time, R6 was watching the clock and asking for frequent pain medications. The physician had initiated use of a [MEDICATION NAME] for R6 and indicated the staff were to monitor for pain control and anxiety related to the pain medications. The physician identified a plan to continue to make pain medication changes if this was not effective. R6 was seen by the physician on 8/5/14, 8/8/14 and 8/12/14, for an acute infection, those progress notes did not address R6's pain. During a visit on 9/5/14, the physician noted, "Will continue with her current pain medications, which are working pretty well for her." The Physician order [REDACTED]. In addition, on 7/6/14, the physician had added [MEDICATION NAME] (medicated pain patch) 25 mcg/ hour to be changed every three days. The facility completed a Pain Data Collection for R6 on 8/30/14 - 9/3/14, 5/31/14 - 6/4/14, 2/27/14 - 3/31/14, and 11/27/13 - 12/1/13. The data collection tools indicated [REDACTED]. The summary repeated the current pain medications, indicated R6 had voiced concerns of pain daily and directed staff to assist with comfort via as needed pain medications, repositioning, occupational and physical therapy interventions. However, the summaries did not address R6's response to the current medication regimens. In addition, the clinical record lacked indication whether the addition of the [MEDICATION NAME] started on 7/6/14, was effective. Review of the resident progress notes (nurse's notes) indicated the following information: - 7/10/14, at 3:29 a.m. R6 was complaining of pain more frequently this shift. She is currently on Tylenol prn which she had received at 6:00 p.m. and 11:23 p.m. R6 continued to holler out and request pain pill frequently (every 15 minutes) throughout the night shift. R6 was repositioned with relief [MEDICATION NAME] 15-30 minutes before she would request additional medications. -7/17/14, at 3:33 a.m. R6 received Tylenol 500 mg at 3:00 am. R6 complains of pain responds well to repositioning and massage as non-pharmacological therapy. - 7/31/14, at 2:57 a.m. R6 had Tylenol 500 mg at 1:30 a.m. Non-pharmacological interventions used before resident was due for PRN included light massage, reposition and range of motion with the affected leg. -8/17/14, at 5:11 a.m. R6 requested Tylenol one time. No further follow up was noted. - 8/28/14, at 6:41 a.m. R6 received Tylenol 500 mg for leg pain. The note lacked follow up to the pain. On 10/1/14, at 9:00 a.m. R6 was observed seated in a wheelchair in the dining room. R6 began to cry with tears running down her face calling out to staff. She stated, "Oh, oh oh." No staff members were observed in the dining room as R6 cried holding her head. A few moments later NA-A walked up to R6 and escorted her to her room. At 9:15 a.m. R6 was observed resting in bed. On 10/2/14, at 9:00 a.m. R6 was observed seated in a wheelchair in the dining room. R6 began to cry, "Ey, ey, ey, oh that leg." R6 turned her head looking for staff members and began to cry "oh my goodness" as she shook her head. At 9:05 a.m. NA-A wheeled R6 to her room. At 9:10 a.m. NA-A stated R6 cried out in pain every day. She stated R6 would complain while sitting in her wheelchair. NA-A reported R6 received pain medications for pain management but she often has to wait until it is time for the next medication. She stated R6 frequently watched the clock in her room waiting for the next pain medication. On 10/2/14, at 9:45 a.m. R6 stated she experienced pain in her left leg every day and will ask for Tylenol. She explained the Tylenol takes care of the pain for about an hour. R6 explained the pain in her left leg woke her at night and she often had to watch the clock to wait for her next dose of pain medication. R6 described the pain as a "toothache that never goes away." She stated the pain prevented her from participating in many of the activities in the facility because sometimes it was better in the chair... and other times it was better in bed. R6 described the pain at an 8 or 9 on a 0-10 pain scale daily. R6 stated she has to watch the clock to make sure she is receiving her pain medications. On 10/2/14, at 10:00 a.m. NA-D stated R6 expressed pain in her left leg every day. She stated she attempts to reposition R6 in bed or rub her leg, but it usually does not give R6 extended relief. She stated R6 may have a few moments of pain relief, but it did not last long. She reports the pain to the nurses. Review of the EMAR revealed the following information: 7/1/14 - 7/31/14, R6 had received 90 doses of PRN Tylenol. 7/1/14 - 7/31/14, R6 had received 90 doses of PRN Tylenol. 8/1/14 - 8/31/13, R6 received 81 doses of PRN Tylenol 500 mg. 9/1//14 - 9/30/14, R6 received 98 doses of PRN Tylenol 500 mg. 10/1/14- 10/2/14, R6 had received 6 doses of PRN Tylenol 500 mg. The reason documented for the medication was "pain" or "leg pain." The medication was noted to be "effective" or "somewhat effective." On 10/2/14, at 10:10 a.m. LPN-B stated R6 reported complaints of pain "all of the time." She stated R6 will request pain medications and will watch the clock waiting for the four hours to pass before she can ask for the next pill. LPN-B stated R6 was uncomfortable, "I wish we could find something to giver her relief." LPN-B stated when she would administer R6's pain medications she followed up with R6 by visually looking at her. She stated if the nurse were to ask her how her pain was, she would just ask for more medications. LPN-B added if R6 looked like she was not in pain, they write effective or somewhat effective. She confirmed she did not discuss pain relief with R6. On 10/2/14, at 11:00 a.m. R6's pain was reviewed with the interim DON and the consultant RN. The interim DON stated she was aware R6 expressed pain daily. The two RNs reviewed R6's clinical record and were unable to find indication in which the staff had completed a comprehensive assessment of R6's pain and were unable to determine if the [MEDICATION NAME] which had been added in 7/2014, was an effective medication for controlling the pain. On 10/2/14, at 11:20 a.m. the consultant RN confirmed R6 experienced pain daily and had not been comprehensively reassessed by the nurses to determine the extent of the pain. She stated the facility had not exhausted resources to reduce R6's pain. She confirmed R6 had not consistently received non-pharmacological interventions to minimize pain and she continued to express pain. She stated she was aware R6 was utilizing PRN medications for the treatment of [REDACTED]. At that time the RN consultant was asked to review R6's medication regimen to determine a timeline of pain medication changes in the past 6 months. On 10/3/14, at 8:50 a.m. the consultant RN stated she had interviewed R6 and confirmed R6 expressed continued pain. She stated she did not find it helpful to review R6's record to determine what had been attempted in the past, but felt it was better to take the time and move forward and treat R6's pain. The consultant RN provided a Patient Comfort Assessment Guide dated 10/3/14, which confirmed R6 continued to express daily pain. R11 was experiencing moderate to severe chronic pain on daily basis which affected her ability to participate in activities of daily living without adequate assessment of the pain and / or efficacy of the narcotic medication nor consistent implementation of non-pharmacological interventions to help alleviate the pain. R11's Physician order [REDACTED]. (causes inflammation of the blood vessels). R11's significant change MDS dated [DATE], indicated R11 had severe cognitive impairment and required extensive assistance of one staff for locomotion on and off the unit, dressing and personal hygiene and limited assistance of one staff for bed mobility, transfer, ambulating in room and corridor and toilet use. The MDS also indicated R11 received scheduled and as needed pain medication and non-medication interventions for pain. The MDS also indicated R11 reported her pain as moderate and frequent but it did not interfere with daily activities or make it difficult to sleep at night. The MDS further indicated R11 received physical therapy (PT) and occupational therapy (OT) services and received active range of motion (ROM) restorative nursing services. R11's quarterly MDS dated [DATE], indicated R11 had moderate cognitive impairment and required limited assistance of one staff for bed mobility, transfers, dressing and toilet use and supervision of one staff for ambulating in room or corridor, locomotion on and off the unit, and personal hygiene. The MDS also indicted R11 received scheduled and as needed pain medications and non-medication interventions for pain. The MDS also indicated R11 reported her pain as moderate and frequent but it did not interfere with daily activities or make it difficult to sleep at night. The MDS indicated R11 did not receive PT, OT or restorative nursing services. R11's pain CAA dated 8/23/14, indicated R11 remained at risk for ongoing pain, increase in pain and unrelieved pain due to debilitating effects of chronic disease. The CAA indicated R11 reported pain to lower back, knees and joints and described it as an "achy, arthritic pain," remained alert and able to communicate needs effectively and appropriately and could alert staff if and when in pain. The CAA indicated staff was to observe and report any non verbal indicators of pain. Finally, the CAA indicated R11's pain was chronic in nature and required scheduled and PRN [MEDICATION NAME] to maintain optimal comfort level. R11's Activities of Daily Living / Functional Rehabilitation CAA dated 8/23/14, indicated R11 remained at risk for further on going decline due to progression of chronic disease processes resulting in a past history of falls, chronic pain and functional urinary incontinence. The CAA indicated R11 had returned to baseline since hospitalization for pneumonia and indicated staff was to continue to assist with ADL and mobility as needed and report changes in ability and tolerance. The CAA also indicated anticipation of on going fluctuation of physical function and tolerance based on potential exacerbation of chronic disease processes. R11's care plan dated 7/17/14, identified R11 had alteration in comfort related to pain secondary to history of compression fractures of her back and indicated R11 would verbally state pain was 2-3 on a verbal scale of 0-10 after administration of pain medication. The care plan directed staff to administer medications as ordered for pain and to monitor for effectiveness of pain medications and possible side effects. The care plan did not identify or address R11's knee/joint pain, nor did it identify non-pharmacological interventions for pain. Review of R11's medical record revealed the following history regarding the ongoing management of R11's knee pain: The RN Assessment Summary dated 1/13/14, on the Pain Data Collection form dated 1/8/14, to 1/12/14, indicated R11 had denied pain during the assessment period and R11 received scheduled [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME])(a narcotic pain reliever for moderate to severe pain) 10-500 mg three times daily and [MEDICATION NAME] (a local anesthetic) to lower back daily. It also identified R11 could also have PRN [MEDICATION NAME] for breakthrough pain though she had not received any during the assessment period. Non-medication interventions to pain included repositioning, exercise/ROM, activities and 1:1 visits. R11's pain was assessed as controlled with medication and interventions at that time. The physician progress notes [REDACTED]. It also identified R11 had a history of [REDACTED]." The progress note further indicated R11 received a cortisone injection to her right knee at the visit. The physician progress notes [REDACTED]. R11 continued to report pain with weight bearing and stated it hurt even while in bed at times. The progress note also identified R11 had been taking [MEDICATION NAME] on a scheduled and PRN basis. R11 reported the medication worked for a while but wore off. The physician assessment identified right knee pain with [MEDICAL CONDITION] joint disease, transient response to cortical steroid injection with constipation likely related to activity and pain medications. The progress note identified the physician's plan was to increase R11's laxatives and switch her to a [MEDICATION NAME] from scheduled [MEDICATION NAME], 12.5 micrograms (mcg) per hours equivalent to her current dose of 30-40 mg per day of [MEDICATION NAME]. The physician's telephone orders dated 3/10/14, included the following: change [MEDICATION NAME] 10-500 to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME])(a narcotic pain reliever for moderate to moderately severe pain) 5-325 mg one by mouth three times a day as needed, trial of [MEDICATION NAME] 12.5 mcg change every 3 days and discontinue scheduled [MEDICATION NAME]. The RN Assessment Summary dated 4/13/14, on the Pain Data Collection form dated 4/7-4/11/14, R11 had reported pain almost daily during the look back period and identified R11 was on scheduled pain medication and took PRN medication frequently with effective results. The summary also indicated R11 was encouraged to ambulate and be as active as possible and during this time a knee brace being worn was discontinued due discomfort. The summary further identified R11 had a recent pain medication change which seemed more effective. The Memo To Physician dated 4/18/14, identified R11 was needing to take her PRN [MEDICATION NAME] three times a day nearly each day and still complained of pain. The memo asked if the medication could be given more often for R11's breakthrough pain. The physician response dated 4/21/14, was an order for [REDACTED]. The Memo to Physician dated 6/1/14, identified R11 appeared to be more drowsy and lethargic and questioned confusion. The memo asked if they could consider going back to increased dose of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) or oral [MEDICATION NAME] versus [MEDICATION NAME]. The memo indicated R11's family had concerns with [MEDICATION NAME] and wanted the physician to consider [MEDICATION NAME](time-released [MEDICATION NAME] usually taken every twelve hours for chronic pain) and an increase of R11's [MEDICATION NAME] back to 10-325 (sic) four times a day and twice a day as needed. The physician response dated 6/12/14, indicated "we'll see how she responds to increased [MEDICATION NAME]" (an antidepressant). The Nursing Home Note dated 6/12/14, identified R11 was seen for bilateral hearing loss and indicated mood wise R11 still had some dysphoria. R11 was not sure if this was related to vision and hearing issues or just mood. The note identified R11 was on 12.5 mg per day of [MEDICATION NAME] that was helping. The note also identified there had been some concern about increasing confusion and there had been some discussion about switching back from [MEDICATION NAME] to [MEDICATION NAME]. The note further identified R11 had only taken 3 PRN [MEDICATION NAME] in the past 2 weeks while on the [MEDICATION NAME]. The physician's impression was some concern for intermittent confusion and indicated he would hold off on the [MEDICATION NAME] change at that time. The impression also indicated a possible mood issue and the physician increased her [MEDICATION NAME] from 12.5 to 25 mg per day. The Nursing Home Note dated 7/8/14, indicated R11's family was very concerned her decline in status might be related to medications, specifically [MEDICATION NAME]. The physician impression indicated he felt R11's mental status changes were possibly related to depression and likely related to her vision and hearing loss. The physician's plan was to lower [MEDICATION NAME] (for restless leg syndrome) from four times a day to twice a day and hold R11's [MEDICATION NAME]. The physician indicated [MEDICATION NAME] was an option down the road if R11 did well off of the [MEDICATION NAME]. Other options identified were discontinuation of [MEDICATION NAME] altogether or increase or decrease of R11's [MEDICATION NAME] dose. The Physician's Telephone Orders dated 7/8/14, included decrease [MEDICATION NAME] to 300 mg twice day and hold [MEDICATION NAME] trial for one week. The RN Assessment Summary dated 7/14/14, on the Pain Data Collection form dated 7/8/14 -7/12/14, identified R11 reported moderate pain daily and indicated the physician was trying to balance pain control and symptoms of confusion. The RN repeated the current pain medication regimen and indicated they would continue to work with the physician for pain control. The assessment did not identify non-pharmacological interventions for pain. The Physician's Telephone Orders dated 7/15/14, discontinued [MEDICATION NAME] and discontinued [MEDICATION NAME]. The Nursing Home Note dated 7/29/14, indicated R11 was seen regarding family concerns related to pain, [MEDICAL CONDITION], hearing and intake issues. The physician's impression included pain issues with vertebral compression fractures and arthritis. The physician's plan identified R11's family was wondering about [MEDICATION NAME]. The physician indicated he was considering a referral to hospice for their advice. His plan further indicated he would not change medications until R11's shortness of breath (identified upon physician examination) was evaluated. R11 was hospitalized from [DATE], through 8/4/14 for pneumonia. The facility completed Pain Data Collection for R11 on 8/5/14 - 8/9/14. The RN assessment summary of the data collection completed on 8/13/14, identified R11 had complained of pain during the assessment period. The RN repeated the current pain medication regimen and indicated R11's pain was rated as mild and the current regimen was meeting R11's needs. The assessment summary did not address non-pharmacological interventions for pain. The Physician order [REDACTED]. for pain. The report also included an order for [REDACTED]. The Nursing Home Note dated 10/1/14, indicated R11 was seen by the nurse practitioner for right knee pain. R11 reported discomfort with walking. The nurse practitioner's plan was to apply ice or alternate heat and ice, continue with pain medications on the MAR (medication administration record) and participate in activities as tolerate. R11's Medication Administration History dated 8/8/14 -10/3/14 revealed: -[MEDICATION NAME] adhesive patch 5% was administered early at R11's request 30 of 57 days. -[MEDICATION NAME] 5-325 mg three times a day (scheduled dose) was given early for the morning dose on 8/25, 9/12, 9/22, 9/25, 9/26, 9/29, 9/30, 10/1, 10/2, and 10/3 and for the afternoon dose on 9/9 (11 doses). R11's PRN Medications Administration History 8/8/14-10/3/14 revealed: -[MEDICATION NAME] 5-325 mg 1

Based on observation, interview and document review, the facility failed to ensure adequate interventions had been implemented related to falls from an electric height control bed to minimize the risk of further falls and accidents for 1 of 3 residents (R33) reviewed for falls. Findings include: R33's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], indicated R33 was severely impaired and was totally dependent on one or two staff for transfers and mobility. The MDS indicated R33 had sustained 2 or more falls since admission with no injury. The Falls Care Area Assessment (CAA) dated 1/25/12, indicated R33 was at risk for falls, had fallen from the wheelchair and had rolled out of his bed on to a mat. The 2/2/12, plan of care (POC) indicated R33 was unable to transfer independently, had a bed mobility deficit, and was at risk for falls. The POC also indicated R33 had a low bed, bed alarm, mat on the floor and staff were to complete a room check every 30 minutes when R33 was in bed. A review of the initial admission nursing documentation dated 1/18/12, indicated R33 was admitted from a hospital following a right BKA. The falls tracking form identified R33 had fallen/slipped from the bed unto the floor 10 times from 1/18/12 through 2/27/12. Review of the nurses progress notes from 2/27/12 to 3/12/12, included the following incidents: 2/27/12, 11:00 p.m. -- R33's alarm was sounding, R33 was found on the floor on the mat, bed in lowest position, no injury. 2/28/12, 5: 50 a.m. -- Alarm sounding, R33 was sitting on the mat leaning against the bed, call light with in reach, bed in lowest position, no injury. 3/2/12, 9:15 p.m. -- R33's alarm sounding, resident on the floor on the matt, head on pillow and covered with blanket, no injury. 3/3/12, 1:30 a.m. -- Staff observed R33 using control at foot of bed to raise the bed up, staff talked to resident and left control alone. 3/4/12, 12:00 midnight -- Staff found R33 sitting on the edge of bed. R33 had raised the bed to highest position and had pushed the mats under the bed. At that time, bed was lowered and bed control was unplugged. 3/6/12, 5:00 a.m. -- Alarm sounding, R33 was found sitting on mat next to low bed, and had stated, "just slid out." No injury was noted. No further falls were identified. On 3/13/12, at 9:35 a.m. R33 was observed in his room, in a wheelchair with an alarm in place. There were mats in his room and the electric bed was plugged in. He was observed to have a splint on the right leg. He stated they had just removed the stitches from his leg and then asked when he would be getting a "wooden leg." On 3/13/12 at 9:40 a.m. nursing assistant (NA)-A stated R33 does not attempt to get out of the wheelchair anymore, but likes to get out of his bed at night. She was not aware R33 could raise the bed with the electric control, but added R33 likes to "fiddle" with things. On 3/12/12, at 3:15 p.m. the director of nursing (DON) stated she was unaware the resident had raised the electric bed up. She stated staff complete a post fall assessment after each fall, a post fall evaluation, and a supervisory report which included a root cause analysis and the actions implemented. At that time, the DON verified R33's bed should not be in the highest position, but because she had not been informed of R33's actions of raising the bed, no interventions had been implemented. The DON added the POC would be revised. On 3/13/12, at 1:15 p.m. the DON stated the unreported incidents involving R33 raising the bed up were concerning. She added the staff did the right thing at the time and unplugged the bed. She added there was a gap in communication and the POC should have been revised right away.

Based on observation, interview, and document review, the facility failed to provide the necessary care and services to prevent a decline in range of motion related to the development of bilateral hip and knee contractures for 1 of 3 residents (R24) in the sample reviewed for range of motion. Findings include: R24's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R24's memory problems and severely impaired decision making skills. The MDS identified R24 did not walk and was dependent on staff for all activities of daily living (ADLs). The MDS indicated R24 had no functional limitations in range of motion (ROM) of upper or lower extremities and no restorative nursing minutes were coded to indicate ROM had been completed. The MDS also indicated R24 had no behavioral symptoms nor resisted care. The annual MDS dated [DATE], identified the same information. The Activities of Daily Living Care Area Assessment (CAA) at the time of the annual MDS dated [DATE], was not completed as this area did not trigger. The Mood State CAA dated 7/1/11, identified R24 had altered clothing to "ease her need for range of motion." No other documentation was included in R24's CAAs from 7/1/11, regarding limitations in range of motion, restorative nursing programs, or other preventative services or treatments. The last assessment areas that addressed ROM and restorative nursing were done at the time of the annual assessment under the Psychological Well Being and Mood State CAA sections dated 10/7/10. The CAAs identified R24 did not walk. The Mood State CAA identified restorative nursing had noted that due to R24's advancing dementia the resident "does not always understand most of what is stated to her and she becomes fearful after things are explained." The CAA also indicated R24 will often refuse restorative nursing but indicated the continuation of restorative nursing for maintaining PROM (passive range of motion) and AROM (active range of motion). However, R24's corresponding MDS dated [DATE], did not indicate R24 received any restorative nursing services at that time. All previous restorative nursing documentation was requested and indicated the last time R24's ROM program was documented was 6/30/09, and the restorative program that was specifically for transferring was last documented 8/31/09. No further restorative notes or nursing notes regarding R24's restorative nursing program had been made after that date. The current plan of care (POC) dated 10/5/11, included "therapy deficit r/t (related to) decreased mobility, cognitive deficits from dementia dx (diagnosis)." The identified goal was, "No decline in ROM will be noted." The POC identified R24's restorative program was discontinued related to refusals. The interventions included to "monitor for any declines, therapy screens prn" (as needed). Restorative Services forms indicated R24 had received restorative nursing services until 2009. On 1/03/12 at 4:57 p.m. R24 was observed sleeping in bed with legs to the side, knees flexed at approximately a 90 degree angle. No splints were in place. On 1/5/12, at 9:27 a.m. R24 was observed during a transfer from the regular wheelchair (w/c) to the toilet with assist of 2 staff and a mechanical stand-up lift. As R24 sat in the w/c and staff uncrossed her legs to place on the stand-up lift platform, R24 said "ow ow ow". R24 then stood with the mechanical lift, and the resident's legs did not completely straighten, both knees were flexed throughout the transfer. R24's medical records were reviewed from 2009-current. R24's medical record did not indicate contractures were present prior to 11/29/11. R24 had pain documented on 6/26/11, when a nursing note identified pain during transfers. A Memo To Physician form dated 8/29/11, identified signs and symptoms of pain during transfers. A nursing note dated 10/26/11, identified R24 complained of pain, saying "ouch" when right knee and foot were manipulated or moved. Another nursing note dated 11/29/11, indicated R24's knee was stiff and sore and not bending at knees. A Physician's Telephone Order form dated 11/29/11, indicated physical therapy (PT) and occupational therapy (OT) to evaluate and treat for LE (lower extremity) joint contractures. PT documentation indicated R24 received skilled services twice a week for 1 month for bilateral hip and knee joint contractures. The PT evaluation dated 12/5/11, identified the medical [DIAGNOSES REDACTED]. The assessment by PT indicated R24 had substantial hip and knee joint contractures making transfers difficult at that time. The PT discharge note dated 12/29/11, indicated R24 "continued to have contractures but with gentle stretching we were able to get her hip abduction to neutral on the right and 15-20 degrees on the left, and knee extension within 20-30 degrees bilaterally to approximately 90 degrees of flexion." R24 was then discharged from PT and restorative nursing was set up for further range of motion of the knee and hips. OT documentation indicated an evaluation was completed 12/13/11, which identified R24's bilateral hip and knee contractures. The evaluation indicated R24 required a custom w/c to ensure proper positioning of the pelvis given LE hip contractures, and to elevate leg rests to accommodate for LE knee contractures. On 1/5/12, at 7:25 a.m. nursing assistant (NA)-A stated when R24 was first admitted no problems were noted. NA-A stated she did not know when the knee problems started and could not recall if it had been over a year or not. On 1/5/12, at approximately 8:00 a.m. restorative aide (RA)-A stated R24 was not receiving ROM services and it had been well over a year since she had. She added it could be a couple years since she last had restorative services. RA-A stated R24 no longer received restorative nursing due to the degree of her dementia. On 1/5/12, at 9:30 a.m. NA-B and NA-C assisted with R24's transfer with the mechanical lift and both stated at that time R24's knees had gotten gradually worse. On 1/5/12, at 1:45 p.m. the physical therapist (PT)-A and the physical therapy assistant (PTA)-A were interviewed. PT-A stated R24's hips and knees had become arthritic. PT-A stated on 12/5/11, R24 was seen for hip and knee contractures, and the goal was for no further pain and complications, to ease the staff when helping to transfer and dress R24, and to help with ROM. PT-A stated R24 would continue with restorative nursing with hip and knee stretching which would start today. PT-A stated he did not know if a restorative program would have prevented the contractures and added it might have but could not say that for sure. PT-A stated their department last assessed R24 in '09 and that last screen indicated R24 was attempting to participate with rehab nursing. When asked if ROM would irritate R24's arthritis, PT-A stated it would not if it was gentle. PT-A stated R24 did not demonstrate signs or symptoms of pain when he had been working with R24. PTA-A stated there was only one time when working with R24 during abduction of the hips that the resident had muscle guarding, but other than that had not expressed pain symptoms. On 1/5/12, at 2:33 p.m. registered nurse (RN)-B stated the only time ROM assessments were done was if residents had a decline or if something was observed such as a change in positioning in the w/c. RN-B stated the NAs report if the residents aren't transferring the same, then they do a screen and then PT does an assessment. When RN-B was asked when the last time restorative/range of motion services were attempted she stated the last sheets in chart were from '09. RN-B verified documentation to indicate why restorative services had stopped was lacking. On 1/5/12, at 2:35 p.m. PTA-A stated he could not find anything in the electric record about R24 being assessed by PT since '09. On 1/6/12, at 9:04 a.m. PTA-A stated R24 did not have complete functional ROM up to 180 degrees of flexion in the knees. PTA-A stated he could comfortably get them to 90 degrees. PTA-A stated it looked like R24 had been semi-participating in the restorative program and with increased confusion that program stopped. PTA-A verified even though R24 could no longer participate in an active ROM program, R24 could have still had a passive program. On 1/6/12, at 9:16 a.m. NA-D stated she had worked at the facility since the resident was admitted . NA-D stated R24's knees did not really straighten and that had probably had been on-going within the last year. NA-D stated it had gotten worse. NA-D stated "I don't think her hips work right either", and added it was hard for R24 to sit up. On 1/6/12, at 1:45 p.m. RN-A stated there had been a loss of function in R24's legs. RN-A stated she just noticed the loss of function on 11/29/11, when staff told her they were having a hard time straightening R24's legs. RN-A stated she did a PT referral then and because R24 was recently sliding down in the wheelchair, OT saw her then too. RN-A verified she did not know of any prior documentation in R24's record about contractures. When RN-A was asked when the contractures developed, she stated she first noticed it was when R24 was not sitting in the w/c properly around 11/29/11. RN-A stated she did not know that R24's restorative program had stopped and could not recollect why it was stopped. RN-A verified there was no documentation as to why R24's restorative program had been stopped. On 1/6/12, at 2:42 p.m. the director of nursing (DON) verified a comprehensive assessment was lacking to pull all the pieces together regarding R24's range of motion. The policies and procedures were requested regarding ROM assessments and the restorative program and the facility provided the undated Restorative Protocol. The protocol indicated the oversight of the restorative nursing program remained the responsibility of the RN and timely decisions and corrective action should be the expected outcome of that oversight.