Every finding on record at Good Samaritan Society - Battle Lake

Based on observation, interview and document review the facility failed to assess for safe self administration for 1 of 1 resident (R37) who had medications left at the bedside.Findings Include: R37's quarterly Minimum Data Set, dated [DATE], identified R37 was cognitively intact and had diagnoses which included: diabetes mellitus, depression and anxiety. R37's MDS also identified R37 was independent in most activities of daily living (ADL). R37's care plan revised 6/20/25, identified R37 had diabetes mellitus, and chose to self-administer medications as demonstrated ability to safely administer insulin via pump per interdisciplinary team determination and physician order. Interventions included:R37 would self-administer insulin per physician's order, keep medication locked in dresser in R37's room, and document R37's self-administration of medications. R37's care plan lacked documentation of topical or ear medications safe to be self-administered. R37's Order Summary Report signed 9/25/25, included the following:-acetic acid otic (ear) solution 2% -instill four drops in both ears as needed for cerumen (ear wax) twice a day (BID) as needed (PRN)-triamcinolone acetonide external cream 0.1 % topical-apply to hands topically as needed for rash/itch BID PRN-ok to self administer insulin via pumpR37's Order Summary Report lacked documentation of topical or ear medication ok to be self-administered. Review of R37's Self-Administration of Medication (SAM) form, dated 4/1/25, identified R37 was safe to administer insulin from pump. However, the evaluation did not identify R37 was safe to self-administer topical medication or ear drops. During interview on 11/17/25 at 3:11 p.m., R37 stated she got rashes on her hands, and used Triamcinolone cream. R37 indicated she usually used it twice a day, but could use it up to four times a day. R37 pulled a tube of Triamcinolone cream out of the pocket on her recliner, and showed surveyor. During observation on 11/19/25 at 8:55 a.m., R37 was in the dining room eating breakfast. R37's door was closed at the time. R37 had one tube of Triamcinolone cream and one new box of Triamcinolone cream with pharmacy label in the pocket of her recliner. R37 also had a small bottle of acetic acid ear drops with pharmacy label, sitting on the table next to her recliner. During phone interview on 11/19/25 at 8:49 a.m., consultant pharmacist (CP)-A stated for self-administration of medications, residents should be assessed and assured competent, and then documented. CP-A indicated it was important to assure medications were administered correctly. During interview on 11/19/25 at 9:10 a.m., R37 indicated she usually administered her Triamcinolone cream at least two times a day, sometimes three. R37 stated she used her ear drops for dry ears and had been doing that for some time. During interview on 11/19/25 at 9:35 a.m., nursing assistant (NA)-A stated she had observed R37 apply the Triamcinolone cream to her hands, but had not observed R37 put her ear drops in. During interview on 11/19/25 at 9:50 a.m., licensed practical nurse (LPN)-A stated R37 self-administered her insulin via her pump and had no concerns with that. LPN indicated was not aware if R37 had any other medications she could self-administer, but stated she had observed R37 self-administer her Triamcinolone cream. At 9:55 a.m. LPN-A entered R37's room, then verified R37 had Triamcinolone cream in the pocket of her recliner, and ear drops on the table next to her while R37 sat in the recliner. LPN-A indicated she thought the facility process for self-administration of medications included a nurse to educate and observe a resident prior to them self-administering medications and an order was needed. During interview on 11/19/25 at 10:50 a.m., registered nurse (RN)-A stated R37 self-administered her insulin via her pump. RN-A reviewed R37's SAM form, and confirmed R37's form lacked documentation R37 could self administer topical medications or ear drops. RN-A indicated, she would expect all other medications would be safely stored in her locked medication drawer. During interview on 11/19/25 at 11:03 a.m., director of nursing (DON) confirmed R37's Triamcinolone cream or acetic acid ear drops were not addressed on R37's SAM form. DON indicated her expectation would be R37's topical medication and ear drops would be documented on her SAM form as safe to administer, or be stored in her locked medication drawer. DON stated this was important to assure medications were accurately administered. The facility policy titled Self-Administration Of Medication dated 10/31/25, identified procedures which included the following: Complete the Resident Self-Administration of Medications form to determine if the resident could safely administer medications and create a plan. The interdisciplinary team would determine where the medications would be stored. The nurse's station, in locked medication cart, or a locked compartment or locked drawer in the resident's room. It would be determined who would document the medication administration. A physician order must be obtained and be specific to which medication would be self-administered. The care plan must indicate which medications the resident was self-administering, where they were kept, who would document the medication, and the location of administration. All medications stored in resident's room must be reconciled and documented by a licensed nurse at least weekly on the medication administration record (MAR).

Based on observation, interview and document review, the facility failed to ensure dishwasher temperatures were maintained according to manufacturer's guidelines to assure sanitization of dishware. This deficient practice had the potential to affect all 45 residents who received food from the kitchen. Findings include: During an observation on 11/27/23 at 7:01 p.m., dietary aide (DA)-A washed the supper dishes. DA-A set some plates and glasses on a plastic rack near the entrance of the [NAME] dishwasher. After scraping and rinsing the dishes, DA-A placed them into the dishwasher and started the machine. The digital gauge on the front of the dishwasher indicated the wash cycle displayed an E7 error code throughout the wash and rinse cycle with a fix it wrench symbol identified as well. The wash cycle temperature ran between 139 to 140 degrees Fahrenheit (F) and the rinse cycle reached 187 degrees F. DA-A repeated the process with another rack of supper dishes and the wash cycle temperature ranged between 137 to 138 degrees F. DA-A reported the dishwasher had been displaying the error code E7 and the fix it wrench for a couple of weeks and DA-A had not reported it to anyone. The metal plate on the front of the dishwasher included instructions for the wash temperature to reach 150 degrees F and the rinse temperature to reach 180 degrees F. During an observation on 11/28/23 at 10:06 a.m., DA-C loaded the dishwasher with dirty dishes and the temperature during the wash cycle reached 138 degrees F during the wash cycle and 189 degrees F during the rinse cycle. DA-C stated the dishwasher temperature usually ranged between 130 to 160 degrees F. DA-C indicated she worked at the facility for several years and understood the wash temperature needed to be greater than 125 degrees F. During an interview on 11/27/23 at 10:25 a.m. , the dietary manager (DM) indicated the facility utilized hot water sanitation and the temperatures were expected to reach 150 degrees F for the wash cycle and 190 degrees F for the rinse cycle. During a follow up interview on 11/28/23 at 12:07 p.m., DM indicated staff were expected to report any concerns directly to DM and staff would run the same dishes again to ensure proper temperature. During a follow-up interview on 11/28/23 at 2:35 p.m., DM indicated was not aware the wash and rinse cycles had not been reaching the necessary temperature to sanitize the dishes. The facility forms titled Dish Machine Temperature Log Chemical Sanitizing Log found on the Cottonwood unit and the form titled Dish Machine Temperature Log Thermal Sanitizing for the Fisherman's unit included columns to record the wash cycle, final rinse cycle, and (staff) initials for Breakfast Meal, Noon Meal and Evening Meal. Review of the logs from 10/1/23 through 11/28/23, identified the following; Fisherman's Unit October 2023: -10/1/23, no morning, noon, evening cycles recorded. -10/7/23, evening wash cycle was recorded at 149 degrees. -10/8/23, no morning rinse cycle recorded , no noon cycle recorded. -10/12/23, evening wash cycle was recorded at 147 degrees. -10/13/23, no morning cycle recorded. -10/19/23, no evening cycle recorded. -10/26/23, evening wash cycle was recorded at 142 degrees F. -10/28/23, evening entry scribbled out. -10/29/23, evening wash cycle was recorded at 140 degrees F. -10/31/23, no evening cycle recorded. Review of the form revealed four of the documented entries identified the wash cycle temperature had not reached the required 150 degrees to achieve proper sanitization. Cottonwood Unit October 2023 -10/7/23, no evening wash cycle recorded. -10/18/23, no evening wash cycle recorded. -10/21/23, evening wash cycle was recorded at 147 degrees. -10/22/23, morning wash cycle was recorded at 134 degrees, evening wash cycle was recorded at 147 degrees. -10/25/23, evening wash cycle was recorded at 109 degrees. -10/26/23, no noon cycle recorded. -10/27/23, evening wash cycle was recorded at 115 degrees. -10/28/23, evening wash cycle was recorded at 148 degrees. -10/30/23, evening wash cycle was recorded at 130 degrees. -10/31/23, evening rinse cycle was recorded at 179 degrees. Review of the form revealed seven of the documented entries identified the wash cycle temperature had not reached the required 150 degrees to achieve proper sanitation. In addition, three of the documented entries identified the rinse cycle temperatures had not reached the required 180 degrees to achieve the proper sanitation. Fisherman's Unit November 2023: -11/2/23, no evening cycle recorded. -11/4/23, morning rinse cycle was recorded at 175 degrees, evening wash cycle was recorded at 140 degrees. -11/5/23, morning rinse cycle was recorded at 170 degrees, noon rinse cycle was recorded at 179 degrees. -11/9/23, evening wash cycle was recorded at 147 degrees. -11/10/23, evening wash cycle was recorded at 143 degrees. -11/12/23, evening wash cycle was recorded at 145 degrees. -11/13/23, evening wash cycle was recorded at 142 degrees. -11/14/23, evening rinse cycle was recorded at 160 degrees. -11/16/23, evening wash cycle was recorded at 147 degrees. -11/17/23, evening wash cycle was recorded at 146 degrees. -11/23/23, evening wash cycle was recorded at 148 degrees. -11/25/23, evening rinse cycle was recorded at 179 degrees. -11/26/23, no noon cycle recorded, evening wash cycle was recorded at 149 degrees. -11/27/23, wash cycle was recorded at 140 degrees. Review of the form revealed ten of the documented entries identified the wash cycle temperature had not reached the required 150 degrees to achieve proper sanitation. In addition, five of the documented entries identified the rinse cycle temperatures had not reached the required 180 degrees to achieve the proper sanitation. Cottonwood Unit November 2023: -11/3/23, no evening cycle recorded. -11/4/23, evening wash cycle was recorded at 144 degrees. -11/5/23, evening wash cycle was recorded at 126 degrees. -11/12/23, evening wash cycle was recorded at 145 degrees. -11/13/23, morning wash cycle was recorded at 122 degree, no noon cycle recorded. -11/15/23, no noon cycle recorded. -11/17/23, evening wash cycle was recorded at 138 degrees. -11/20/23, evening wash cycle was recorded at 133 degrees. -11/21/23, no evening cycle recorded. -11/25/23, evening wash cycle was recorded at 149 degrees. -11/27/23, evening wash cycle was recorded at 144 degrees. -11/28/23, morning wash cycle was recorded at 142 degrees. Review of the form revealed nine of the documented entries identified the wash cycle temperature had not reached the required 150 degrees to achieve proper sanitation. During a telephone interview on 11/28/23 at 2:47 p.m., the [NAME] representative from the dishwasher manufacturer, verified the facility used hot water sanitation dishwashers. The representative explained wash cycle temperatures were expected to reach 150 degrees minimum 150 and rinse cycle temperatures were expected to reach a minimum 180 degrees. The representative indicated temperatures had to reach the minimum for both cycles to sterilize by getting the plate temperature to 160 degrees. The infection control log was reviewed from 10/1/23. to 11/28/23, and no food borne illnesses had been identified. The LXi Series Dishwasher owner's manual provided by the facility specified for hot water sanitizing the wash temperature required was 150 degrees F, and the final rinse temperature was 180 degrees F. The facility policy titled Warewashing-Mechanical and Manual-Food and Nutrition dated 4/02/2023, identified for High-temperature machine the temperatures must be maintained at a minimum of 150 degrees F for the wash cycle and the rinse cycle temperature must be maintained at a minimum of 180 degrees F per gauge. The policy indicated the dish machine temperature log must be completed by dining service employees directly involved in the dishwashing process prior to running any item through the dish machine. This ensured the wash and rinse temperatures were properly monitored and controlled. Instructions included to cease dishwashing when temperatures were below required levels and to report temperatures that were below the required levels to the director of dining immediately. The policy instructed staff to sanitize items in the pot-and-sink with approved sanitizer at manufacturer-recommended strength if the heaters were not operating properly.

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 3 of 6 hallways observed for linen transportation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. During an observation on 11/27/23 at 12:16 p.m., in the cottonwood hallway laundry aide (LA)-A exited R21's room and hung up hangers on an uncovered laundry cart in the hallway. LA-A proceeded to remove laundry from the uncovered cart and placed the laundry in R10's closet. LA-A pushed the uncovered laundry cart down the hallway past two residents and one staff member who were in the hallway. LA-A removed laundry from the uncovered cart and placed the laundry in R24's closet. Administrator walked by the uncovered laundry cart and closed the cover on the laundry cart. During an observation on 11/28/23 at 11:55 a.m., in the fisherman's hallway, LA-A stood at an uncovered laundry cart and removed laundry from the cart and placed the laundry in R27's closet. LA-A proceeded to place two empty hangers from R27's closet on the uncovered laundry cart. LA-A then covered the laundry cart and wheeled the cart down the hall. LA-A stopped in the Heritage hallway, uncovered the cart, removed laundry from the cart and left the cart uncovered while she placed the laundry in R5's closet. During an interview on 11/28/23 at 12:03 p.m., LA-A confirmed the personal laundry she had not been covered. LA-A stated her usual practice was to ensure the laundry cart was covered however indicated she would leave the cart uncovered at times while she delivered the personal laundry. During an interview on 11/28/23 at 3:40 p.m., environmental services supervisor (ESS) stated she was unaware laundry was being delivered in an uncovered cart. ESS stated her expectation was laundry would always be covered while being delivered. During an interview on 11/28/23 at 3:48 p.m., director of nursing (DON) stated stated staff were expected to deliver laundry in a covered cart. During an interview on 11/29/23 at 7:33 a.m., administrator verified the laundry cart had been uncovered on 11/27/23. Administrator stated she had covered the laundry cart when she noticed it was not covered. Administrator indicated her expectation was laundry would have been covered while being delivered. Review of a facility policy titled Laundering and Drying Clothes and Linens revised 2/16/23, indicated laundry should be packaged, transported and stored in a manner that ensured cleanliness and protected the laundry from dust and soil.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R14, R33, R 34 and R40) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Current CDC recommendations 3/15/2023, revealed the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 at age 65 and older, based on shared clinical decision-making, should receive one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R 14's facesheet identified R14, age 100 was admitted to the facility on [DATE]. Review of R14's Minnesota Immunization Information Connection (MIIC) undated, identified R14 had received PPSV23 on 11/21/2011, and the the PCV13 on 4/21/2015. R14's medical record lacked documentation R14 had been offered or received the PCV20 vaccine. Review of R33's facesheet identified R33, age 89 was admitted to the facility on [DATE]. Review of R33's MIIC undated identified R33 had received PPSV23 on 1/6/2000 and 8/27/2007 and received the PCV13 on 11/23/2016. R33's medical record lacked documentation R33 had been offered or received the PCV20 vaccine. Review of R34's facesheet identified R34, age 80 was admitted to the facility on [DATE]. Review of R34's MIIC undated identified R34 had received PPSV23 on 1/12/2001, and the PCV13 on 5/4/2015. R34's medical record lacked documentation R34 had been offered or received the PCV20 vaccine. Review of R40's face sheet identified R40, age 83 was admitted to the facility on [DATE]. Review of R40's MIIC undated identified R40 had received PCV13 on 4/17/2017, and PPSV23 on 5/16/2018. R40's medical record lacked documentation R40 had been offered or received the PCV20 vaccine. During an interview on 11/28/23 at 2:52 p.m., infection preventionist (IP) confirmed R14, R33, R34, and R40 had not been offered or received the pneumococcal vaccinations as recommended by the CDC. IP stated the expectation was the facility would offer and administer all vaccinations per CDC recommendations. During an interview on 11/29/23 at 11:45 a.m., director of nursing (DON) stated she was aware of the CDC recommendations for the pneumococcal vaccinations. DON confirmed R 14, R33, R34, and R40 had not received the pneumococcal vaccinations as recommended by the CDC. DON stated her expectation would have been that all residents would have been offered and received all pneumococcal vaccines per Centers For Disease Control (CDC) recommendations. Review of a facility policy titled Immunizations/Vaccinations for residents, Pneumococcal, Influenza, Covid-19, Other, AL,R/S,LTC, HBS-Enterprise revised 9/21/23, indicated it is recommended that all clients and residents receive pneumococcal vaccinations per CDC guidelines for eligibility and timing.

Based on interview and document review, the facility failed to thoroughly investigate allegations of injury of unknown origin for 1 of 3 residents (R1) reviewed for allegations of abuse. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, R1's MDS indicated R1 required extensive assistance with two staff for activities of daily living (ADLs) such as bed mobility, transfers and toileting and required assistance with one staff for dressing and grooming. R1's incident report dated 5/30/22, indicated R1's bruise on left breast was from the nipple to her left side and measured approximately 11 centimeters wide by 7 centimeters long. Another bruise was noted on the top of the left breast measuring approximately 5 centimeters long by 3 centimeters wide. Both bruises were noted to be dark reddish-purple with some green on the breast. Review of facility report to the State Agency (SA) dated 5/30/22, at 1:07 p.m. indicated R1 had a skin check completed on 5/30/22, at 7:40 a.m. and was noted to have a very large bruise on her left breast and was dark in color. R1 was unaware of how the bruise occurred due to cognitive level. Review of facility's 5-day investigation to the SA dated 6/1/22, indicated staff were interviewed who worked with R1 in the past 24-hours with no report of bruising noted prior to skin check on the morning of 5/30/22. Further review of investigation indicated R1 requires the use of the mechanical standing lift and R1's bruising lines up with harness and question if this may have been placed improperly leading to bruising. Additionally the report indicated that R1 had reported to family that staff were too rough with her at times as reported by family to the facility on [DATE]. Interventions implemented to prevent reoccurrence were physical therapy evaluation to ensure ongoing safety with current transfers, placing a sheep skin pad under left side under harness to prevent discomfort, and staff education related to using caution with ADLs and transfers per facility's safe resident handling protocols and update licensed staff if staff are feeling they need any further training or if staff had concerns with transferring any resident. In addition, facility's 5-day investigation lacked evidence of interventions implemented to address and protect R1 and other residents following the allegation of rough care, as well as interventions to protect R1 and other residents who utilize the standing mechanical lift when the root cause of the bruise was determined to be improper use of the harness. On 6/3/22, at 9:38 a.m. case manager (CM)-A stated she completed the facility's 5-day investigation for R1's bruise. CM-A stated her investigation included reviewing R1's incident report, interviews with staff that worked with R1 within the past 24-hours of 5/30/22, interviewed R1 and R1's family. Further, CM-A stated she reviewed R1's medications and hemoglobin levels with no concerns noted with those two things. CM-A determined R1 utilizes the mechanical standing lift for transfers and the bruise was in line with the harness used for the mechanical lift so a sheep skin pad with implemented as a preventative measure as well as ordering a physical therapy evaluation to ensure R1 was safe to use the mechanical stand for transfers. CM-A stated she typed up an education sheet on ensuring staff are careful with cares due to this complaint and bruising and staff were to sign and acknowledge they understood. When asked what prevention measures were implemented to protect R1 and other resident's residing on the unit following the allegation of rough care, CM-A stated the education she typed for the staff that direct staff to be careful during cares. CM-A confirmed no additional residents on the unit were interviewed to determine if there were additional concerns related to rough care because there had been no additional complaints reported by other residents regarding rough care and no additional skin concerns had been noted on the other resident's weekly skin check. In addition, CM-A stated interviewing other residents would be important if there were a concern for abuse, however CM-A stated she personally did not have any concerns about abuse but indicated she was not on the floor with staff observing everything the staff are doing. CM-A confirmed she did not observe any staff transferring residents using the mechanical standing lift or provide education on the proper use of the lift following the determination of the root cause of R1's bruising to be improper placement of the harness. On 6/3/22, at 11:12 a.m. administrator stated R1's family reported the allegation of rough care to the administrator who then reported the additional concern to CM-A to add into the investigation for R1. Administrator stated staff were expected to interview the resident when an allegation of rough care is made, however if the resident is cognitively impaired staff were expected to interview other cognitive residents on the unit and other staff to determine if there are any trends or a widespread issue. On 6/3/22, at 11:30 a.m. director of nursing (DON) stated rough care allegations were expected to be investigated by completing staff interview and other resident interviews to see if there are additional concerns or trends or if the allegation can be narrowed down to a specific staff member. Further, DON stated she was not aware of R1's allegation of rough care until 6/3/22. In addition, DON stated CM-A deemed the cause of the bruise occurred potentially from the lift harness which DON stated she would expect CM-A to re-evaluate the use of the mechanical lift and complete a facility assessment titled Sit, Stand, Walk to ensure resident is appropriate for the lift and no changes need to be made. DON confirmed CM-A did not complete a new Sit, Stand, Walk assessment and R1 had not had one completed since 3/22 for her quarterly assessment and there was no further education provided to staff related to safe transfers with mechanical lifts following the incident. Review of facility policy titled Abuse and Neglect policy revised 3/31/22, indicated the investigation team will review all incidents no later than the next working day following the incident. The investigation team will determine whether further investigation is needed. Further, the policy indicated the investigation may include interviewing employees, residents, or other witnesses to the incident.

Based on interview and document review, the facility failed to report an injury of unknown origin to the State Agency (SA), within two hours, as required for 1 of 3 residents (R1) who were reviewed for abuse. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's incident report dated 5/30/22, indicated R1's bruise on left breast was from the nipple to her left side and measured approximately 11 centimeters wide by 7 centimeters long. Another bruise was noted on the top of the left breast measuring approximately 5 centimeters long by 3 centimeters wide. Both bruises were noted to be dark reddish-purple with some green on the breast. Review of facility report to the SA dated 5/30/22, at 1:07 p.m. indicated R1 had a skin check completed on 5/30/22, at 7:40 a.m. and was noted to have a very large bruise on her left breast and was dark in color. R1 was unaware of how the bruise occurred. On 6/2/22, at 1:41 p.m. during interview with R1, she stated she was not sure how the bruise occurred and denied any abuse. On 6/2/22, at 1:56 p.m. registered nurse (RN)-A stated facility policy for injuries of unknown origin were to be reported to the SA within a short time-frame but for sure less than 24-hours. RN-A stated she was notified of the bruise when nursing assistant (NA)-A reported to RN-A during R1's bath on 5/30/22. RN-A was unsure what time R1 had received her bath but stated before 9:30 a.m. RN-A could not determine the cause of the bruise or rule out abuse at the time of identification. RN-A stated she reported the new bruise to the director of nursing (DON) and Administrator who indicated a report to the SA needed to be completed. RN-A stated she began the report shortly after, however was unable to complete the report due to being needed on the floor. RN-A confirmed she did not report the injury of unknown origin to the SA within the two-hour timeframe and stated the importance of reporting timely was to begin the investigation. On 6/3/22, at 9:38 a.m. case manager (CM)-A stated facility policy for injury of unknown origin were to be reported to the SA within two hours. Further, CM-A stated R1's bruise was identified on 5/30/22, in the morning during her bath and was reported to the SA sometime in the afternoon. CM-A confirmed RN-A did not submit the report to the SA within the two-hour time frame as expected and was not aware of the late report until surveyor interviewed RN-A on 6/2/22. In addition, CM-A stated reporting to the SA timely was important due to the possibility of abuse due to the unknown nature of the bruise and to ensure R1 is safe and not subject to further potential harm. On 6/3/22, at 11:12 a.m. administrator stated the facility policy for injuries of unknown origin were to be reported to the SA within two-hours which was important to prevent any potential harm to the resident and ensure safety. In addition, administrator stated he was unaware R1's bruise was not report timely to the SA until surveyor interviewed RN-A. On 6/3/22, at 11:30 a.m. DON stated facility policy for reporting injuries of unknown to the SA was within two hours, however occasionally it has been a little more than two hours but the more serious injury the facility would try to be quicker. Further, DON stated she was not aware R1's bruise was not reported to the SA timely until 6/3/22, and indicated staff need more education on reporting as soon as staff are aware. In addition, DON stated reporting to the SA timely was important due to the possibility of abuse and to investigation to ensure no further abuse and neglect occurs. Review of facility policy titled Abuse and Neglect policy revised 3/31/22, indicated the purpose of the policy was to ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported, and investigated. Further review of policy directed if there is an allegation of abuse, neglect, exploitation of mistreatment, including injuries of unknown source, then it will be reported immediately but not later than two hours after the allegation is made.

Based on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 3 residents (R17) with cognitive impairments who were reviewed for activities. Findings include: R17's quarterly Minimum Data Set ((MDS) dated [DATE], identified R17 as having severe cognitive impairment with [DIAGNOSES REDACTED]. R17 had moderate hearing difficulty and required speaker to increase volume and speak distinctly. R17 had moderately impaired vision. R17's MDS further identified R17 did not walk and required extensive assistance with activities of daily living. R17's annual MDS dated [DATE], identified R17 had significant cognitive impairment and moderate hearing and vision impairment. R17's MDS further identified listening to music, doing things with a group of people was somewhat important and religious services were very important to R17. R17's comprehensive care plan dated 2/11/21, identified R17 had a potential for psychosocial well-being deficit related to visitor restrictions secondary to COVID-19. Interventions included to increase communication between R17 and family and assist R17 with phone calls. R17's interventions also included 1:1 visits, take for walks around building and outside when weather was warmer. On 2/8/21, at 12:35 p.m. R17 was dressed in street clothes, in his wheelchair in his room. R17 had a blanket over his legs, eyes open, he was facing his doorway. R17's radio and television were off. R17 opened his eyes when surveyor entered the room, but did not respond verbally. On 2/8/21, at 12:44 p.m. R17 was in his wheelchair in his room, being fed by nursing assistant/activity aide (AA)-A. AA-A talked at times with R17 while feeding him. On 2/8/21, at 2:37 p.m. R17 was lying in his bed, eyes closed, door open. On 2/8/21, at 6:36 p.m. R17 was in his wheelchair in his room, eyes slightly closed facing the doorway, no television or music was on. On 2/8/21, R17 was not observed in any group activities or 1:1 activities. On 2/9/21, at 12:38 p.m. R17 was dressed in street clothes sitting in his doorway to his room. Registered nurse (RN)-A stopped and asked R17 if she could help him back to his room, and informed him they were bringing lunch soon. RN-A pushed R17 backwards into his room, attached his call light to his wheelchair then turned on his radio, which then played music softly. On 2/9/21, at 2:15 p.m. R17 was lying on his back in his bed, eyes closed, his door was open. On 2/9/21, at 3:24 p.m. R17 continued in his bed, eyes closed. At 3:29 p.m. nursing assistant (NA)-C and RN-C transferred R17 from his bed to his wheelchair. R17's radio was softly playing music, and difficult to hear unless near the radio. NA-C propelled R17 in his wheelchair to the sun room where R17 was visited by the priest. On 2/10/21, at 8:59 a.m. R17 was dressed in street clothes in his wheelchair, in his room, being fed by NA-B. On 2/10/21, at 1:06 p.m. R17 was sitting in his wheelchair, in his room, eyes open, his radio was on, playing polka music softly, which could only be heard near his radio. On 2/10/21, R17 was not observed in any group activities or 1:1 activities. Review of R17's progress notes from 7/1/20, to 2/11/21 identified the following: -7/14/20, activities quarterly note, R17 had dementia with disorganized thinking. He is hard of hearing and wears hearing aides but stills struggles to hear. R17 also had left side vision impairment and staff assist R17 to specific destination. R17's family used to visit often prior to COVID visitor restrictions. R17 enjoys music, and has a Wi-Fi radio in his room, but even turned up loud cannot hear it. R17 had a television in his room, but again due to poor vision was unable to see it. R17 enjoyed snacks and hot chocolate. R17 was barely in his room, but would take a nap in the afternoon. Staff provided R17 1:1 visits, would take him outdoors and strolls throughout the building. -12/11/20, care plan review identified R17 had several children who would call and visit as able. Family member now an essential care giver so would start coming now. Continue with interventions. -2/5/21, family member requested priest come and bless R17 today. Review of R17's Activity Interest Date Collection Tool dated 7/14/20, identified R17 preferred spending time with others and talking/conversion, listening to others and preferred television shows was news. R17's tool identified R17 had support of family and enjoyed Polka and Waltz music. Review of the untitled undated document which identified 1:1 visits for facility residents identified R17 received PRN (as needed) 1:1 visits. Review of R17's activity Follow Up Question Report 1:1 visits dated 1/11/21, to 2/11/21 identified the following: -1/14/21, social, staff visit -1/15/21, social, staff visit -1/17/21, social, staff visit -1/18/21, educational/cognitive, library cart -1/20/21, social, staff visit -1/22/21, social, other visit -1/25/21, social, family/friend visit -2/1/21, educational/cognitive, library cart -2/3/21, social, family/friend visit -2/5/21, spiritual, clergy visit -2/8/21, educational/cognitive, coffee/tea -2/9/21, sensory stimulation, radio/Ipod, staff visit Review of R17's activity Follow Up Question Report of group/self directed activities dated 1/11/21, to 2/11/21 identified documentation of social-communication with others, walking/wheeling, bird watching, TV and radio/Ipod on most days. On Sundays, it was documented spiritual, religious services. On group activities of exercise or bingo, it was documented not available or refused. On 2/10/21, at 9:12 a.m. NA-A indicated R17 did not participate in activities. NA-A indicated he was hard of hearing and had vision loss. NA-A indicated before COVID-19, R17 was out and about, liked to have snacks in the dining room and liked to talk and R17 was social. On 2/10/21, at 12:49 p.m. family member (FM)-A during a phone interview indicated since COVID she felt R17 spent a lot of his time alone in his room with lack of stimulation. FM-A indicated R17 liked 1:1 visits. FM-A indicated R17 could not hear well and had vision problems, so he did not do well in groups, but felt 1:1 visits were best. FM-A indicated R17 liked to be in the common area in the recliner by the television. On 2/10/21, at 1:26 p.m. RN-A indicated R17 loved polka music, but it was hard to tell if R17 could hear the music from his radio. RN-A indicated R17 probably did not receive other activities since the pandemic, but indicated R17 used to come out to the dining room in the afternoon for coffee and was more alert then. RN-A indicated his family comes for essential care visits about 1 time a week, and yesterday R17 had a visit from the priest. RN-A indicated R17 enjoyed topics such as farming and auctions. On 2/10/21, at 1:42 p.m. AA-A indicated R17 had cognitive impairment and was difficult to keep on track. AA-A indicated R17 had strong faith and liked to watch television, listen to the radio and observe activities. AA-A indicated R17 did not participate in activities, but visited, had coffee and cookies and on Sundays would watch Catholic services on television. AA-A indicated she had not done much with R17 in the past week, usually AA-A would feed R17, like she did on 2/8/21. AA-A indicated she had not done any activities with R17 recently. AA-A indicated R17 was scheduled for 1:1 visits PRN (as needed). AA-A indicated R17 was hard of hearing but liked someone by him and liked snacks like hot chocolate, cookies and milk. AA-A indicated a good activity was to give him rides around the facility, but it had been a while since that had been done. AA-A indicated the nursing assistants put him in his recliner, wheelchair or bed. AA-A indicated activities were hard for R17, as he was an observer. AA-A indicated she did not take him to group activities like bingo or exercises to participate or observe. AA-A showed surveyor how she documented in R17's electronic record, and indicated some of the documentation, such as social, indicated communication with others, such as when nursing assistant staff spoke to R17 while providing cares, not necessarily activity staff providing 1:1 visits. On 2/11/21, at 8:29 a.m. RN clinical manager (CM)-A indicted R17 liked to visit, was hard of hearing and had poor vision and liked polka music. CM-A indicated she was not sure if R17 could hear the music played on his radio in his room and felt because of his hearing loss, the music would have to be turned up. CM-A indicated R17 liked to visit about farming and she thought activities completed 1:1 visits with R17. On 2/11/21, at 8:38 a.m. activity director (AD)-A indicated activities they provided for R17 included taking him out when weather was nice, turn on polka music and offer snacks. AD-A indicated they do 1:1 visits with him at times, or push him through the facility if he was restless. AD-A indicated R17 liked to talk about farming, his family and his faith was important to him. AD-A indicated his family used to visit often, but more sporadic now. AD-A indicated R17 would go out to the common areas, but now rests often. AD-A reviewed R17's activity follow up report and indicated television, birds, and radio, were listed, and he was often resting after lunch. AD-A indicated she thought R17 received 1:1 at least daily by AA-A, and indicated she was not aware of why R17 did not go out of his room this week. AD-A indicated prior to the pandemic they had weekly entertainment that R17 would attend. AD-A confirmed R17 was very hard of hearing, and was not sure if R17 could hear the music on his radio in his room, and confirmed R17 did not use headphones. At 10:38 a.m. during follow up visit, AD-A confirmed R17 received 1:1 visits PRN because sometimes he was resting and sometimes would be agitated. On 2/11/21, at 9:43 a.m. NA-B indicated since the pandemic the facility did not provide any activities to speak of, but the facility was working on some group activities that were being worked back in. NA-B indicated they turned on Catholic services on the television for R17 on Sundays, but felt he could not hear or see it. NA-B indicated prior to the pandemic he had visitors with kids almost every day. NA-B indicated she could not tell if R17 could hear his radio when it was on, but indicated he could hear staff at times when they spoke to him. NA-B indicated she did not think R17 received 1:1 visits at this time and had not seen R17 receive a 1:1 visit in a while, but was not sure. NA-B indicated prior to the pandemic residents received 1:1 visits on the PM shift, but was not sure if this was being done now. On 2/11/21, at 11:07 a.m. director of nursing confirmed AD-A was the activity director. The DON indicated prior to COVID they had 3 activity staff, but only had AA-A and AD-A at this time. The DON indicated the facility was working on rebuilding their small group activities now and indicated AD-A completed the activity assessments for the residents in the facility. The facility policy titled Activities Program -ACT dated 6/22/20, identified activities as any endeavor in which a resident participates that is intended to enhance her or his sense of well-being and to enhance or promote physical, cognitive and emotional health. The policy also identified based on their comprehensive assessment and care plan and preferences, the facility would provide an ongoing program to support resident choices in their choices of activities.

Based on observation, interview and document review, the facility failed to develop interventions to address unplanned weight loss for 1 of 2 residents (R12) reviewed for nutrition. Findings include: R12's quarterly Minimum Data Set ((MDS) dated [DATE], identified R12 had severe cognitive impairment and had [DIAGNOSES REDACTED]. R12's MDS further identified required supervision with eating, personal hygiene, dressing and toilet use. R12's MDS identified current weight of 146 with no known weight loss. R12's annual MDS dated [DATE], identified R12's current weight of 160 with no known weight loss. R12's MDS further identified R12 required extensive assistance with dressing and was independent in all other activities of daily living (ADL) including eating. R12's care area assessments (CAAs) dated 6/4/20, identified R12 ate independently with occasional set up help provided. R12's CAAs also identified R12 was able to eat independently with good appetite despite dementia history and anxiety symptoms. R12's comprehensive care plan dated 2/11/21, identified R12 had self care deficit related to dementia and required assistance with ADLs. R12's comprehensive care plan interventions identified R12 was able to feed self after set up help. On 2/8/21, at 6:25 p.m. R12 was finished eating in the dining room. R12 ate 2/3 of her hamburger, none of her tomato slices or berry cobbler desert. On 2/10/21, at 7:48 a.m. nursing assistant (NA)-A was in R12's room attempting to assist R12 with morning cares. R12 refused assistance. NA-A told R12 that they would bring breakfast shortly, R12 said she was not really hungry. At 8:52 a.m. director of nursing (DON) was leaving R12's room and indicated R12 ate about 1/2 of her breakfast and R12 had told DON she could not eat all of it. Review of R12's Order Summary Report signed 1/19/21, identified: - diet order- NAS (no added salt) regular texture, regular fluid consistency. -POLST (provider orders for life sustaining treatment), artificially administered nutrition- Offer food by mouth if feasible. Defined trial period of artificial nutrition by tube. R12's order's did not indicate any further supplements or fortified foods ordered. Review of R12's progress notes from 8/10/20, to 2/11/21 identified the following: -11/10/20, R12 positive for COVID infection -11/24/20, dietary/nutrition-regular texture with NAS foods recommended and smaller portions not to overwhelm her. R12's weight 145.5 which is below previous weights, but not significant and BMI (body mass index) is not out of normal range, BMI at 26.6. Continue to monitor and record intakes and weights per facility protocol and observe for changes that may alter dietary interventions and review weights to be sure weight loss does not become significant. -12/2/20, R12 significant weight loss, appetite quite poor for approximately 2 weeks with positive COVID infection, slightly improved now will update GNP (general nurse practitioner) on rounds today with recent weights. -12/9/20, consultant pharmacist recommendation, R12's weight loss does not appear to be medication related, but rather acute illness. -12/20/20, R12 reviewed at risk meeting, decreased appetite, noted to eat better in the dining room, will reassess options for this. R12 some recent weight loss since COVID infection, increased confusion, R12 likes cheese sticks, but does not snack as much as previously, will look at alternative snacks and alert staff to offer snacks with 1:1 for wandering etc. -12/17/20, R12 reviewed at risk meeting today. R12 had some recent weight loss and decline in appetite. Recently started [MEDICATION NAME] for decline in mood and anxiety. -1/12/21, nutritional status-R12 had weight decline/intakes, does much walking during the day, small appetite, weight 138.5. BMI 25.3 normal weight status. Weight was 143 30 days prior, 154.5 180 days prior, and weight 160 1 year ago. R12 had had a weight loss trend in past 60 days, meal intake remains greater than 75%, plan to offer snacks for activity between meals. -1/20/21, R12 reviewed at risk meeting, slight weight gain noted, more hungry, better intake. -2/11/21, R12 has not had much of appetite, some meals does eat more. R12 offered snacks throughout the day as she is willing to have them. Weight is down 4 pounds this week. R12's GNP progress note dated 11/4/20, identified R12 had significant weight loss of 9 pounds in the past 4 months, 14 pounds in the past 8 months and current weight was 145.5, down from 150 in September. R12's GNP note also identified R12 appeared well nourished. R12's progress note identified slow weight loss, R12 walked hall continuously which likely contributed to slow weight loss. R12's primary physician telehealth progress note dated 1/19/21, identified R12 in stable condition with some weight loss, suspected this was doing well, and would recheck R12's A1C (diabetic blood test to test blood sugar levels) in the future. On 2/10/21, at 9:03 a.m. NA-A indicated R12 was declining rapidly and required more assistance and help keeping on track to participate in cares. NA-A indicated it was more of a struggle and was harder and harder to get R12 to eat. NA-A indicated R12 was eating less and less and she could tell by R12's jeans that she had lost weight. On 2/10/21, at 1:13 p.m. registered nurse (RN)-A indicated R12 had been declining and thought she had noticed R12 had more of a cognitive decline recently with more wandering in the past 2 weeks. RN-A indicated R12 had declined quite a bit with her eating and RN-A indicated she had noted a weight loss with R12. RN-A indicated R12 had a steady decline since she had COVID-19 and her intake had declined also. RN-A indicated there had been no changes in her diet, and that staff provided redirection and encouragement. RN-A indicated R12 had no nutritional supplements ordered. RN-A indicated her usual practice included checking on resident weights that were completed, compared them to previous weights and reported changes in the electronic shift communications and during report. On 2/11/21, at 8:18 a.m. RN clinical manager (CM)-A confirmed R12 had [MEDICAL CONDITION] and was declining. CM-A indicated R12 was now more confused, anxious and walking more. CM-A indicated R12 had a change in her appetite with more anxiety and confusion after she had COVID-19. CM-A indicated they had recently started [MEDICATION NAME] (anti-depressant) for her mood, weight loss, sleep and for quality of life. CM-A indicated R12 had quite a bit of weight loss with COVID and they offered her snacks and she felt R12's appetite had improved. CM-A indicated the usual facility practice for weight loss was to try foods first, then alternatives and get to the root cause of the reason for weight loss, before beginning supplements. On 2/11/21, at 9:49 a.m. NA-B indicated R12 had declined and she was more confused since she had COVID in November. NA-B indicated R12 was on a regular diet and ate independently in the dining room. NA-B indicated she felt R12 was not eating as well, and not eating as much as in the past. NA-B indicated until recently she was fine, but now R12 had more concerns about others eating than herself and was hard to redirect. NA-B indicated she was not sure but felt R12 had lost weight. On 2/11/21, at 10:13 a.m. during a phone interview dietician (D)-A indicated she was at the facility a couple of times monthly. D-A indicated she understood R12 was more distracted at meals and would not sit long at meals, which may have affected her appetite and intake. D-A indicated her last assessment for R12 was in January. D-A indicated she was aware R12 was walking more and constantly on the move. D-A indicated she thought R12 was on a weight loss trend. D-A indicated the usual facility policy was to first offer snacks, and use foods first for weight loss. D-A indicated the facility also had some high calorie drinks they offered some residents and indicated she was not sure if R12 was receiving supplements. D-A indicated her usual practice was to review the residents' weights by reviewing the weight loss reports and also said the electronic health records gave weight alert warnings she also reviewed. D-A indicated the facility also would make her aware of any concerns through their monthly risk meetings that they held. D-A indicated the clinical managers would make the physicians aware of any weight loss. D-A reviewed R12's electronic health record during the interview and indicated her last annual nutritional assessment was completed in June. At that time R12's intake was over 75% of her meals. D-A indicated she would be concerned if R12 developed fast weight loss. D-A indicated R12's weight began changing in November and she last charted on her 1/12/21. D-A indicated R12 had a small appetite at that time and was doing much walking during the day. D-A indicated at that time she weighed 138.5 and was now at 134, which was an additional 4 pound weight loss, but comparing her to 6 months ago, her weight loss could have been triggered. D-A indicated the interventions for R12 in January was to offer snacks. D-A indicated they could look at a trial kind of drink and look at medical supplements for R12 or fortified foods. D-A indicated the facility opted for fortified foods first. D-A indicated at this point with further evaluation, she felt that even though R12 had gained 1/2 pound with her last weight, she felt that she was now completely aware of R12's weight loss and would put a plan in place. D-A indicated she would follow up with the facility and see what could be done and to try something different to stop R12 from any further weight loss. D-A indicated they had to keep the residents' advanced directives in mind first. D-A indicated R12's advance directive review indicated they wanted to do a trial tube feeding for R12, but would not recommend this. D-A indicated now that she was aware of R12's weight loss R12 needed more than meals and snacks. On 2/11/21, at 11:09 a.m. the DON indicated R12 had changed a lot since she had COVID-19 . The DON stated R12 was previously independent with some supervision with ADLs. The DON indicated she was aware of R12's weight loss and that she was not eating as well or completing her meals she received in the dining room. The DON indicated her expectation was that if the nurse or dietician noticed weight loss of a resident, she would expect they make recommendations for interventions and involve R12's primary physician. The DON indicated they expected the addition of [MEDICATION NAME] would help and confirmed [MEDICATION NAME] was not ordered for her weight loss or appetite, but for her mood. The DON indicated she would expect D-A to follow up on R12's weight loss. DON confirmed R12 had continued weight loss. The facility policy titled Responsibilities for Dietician-Food and Nutrition Services dated 7/8/20, identified the dietician was an active member of the dietary risk committee and the interdisciplinary team and conducted assessment of nutritional status on site. The facility policy titled Nutrition Documentation-Food And Nutrition Services dated 7/8/20, identified the purpose was to identify the nutritional status and needs of the residents and to assess the residents needs and plan appropriate nutrition for each resident. The policy further identified the dietician would document monthly on residents identified to be at nutritional risk in the progress notes. The policy also identified if the nutritional interventions had not been effective, to new goals and interventions would be added to the care plan.

Based on observation, interview and record review, the facility failed to properly monitor for potential side effects for 1 of 3 residents (R32) reviewed for antipsychotic medication use. Findings included: R32's face sheet indicated R32's [DIAGNOSES REDACTED]. R32's quarterly Minimum Data Set ((MDS) dated [DATE] indicated R32 had moderate cognitive impairment. R32's medication orders, signed 1/14/21, included [MEDICATION NAME] (medication used to treat anxiety) and quetiapine (an antipsychotic medication used to treat mood and mental conditions). R32's Abnormal Involuntary Movement Scale (AIMS) used to assess for dyskinesias (movement disorders that are characterized by involuntary muscle movements) in residents taking neuroleptic medications dated 12/22/20, indicated facial and oral movements were not noted. According to facility document, possible areas of movements included the forehead, eyebrows, periorbital (around the eye), cheeks, lips, perioral (around the mouth), jaw and tongue. R32's consulting pharmacist progress note dated 1/11/21 indicated R32 had a long history of [MEDICAL CONDITION], recurrent depression and hallucinations which warranted current medication use which included quetiapine. The progress note indicated R32 was tolerating dosages of medications well and recommended adjustments to [MEDICAL CONDITION] medications (medication that affects behavior, mood, thoughts or perception) be left to psychiatry. The progress note indicated R32 was to see psychiatry in the near future. R32's primary provider progress notes dated 1/14/21, did not identify R32 was having adverse effects from use of [MEDICAL CONDITION] medications. R32's progress notes did not include any notes identifying facial or hand movements. R32's treatment sheets and current care plan did not identify the need to observe for uncontrolled facial or hand movements related to medication use. On 2/8/21, at 12:26 p.m. R32 was observed continuously moving his mouth, as though he was chewing on something and smacking his lips. R32 denied having food, fluid, or other object in his mouth. On 2/8/21, at 5:40 p.m. R32 was observed to continuously move his mouth, as though he was chewing on something. Movements not noted when R32 was talking but would immediately return when he stopped talking. R32 was able to stop these movements when made aware of them, but they returned in less than a minute. Infrequent pill rolling (circular movements of the tips of the index finger and thumb) observed in R32's right hand. On 2/9/21, at 12:42 p.m. R32 was observed sitting up in bed, but leaning against pillows between him and the wall. Noted continuous facial movements, as if he was chewing on something and smacking his lips. R32 confirmed he did not have anything in his mouth and denied chewing on his tongue. The facial movements would stop when R32 was talking but would immediately return when he stopped talking. Pill rolling not noted in right or left hands, but R32 was hanging onto the television remote with is right hand at the time of observation and declined to put it down. On 2/9/21, at 2:09 p.m. R32 was observed to continue with facial movements. Mouth slightly open during this observation. Noted his tongue remained in his mouth but was frequently moving forward and back and along his gum line. Pill rolling of right hand not noted but had the television remote in his hand. On 2/10/21, at 7:52 a.m. R32 was observed resting in bed with his eyes closed. He did not respond to quiet mention of his name. No facial or tongue movements noted. R32's hands were not visible at the time of this observation. On 2/10/21, at 8:13 a.m. R32 stated he was not aware of the facial movements and had not been asked about them by staff, including licensed staff. On 2/10/21, at 8:15 a.m. R32 was observed lying bed, but with eyes open. Facial movements, as if he was chewing on something, noted but were not continuous. These movements were less severe that previously noted. R32 able to stop the movements when asked about them, but quickly returned between episodes of R32 talking. Pill rolling not noted in R32's right or left hands. On 2/10/21, at 11:20 a.m. R32 was observed resting in bed with his eyes closed. No facial movements noted. On 2/10/21, at 1:13 p.m. nursing assistant (NA)-D stated she has worked with R32 frequently. NA-D has noted facial movements, other than when talking, off and on and R32 has days when the movements are not as noticeable. NA-D indicated being told the reason for the facial movements when NA-D first started at the facility but didn't remember what that reason was. NA-D stated the facial movements has not been reported to a nurse because NA-D assumed the nurses were aware of it and as long as the nurses were aware of it, then it was okay with NA-D. On 2/10/21, at 1:27 p.m. registered nurse (RN)-B stated R32's facial movements were noticed once in a while. RN-B stated noting increased shaking in R32's hands as well. RN-B did not recall when the facial movements started, RN-B stated being used to seeing it so has not noticed it as much. RN-B confirmed these movements of R32's mouth and hands could be a side effect of the [MEDICAL CONDITION] medication R32 is taking. RN-B confirmed she had not reported the facial or hand movements to another nurse, including the MDS Coordinator (RN)-B or the Director of Nursing (DON). RN-B indicate she assumed they were already aware. On 2/10/21, at 1:39 p.m. case manager (CM)-A stated she had not noticed R32 having a facial tremor and had not been told about it. CM-A indicated residents who receive [MEDICAL CONDITION] medications receive an AIMS assessment upon admission or start of medication, quarterly after that and as needed. CM-A stated she completed an AIMS assessment with R32 with his last MDS and confirmed her findings indicated no involuntary movements, of R32's face or hands, at the time of the assessment. CM-A stated this assessment is completed face-to-face. At this time, CM-A observed R32 and interviewed him regarding facial movements. After CM-A interview with R32, CM-A confirmed she had not been previously told about the facial movements and that they were well pronounced and not easily ignored. On 2/10/21, at 2:13 p.m. the director of nursing (DON) confirmed the AIMS assessment is completed face-to-face, it is a visual assessment of movements of face and hands. The DON stated, if unlicensed staff notice new or worsening facial or hand movements, they should report these concerns to the floor nurse. If the floor nurse notices new or worsening hand or facial movements, these should be documented and reported to the MDS Coordinator. The MDS Coordinator would be expected to complete an AIMS assessment to determine severity of these movements. The DON indicated she was not aware of R32 having facial or hand movements. She had spent up to 10 minutes with him the morning of 2/8/21 and had not noticed facial or hand movements. The DON confirmed R32 had a facial mask on at that time. On 2/11/21, at 3:16 p.m. R32's primary provider confirmed he did not notice facial movements during telehealth visit with R32 on 1/14/21. R32's primary provider indicated, during telehealth visits, the resident does not wear a mask so facial movements would be seen, if they were present. R32's primary provider confirmed R32 receives [MEDICAL CONDITION] medication and may have side effects that included uncontrolled facial movements. The presence of these movements as well as the severity may vary. R32's primary provider indicated it is possible to have the facial movements on some days, but not on others. R32's primary provider indicated he had not been made aware of R32's facial movements prior to 2/10/21 when the facility updated him on the facial movements. Facility policy: Interact- Change In Condition Evaluation revision date 12/11/20, indicated a change in condition alert can be created to communicate or remind nurses to keep a closer eye on a resident when something seems different. Facility policy: [MEDICAL CONDITION] Medications-Rehab/Skilled revision date 11/19/20, indicated residents using [MEDICAL CONDITION] medications are to be monitored for side effects of the medication. If a side effect occurs or worsening of a known side effect is noted, the nurse will make a note in the progress notes and notify the physician and family/legal representative of this change in condition.

Based on observation, interview, and document review, the facility failed to ensure facial hair was removed for 1 of 3 residents (R15) who required assistance with hygiene, and were reviewed for activities of daily living. Findings include: R15's [DIAGNOSES REDACTED]. R15's significant change Minimum Data Set ((MDS) dated [DATE], identified R15 had severe cognitive impairment. MDS further identified R15 required extensive assistance with personal hygiene and dressing. R15's care area assessment (CAA) dated 11/20/20, indicated R15 had limited ability to perform personal hygiene due to loss of voluntary arm movement, functional limitation in upper extremity range of motion, impaired hand dexterity and decreased mobility. R15's care plan revised on 11/28/17, identified a self care deficit that required assistance of one to encourage R15 to participate as able. Care plan did not specify R15 not wanting facial grooming. On 2/8/21, at 4:12 p.m. R15 was observed with three long white chin hairs that were approximately 1 inch in length. R15 stated the chin hairs bothered her and would like them removed. On 2/9/21, at 1:53 p.m. R15 was observed rubbing her chin hairs and stated it bothered her. R15 did not recall if staff offered to remove the chin hairs. On 2/10/21, at 11:45 a.m. R15 was observed sleeping in recliner and three white chin hairs approximately 1 inch in length remained. On 2/10/21, at 1:24 p.m. interview with nursing assistant (NA)-A stated R15 had not verbalized concerns with facial hair. NA-A stated she was not aware of this special request of grooming chin hairs to be included on R15's care plan. NA-A stated R15 bathroom did not have an electric razor which would also indicate to groom R15 chin hairs. On 2/10/21, at 1:34 p.m. interview with clinical manager (CM)-A stated the care plan would indicate if a resident did not want their facial hair trimmed. CM-A stated R15 should have her chin hair trimmed by the nursing assistant. CM-A said if R15 does not have an electric razor the facility would provide one and store in R15 bathroom. On 2/10/21, at 1:40 p.m. it was observed no electric razor in R15 bathroom. On 2/11/21, at 9:29 a.m. interview with director of nursing (DON) stated the nursing assistants were to follow the care plan. The DON stated the care plan would state if a resident did not want facial grooming. The DON stated if there was nothing stated in the care plan about grooming it is then expected the nursing assistant would provide facial grooming or trimming of chin hair even on female residents. The DON stated R15 care plan did not indicate to not provide facial grooming. The facility policy titled Activities of Daily Living-Rehab/Skilled revised 12/28/20, identified the purpose of the procedure is to provide residents with appropriate treatment and services to maintain or improve abilities in activities of daily living for the well-being of mind, body and soul. The policy further directed ADLs are those necessary tasks conducted in the normal course of a resident's daily life. General personal, daily hygiene/grooming: care of hair, hands, face, shaving, applying makeup, skin, nails and oral care.

Based on observation, interview, and document review, the facility failed to ensure facial hair was removed for 1 of 3 residents (R12) who required assistance with hygiene, and were reviewed for activities of daily living. Findings Include: R12's quarterly Minimum Data Set ((MDS) dated [DATE], identified R12 had severe cognitive impairment and had [DIAGNOSES REDACTED]. R12's MDS further identified required supervision with personal hygiene, dressing and toilet use. R12's comprehensive care plan dated 2/11/21, identified R12 had self care deficit related to dementia and had need for assistance with ADLs (activities of daily living). R12's comprehensive care plan interventions identified R12 required cuing at times for personal hygiene. R12's care plan did not include instructions to not assist R12 with shaving facial hair. On 2/08/21, at 6:35 p.m. R12 was observed in the hallway near her room dressed in street clothes. R12 had 6-8 1/4 inch long blonde facial hairs on her chin. On 2/09/21, at 9:26 a.m. R12 was observed lying in her bed with her eyes closed. R12 was dressed in street clothes, and continued to have 6-8 1/4 inch long blonde facial hairs on her chin. During observation on 2/10/21, at 7:44 a.m. nursing assistant (NA)-A was in R12's room wearing gown, gloves, eye protection and mask while attempting to complete R12's morning cares. R12 was currently on transmission based precautions due to symptoms following her COVID vaccination. R12 was dressed in her same street clothes she wore the previous day and her hair was uncombed. R12 continued to have facial hair on her chin. R12 became anxious and began to refuse all cares offered while sitting in her padded chair in her room. NA-A indicated this was not R12's usual behavior, then she contacted registered nurse (RN)-A by walkie-talkie and informed her that R12 was refusing all cares. RN-A instructed NA-A to leave R12's room and re-approach R12 later. NA-A removed her gown and gloves, sanitized her hands and left R12's room. On 2/10/21, at 9:03 a.m. NA-A indicated R12 was rapidly declining and required extensive assistance with cares, but could participate with some hygiene, but R12 required cuing to keep her on track. NA-A indicated she had not shaven R12, and indicated it would be in R12's care plan if she could be shaven and that R12 would have an electric razor in her room. NA-A indicated some women preferred not to be shaven so they had it written in their care plan not be shave them. NA-A indicated she had never shaven R12 before and indicated she did not know if R12 was to be shaven. NA-A indicated she was not aware if R12 had a razor. On 2/10/21, at 11:00 a.m. R12 was observed sitting in the common area near the bird aviary dressed in street clothes and a sweater. R12 continued to have facial hair on her chin. On 2/10/21, at 12:58 p.m. surveyor attempted to contact R12's family member for interview, but unable to contact by phone. On 2/10/21, at 1:13 p.m. RN-A confirmed R12 had a cognitive decline recently and now required more assistance. RN-A indicated she did not know R12's preference for removing facial hairs, and would have to check with clinical manager (CM)-A. RN-A indicated it should be on R12's care plan. On 2/11/21, at 9:22 a.m. RN-A indicated in a follow up interview that she had spoken to CM-A yesterday and confirmed that if a resident does not want their facial hair shaven it would be on their care plan. RN-A indicated the unit had only two women identified who were not to be shaven, and R12 was not one of those. RN-A indicated she would expect all female residents to be shaven unless identified not to on their care plan with their a.m. or p.m. cares. On 2/11/21, at 8:18 a.m. CM-A indicated R12 was more confused and anxious and had a decline related to her dementia progression. CM-A indicated the facility staff should assist R12 with shaving of her facial hair. CM-A indicated R12 had been doing it independently before the decline. CM-A indicated the staff found R12's razor yesterday and she thought they shaved R12's facial hair last night. CM-A indicated the usual facility practice was for those residents who did not want their facial hair shaven, it would be care planned and for all others the staff should assist them with shaving. CM-A indicated it was her expectation that R12 would be shaven to remove facial hair as needed. CM-A confirmed the facility social worker had extra razors for staff to use if a resident did not have their own razor, but was not sure if the nursing assistants were aware of this. On 2/11/21, at 9:49 a.m. NA-B indicated R12 was more confused and required more assistance with ADLs now. NA-B indicated she thought R12 may have had her facial hairs removed while in the beauty shop, but was not sure. NA-B indicated it would be in R12's care plan if she did not wish to be shaven by staff. NA-B indicated her usual practice was to let CM-A know if a resident needed to be shaven and did not have a razor. On 2/11/21, at 11:09 a.m. director of nursing (DON) confirmed R12 had changed a lot and had been completely independent with cares with some supervision of some cares prior to having COVID. DON indicate since R12 had COVID her memory was worse, she had more behaviors and required more assistance with cares. DON indicated the usual facility practice was all residents received assistance with facial hair unless they refused and this would be on their care plan. DON confirmed it was her expectation that unless it was care planned to not be shaven, that all residents be shaven with cares as needed. The facility policy titled Shaving-Rehab/Skilled reviewed/revised 9/20/20 identified the policy purpose included to promote positive self-image and well-being. The policy further identified if a resident chose not to shave, to report to nurse or physician as appropriate.

Based on observation, interview and document review, the facility failed to provide adequate and sufficient supervision, implement facility policy to ensure heat treatments were applied in a safe manner to prevent injury and minimize the potential for serious injury, impairment or death with the use of hot packs for 1 of 1 residents (R1) who sustained a second degree burn to his left thigh with the placement of hot pack. These findings constituted an immediate jeopardy (IJ) situation for R1 who had the potential for serious injury, impairment or death. The immediate jeopardy was removed, and the deficient practice was corrected on 1/28/21, prior to the start of the survey and was therefore past noncompliance. The IJ began on 1/25/21, when trained medication aid (TMA)-A placed a hot pack prepared with hot water taken from the hot water coffee machine, placed under R1's left thigh without protection between his skin and the hot pack, and left R1 unattended. The administrator and director of nursing (DON) were notified of the IJ on 2/2/21 at 4:43 p.m. However, the facility had already implemented several actions which included modification of R1's care plan, education provided immediately to TMA-A and re-education regarding the facility policy, scope of practice, and expectations provided to TMA's and licensed nursing staff to ensure compliance was followed and to prevent reoccurrence. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 had diagnoses which included [CONDITION(S)], [CONDITION(S)] (PVD), and Diabetes Mellitus. The MDS identified R1 was cognitively intact, required total assistance for bed mobility, transfers, eating, personal hygiene, toileting, and locomotion. R1's Care Area Assessment (CAA) dated 11/11/20, identified R1's decreased mobility, loss of voluntary arm movement, total dependence for bed mobility, locomotion on unit, dressing, eating, toilet use, personal hygiene, bathing, and transfers. The CAA listed R1 had diagnoses including diabetes, [CONDITION(S)], neurological disorder, and PVD. R1's Careplan revised 1/29/21, listed R1 had no purposeful mobility R/T [related to] [CONDITION(S)]/spastic [CONDITION(S)] E/B [evidenced by] need for assistance with mobility. The care plan identified R1 had 2nd degree burn to left posterior thigh and directed staff to encourage use of sheep skin between lift sling and leg with transfers to prevent additional shearing until burn is resolved. A review of R1's progress notes from 12/26/20 through 1/31/21, identified the following: -On 1/25/21, at 11:30 p.m. TMA-B provided cares to R1 and noted a warm pack under his left thigh. The warm pack was removed and had no towel or cloth between the plastic and R1's skin. TMA-B noted a red area approximately 5 inches by 7 inches rectangle area. R1 stated a TMA had applied it at 9:00 p.m. and he thought it was hot but did not say anything. At 3:00 a.m. the area was irregular shaped and raised in the center. At 5:30 a.m. the area had multiple blisters form on top. R1 had no complains of pain. - On 1/26/20, at 8:37 a.m. RN-B spoke with GNP (general nurse practitioner ) regarding second degree burn to rear left thigh. GNP ordered silver sulfadazine [sic] cream to be applied BID (twice daily) until resolved. Cover with non-adherent dressing. -On 1/27/20, at 8:37 a.m. 2nd degree burn present to rear left thigh assessed with wound round this AM (morning). 2 large filled blisters have ruptured, revealing dermal wound bed. Minimal amount of serous exudate noted. At 10:41 p.m. blisters to area have drained and tx (treatment) done as ordered, some skin has sloughed off, one small area deeper then the rest, does not c/o (complain of) pain to the area, the other scabbed wounds cleansed and dressed as ordered. - On 1/29/20, at 10:06 a.m. communication/visit with physician, R1 has a large burn to upper posterior thigh (from hot pack) that is being treated with silver sulfanide [sic]. Does have increased redness around this area as well but this is more purplish in color and appears more consistent with scar tissue and is not warm touch. R1 did have 2 blisters open up to this area with dressing regimen also being utilized for this. -On 1/29/20, at 10:54 a.m. incident reviewed from 1/25/21. R1 was noted to have warm pack found underneath him on 1/25/21 on noc (night) shift. Noc shift noted this with cares around 11:30 p.m. and R1 had reported the hot pack was placed around 9:00 p.m. by a TMA on the evening shift but upon investigation it was determined that this was not passed on to the night shift and not re-checked. R1 noted to have several blisters develop to area during the noc and developed into 2nd degree burn. No barrier was used over the hot pack and no f/u (follow up). The hot pack was improperly prepared and placed by TMA. -On 1/29/20, at 5:47 p.m. communication visit with physician, [MEDICATION(S)] ointment 500 unit/GM (unit/grams) apply to left thigh burn topically two times a day for second degree burn after cleansing with NS (normal saline), then cover with dressing, and paper tape. A facility internal investigation report, dated 1/25/21, at 11:30 p.m. completed by registered nurse (RN)-A identified during R1's cares a warm pack was noted under R1's left thigh. Upon removal noted approximate 5 inches by 7 inches rectangle red areas on R1's skin. TMA placed a washcloth in a plastic bag and failed to place a towel or cloth between skin and plastic bag. R1 stated warm pack had been applied by TMA around 9:00 p.m. R1 stated it felt hot but did not say anything to staff. At 3:00 a.m. t/r [sic] checked area and had become irregular shaped and raised in the center. A treatment order was not identified to apply warm packs to that area only an order to monitor the boil like areas. Hot pack applied by TMA, not assessed after 20 minutes, and not removed. There was no cloth between the warm pack and the skin of the resident. During observation on 2/1/21, at 12:35 p.m. nursing assistant (NA)-A and TMA-C entered R1's room with a total lift machine to reposition him. A large piece of sheep skin was noted to be located between R1's left thigh area and the wheel chair. Both staff attached lift sling hooks to lift machine and raised R1 up into the air. R1 grimaced and stated ouch my left thigh burn hurts. During observation on 2/1/21, at 2:15 p.m. registered nurse, wound nurse (RN)-B and NA-A transferred R1 from wheel chair to the bed using a total lift machine. RN-B and NA-A turned R1 onto his right side and lifted his pants over the left thigh area. An ace wrap was located around the lower left thigh and on the upper rear thigh two [MEDICATION(S)] foam wound dressings (3 inches by 3 inches). The dressings were secured with [MEDICATION(S)] adhesive tape. RN-B stated the hot pack was to be placed on the boils but must have been placed further down on the thigh or possibly slid down. RN-B pulled down the ace wrap to expose the burn area located on the rear left thigh. R1 stated, Oh, that's tender, be careful. RN-B indicated and verified the burn area was measured approximately 5 inches by 7 inches with two blisters that measured approximately 2 inches in diameter, and many other little blisters that covered the entire red burn area and drained a minimal amount of clear liquid. RN-B also verified she measured the initial burn on 1/26/21 but had not measured it since then. During a telephone interview on 2/1/21, at 3:27 p.m. family member (FM)-A identified a hot cloth had been placed in a garbage bag and then under R1's left leg at the end of the shift. FM-A stated this was not ordered and it was not a procedure that should have been done. FM-A also indicated there was no communication in the chart or with other staff, and R1 received a large second degree burn to his left thigh with blisters. During observation on 2/2/21 at 8:25 a.m. Maintenance (M)-A used the facility thermometer and verified the water temperatures of all 3 hot water coffee machines in the facility and R1's bathroom sink water: -Heritage dining room located on the 100 wing 172 degrees -Cottonwood dining room area located on the 200 wing 157 degrees -[NAME] dining room area located on the 300 wing 151 degrees -R1's bathroom sink 112.7 degrees During interview on 2/1/21 at 1:22 pm TMA-C verified R1 needed total cares completed by staff and all transfers with a total lift machine. TMA-C bathed R1 today and identified a burn area on the back side of R1's left thigh. TMA-C also indicated a TMA applied a hot pack for the 2 boils located on the back side of R1's left thigh and during the shift change it got left on too long. The NA on the night shift found the hot pack. TMA-C identified the burn on R1's left thigh was pretty large, more than 6 inches long and wide, the skin surrounding it is very red, and drained a yellowish color fluid with blood in it. TMA-C also indicated she was unsure if TMA's are allowed to apply hot packs. During interview on 2/1/21, at 1:35 p.m. R1 stated one week ago on 1/25/21 TMA-A entered his room at 9:00 p.m. with a hot washcloth in a clear garbage bag. TMA-A stated to R1 it's really really hot and placed it under his left thigh. R1 indicated he could tell it was very hot but never thought it would cause a burn with blisters. R1 stated TMA-A left the room, went home and never came back to check on it. R1 indicated around 11:00 p.m. NA-B rolled R1 onto his right side to position him for sleep. R1 stated NA-B stated, Oh what is this? and pulled out the hot pack, at which time NA-B informed R1 the left rear thigh was really red and had blisters. R1 stated he had a high level pain tolerance and thought he could take the heat but never thought it would cause a burn with blisters. R1 indicted he could not change positions in bed and was dependent on staff to help him. R1 indicated he expected TMA-A to come back and check on him prior to leaving the building. During interview on 2/1/21, at 4:38 p.m. TMA-A stated she worked 1/25/21 on the evening shift. TMA-A indicated she used a few drops of hot water taken from the hot water coffee machine and saturated the middle of a wash cloth. Once the water spread outwards on the cloth, she placed the wash cloth into a clear trash bag. TMA-A verified she forgot to put a towel barrier between the hot pack and R1's skin. R1 laid in bed and the hot pack was placed by TMA-A under his left thigh. TMA-A said she'd asked R1 if he felt ok or if it was too hot prior to leaving the room. TMA-A exited R1's room, did not return, informed TMA-D the hot packed had been placed, and went home. TMA-A indicated the DON called her on 1/27/21, and informed her it should have been a nurse that placed the hot pack, there was not an order for this treatment, and provided education regarding the facility policy on heat applications, and the TMA's scope of practice. During interview on 2/2/21, at 8:28 a.m. NA-B indicated she worked the night shift on 1/25/21. NA-B said at 10:30 p.m., R1 placed his light on and NA-B got him ready for bed. NA-B said when she turned R1, she noticed a hot pack under his left leg, and asked him what it was. NA-B removed the hot pack and saw a pretty large red mark that looked like a burn. NA-B notified RN-A. RN-A measured a bright stop sign red area it was 7 inches by 5 inches. NA-B and RN-A repositioned R1 him off of the left leg. At 3:00 a.m. NA-B repositioned R1 and noted the burn area on the left leg had started to blister. NA-B indicated there were a mixture of large and small blisters. NA-B stated she moved R1's left leg he grimaced, and said he could feel the burn. A cool tap water cloth placed in a bag was placed on R1's left leg by RN-A and removed 20 minutes later. NA-B indicated the burn area looked the same at that time and no open areas were noted. During interview on 2/2/21, at 11:12 a.m. TMA-D indicated she worked as a TMA on 1/25/21 evening shift. TMA-D identified TMA-A asked her if she could get a warm pack and had stated, Yes go ahead. TMA-D identified TMA-A used too hot of water and placed it on R1's left leg. TMA-D indicated a hot pack should not have been applied to R1 by a TMA and R1 was not checked on after it was placed. During interview on 2/2/21, at 11:27 a.m. DON indicated she received a phone call on the morning of 1/26/21, from the night shift nurse to inform her at 9:00 p.m. a hot pack had been applied by the evening TMA to R1's left thigh, 11:00 p.m. the night shift TMA repositioned him, removed it and there was a red area. DON also indicated she was informed at the same time the burn looked worse by morning and had blisters. DON stated on the morning of 1/26/21 the wound nurse RN-B assessed it and confirmed it had all the qualities of being a second degree burn with blisters that remained intact. DON indicated it is uncertain if the hot pack was placed in the correct spot on the left thigh or if it slid down when the head of the bed was raised, however, R1 could not move himself. DON indicated a TMA should have not applied a hot pack, and indicated this was not in their scope of practice according to the facility policy. DON identified a heat application must be ordered by a physician and this treatment should be done by a nurse, restorative aides or a therapist provided with education to apply excessive hot or cold. DON stated there were many processes during this incident that were not correctly followed according to the facility policy and procedures. DON indicated there was a lack of communication and understanding for the TMA that applied the hot pack. DON indicated the facility did not have a policy specific to hot water packs and indicated the water from a resident's bathroom sink should be used instead of the hot water from the coffee machine. On 2/2/21, at 2:00 p.m. during a follow up interview with TMA-C she stated she met with DON the day after the recent TMA/licensed nursing meeting, and received the necessary education regarding the facility policy, procedures, and scope of practice regarding the application of hot packs. TMA-C identified TMA's or NAs were not allowed to apply a warm pack per facility policy and if they have questions or concerns the staff nurse should be contacted. During interview on 2/2/21, at 2:45 p.m. wound nurse (RN)-B identified she assessed R1's left rear thigh burn on the morning of 1/26/21. RN-B indicated she had been informed a hot pack had been applied and left on by a TMA on the evening shift on 1/25/21. RN-B noted there were two intact large blisters and the entire red area was covered with small blisters. RN-B indicated the small blisters reabsorbed through the day on 1/26/21 and by the end of the day and the burn site started to weep a clear fluid. Review of facility policy titled Heat Applications date revised 11/24/20, identified the purpose of the policy was to apply heat treatments in a safe manner by responsible employees in the skilled care facility which included therapist, licensed nurse, rehabilitation nurse, or restorative nursing assistants with documented training. The policy addressed types of heat application such as K-pad (or aqua/thermia pad) and microwave heating packs (rice, grain or commercial packs). Further, the policy indicated a physician's order is required for heat application and time for treatment is usually 15 to 20 minutes. The IJ was issued at past non-compliance beginning on 1/25/21. The IJ was corrected on 1/28/20, prior to the start of the abbreviated survey. It was verified by observation, interview and document review the facility had implemented sufficient steps to remove the immediacy and correct the identified non-compliance. These steps included review of the the facility's policy, procedures, and orders needed for heat application, scope of practice, processes and expectations for TMA's and nurses who are supervising them, and communication of any changes noted to the nurse to ensure compliance was followed to prevent reoccurrence. The facility educated licensed nursing staff and TMA's on the policy and expectations for use of heat application for residents.

Based on interview and document review, the facility failed to ensure an emergency dental agreement had been completed which had the potential to affect all 43 residents residing in the facility reviewed during the extended survey. Findings include: During the extended survey document review on 2/3/21, at 10:59 a.m. a copy of the facility dental agreement was requested. The facility was unable to provide a copy of an agreement. The Administrator confirmed the facility did not have a current dental agreement in place.

Based on observation, interview and document review the agency failed to implement the use of appropriate eye protection when entering residents' rooms to help prevent the spread of COVID 19 according to Centers for Disease Control and Prevention (CDC) and Minnesota Department of Health (MDH) which had the potential to affect all 17 residents who resided on the 100 wing at the time of the COVID-19 Focused Infection Control Survey. In addition the facility failed to clean equipment between residents (R4, R5) which had the potential to spread COVID 19 to other residents and staff members. Findings include: MDH Contingency Standards Of Care For COVID-19 Personal Protective Equipment For Congregate Care Settings, updated 9/25/20, identified the recommendation for HCP (healthcare personal) with face-to-face contact with COVID negative residents to include surgical mask, eye protection and hand hygiene. On 11/24/20, at 10:08 a.m. registered nurse (RN)-A entered R4's room with an infrared thermometer while she asked R4 if she could get his temperature, then RN-A closed the door behind her. At 10:11 a.m. RN-A left R4's room with the thermometer and R4's breakfast tray, then took the tray to the kitchenette area. RN-A then returned to the nursing cart, with the thermometer and piece of paper. RN-A laid both down on the cart, applied new gloves, then entered R5's room with the thermometer, without first cleaning the therometer after being used by R4. RN-A then left R5's room while carrying thermometer, then walked off of the wing. RN-A failed to sanitize the thermometer between two residents and before she laid it down on the nursing cart. At 10:51 a.m. RN-A confirmed that she had not sanitized the thermometer between 2-3 residents earlier. RN-A indicated that she had not had sanitizing wipes on the cart at that time, and should have sanitized the thermometer between residents. RN-A indicated that when she realized she had not sanitized the thermometer between residents, she left the wing to get sanitizing wipes. On 11/24/20, at 11:27 a.m. housekeeper (HK)-A was on the 100 wing, a long term care unit that was not a quarantine or COVID positive unit, near a laundry cart. HK-A was wearing a N95 mask, with prescription eye glasses and no eye protection. HK-A took clothing off the laundry cart then entered R7's room, who was currently in the room. HK-A left R7's room, then was approached by a staff member who informed her R6, a resident who also resided on the 100 wing, was running a high temperature. HK-A returned to R7's room with more clothing. HK-A then returned to the cart, removed clothing from the laundry cart, then entered R8's room to deliver clothing, wearing no eye protection. At 11:34 a.m. HK-A approached surveyor and informed her she was now delivering laundry. HK-A indicated she was not required to wear eye protection while delivering laundry, only while cleaning. HK-A returned to the cart, removed clothing then entered R9's room with clothing wearing no eye protection. At 11:36 a.m. HK-A left R9's room, returned to the cart, then took clothing into R10's room and closed the door. HK-A then left R10's room, approached the laundry cart, then walked down the hall and entered the therapy room with linen in her hand. At 11:39 a.m. head of housekeeping (HHK)-A indicated her expectations were for HK-A to wear a face shield when delivering laundry. HK-A left the therapy room, then HHK-A stopped HK-A in the hallway and performed education to HK-A. HHK-A informed HK-A that she needed to wear a gown and a face shield when delivering clothing to residents. HK-A indicated that she needed a new face shield, in which HHK-A informed her she would get her one. HHK-A then confirmed again with surveyor that her expectation was that staff wore a face shield and gown while delivering clothing to residents in their rooms. HHK-A indicated that eye protection was important to protect HK-A and the residents, and the face shields should be worn at all times. On 11/25/20, at 3:11 p.m. director of nursing (DON) confirmed her expectation was for a face shield to be worn while in resident care areas and while delivering laundry into residents' rooms. The DON indicated she expected housekeeping staff to wear that personal protective equipment (PPE) because of the risk of transmitting anything that resident may have. The DON indicated a resident may be asymptomatic and be positive of COVID-19 and pass it on to the staff member. The DON also confirmed her expectations included nursing staff to sanitize all equipment between residents, including the infrared thermometer, to prevent transmission of COVID-19. The facility policy titled Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID) Enterprise last reviewed 11/17/20, provided guidance to healthcare personal working in healthcare settings who have the potential of exposure to patients presenting with an emerging respiratory threat including coronavirus. The policy indicated it's purpose included prevention of transmission of person to person respiratory pathogens. The policy also identified that all equipment in a patient's room is considered contaminated. Nursing staff will wear proper PPE while cleaning reusable equipment prior to removal from the room. In addition the policy instructed staff to clean and disinfect reusable equipment with an EPA (Environmental Protection Agency)-approved emerging [MEDICAL CONDITION] pathogens product before removing equipment from the resident room. The policy also identified when healthcare workers were in close contact or providing cumulative care for 15 minutes or more, would wear eye protection unless the resident was wearing a cloth or surgical mask. The policy direction of when eye protection was not consistent with current guidance.

Based on observation, interview and record review, the facility failed to ensure expired medications were not available for use for 4 of 23 residents (R28, R30, R35, and R46) reviewed during observations of medication administration and storage. Findings include: During observation on 3/13/19, at 10:01 a.m. in the medication storage drawer in R35's room, a bottle of expired [MEDICATION NAME] dated 2/12/2019, was observed. Trained medication aide (TMA)-A stated she would turn in the expired medication to the clinical manager (CM)-A and indicated she was not aware of a process for checking the dates of the medications in the medication storage drawers. TMA-A reviewed R35's Medication Administration Record [REDACTED]. On 3/14/19, at 10:31 a.m. R28's medication storage drawer was observed with registered nurse (RN)-A present. An open bottle of [MEDICATION NAME] 325 mg tablets, which had expired on 2/21/19, was observed. RN-A stated there was no specific person responsible, or system in place, to check medication storage drawers in the residents' rooms. On 3/14/19, at 10:33 a.m. R30's medication storage drawer was observed with RN-A present. The drawer had an open bottle of latanoprost eye drops opened on 1/28/19, and had expired on 3/13/19. RN-A stated most eye drops expired in 28 days but the latanoprost eye drops were good for 42 days, and verified the medication was expired and available for use in R30's drawer. RN-A verified the orders for R30's lantoprost eye drops were to instill 1 drop in both eyes at bedtime for [MEDICAL CONDITION], and verified the expired eye drops had been given. On 3/14/19, at 3:01 p.m. during a review of R46's medication storage drawer with licensed practical nurse (LPN)-B, revealed [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]) 25 mg tablets which expired on 3/12/19, and was still available for administration. LPN-B verified R46's [MEDICATION NAME][MEDICATION NAME] had expired, and stated she would send it back to the pharmacy. Upon review of R46's MAR indicated [REDACTED]. At 3:15 p.m. LPN-B stated there was not a process in place to look for expired medications in the medication storage drawers in the residents' room. LPN-B stated in the past the night nurses went through the medications and drawers, but indicated at present that process was not being done. During an interview on 3/14/19, at 3:04 p.m. the facility's pharmacy consultant (PC)-A stated each month she checked the medication storage rooms, medication cart, and completed a spot check of medication storage drawers in residents' rooms. PC-A stated she would expect the facility to have a routine in place to check the medication storage drawers for expired medications, and indicated every time staff were in the drawer they should look at the dates. During a follow up interview on 3/14/19, at 3:21 p.m. the expired medications were reviewed with PC-A who stated she felt there would be no adverse effect or change in effectiveness of the medications if administered. PC-A stated it was good nursing practice to check expiration dates on medications to be given prior to administration, and to replace expired medications. PC-A stated she would expect the facility to have a system in place for auditing and inspecting the medications in the resident medication storage drawers. On 3/14/19, at 11:47 a.m. the DON verified there was no current process in place for checking the medications in the medication storage drawers in the residents' rooms. The DON stated she had recently discussed doing medication drawer audits with medication card exchange every two weeks, however the process had yet to been implemented. A policy for medication storage was requested and not received.

Based on observation, interview and document review, the facility failed to ensure proper hand hygiene had been implemented during assistance of personal cares to prevent the spread of infection for 2 of 3 residents (R13, R48) observed during personal cares. Findings include: R48's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R48 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS indicated R48 required extensive assistance of one to two staff with bed mobility, dressing, and toileting, and was totally dependant on two staff with transfers using a full body mechanical lift. R48's Care Area Assessment (CAA) dated 12/6/18, indicated R48 was cognitively intact and required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, and incontinence care. The CAA identified R48 was frequently incontinent of urine, always incontinent of bowel, and indicated R48 had no urge or control of her bowel and bladder function. R48's CAA indicated a limited range of motion, poor trunk control and required extensive assistance from two staff and a full body mechanical lift for transfers. R48's care plan, dated 3/6/19, indicated R48 had a self care deficit related [MEDICAL CONDITION] left sided [MEDICAL CONDITION] and required extensive assistance from one to two staff with dressing, personally hygiene, and transfers. The care plan identified R48 was able to participate with rolling to one side using her unaffected upper arm to pull on an assist bar to turn. On 3/11/19, at 6:58 p.m. R48 was assisted to bed with two staff assist and a full body lift. Nursing assistant (NA)-E remained in the room to provide perineal cares, gathered supplies, applied gloves and opened the residents incontinent brief and stated R48's bottom had been a little red due to loose incontinent stools that day. NA-E stated R48 had another loose stool and cleaned R48's front perineal area using incontinence wipes and tucked the soiled wipes into the soiled brief. With the same soiled gloves used for incontinence cares, NA-E grabbed R48's protective sleeves, left arm, left shoulder to assist R48 to roll onto her right side. NA-E used her right hand to hold R48 on the right side and used her left soiled, gloved hand to help move her left leg and roll R48 more onto the right side. NA-E used incontinence wipes to clean R48's buttocks, tucked the soiled wipes into the brief and rolled the brief up. NA-E picked several pieces of visible stool off of her gloves and wiped them on the dirty brief, and tucked the brief under R48's hip. NA-E grabbed R48 with soiled gloved hands, touching R48's shoulders and legs as she assisted R48 to roll towards her, touching R48's hands, and arms as she turned. NA-E removed the soiled gloves and tucked them into the soiled brief, then removed the brief from underneath R48. Without washing her hands NA-E placed the new clean incontinent brief under R48 and radioed the nurse to request a skin check. R48's reddened perineal, rectal area, and labia were observed with NA-E. Without washing her hands NA-E applied a new pair of gloves and used a washcloth and towel to wash and pat dry R48's perineal area. NA-E stood by the edge of R48 who was lying on the right side and slightly lifted R48's gluteal fold and blew air into her inter gluteal cleft. NA-E stated if R48 was clean and dry the barrier cream would stay better. On 3/11/19, at 7:24 p.m. RN-C entered the room and R48 told RN-C her bottom burned. RN-C stated R48 had some redness by the anus and labia and instructed NA-E to apply barrier cream. NA-E removed her gloves after applying barrier cream to R48's perineal area, and without washing her hands applied lotion to R48's arms, hands, and legs. NA-E then pulled R48's blankets up to cover her, then washed her hands and exited the room. On 3/14/19, at 10:11 a.m. clinical manager (CM)-B stated hand washing and infection control was reviewed with staff annually. CM-B stated she would expect after a soiled brief was removed that staff would wash their hands and apply new gloves before beginning the clean process of applying a new brief. CM-B stated rolling a resident from side to side to provide perineal cares without washing hands or changing gloves would be an infection control concern. On 3/14/19, at 2:21 p.m. infection preventionist (IP)-A stated she would expect that gloves be worn when in contact with body fluids. IP-A stated gloves which are contaminated with feces and urine during incontinent perineal cares should be removed folded in or put in the brief. She stated staff should wash hands and put on clean gloves prior to applying a clean brief or touching the resident or clothing. IP-A stated the clean and dirty cares should be separated completely with hand hygiene in between. IP-A stated if staff were not changing gloves and keeping clean processes from the dirty it could result in contamination and transfer to surfaces in the room and would be an infection control concern. On 3/14/19, at 4:15 p.m. director of nursing (DON) stated incontinent cares, glove use, and hand washing was an infection control concern. The DON stated hand hygiene was used for control of the spread of infection, and would expect the soiled gloves to be removed, and hand hygiene completed before a clean process of applying the clean brief, or touching anything. R13's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R13 had moderately impaired cognition and had [DIAGNOSES REDACTED]. The MDS further indicated R13 required extensive assistance of one staff with bed mobility, transfers, dressing, toileting, grooming and bathing. The MDS identified R13 had occasional urinary incontinence and was on a toileting program. R13's admission Care Area Assessment (CAA) for urinary incontinence dated 10/10/18, indicated R13 required assistance from staff with toileting tasks and completing perineal cares. R13's care plan revised 2/27/19, indicated R13 had urinary incontinence related to urgency and required the use of briefs (incontinence product). The care plan further indicated R13 required assistance from one staff with personal hygiene. On 3/11/19, at 6:50 p.m. nursing assistant (NA)-B assisted R13 with evening cares in the bathroom. NA-B had not completed hand hygiene prior to initiating cares for R13. NA-B provided assistance with removing R13's shirt and washing chest, abdomen and back with ungloved hands. NA-B then proceeded to apply a pajama gown over R13's head and arms. At 6:57 p.m. NA-B assisted R13 to the toilet in the bathroom, utilizing a standing lift. NA-B removed R13's pants and brief to check for urinary incontinence with ungloved hands and commented R13's brief was dry and reapplied the brief. NA-B then proceeded to apply gloves without completing hand hygiene and provided R13 with a toothbrush and toothpaste to complete oral cares. After R13 had completed oral cares, NA-B retrieved oral care supplies and brought them to the sink and rinsed them with water. NA-B proceeded to assist R13 from the toilet, utilizing the standing lift, and provided perineal cares once R13 was in the standing position. At 7:06 p.m. NA-B removed gloves without completing hand hygiene and assisted R13 to the edge of the bed utilizing the standing lift. NA-B removed R13's pants and compression wraps from R13's legs and assisted R13 to the right side in bed. NA-B applied blue boots to R13's feet and placed a pillow behind R13's back and covered R13 with a blanket. At 7:08 p.m. NA-B placed R13's oxygen tubing in R13's nares and turned R13's oxygen concentrator on at two liters. NA-B completed hand hygiene after gathering up supplies and tidying up R13's bedroom. On 3/11/19, at 7:11 p.m. NA-B stated hand hygiene should have been performed prior to applying gloves and after completing direct cares with R13. NA-B confirmed she had not completed hand hygiene prior to applying gloves when completing cares on R13 nor at any time during the course of providing bedtime cares to R13. On 3/14/19, at 2:15 p.m. infection preventionist (IP)-A confirmed hand hygiene should have been completed prior to applying gloves and after providing direct cares to R13. IP-A further stated hand hygiene was important to prevent the spread of infection between residents. On 3/14/19, at 3:48 p.m. director of nursing (DON) confirmed it was expected staff were to complete hand hygiene prior to applying gloves and after proving toileting cares. DON stated hand hygiene was important to prevent the spread of infection for all residents. Review of facility procedure titled Hand Hygiene and Handwashing revised 1/18, indicated the goal was to prevent the spread of infection between residents. The procedure instructed staff to complete hand hygiene prior to having direct contact with residents, after having direct contact with a resident's skin and after removing gloves.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 3 residents (R16) who currently received hospice services. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2018, identified Section M1040: Other Ulcers, Wounds and Skin. The rationale for assessment indicated Skin wounds and [MEDICAL CONDITION] affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatment and dressing changes. Further, the manual provided several coding instructions, including completing question [MEDICAL CONDITION](Second or Third Degree), Do not include first [MEDICAL CONDITION](changes in skin color only). R16's Significant Change in Status Assessment (SCSA) MDS dated [DATE], indicated Section M, Skin Conditions question M1040F identified R16 had no Burn(s) (second or third degree). Review of R16's progress notes on 10/12/18, revealed R16 has a red area on top of her left thigh that appears to be burned. It has a couple of pinpoint spots that are bleeding. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2018, identified Section J1400 Prognosis. The steps for assessment indicated Review the medical record for documentation by the physician that the resident's condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness. The accompanying definition for Hospice Services indicated .Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the documentation is in the medical record. The manual further identified Section O0100K Hospice care, which directed staff to code residents as being in a hospice program for terminally ill persons . R16's quarterly MDS dated [DATE], indicated Section J, Health Conditions question J1400 Prognosis Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) was coded as No. R16's MDS further indicated Section O Special Treatments and Programs question O0100K Hospice care was left unchecked, which indicated R16 was not receiving hospice care. Review of R16's physician notes from 10/11/18, through 2/14/19, revealed the following: -10/11/18, R16 had overall decline and was admitted to hospice care that past weekend. -12/7/18, R16 overall was slowly declining. The physician indicated I still think that she meets criteria for hospice care. -2/14/19, R16 remains on hospice care. On 3/14/19, at 2:26 p.m. MDS coordinator (MDSC)-A confirmed she completed R16's SCSA MDS dated [DATE], and quarterly MDS dated [DATE], following the RAI manual. MDSC-A reviewed R16's SCSA MDS dated [DATE], and confirmed question M1040F identified R16 had no burn. MDSC-A reviewed R16's progress note from 10/12/18, and stated the burn had occurred on 10/12/18, and was due to spilled coffee. MDSC-A reviewed R16's quarterly MDS dated [DATE], question J1400: Prognosis coded no and stated that's an error. MDSC-A then reviewed question O0100K Hospice Care and stated that's an error and confirmed R16 was receiving hospice services during R16's quarterly MDS. On 3/14/19, at 3:36 p.m. director of nursing (DON) indicated MDSC-A was responsible for R16's MDS assessments. The DON stated she expected R16's MDS assessments to be accurate and completed, following the RAI manual. A facility procedure titled MDS 3.0 / Resident Assessment Instrument (RAI) revised 9/17, instructed staff to See also RAI User's Manual The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual for Version 3.0 dated 10/18, was published by the Centers for Medicare & Medicaid Services (CMS). CMS's goal was to disseminate information broadly to facilitate accurate and effective resident assessment practices in long-term care facilities.

Based on interview and document review, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) when two or more areas of change in resident status were noted for 2 of 3 (R13, R16) residents reviewed for decline in health status. Findings include: R16's SCSA MDS dated [DATE], identified R16 had moderately impaired cognition and had [DIAGNOSES REDACTED]. The MDS indicated R16 had no delusions, had other behavioral symptoms not directed toward others on one to three days during the seven day assessment, and did not reject care. The MDS further indicated R16 was frequently incontinent of bladder and bowel, and had no pressure ulcers. R16's quarterly MDS dated [DATE], identified R16 had moderately impaired cognition and had [DIAGNOSES REDACTED]. The MDS indicated R16 had delusions, verbal behavioral symptoms directed towards others on one to three days during the seven day assessment, other behavioral symptoms not directed toward others on one to three days of the seven day assessment, and rejected cares on one to three days during the seven day assessment. The MDS further indicated R16 was always incontinent of bladder and bowel, and had a Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling). Review of the above assessments indicated R16 had an increase in the number of areas where behavioral symptoms were coded as being present, newly coded [DIAGNOSES REDACTED]. On 3/14/19, at 2:26 p.m. MDS coordinator (MDSC)-A confirmed she completed R16's SCSA MDS dated [DATE], and quarterly MDS dated [DATE], following the Resident Assessment Instrument (RAI) manual. MDSC-A stated the interdisciplinary team (IDT) would review residents' status after the quarterly MDS to evaluate if a SCSA MDS would be required. MDSC-A indicated the IDT reviewed R16's quarterly MDS dated [DATE], but had started to look at R16's current status more lately as R16 was declining. MDSC-A reviewed the above MDS information and confirmed R16 was newly coded as having a Stage 3 pressure ulcer and R16's incontinence pattern had changed from frequently incontinent to totally incontinent. On 3/14/19, at 3:36 p.m. director of nursing (DON) indicated MDSC-A was responsible for R16's MDS assessments. The DON stated she expected R16's MDS assessments to be completed following the RAI manual, which included SCSA assessments. R13's admission Minimal Data Set ((MDS) dated [DATE], indicated R13 had moderately impaired cognition and had [DIAGNOSES REDACTED]. The MDS further indicated R13 had a weight of 113 pounds, experienced an unplanned weight loss of five percent or more in the past month, or 10 percent or more in the past six months and had no current pressure ulcers. R13's quarterly MDS dated [DATE], identified R13 had moderately impaired cognition and had [DIAGNOSES REDACTED]. The MDS indicated R13's current weight was 98 pounds, had not experienced an unplanned weight loss of five percent or more in the past month, or 10 percent or more in the past six months. The MDS further indicated R13 had no pressure ulcers present. R13's care plan last reviewed 2/27/19, indicated R13 had unplanned weight loss related to low food intake and an unstageable (anatomic depth of soft tissue damage could not be visualized or palpated in the wound bed) pressure ulcer present on the right heel. Review of R13's Progress Notes from 1/1/19, through 3/14/19, revealed the following: -On 1/18/19, R13 developed a suspected deep tissue injury (unstageable) right heel pressure ulcer. -On 2/17/19, R13's weight was 94.5 which was a five percent decline in one month's time as well as a 10 percent decline over six months. On 3/14/19, at 2:15 p.m. MDS coordinator (MDSC)-A confirmed a SCSA should have been completed within two weeks when two or more areas of decline were noted. The MDSC-A further confirmed R13 had experienced a decline in two areas and a SCSA should have been completed two weeks ago. On 3/14/19, at 3:48 p.m. director of nursing (DON) stated the MDSC-A was responsible for completion of R13's MDS assessments. The DON confirmed a SCSA should have been completed on R13 within two weeks after two areas of decline were noted. A facility procedure titled Minimum Data Set MDS 3.0 (Minimum data Set)/ Resident Assessment Instrument (RAI) revised 9/17, instructed staff to document in the Progress Notes when a significant change had occurred and if it had been an improvement or a decline. The procedure further instructed staff to refer to the RAI manual for further information. The RAI manual dated 10/1/18, included the definition of a significant change as a decline or improvement in a resident's status of which: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions, the decline is not considered self-limiting, 2. Impacts more than one area of the resident's health status: and 3. Requires interdisciplinary review and/or revision of the care plan. The manual further directed when the interdisciplinary team (IDT) determined that a significant change occurred, the nursing home should have documented the initial identification of the significant change in the clinical record. The final decision regarding what constitutes a significant change in status must be based upon the judgment of the IDT. The manual clarified that MDS assessments are not required for minor or temporary variations in resident status.

Based on observation, interview and document review, the facility failed to implement appropriate hand hygiene practices during dressing change of a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer for 1 of 1 resident (R16) who had a recent history of pressure ulcer site infection . Findings include: R16's quarterly MDS dated [DATE], identified R16 had moderately impaired cognition and had [DIAGNOSES REDACTED]. The MDS indicated R16 required total assistance for transfers and extensive assistance for all other ADLs. The MDS further indicated R16 had a Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling). R16's Care Area Assessments (CAA) dated 10/18/18, indicated R16 had a decline in mobility and was dependent upon staff for assistance with all mobility. The CAA further indicated R16 had preventative interventions in place which included special mattress on bed, gel cushion in wheelchair, routine repositioning and toileting in place, legs elevated when at rest for dependent [MEDICAL CONDITION], and hospice services due to terminal prognosis and changes in condition. The CAA identified R16 at risk for skin breakdown with preventative measures in place. R16's signed physician orders [REDACTED]. Skin prep periwound. Apply Santyl (enzymatic [MEDICATION NAME] ointment) to areas of slough. Lightly tuck calcium alginate fluffy rope (highly absorbent dressing for moderate to high exudate wounds) into tunneling and wound base. Cover entire ulcer with absorptive dressing. Secure with tape. Every day shift for stage four pressure injury to coccyx. On 3/13/19, at 8:14 a.m. nursing assistant (NA)-C entered R16's room where R16 was lying in bed with eyes closed. NA-C washed hands and applied gloves, checked R16 incontinence product and stated R16 was incontinent. NA-C gathered perineal wash and incontinence wipes and removed R16's soiled incontinence product. In the back of R16's incontinent product was a collection of brown/red drainage. On R16's mid-buttocks was a blue dressing with the same brown/red drainage on the bottom third of the dressing. The blue dressing was held in place by tape which had released on two of the four sides, and the same brown/red drainage was in the cleft of R16's buttocks. NA-C cleaned the drainage from around R16's blue dressing, and indicated she would call the nurse to change R16's dressing. At 8:28 a.m. registered nurse (RN)-B entered R16's room, gathered the pressure ulcer wound supplies and placed them on top of the over the bed (OTB) table, without cleaning the working surface. RN-B then washed her hands and applied gloves. RN-B indicated she required additional supplies, removed her gloves and immediately exited the room. At 8:33 a.m. RN-B returned to R16's room, applied gloves and approached R16 in the bed. RN-B, assisted by NA-C, turned R16 to the left side-lying position and removed R16's soiled dressing which had an area of approximately two inches of brown/red drainage on the outside of the blue dressing. RN-B threw the dressing into the garbage, removed her gloves, and without sanitizing or completing hand hygiene, applied new gloves. RN-B then cleaned the wound per orders. As RN-B cleaned the tunneling/undermining of the pressure ulcer, her right hand glove, fingers one to three, had a light pink/red thin substance on them. RN-B stated R16 had a Stage 4 pressure ulcer with significant depth at the sacrum. RN-B then threw away the cotton tipped applicator, removed gloves and without completing hand hygiene or sanitizing, applied new gloves. RN-B proceeded to complete R16's dressing change and applied a dressing at the site. At 8:45 a.m. RN-B removed the incontinent product from under R16, gathered the pressure ulcer dressing packaging from the OTB table and threw in garbage, and removed gloves and applied new gloves. RN-B then placed a new incontinence product under R16, removed her gloves, threw them away and without completing hand hygiene or sanitizing, she proceeded to assist NA-C to transfer R16 into a wheelchair at 8:52 a.m. RN-B proceeded to assist R16 to comb her hair, apply hearing aids in both of her ears, and apply a neck bolster for R16. After RN-B removed the soiled linen and garbage from R16's room, she used hand sanitizer to sanitize her hands. On 3/13/19, at 9:03 a.m. RN-B stated she was responsible for the wound care routinely in the facility. RN-B indicated the procedure for hand hygiene and glove use was to wash hands when enter a room, before gloving, washing hands when soiled, washing hands after removing gloves, and before leaving the resident's room. RN-B confirmed she performed hand hygiene when entering R16's room (at 8:28 a.m.) and not again until after leaving the soiled utility room (at 9:03 a.m.). On 3/13/19, at 2:11 p.m. during a follow up interview with RN-B, she stated R16's pressure ulcer was first observed on 11/2/18 and indicated on 1/30/19, R16's pressure ulcer had worsened with signs of infection. She indicated R16's hospice provider had been updated and oral antibiotics were ordered at that time. Review of R16's progress note, dated 1/30/19, revealed R16's pressure ulcer had worsened with significant depth, boggy slough tissue and some tunneling with increased odor and drainage. Redness and inflammation to periwound was also present. Call placed to R16's hospice provider for oral antibiotics due to infection symptoms present to pressure ulcer. On 3/14/19, at 9:37 a.m. nurse practitioner (NP)-A stated hand washing and gloving was important in preventing infection due to cross contamination. NP-A indicated she would expect hand hygiene in between glove use. On 3/14/19, at 9:56 a.m. RN-A stated R16 had a Stage 4 pressure ulcer to the sacrum and staff completed dressing changes twice daily. RN-A indicated the procedure for hand hygiene with R16's pressure ulcer dressing change would be to complete hand hygiene when entering the room before placing gloves, removing the old dressing, then remove gloves and wash hands, new gloves to clean the pressure ulcer, remove gloves and wash hands, apply new gloves and complete wound orders, remove gloves and wash hands. On 3/14/19, at 3:21 p.m. infection preventionist (IP)-A indicated the procedure for hand hygiene with pressure ulcer wound care would be to wash hands, place gloves and remove soiled dressing, remove gloves and wash hands, apply new gloves to clean the wound, remove gloves and wash hands, apply new gloves to place new wound dressing, remove gloves and wash hands. IP-A indicated by not following this procedure, it would increase the risk for infection of the wound by transferring contaminated material which could potentially spread infection. On 3/14/19, at 3:36 p.m. director of nursing (DON) stated her expectation for hand hygiene was to wash hands before new gloves were applied to decrease the risk of spreading infection. DON stated R16 was at risk for infections with the Stage 4 pressure ulcer and was aware RN-B had not followed appropriate hand hygiene practices during the recent dressing change. Review of facility policy titled Wound Dressing Change last revised 10/17, indicated the purpose of the policy was to promote wound healing and help wound remain free of infection. The policy's procedure listed various steps which included 2. Perform beginning five (Assemble equipment, knock on door, identify resident, explain procedure and provide privacy, perform hand hygiene), 4. Put on gloves, 7. Remove soiled dressing and discard in plastic bag, avoiding contact and thus contamination of other surfaces. Remove gloves and discard in same plastic bag. Perform hand hygiene, 10. Put on gloves, 16. Perform ending five (Remove gloves if applicable, perform hand hygiene, leave resident comfortable, place call light within reach, document where/when appropriate). Review of facility policy titled Pressure Ulcers, revised 1/17, indicated A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing.

Based on observation, interview, and document review, the facility failed to ensure the required daily nurse staffing information included current information. This had the potential to affect all of the 54 residents residing in the facility and/or their visitors who may wish to view this information. Findings include: On 3/11/19, at 7:59 p.m. the nurse staff posting was observed in a clear, movable, plastic display which was positioned on a counter directly in front of the facility's front entry door. The nurse staff posting lacked information regarding the evening shifts total number of staff in each category and the actual hours and total hours worked by each category on the evening shift. On 3/12/19, at 4:05 p.m. the nurse staff posting was observed in the same location near the front door. The posting lacked information regarding the evening shifts total number of staff in each category and the actual hours and total hours worked by each category on the evening shift. On 3/14/19, at 10:17 a.m. the nurse staff posting was observed on the counter near the front entrance. The staff posting lacked nurse staff information for the day and evening shifts. At 1:01 p.m., registered nurse (RN)-A was observed to have removed the nurse staff posting from the plastic display, and was completing the day shifts' total number of staff in each category and the actual hours and total hours worked by each category on the day shift . On 3/14/19, at 10:25 a.m. RN-A stated the nurse assigned to Heritage Lane was responsible for completing the daily nursing hours posting for their current shift. RN-A indicated the staff posting needed to be completed by the end of her shift. When interviewed on 3/14/19, at 1:31 p.m. the DON stated she was unsure who was responsible for completing the daily nursing hours posting, but indicated it had been the Heritage Lane RN's duty in the past. The DON verified the current daily nursing hours posting was incomplete and stated she was unaware that the nursing hours posting had not been completed at the start of each shift. The DON stated she had never looked at the posted staff hours to verify the posting had been completed. The DON stated when she had received the daily nursing hours posting from the previous day in her mailbox it had always been completed. The DON indicated they would need to update their process and ensure the daily staffing posting was complete and accurate. A review of daily nursing staffing postings from 2/27/19, through 3/12/19, was reviewed with the DON and she stated the forms placed in her mail box for filing had been complete when she received them. A policy was requested, none received.