Every finding on record at Good Samaritan Society - Bethany

Based on observation and interview, the facility failed to ensure dignity was maintained for 1 of 3 residents (R2) reviewed for dignity related to dressing. Findings Include: R2's admission minimum data set (MDS) dated [DATE], indicated R2 was admitted on [DATE], was able to communicate clearly and understand others, moderate to mild cognitive impairment category, and had the following diagnoses: anxiety, mood disturbance, and dementia. R2's care plan last revised 8/29/25, indicated R2 required an assist of one for dressing related to activity intolerance, Dementia, and impaired balance. The care plan also indicated R2 had enhanced psychosocial well-being related to individualized daily routine and honoring personal preference. During observation on 10/1/25 at 9:40 a.m., the following events occurred:- 9:40 a.m., R2 was observed lying in bed in the highest position, wearing only a brief with his door wide open. - 9:55 a.m. nursing assistant (NA)-A was walking down R2's hall and walked right past R2's room which still had the door wide open leaving R2 exposed only in his brief. - 10:04 a.m. R2 sits up in his bed and begins to say help, help- 10:06 a.m. NA-B is observed walking past R2's room.- 10:12 a.m. an unidentified male staff is observed walking past R2's room.- 10:22 a.m. facility activity aid is observed entering R2's room and placing an activity calendar on his wall. - 10:35 a.m. NA-A walks past R2's room.- 10:38 a.m. NA-B walks past R2's room.- 10:39 a.m. facility social worker (SW)-A walks past R2's room.- 10:49 a.m. registered nurse (RN)-B walks past R2's room.- 10:50 a.m. SW-A walks past R2's room.- 10:52 a.m. RN-B walks past R2's room.- 11:00 a.m. an unidentified facility resident in a wheelchair, wheels past R2's room.- 11:03 a.m. NA-A walks past R2's room.- 11:05 a.m. NA-A walks past R2's room.- 11:10 a.m. NA-B walks past R2's room.- 11:12 a.m. an unidentified female resident walk past R2's room.- 11:18 a.m. an unidentified female enters R2's room and closes the door. On 10/1/25, at 11:18 a.m. NA-C stated she was a nursing assistant from hospice. NA-C stated when she arrived R2's door was wide open and R2 was lying in his bed in only a brief. R2 had no other clothing was on him, nor was there a blanket covering him. NA-C comes typically 3 x a week to provide cares, and this is typical to find R2 like this. On 10/1/25, at 10:23 a.m. during an interview R2 stated he would not want others to see him only in his brief. On 10/1/25, at 10:34 a.m., NA-B stated part of their role is to get residents up and assist them with activities of daily living (ADL), which would include getting the residents dressed. It would be a dignity issue if residents are exposed due to being left in only their brief with the door open. On 10/1/25, at 10:44 a.m. NA-A stated R2 is one of her assigned residents for the day and her shift had started at 6:00 a.m. R2 has not been assisted with any activities of daily living yet this morning, including repositioning, incontinence care, getting out of bed, or dressing. Leaving a resident in only their brief with the door open is a dignity concern and should not happen. On 10/1/25, at 11:48 a.m. director of nursing (DON) stated leaving a resident exposed in only their brief with the door open is a dignity concern. All residents have the right to have privacy and to be treated with dignity. All staff is responsible in ensuring residents are provided care with dignity. The facility Resident Dignity policy last reviewed 12/2024, indicated the facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality. The facility activities of Daily Living policy last reviewed 12/2024, indicated facility staff are 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.

Based on observation, interview and document review failed to provide repositioning and toileting/incontinence cares for 1 of 3 residents (R2) reviewed for activities of daily living (ADL) and who were dependent on staff for ADL's.Findings Include: R2's admission minimum data set (MDS) dated [DATE], indicated R2 was admitted on [DATE], was able to communicate clearly and understand others, was moderate to mild cognitive impairment category, and had the following diagnoses: anxiety, mood disturbance, and dementia. R2's Braden Scale for Predicting Pressure Sore Risk dated 9/23/25 had a score of 14 indicating R2 is a moderate risk for skin breakdown. The intervention guide included frequent turning with a planned schedule and managing moisture. R2's care plan last revised 8/29/25, indicated R2 has bowel and blader incontinence related to Alzheimer's Disease. The care plan indicated R2 will remain free from skin breakdown due to incontinence and brief use. RS was to be checked for incontinence every two hours. The care plan also indicted R2 has potential for pressure ulcer development related to disease process and immobility. Staff are to turn and reposition R2 in bed every 2 hours. During observation on 10/1/25 at 9:40 a.m., the following events occurred:- 9:40 a.m., R2 was observed lying in bed in the highest position, wearing only a brief with his door wide open. - 9:55 a.m. nursing assistant (NA)-A was walking down R2's hall and walked right past R2's room which still had the door wide open leaving R2 exposed only in his brief. - 10:04 a.m. R2 sits up in his bed and begins to say help, help- 10:06 a.m. NA-B is observed walking past R2s room.- 10:35 a.m. NA-A walks past R2's room.- 10:38 a.m. NA-B walks past R2's room.- 10:49 a.m. registered nurse (RN)-B walks past R2's room.- 10:50 a.m. SW-A walks past R2's room.- 10:52 a.m. RN-B walks past R2's room.- 11:03 a.m. NA-A walks past R2's room.- 11:05 a.m. NA-A walks past R2's room.- 11:10 a.m. NA-B walks past R2's room.- 11:8 a.m. an unidentified female enters R2's room and closes the door.On 10/1/25, at 11:18 a.m. NA-C stated she was a nursing assistant from hospice. NA-C stated when she arrived R2's door was wide open and R2 was lying in his bed in only a brief. R2 had no other clothing was on him, nor was there a blanket covering him. NA-C stated R2's brief was saturated with urine and feces. The brief was so saturated with urine that the sheet R2 was lying on was also soaked in urine. NA-C comes typically 3 x a week to provide cares, and this is common to find R2 like this. On 10/1/25, at 10:23 a.m. during an interview R2 stated he would not want others to see him only in his brief. On 10/1/25, at 10:34 a.m., NA-B stated part of their role is to get residents up and assist them with activities of daily living (ADL), which would include getting the residents dressed. It would be a dignity issue if residents are exposed due to being left in only their brief with the door open. She has not provided any care for R2 so far this shift. On 10/1/25, at 10:44 a.m. NA-A stated R2 is one of her assigned residents for the day and her shift had started at 6:00 a.m. R2 has not been assisted with any activities of daily living yet this morning, including repositioning, incontinence care, getting out of bed, or dressing. R2 is to have his brief checked and changed at least every 2 hours. On 10/1/25, at 11:48 a.m. director of nursing (DON) stated leaving a resident in their brief for greater than 2 hours and not repositioning if needed increases the risk for skin breakdown. Staff are to be following the individual residents care plan and if it directs staff to check and change a resident and reposition every 2 hours then staff are to be doing so. R2 should have been assisted with incontinence and repositioned at a minimum every 2 hours. The facility Bowel and Bladder: Evaluation Assessment, Toileting Program policy last reviewed 5/2025, indicated based on the resident's comprehensive assessment, the location will ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much normal bowel or bladder functioning as possible. The facility Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy last reviewed 4/2025, indicated residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool UDA, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility, and observation of the resident's skin over a period of time. The facility activities of Daily Living policy last reviewed 12/2024, indicated facility staff are 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 facility Resident Dignity policy last reviewed 12/2024, indicated the facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality.

Based on observation, interview and document review, the facility failed to ensure acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or recorded to ensure efficacy of as-needed (PRN) psychotropic medication for 2 of 3 residents (R1, R3) reviewed for unnecessary medications. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included depression, anxiety, and R1 was cognitively intact. Identified R1 did not exhibit any behaviors. R1's care plan revised on 2/12/25, indicated R1 had a potential mood problem related to depression and anxiety disorder and directed staff to provide encouragement/assistance/support to maintain as much independent and control as possible, for relaxation: keep on classical music, essential oils (lavender), keeping clean (hand washing), lotion, and foot massage. Further, R1's care plan revised 2/11/25, indicated R1 had a behavioral symptom related to anxiety and depression and would frequently refuse baths, medications, and daily cares and directed staff to attempt non-pharmacological interventions which included 1-1 visits, classical music, massage, repositioning as needed, and ask if R1 needed toileting or to be changed. R1's Medication Administration Record (MAR) for February 2025, indicated R1 had a physician order for Lorazepam (an anti-anxiety medication) 0.125 milliliters (ml) every 4 hours as needed for anxiety related to anxiety disorder. Further, MAR revealed R1 received Lorazepam twice on 2/9/25, and once on 2/10/25. R1's progress notes revealed the following: -On 2/9/25 at 6:48 a.m., Lorazepam was administered at 7:49 a.m. Lorazepam and was documented as effective. -On 2/9/25 at 4:05 p.m., R1 was calling out constantly at beginning of shift for help and pain medications and staff helped her and nurse gave some Ativan (Lorazepam) to help with calling out and anxiety, due to not being able to have pain medication yet. This was successful and resident was able to rest for a while. Resident was calling out in sleep throughout shift. There had been times she was calling out and not remembering she can't stand or use toileting. -On 2/9/25 at 5:50 p.m., Lorazepam was administered per resident request. At 10:42 p.m., Lorazepam was documented as effective. -On 2/10/25 at 12:30 p.m., Lorazepam was administered and at 3:33 a.m. Lorazepam effectiveness was documented as unknown. -On 2/10/25 at 9:36 a.m., R1's daughter called and very mad about R1 being full of bowel last night. Daughter said she was snowed when she was there and unable to converse with her. Does not want Ativan (Lorazepam) given again unless heard from her or consult her. R1's progress notes lacked anxiety symptoms R1 was exhibiting at the time the PRN Lorazepam was administered, as well as lacked evidence of non-pharmacological interventions attempted prior to administration. R3's admission MDS dated [DATE], indicated R3 had diagnoses of anxiety disorder, depression, and R1 had moderately impaired cognition. Further, R1 did not exhibit any behaviors. R3's care plan revised on 2/4/25, indicated R1 had orders for Ativan (Lorazepam), however R3's care plan lacked non-pharmacological interventions for staff to implement when R3 would be exhibiting symptoms of agitation and/or anxiety. Further, R3's care plan identified R1 had depression related to admission to facility with hospice services and R3's care plan directed staff to implement brief visits to her room when she was awake. R3's MAR for February 2025, indicated R3 had a physician order for Lorazepam 0.5 mg (milligrams) every 6 hours as needed for agitation or anxiety related to anxiety disorder. Further, MAR revealed R1 had received Lorazepam one time on 2/2/25, twice on 2/3/25, and once on 2/11/25. R3's Progress Notes revealed the following: -On 2/2/25 at 7:34 a.m., Lorazepam was administered and at 7:41 a.m. Lorazepam was documented as ineffective due to R3 vomiting. -On 2/2/25 at 2:34 p.m., Resident uncomfortable at start of shift. Resident stated I haven't slept for two nights. I am just so worried about death. She remains restless and worried. Writer administered PRN Lorazepam 0.5 mg; patient regurgitates pill. -On 2/3/25 at 9:14 a.m., Lorazepam was administered and at 10:16 a.m., Lorazepam was documented as effective. -On 2/3/25 at 3:17 p.m., Resident was crawling out of bed this morning. PRN Lorazepam was given when resident was agitated. -On 2/3/25 at 3:30 p.m., Lorazepam was administered and at 8:08 p.m., Lorazepam was documented as effective. -On 2/11/25 at 9:57 a.m., Lorazepam was administered and at 12:59 p.m., Lorazepam was documented as effective. R3's progress notes lacked agitation or anxiety symptoms R3 was exhibiting at the time the PRN Lorazepam was administered, as well as lacked evidence of non-pharmacological interventions attempted prior to administration. During an interview on 2/13/25 at 11:09 a.m., family member (FM)-A stated R1 was just prescribed Lorazepam recently by hospice and FM-A stated R1 was given a few doses in less than 24-hour period without the facility attempting to meet R1's needs and/or non-pharmacological interventions prior to the administration. During an observation on 2/13/25 at 1:51 p.m., R1 was observed lying in bed: appeared to be comfortable and content and no anxiety symptoms were noted. During an observation on 2/14/25 at 9:17 a.m., R3 was observed to be lying in bed, appeared to be sleeping with her eyes closed, appeared comfortable and no agitation or anxiety symptoms noted. During an interview on 2/14/15 at 11:42 a.m., nursing assistant (NA)-A stated she had not observed any side effects from medications for R1 and stated R1 had anxiety related to family not visiting often and staff were directed to offer her a cold pack for distraction, oils, and music. Further, NA-A stated R3 had not exhibited any agitation or anxiety symptoms that she had observed. During an interview on 2/14/25 at 12:06 p.m., registered nurse (RN)-A stated R1 exhibited behaviors of calling out when she was needing something rather than using the call light. RN-A stated R1 had an order for PRN Lorazepam and RN-A had administered the PRN medication due to resident calling out and non-pharmacological interventions of pain control, repositioning, and bed bath were unsuccessful. RN-A stated after the administration of PRN Lorazepam, R1 appeared comfortable and was not anxious. Further, RN-A stated if a resident was on hospice, staff would be expected to ensure the resident was comfortable, and attempt non-pharmacological interventions, which would be listed and identified in the resident's care plan, prior to administered a PRN psychotropic medication. In addition, RN-A stated the facility's EMR system lacked a place for staff to document interventions that were attempted. During an interview On 2/14/25 at 1:39 p.m., RN-E stated R3 was on hospice and RN-E had administered R3's PRN Lorazepam 2 or 3 times due to either family's request or R3 yelling out and hallucinating about something that was not real. RN-E stated R3 responded well to the PRN Lorazepam and would calm down and appear comfortable. Further, RN-E stated staff were expected to try least restrictive methods for addressing anxiety or agitation, such as non-pharmacological interventions of snacks, television, music, or calling family, prior to administering a PRN. RN-E stated staff did not chart in the resident's EMR non-pharmacological interventions that were attempted. During an interview on 2/14/25 at 2:36 p.m., RN-B stated R1 had an order for PRN Lorazepam that RN-B had administered one time due to R1 being anxious and RN-B attempted to comfort R1 by sitting with her and visiting and offering to call R1's family prior to administering the PRN. RN-B stated R3 also had a PRN order for Lorazepam but had never administered the medication for R3 before. Further, RN-B stated staff were expected to attempt non-pharmacological interventions prior to administering a PRN psychotropic medication and document in the EMR what was attempted and what was effective or not effective. On 2/14/25 at 3:08 p.m., RN-C stated she would observe the resident and if a resident appeared to be anxious, restless, or uncomfortable she would administer a PRN psychotropic medication. RN-C stated she would attempt deep breathing exercise with the resident prior to administering the PRN psychotropic, as that would be an intervention for nursing, but no other non-pharmacological intervention would be attempted. RN-C stated R3 was disoriented and would often attempt to crawl out of her bed. Further, RN-C stated she had administered R3's PRN Lorazepam due to R3 yelling and attempting to crawl out of bed and appeared to be very anxious but confirmed she had not attempted any non-pharmacological interventions prior to administration of the PRN. On 2/14/25 at 3:33 p.m., RN-D stated staff would be expected to attempt non-pharmacological interventions such as snack, distraction, calling family, activities, or a walk prior to administering a PRN psychotropic medication. RN-D stated person-centered interventions would be listed in each resident's care plan in the EMR for staff to reference. Further, RN-D stated staff would be expected to document in the resident's EMR regarding the symptoms the resident was exhibiting and what interventions were attempted prior to administering the PRN medication. In addition, RN-D confirmed R1 and R3's EMR lacked evidence of the signs the residents were exhibiting and what non-pharmacological interventions were attempted prior to administering their PRN psychotropic medication and R3's care plan lacked interventions related to R3's agitation and anxiety. On 2/14/25 at 4:13 p.m., director of nursing (DON) stated staff would be expected to chart in the resident's EMR non-pharmacological interventions such as redirection, snacks, toileting, etc., prior to giving a PRN psychotropic medication. DON stated staff should also document the reasoning or rationale for the PRN psychotropic medication use and what signs the resident was exhibiting at the time of the administration and then the effectiveness. DON stated each resident would have person-centered non-pharmacological interventions in their care plan for staff to reference. Review of facility policy titled Medication: Administration Including Scheduling and Medication Aides revised 5/21/24, indicated when PRN medications were administered, staff were directed to evaluate and document the efficacy of the medication. However, the policy lacked staff direction on documenting reasoning for administering a PRN psychotropic medication as well as attempting and documenting non-pharmacological interventions prior to the PRN administration.

Based on observation, interview and document review, the facility failed to initiate appropriate transmission based precautions according to The Centers for Disease Control (CDC) for 2 of 3 residents (R11, R224) reviewed for transmission based precautions, failed to track and trend potential/actual infections for 6 of 6 residents (R11, R35, R36, R24, R1, R224) identified to have potential/actual infections; and failed to conduct COVID-19 testing per CDC guidelines for 5 of 5 residents (R11, R35, R36, R24, R15) who were identified to have COVID-19 signs and symptoms. This had the potential to affect all 68 residents residing in the facility. Findings include: Transmission-Based Precautions: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 was [AGE] years old, cognitively intact and diagnoses included acute prostatitis (a disorder of the prostate gland associated with inflammation), urinary tract infection (UTI), COVID-19, and Type 2 diabetes. R11's care plan revised 7/24/24, identified R11 had an activities of daily living (ADL) self-care performance deficit related to weakness exhibited by inability to complete at baseline level. Staff were directed to provide extensive assistance of 1-2 for all care activities. However, the care plan failed to identify R11's COVID-19 diagnosis and/or need for transmission-based precautions. During an observation on 10/14/24 at 12:41 p.m., R11's room door was shut, and 3 signs were taped to the outside of the door: Enhanced Barrier Precautions, Contact Precautions and Droplet Precautions. In the hallway, to the left of R11's closed room door was a 3-drawer bedside stand next to the door that contained disinfectant wipes, N95 masks, gloves, surgical masks, and face shields. There was a facility laundry bin next to the bedside stand containing reusable gowns and was covered with a folded flat sheet. On the right of R11's closed room door was a covered, red biohazard linen container and a trash container. - At 1:13 p.m., nursing assistant (NA)-A approached R11's door and donned gloves, gown and continued to wear the same surgical mask. NA-A did not don eye protection and entered R11's door. - At 1:32 p.m., NA-A exited R11's room and doffed her gown, gloves and mask throwing the items in the uncovered trash. NA-A used hand sanitizer and donned a clean surgical mask. During an interview on 10/14/24 at 1:35 p.m., NA-A stated R11 had COVID. Staff needed to wear a gown, gloves, and a mask when they went into R11's room. The N95 and/or eye protection wasn't needed but was extra. NA-A stated you could wear it if you wanted to be extra careful. NA-A had never been directed to wear eye protection in a COVID positive room during her employment at the facility. During an interview on 10/14/24 at 1:45 p.m., registered nurse (RN)-C was observed exiting R11's room and doffed a gown, gloves, mask, and face shield. RN-C cleaned the face shield with a disinfectant wipe, put the soiled gown in the biohazard linen bin and threw the soiled gloves in the uncovered trash. RN-C stated the biohazard linen bin and trash container should be on the inside of R11's door, but there was no room for it. If it was on the inside of the door it would have to be at least 6 feet inside the room and that defeated the purpose of wearing personal protective equipment (PPE) inside R11's room. Staff were expected to wear a gown, gloves, N95 mask and eye protection whenever entering R11's door. During an interview on 10/15/24 at 12:38 p.m., the director of nursing (DON) stated R11 was placed into Droplet Precautions when he tested positive for COVID-19 on 10/7/24. The signage on the door tells staff what PPE was required. The DON stated no audits had been conducted to determine if staff were following guidance during the facility's COVID-19 outbreak. Because R11 had a suprapubic catheter, R11 was in Enhanced Barrier Precautions prior to getting ill. Having multiple signs on the door would be confusing for staff because which one should staff follow. However, the DON stated staff have been educated what PPE was required for COVID-19 and were expected to use it as directed. Additionally, all biohazard linen bins and trash bins should have been in the R11's room for staff to doff while in the room. There was room in the resident rooms for them. This was important to prevent the potential spread of infection between other residents, staff, and visitors. The Centers for Disease Control and Prevention (CDC) Appendix A - Type and Duration of Precautions Recommended for Selected Infections and Conditions of the CDC Guideline for Isolation Precautions updated 9/20/24, identified severe acute respiratory syndrome (SARS) (COVID-19) required droplet precautions for the duration of illness plus 10 days after resolution of fever, provided respiratory symptoms were absent or improving. R224's 5-day MDS dated [DATE], identified R224 was [AGE] years old and had intact cognition. R224's diagnoses included bacteremia, weakness, acute kidney injury and hypertension. R224 used an indwelling catheter and an antibiotic. The MDS failed to identify R224 had an infection with a multi drug resistant organism (MDRO). R224's Urinary Incontinence and Indwelling Catheter care area assessment (CAA) dated 9/29/24, identified R224 had an indwelling catheter, a urinary tract infection (UTI) and benign prostatic hyperplasia (BPH) (an enlarged prostate). The CAA further identified urinary incontinence and indwelling catheter use would not be addressed on R224's care plan. R224's care plan dated 10/14/24, identified R224 required Enhanced Barrier Precautions (EBP) related to R224's indwelling urinary catheter. Staff were directed to don a gown and gloves when performed high contact care activities including dressing, changing linens, repositioning, check and changing, device care and/or use, and wound care. Staff were directed to doff gown and gloves inside R224's room and perform hand hygiene. R224's physician orders identified R224's indwelling urinary catheter was placed on 9/11/24. R224's progress note dated 10/7/24 at 4:05 p.m., identified R224 had been hospitalized due to hypotension related hypovolemia (a condition in which the volume of blood plasma is too low. This causes a rapid heart beat, weak pulse, confusion, and loss of consciousness ); acute kidney injury superimposed on chronic kidney disease, history of Methicillin-resistant staph aureus (MRSA). R224's hospital discharge summary dated 9/26/24, identified R224 discharge diagnoses included MRSA sepsis and early septic shock due to complicated UTI and MRSA complicated UTI. R224 was to continue vancomycin (an antibiotic) for 4 weeks. During an interview on 10/15/24 at 8:29 a.m., R224's indwelling catheter was in a cloth cover lying on the floor of his room. R224 stated nursing was good about cleaning his indwelling catheter, but R224 never saw factility staff wear a gown like the hospital nurses did. During an observation on 10/15/24 at 11:03 a.m., R224's door was open with an Enhanced Barrier Precautions sign taped to the door.Registered nurse (RN)-H exited R224's room and doffed a gown and gloves. RN-H placed the gown in the red, covered biohazard linen container in the hallway and placed the soiled gloves in the uncovered trash. RN-H did not doff her surgical mask. - At 11:05 a.m., RN-H went approximately 50 feet down the hallway, around the corner to the nurses' station and donned gown and gloves on the way back to R224's room and entered. No PPE supplies were near R224's room. - At 11:10 a.m., RN-I approached R224's door, looked around then walked away asking staff why there were no gowns for R224. RN-I went to the nurses' station and donned a gown and gloves while returning to R224's room. RN-I stated over half the resident rooms required Enhanced Barrier Precautions due to surgical wounds. Because of this, there were not enough carts to go around and the nurses' placed gowns at the nurses' station to be centrally located. - At 11:15 a.m., RN-H exited R224's room with the soiled gown bunched up in her hand and placed the gown in the biohazard linen bin. - At 11:17 a.m., RN-I exited R224's room with a gown bunched up in her hand and placed the soiled gown in the biohazard bin. RN-I did not use hand sanitizer and went to her office with a visitor. During an interview on 10/15/24 at 11:19 a.m., RN-H stated R224 was on precautions due to having an indwelling catheter. RN-H stated she did not know what an MDRO was, but confirmed R224 did have MRSA. Well, R224 should have been on Contact Precautions but what's the difference. Staff were already wearing gowns, gloves, and masks. RN-H then stated she guessed it would depend on the infection, where the infection was and what the precautions should be. However, staff probably weren't even aware R224 had an infection. RN-H stated she was unaware R224 had an infection until asked and a Contact Precautions sign on R224's door may have triggered her to review his chart earlier to see what R224 had and what R224 required to keep other residents, staff, and visitors safe. During an interview on 10/15/24 at 11:45 a.m., laundry aide (LA)-A was observed donning a gown and gloves while walking down the hall from the nurses' station. LA-A stated a huge stack of gowns were delivered in a facility laundry bin on 10/14/24. LA-A had put one bin in each hallway and stated there just was not enough carts for each room, so she had tried to keep them centrally located. During an interview on 10/15/24 at 12:04 p.m., RN-J stated nursing staff moved the gowns to the nurses' station that morning because staff didn't want to run all over to get gowns. During an interview on 10/15/24 at 12:12 p.m., the director of nursing (DON) stated she was not aware R224 had MRSA. R224 did have MRSA in his diagnosis list. However, diagnoses are entered by health information management (HIM) who only input the diagnosis code. Nursing is not alerted to high risk/high alert diagnoses by HIM. The admitting nurse reviewed a potential resident's hospital medical record then would send an email with information. The DON stated the initial review did not identify R224 required Enhanced Barrier Precautions on his initial admission. However, R224 was re-hospitalized and returned on 10/7/24 and Enhanced Barrier Precautions were then implemented. However, the DON stated R224's hospital discharge summary identified R224 had an active MRSA UTI and should have been placed into Contact Precautions when he was admitted to the facility on [DATE]. It was important for the staff to know the differences in the different type of transmission-based precautions and Enhanced Barrier Precautions to prevent the chance to spread infection not only between the residents but the staff as well. During an interview with the DON and RN-I on 10/15/24 at 12:57 p.m., RN-I stated she didn't review resident's charts for MDRO unless she had time to do so. If a resident was admitted on an antibiotic, it would prompt the implementation of Clinical Monitoring- Infections/Suspected Infections V10 form in the resident assessments. If there was an identified history of MDRO, Enhanced Barrier Precautions were implemented as well. After admission, if an infection was diagnosed , any nurse could implement the Clinical Monitoring- Infections/Suspected Infections V10 form as well. R224, RN-I stated more than likely RN-I was aware of the MRSA infection but could not verify that. If RN-I wasn't told by admission nurse, RN-I wouldn't go diving for that. RN-I stated she implemented Enhanced Barrier Precautions for R224 on 10/14/24 due to R224's indwelling catheter but R224 should have been in Contact Precautions since his admission on 9/26/24 because he had an active MRSA infection to prevent the spread of infection. Additionally, the soiled bins should be on the inside of the room. The DON stated they clearly had a process problem and needed to educate their staff. The Centers for Disease Control and Prevention (CDC) Appendix A - Type and Duration of Precautions Recommended for Selected Infections and Conditions of the CDC Guideline for Isolation Precautions updated 9/20/24, identified Multidrug-Resistant organisms (e.g. MRSA) required contact precautions recommended in settings with evidence of ongoing transmission, acute care settings with increased risk for transmission or wounds that cannot be contained by dressings. The facility policy Multidrug-Resistant Organisms, MRSA, VRE, CRE and ESBL, All Service Lines revised 4/12/24, identified residents colonized with a CDC-targeted [NAME] and select epidemiologically important MDROs at the facilities discretion are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility. Because [NAME] colonization is prolonged and follow-up testing to determine clearance may yield false negatives, CDC does not recommend routine retesting of residents with a history of colonization or infection with a targeted MDRO. Use contact precautions when the resident is infected or colonized with an MDRO and secretions and excretions are unable to be contained. This includes: - Residents with multidrug-resistant organism infected or colonized wounds that cannot be covered fully by dressings or who have drainage that cannot be contained by dressings. Residents with fecal or urinary carriage of multidrug-resistant organisms whose urine or stool cannot be contained in incontinent products, urine bags or ostomy bags. - Residents with a tracheostomy who have colonized or infected respiratory tracts and large amounts of uncontained respiratory secretions. - Residents who have been linked to transmission of multidrug-resistant organisms. The policy further directed for infections (e.g., C. difficile, norovirus, scabies) and other conditions where Contact Precautions is recommended see Appendix A - Type and Duration of Precautions Recommended for Selected Infections and Conditions of the CDC Guideline for Isolation Precautions. Surveillance: The Infection Control Report - September 2024, identified the infection rates for the facility, an analysis of the data collected, resident name, room, source, site, comments and dates of infection and a color-coded map. R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 was [AGE] years old, cognitively intact and had diagnoses that included acute prostatitis (a disorder of the prostate gland associated with inflammation), urinary tract infection (UTI), COVID-19, and Type 2 diabetes. R11's progress note dated 9/26/24 at 8:30 p.m., identified R11 reported that he was feeling feverish. Temperature 98.3 degrees F. However, R11's medical record failed to identify if R11 was placed in transmission-based precautions until a confirmatory test was collected. The facility's Infection Control Report - September 2024 failed to identify R11's symptoms. R35's annual MDS dated [DATE], identified R35 was [AGE] years old and had diagnoses that included chronic kidney disease and Type 2 diabetes. R35's progress note dated 9/26/24 at 1:48 p.m., identified R36 slept in bed throughout shift. R35 reported feeling run down and achy. The facility's Infection Control Report - September 2024 failed to identify R35's potential infection symptoms. R36's quarterly MDS dated [DATE], identified R36 was [AGE] years old and had diagnoses that included hypertension, heart disease, dysphagia, and congestive heart failure. R36's progress note date 10/2/24 at 1:38 p.m., identified R36 was withdrawn and not eating or drinking much. R36's face was flushed, dry and ruddy. R36 was slow to respond when spoken to. R36's temperature was 98 degrees F. The facility's Infection Control Report - September 2024 failed to identify R35's potential infection symptoms. R24's quarterly MDS dated [DATE], identified R24 was [AGE] years old and had diagnoses that included hypertension and Type 2 diabetes. R24's progress note dated 10/16/24 at 4:33 p.m., identified R24 was warm to touch, diaphoretic (excessive sweating). R24's vitals were as follows: blood pressure 118/73, temperature 98.0 degrees F, blood sugar 129, respirations 18, heartrate 74. R24 complained of increased discomfort to bilateral legs after therapy. Tylenol 650 mg administered x 1. The facility's Infection Control Report - September 2024 failed to identify R24's potential infection symptoms. R15's quarterly MDS dated [DATE], identified R15 was [AGE] years old and had diagnoses that included diabetes insipidus and hypertension. R15's progress note dated 10/15/24 at 4:24 p.m., identified R15's skin felt very warm, but her temp was 97.7 degrees F. R15 was frowning and upset when staff approached her. R15 was less irritable when not touched. R15 she pinched and scratched nurse's forearms when nurse attempted to take temperature. The facility's Infection Control Report - September 2024 failed to identify R15's potential infection symptoms. During an interview on 10/17/24 at 10:30 a.m., the DON stated she was responsible for the facility's infection control program. The DON used two processes for the facility's infection surveillance. The first process was the infection dashboard in the facility's electronic medical record system. The nurses entered resident infection data into Clinical Monitoring- Infections/Suspected Infections V10 form in the resident assessments. Every morning that information was pulled into the infection log. The DON stated the facility's infection surveillance log was dependent on nursing to enter the data or it would not be reflected on the surveillance reports. When reviewing the infection control dashboard in the electronic medical record system, each individual resident would need to be reviewed. For an example, when a resident tested positive for COVID-19, Clinical Monitoring- Infections/Suspected Infections V10 form was completed every shift until the resident's illness resolved. If the form was not completed, the data would not be pulled into the log. The second process was a paper log. The DON was taking information from the dashboard and entered the data in the paper log. The DON stated she did not know how to print any reports from the dashboard, and this eased tracking and trending. The DON stated resident illness needed to be tracked to determine trends in the facility and for the prevention of possible spread of infection. A facility policy regarding infection control surveillance was requested but not received. A copy of the facility's dashboard surveillance was requested but not received. A copy of the facility's Infection Control Report - October 2024 was requested but not received. COVID-19 Testing: The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 3/18/24, identified the decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. - If using NAAT (molecular) (A Nucleic Acid Amplification Test is a type of viral diagnostic test for SARS-CoV-2, the virus that causes COVID-19. NAATs detect genetic material (nucleic acids). NAATs for SARS-CoV-2 specifically identify the RNA (ribonucleic acid) sequences that comprise the genetic material of the virus), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT. - If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. - If a patient suspected of having SARS-CoV-2 infection is never tested , the decision to discontinue Transmission-Based Precautions can be made based on time from symptom onset as described in the Isolation section below. Ultimately, clinical judgment and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions. R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 was [AGE] years old, cognitively intact and had diagnoses that included acute prostatitis (a disorder of the prostate gland associated with inflammation), urinary tract infection (UTI), COVID-19, and Type 2 diabetes. R11's progress note dated 9/26/24 at 8:30 p.m., identified R11 reported that he was feeling feverish. Temperature 98.3 degrees F. COVID test repeated with negative results. R11's medical record failed to identify if R11 had a confirmatory COVID-19 test and/or if/when R11 had been placed in isolation. R35's annual MDS dated [DATE], identified R35 was [AGE] years old and had diagnoses that included chronic kidney disease and Type 2 diabetes. R35's progress note dated 9/26/24 at 1:48 p.m., identified R36 slept in bed throughout shift. R35 reported feeling run down and achy. Covid swab was negative. R35's medical record failed to identify if R35 had a confirmatory COVID-19 test and/or if/when R35 had been placed in isolation. R36's quarterly MDS dated [DATE], identified R36 was [AGE] years old and had diagnoses that included hypertension, heart disease, dysphagia, and congestive heart failure. R36's progress note date 10/2/24 at 1:38 p.m., identified R36 was withdrawn and not eating or drinking much. R36's face was flushed, dry and ruddy. R36 was slow to respond when spoken to. R36's temperature was 98 degrees F. R36's Covid Swab test was negative. R36's medical record failed to identify if R36 had a confirmatory COVID-19 test and/or if/when R36 had been placed in isolation. R24's quarterly MDS dated [DATE], identified R24 was [AGE] years old and had diagnoses that included hypertension and Type 2 diabetes. R24's progress note dated 10/16/24 at 4:33 p.m., identified R24 was warm to touch, diaphoretic (excessive sweating). R24's vitals were as follows: blood pressure 118/73, temperature 98.0 degrees F, blood sugar 129, respirations 18, heartrate 74. Rapid Covid screen negative. R24 complained of increased discomfort to bilateral legs after therapy. Tylenol 650 mg administered x 1. R24's medical record failed to identify if R24 had a confirmatory COVID-19 test and/or if/when R24 had been placed in isolation. R15's quarterly MDS dated [DATE], identified R15 was [AGE] years old and had diagnoses that included diabetes insipidus and hypertension. R15's progress note dated 10/15/24 at 4:24 p.m., identified R15's skin felt very warm, but her temp was 97.7 degrees F. R15 was frowning and upset when staff approached her. R15 was less irritable when not touched. R15 she pinched and scratched nurse's forearms when nurse attempted to take temperature. R15 was tested for COVID-19 and R15's antigen test was negative. R15's medical record failed to identify if R15 had a confirmatory COVID-19 test and/or if/when R15 had been placed in isolation. During an interview on 10/17/24 at 10:30 a.m., the DON stated she tracked positive COVID-19 residents and staff. Also, a list of residents and staff tested due to outbreak testing was available. However, residents who were tested due to symptoms were only tracked by the progress note in each resident's medical record and were not tracked. Additionally, symptomatic residents who had an antigen test negative result were not placed into transmission-based precautions and/or a confirmatory test collected. The facility policy Emerging Threats - Acute Respiratory Syndromes Coronavirus (COVID) revised 4/19/24, identified residents were monitored for signs and symptoms of COVID-19 per routine. practice. Residents with symptoms of COVID-19 will be isolated and tested immediately. Removal from isolation will follow current CDC guidelines.

Based on observation, interview, and document review, the facility failed to ensure a urinary catheter bag was placed in a privacy bag to maintain dignity for 1 of 3 residents (R25) reviewed for dignity. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25's cognition was severely impaired and diagnoses included Huntington's disease (a rare genetic disorder that affects the brain and causes movement, cognitive and mental health problems). R25 used an indwelling urinary catheter due to having a neurogenic bladder (when the relationship between the nervous system and bladder function was disrupted by injury or disease). R25's care plan revised 2/12/24, identified R25 had an indwelling catheter due to urinary outlet obstruction and neurogenic bladder. The care plan directed catheter care was performed by nursing assistants twice daily with cares and as needed. A non-adhesive secure anchor on leg. However, the care plan failed to direct staff to keep the catheter bag in a privacy bag to maintain dignity. During an observation on 10/14/24 at 5:20 p.m., R25 was lying in bed on his back with a fleece blanket covering R25 to his chest. The room lights were on and R25 was watching a tv program. R25's catheter bed bag was hanging from the bed frame and clearly visible from the hallway. The catheter bag was not in a privacy bag. During an observation on 10/15/24 at 2:18 p.m., R25 was lying in bed in his room. R25's catheter bed bag was hanging from the bed frame and was visible from the hallway. -At 3:16 p.m., activity aide (AA)-A visited with R25 at his bedside but did not cover R25's catheter bed bag before leaving. - At 3:59 p.m., R25's catheter bed bag continued to hang from R25's bed frame without a privacy bag and was clearly visible from the hallway. During an observation on 10/16/24 at 7:14 a.m., R25 was lying in bed with his catheter bed bag hanging from the bed frame without a privacy bag and was clearly visible from the hallway. - At 8:19 a.m., R25 was assisted into his wheelchair and registered nurse (RN)-C was observed placing R25's catheter bed bag in a privacy bag underneath R25's wheelchair. During an observation on 10/16/24 at 1:12 p.m., R25 was lying in bed with his catheter bed bag hanging from the bed frame. The catheter bed bag was clearly visible from the hallway. During an interview on 10/16/24 at 3:06 p.m., nursing assistant (NA)-D stated it was normal to hang the catheter bed bag from the bed frame on the hallway side of the bed because the catheter tubing was anchored to R25's right leg. NA-D stated she did put R25's catheter bed bag in a privacy bag when he was in his wheelchair but did not even consider it when he was in bed. NA-D stated a privacy bag was important to maintain R25's dignity and privacy. [NAME] needs to know about R25 catheter except R25. During an interview on 10/16/24 at 3:20 p.m., RN-C stated yea, staff hung R25's catheter bed bag from the bed frame without a privacy bag. That's just what we do. A privacy bag was available on the wheelchair, but it was not easily removed from the wheelchair because it was tied on. The facility used to use a different supply company that provided covers, but they no longer used that brand. The facility did not have privacy bags available for the resident's bed. RN-C stated it was much better because the catheter bed bag was always covered to maintain privacy and dignity and now anyone walking past R25's door could see R25's catheter. During an interview on 10/17/24 at 9:07 a.m., RN-B stated a catheter bed bag was supposed to have a privacy bag. Staff knew better. Staff had never been directed to place the catheter bed bag on one side of the bed or the other but had been directed to keep the catheter bed bag always covered because it was a privacy and dignity issue but also an infection prevention issue as well. Staff needed to allow as much dignity as possible because it was nobody's business that R25 had a catheter. During an interview on 10/17/24 at 10:53 a.m., the director of nursing stated all residents should have a privacy bag for their catheter bed bag on their bed and wheelchair. It was important to protect every resident's dignity and privacy as a person. The facility policy Resident Dignity revised 11/16/23, identified the facility would promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality.

Based on interview and document review, the facility failed ensure clinical monitoring was completed and documented for 2 of 3 residents (R37, R39) reviewed with recent COVID-19 infections. Findings include: R37's significant change Minimum Data Set (MDS) dated [DATE], identified R37 was [AGE] years old, had a severe cognitive impairment and diagnoses included chronic respiratory failure, atrial fibrillation, and chronic kidney disease. R37's care plan revised 9/26/24, identified R37 had a respiratory infection: COVID-19 and directed staff to observe for symptoms and monitor/document/report new or worsening signs/symptoms of COVID-19. R37's Order Summary Report dated 10/1/24 - 10/13/24, directed staff to obtain clinical monitoring - infection/suspected infection two times a day for 12 days. R37's progress from 9/26/24 through 10/4/24, identified R37 was positive for COVID-19 on 9/26/24 and R37's urine was collected for a urinary analysis and culture on 9/30/24. However, the progress notes failed to identify any monitoring of vitals, conditions, or symptoms during R37's COVID-19 infection and/or why the urine sample was collected. R37's Clinical Monitoring - Infection/Suspected Infection V10 dated 10/4/24 at 2:16 p.m., identified R37 was monitored for a respiratory and urinary infection, weight 189.8 pounds, temperature 97.0 degrees Fahrenheit (F), pulse 70, respirations 20, blood pressure 130/70 and oxygen saturations 98% on room air. R37 was alert and oriented t person and place and exhibited agitation and impaired decision making. R37 had a cough, lung sounds were clear and normal quality. Interventions included monitor/observe and fluids/hydration. However, R37's medical record failed to identify any clinical monitoring starting 9/26/24 through 10/3/24. R37's vitals record failed to identify vitals collected 9/26/24 though 10/4/24. R39's significant change MDS dated [DATE], identified R39 was [AGE] years old with diagnoses that included chronic obstructive pulmonary disease (COPD) (a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), chronic kidney disease atherosclerotic heart disease, and atrial fibrillation. R39's care plan revised 7/23/24, identified R39 had an altered respiratory status/difficulty breathing related to COPD. Staff were directed to monitor for signs of respiratory distress and report to health care provider as needed: increased respirations; decreased pulse oximetry; increased heart rate (tachycardia); restlessness, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage; skin color changes to blue/grey. Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. However, the care plan did not direct staff to obtain vitals and/or where/how to document nor how frequently to do so, especially in times of illness. R39's progress notes 9/28/24 through 9/30/24, identified R39 tested positive for COVID-19 on 9/28/24, was hoarse and felt pukey. However, the progress notes failed to identify any monitoring of vitals, conditions, or symptoms during R39's COVID-19 infection. R39's vitals record failed to identify vitals collected 9/28/24 through 9/30/24. R39's medical record failed to identify Clinical Monitoring - Infection/Suspected Infection V10 completed for R39 from 9/28/24 through 9/30/24. During an interview on 10/16/24 at 3:14 p.m., registered nurse (RN)-C stated when a resident had COVID-19, RN-C would get vitals and, at least, lung sounds every shift and that's documented in the Clinical Monitoring - Infection/Suspected Infection V10 in the resident's assessment tab. During an interview on 10/16/24 at 3:59 p.m., RN-F stated, when a resident was ill, but especially COVID-19, RN-F would get vitals every shift and assess the resident for changes. RN-F would document this in the progress notes. RN-F stated she was unaware of the Clinical Monitoring - Infection/Suspected Infection V10 the assessment tab and had never used it. During a telephone interview on 10/16/24 at 7:42 p.m., nursing assistant (NA)-E stated, when a resident showed a possible sign or symptom of COVID-19, she notified the nurse on the unit and then would obtain a set of vitals for the nurse. NA-E would encourage the resident to stay in his/her room until a test was collected. After that, staff needed to be aware of a resident's condition, were they showing signs of COVID-19 and report that to the nurse. During a telephone interview on 10/16/24 at 7:43 p.m., RN-A stated when a resident started to show symptoms of illness, staff collected an COVID-19 antigen test and, if positive, the resident would be placed into transmission-based precautions that sort of thing. Clinical monitoring of the resident depended on symptoms. If the resident was having respiratory issues, nursing staff would listen to lung sounds and clinical monitoring documentation would be triggered in the resident's medical record. Implementation of clinical monitoring depended on the nurse on duty that shift. If it was a seasoned nurse, the unit nurse on duty would implement clinical monitoring. RN-E stated she did work 9/28/24 and 9/29/24. RN-A was aware of positive COVID-19 residents in the facility but did not recall personally assessing residents for illness and/or implementing clinical monitoring documentation in the residents' medical records. During an interview on 10/17/24 at 8:54 a.m., RN-F stated, when a resident was symptomatic for respiratory illness, an antigen COVID-19 test, and vitals were collected to determine if the resident had a fever and/or something else going on. RN-F then would document those findings in the vitals tab of the resident's medical record. After that, vitals would be collected and documented in the vitals tab every shift or more often depending on the resident's condition. RN-F stated she has never implemented the clinical monitoring form in the assessment tab nor put an order into direct staff to assess the resident every shift. During an interview on 10/17/24 at 9:06 a.m., RN-B stated residents symptomatic for respiratory illness, staff were expected to evaluate the resident at least twice a day: lung sounds, vitals, etc. Night shift could also evaluate the resident depending on condition. Staff were directed to do this by implementing the Clinical Monitoring- Infections/Suspected Infections V10 form in the resident's assessments because that provided for the facility's infection control program. During weekend hours, nursing was expected to implement the Clinical Monitoring- Infections/Suspected Infections V10 form and, on Monday, RN-B would ensure this had been implemented. If not, RN-B would implement at that time. During a telephone interview on 10/17/24 at 10:00 a.m., RN-G stated, when a resident was showing symptoms of respiratory illness, the resident was first tested for COVID-19 with an antigen test and vitals were collected. After this, vitals and the resident's condition would be documented in a nursing progress note. This is what was routinely done, but how often really depended on how sick the resident was. RN-G stated R37 was fine on 9/28/24 and 9/29/24. RN-G did not collect vitals and/or assess R37 on 9/28/24 and/or 9/29/24 because R37 wouldn't stay in his room and he kept coming out and screaming at me. During an interview on 10/17/24 at 10:34 a.m., the director of nursing (DON) stated it was very disappointing to not find nursing assessments twice daily for R37 or R39 from 9/26/24 to 10/4/24. The DON expected staff to collect vitals and do a nursing assessment of any ill resident every shift while not feeling well. Any nurse can initiate the Clinical Monitoring- Infections/Suspected Infections V10 form in the resident's medical record. Additionally, the DON expected the unit manager to ensure it was implemented as well; this included the weekend nursing managers. This was the facility infection control process, and it allowed communication between staff. During an interview on 10/17/24 at 11:53 a.m., the administrator stated she expected staff to follow the facility's policies, procedures and/or processes and to also communicate with each other to keep the residents, staff, and visitors safe. The facility policy Emerging Threats - Acute Respiratory Syndromes Coronavirus (COVID) revised 4/19/24, identified residents were monitored for signs and symptoms of COVID-19 per routine practice. However, the policy failed to direct staff on frequency of monitoring and/or how monitoring should be documented. A policy regarding illness monitoring and documentation was requested but not received.

Based on interview and document review, the facility failed to ensure an appropriate provider's order and rational for use were obtained for an indwelling urinary catheter for 1 of 3 residents (R30) who were reviewed for catheter care. Findings include: R30's significant change Minimum Data Set (MDS) dated [DATE] identified no cognitive impairment and identified R30 was always continent of bladder. R30's urinary/catheter assessment dated [DATE], identified resident was admitted to the unit with indwelling urinary catheter in place. The rational provided was the resident was on hospice. R30's provider's orders dated 9/30/24, identified an order for Foley Cath (catheter) Care dated 9/30/24. The provider's orders lacked any order for insertion or use of a Foley Cath, or the rational for the use of it. During observation on 10/16/24 at 12:25 p.m., R30 sat up in her bed and ate lunch. R30's Foley catheter bag was hanging on the side of her bed. During interview on 10/16/24 at 1:24 p.m., R30 stated she did not know why the catheter was placed. She could not think of a reason why she would need it. During an interview on 10/17/24 at 10:33 a.m., licensed practical nurse (LPN)-A stated R30 was admitted to the unit with the catheter already in place and could not find an order or reason it was placed. During an interview on 10/17/24 at 10:48 a.m., registered nurse (RN)-D stated if a resident needed a catheter there should be a provider's order and a rational for why a catheter was needed. This information would be important as it would drive the plan of care for the catheter. R30's medical record lacked any documentation of why the catheter was inserted. The R30's medical record did not contain an order for the catheter or the rational for why it was needed. During an interview on 10/17/24 at 11:02 a.m., the director of nursing (DON) stated it is the expectation that every resident who had a catheter in place would have had a provider's order for the catheter and the rational for why the catheter was needed. It would not be appropriate for a catheter to be placed just because a resident was on hospice. The facility's Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation and Specimen-LTC policy dated 7/30/24, identified a resident is not to be catheterized unless the clinical condition demonstrates that catheterization is medically necessary and is not used solely for nurse/physician convenience. Also identified Catheters will be utilized only with a physician's order.

Based on observation, interview and document review, the facility failed to ensure staff provided care according to standards of practice and per physician orders for gastrostomy tube feeding for 1 of 1 resident (R15) reviewed for tube feedings. Finding include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of traumatic brain dysfunction, hemiplegia (one-sided paralysis or weakness), and seizure disorder. R15 was dependent on staff for bed mobility and had a gastrostomy tube (g-tube) for feeding. R15's Order summary report signed by the primary Physician on 8/28/24, identified an order for enteral feeding two times a day with Nutren 1.5 at 75 milliliters per hour (ml/hr., to run for 16 hours per 24-hour period. Elevate head of bed (HOB) greater than 30 degrees with tube feeding running, Start at 1700 (5:00 p.m.), end at 0900, for a total of 1200ml/day. Reset count to zero with new bag. R15's care plan dated 5/15/17, identified R15 required a tube feeding related to the inability to swallow. Staff were directed to elevate the head of the bed at least 30 degrees during and 30-40 minutes after tube feeding was stopped. During an observation on 10/16/24 at 8:56 a.m., nursing assistant (NA)-A and NA-B put on gowns and gloves and went to R15's room. R15 tube feeding was running at 75 (ml/hr.). R15's head of the bed was at a 30-degree angle. Staff lowered the head of the bed to do morning hygiene care. NA-A washed R15's face, hands, underarms, and breast, and performed perineal care. NA-A put on new gloves and applied a cream under R15's bilateral breasts. NA-A put a new gown on R15. The head of the bed was raised after the morning activities of daily living (ADL's) were completed around 9:20 a.m. During an interview on 10/15/24 at 9:36 a.m., NA-A stated R15 had a g-tube and R15 did not have negative effects when the head of the bed was lowered for care. Licensed nurses do not stop feeding when ADLs are being performed. During an interview on 10/16/24 at 9:36 a.m., NA-B stated nursing assistants cannot stop the g-tube feedings, and only a licensed nurse can stop a feeding. Lowering R15's head of the bed when doing care had not bothered R15. During an interview on 10/16/24 at 12:26 p.m., registered nurse (RN)-C stated the nursing assistants put the head of the bed down long enough to do care. The nursing assistant had never asked for the tube feeding to be stopped as it had not been an issue. On nights the tube feeding would be paused as R15 has vomited in the past on the night shift. During an interview on 10/16/24 at 2:00 p.m., RN-B stated staff would try to keep the head of the bed up. The nursing assistants did not ask the licensed nurses to put the feeding on hold. Between 2:00 a.m. and 4:00 a.m., R15 has vomited in the morning, and then the licensed staff will turn off the tube feeding and run it later during the day. During an interview on 10/16/24 at 3:18 p.m., the director of nursing (DON) stated it would be her expectation that the head of the would be elevated if R15 could tolerate it. If staff needed to perform extensive care, then the feeding could be stopped. The facility Tube-Gastrostomy or Jejunostomy-Enteral Feeding, Care, Placement or Removal policy dated 12/4/24, directed staff to raise the head of the bed 30-45 degrees during feeding and keep elevated for 30-60 minutes after feeding to prevent regurgitation or aspiration unless contraindicated per physician's order.

Based on observation, interview, and document review, the facility failed to ensure a discontinued presciption topical antifungal medication was detroyed and not administered; and failed to ensure only authorizied staff administered prescribed adminstered prescribed creams for 1 of 1 resident (R15) observed to have nursing assistants apply prescribtion creams during cares without an order. Finding include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had severe cognitive impairment and diagnoses of traumatic brain dysfunction, non-Alzheimer's dementia, hemiplegia (one-sided paralysis or weakness), and seizure disorder. R15 was dependent on staff for all activities of daily living (ADLs) such as personal hygiene, oral hygiene, bed mobility, and dressing. R15's Order summary report signed by the primary Physician on [DATE], identified Nystatin External Cream 1000 unit/gram (nystatin topical) and appply to under breast topically two times a day for rash related to rash and other nonspecific skin eruption until resolved; however the ordered was discontinued on [DATE]. R15's electronic medical administration record (EMAR) for [DATE] identified no administration for nystatin cream. During an observation on [DATE] at 8:56 a.m., nursing assistant (NA)-A and NA-B donned gowns and gloves and went to R15's room. NA-A and NA-B washed R15's face, underarms, under breasts, and performed perineal care. NA-A changed gloves and picked up a white tube of cream from the bedside table. Tube had a label from the pharmacy, NA-A squeezed out the last of the cream onto a gloved finger. NA-A applied the cream under both breasts. NA-A reported the cream being applied was Nystatin which goes under R15 breasts. The Nystatin tube was placed back on the side table. The pharmacy label was old, and the writing was worn off in some areas and unable to read the date it was filled and the date it expired. R15's name with the name of the medication nystatin was visible. During an interview on [DATE] at 12:26 p.m., registered nurse (RN)-C verified that R15 did not have a current order for nystatin cream. During an interview on [DATE] at 2:00 p.m., RN -B verified R15 did not have a current order for nystatin and the nursing assistants do not apply prescription creams. Prescription creams should be locked in the medication cart. During an interview on [DATE] at 3:18 p.m. director of nursing (DON) stated creams with a prescription like nystatin should be kept in the medication cart unless the resident had an order to keep them at the bedside. The DON's expected there would be an order for the medication being applied. The facility Medication: Administration including Scheduling and Medication Aids policy dated [DATE], directed the following: A provider's order for any medication is required and must include: diagnosis, name of medication, dose, route, frequency and STOP order if indicated. If the medication order is not legible or does not include the items listed above, the provider is notified for clarification prior to administration of medications. Medications are administered to the resident according to the Six Rights. All employees passing medications are familiar with action and adverse reactions of medications Perform three checks: read the label on the medication container and compare with the MAR when removing the container from the supply drawer, Do not touch the medication with ungloved hands. Do not leave medications at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration.

Based on interview and document review, the facility failed to create an individualized discharge care plan, to develop interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition from the facility to the post-discharge setting, for 1 of 3 residents (R3) reviewed. Findings include: R3's quarterly Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses of heart failure, respiratory failure, and was cognitively intact. Further, assessment indicated there was an active discharge plan in place for R3 to return to the community and a referral had been made to the Local Contact Agency. R3's care plan dated 3/28/24, lacked evidence of a comprehensive discharge plan to address the goals for care, treatment preferences, identify needs that must be addressed before discharge, interest in and any referrals made to the local contact agency, as well as identifying post-discharge needs such as nursing, therapy services, medical equipment or modifications to the home, or activities of daily living (ADLs) assistance. On 6/12/24 at 1:25 p.m., social services (SS)-A stated discharge planning started the day the resident was admitted to the facility and the planning continues to be in progress during the resident's stay at that facility. Further, SS-A stated she does not add discharge planning into the resident's care plan but keeps the information in my brain. On 6/12/24 at 4:27 p.m., attempt to interview registered nurse (RN)-E was unsuccessful. On 6/12/24 at 4:38 p.m., director of nursing (DON) stated SS would be expected to develop a comprehensive discharge plan in the resident's care plan that would include the resident's wishes, desires, plan, and goals. DON confirmed R3 did not have a discharge plan in her care plan. On 6/12/24 at approximately 4:38 p.m., a policy related to discharge planning was requested, but facility failed to provide a copy.

Based on observation, interview, and document review the facility failed to ensure physician treatment orders were followed for 1 of 3 (R2) residents reviewed for pressure ulcers. Findings include: R2's quarterly Minimal Data Set (MDS) dated [DATE], indicated R2 had diagnoses of pressure ulcer of left buttock, pressure ulcer of the sacral region and was cognitively intact. R2's Wound Data Collection dated 6/6/24, indicated the wound was in the peri-anal area which originally started as a moisture associate skin injury. The wound measure 5 centimeters (cm) long by 5 cm width and depth carried due to tunneling at 3:00 measuring 3 cm and tunneling between 12:00 and 1:00 measured 9.5 cm. Per wound care nurse at the hospital there was necrotic tissue on the distal area of the wound. R2's Order Summary Report dated 6/6/24, indicated wound care instructions for R2's sacral wound included: cleanse wound with saline and pat dry, wet-dry dressing changes utilizing sterile saline, ensure tail for easy removal, and apply ABD and secure with Medipore tape. On 6/12/24 at 10:44 a.m., registered nurse (RN)-A knocks and enters R2's room to completed R2's wound care. RN-A was observed to wash her hands in the bathroom, she then applied an isolation gown and gloves. RN-A stated she removed the old dressing from the wound on R1's bottom placed into the garbage can along with her soiled gloves. RN-A washed hands in the bathroom and applied clean gloves. RN-A then cleaned the wound with saline and gauze pad and RN-A stated the wound looked like it had improved with no signs of infection, no necrotic tissue noted, and no odor. RN-A removed soiled gloves into the garbage can and washed hands in the bathroom and applied clean gloves. RN-A soaks gauze with sterile saline and packs the gauze into the wound using a sterile cotton swab and left a tail of gauze out. RN-A removes gloves into the garbage and washed hands in the bathroom and applied clean gloves. RN-A soaks cotton swab with sterile saline and cleans around the wound on the tissue. RN-A again removed soiled gloves and washes hands in the bathroom. RN-A stated R1's wound care was complete and assisted the nursing assistant with getting R1's incontinent brief back on. Further, when questioned about R2's treatment order RN-A went to R2's wound supply drawer and stated staff do not cover the wound or use tape, leave as is with the gauze. At 11:03 a.m., RN-A entered RN-D's office and questioned about the pad and tape over the gauze. On 6/12/24 at 11:03 a.m., RN-D confirmed R2's wound needed to be covered with an ABD pad (abdominal pad used as a secondary dressing over wounds that discharge fluid). RN-D knocks on R2's door and explained RN-D needed to cover the wound, which R2 was compliant. RN-D applied gown and gloves and places the ABD pad over the wound and applied tape to both sides. RN-D stated the wound was open and we are trying to protect it. RN-D stated the wound had improved. On 6/12/24 at 11:16 a.m. RN-A stated she typically did not work on R2's unit but staff were expected to review the resident's treatment administration record (TAR) for the wound treatment order. RN-A confirmed at the start of R2's wound treatment when she removed the old gauze from R2's wound, the wound was not covered with an ABD pad or taped. Further, RN-A stated R2 could have removed the tape himself and RN-A did not recall any concerns regarding R2's wound or him removing the dressing through report from previous shift. On 6/12/24 at 11:28 a.m., R2 denied removing any dressing from his wound, and did not remove any gauze or tape. R2 confirmed the previous nurse did not cover or put tape on the wound from the previous day. On 6/12/24 at 4:38 p.m., director of nursing (DON) indicated staff were expected to read each resident's wound treatment order each time they do the treatment. DON stated if the order was complex the staff could write the order on a piece of paper to bring with them while they complete the treatment or if there were multiple steps to the treatment order the nurse could print the order as well. On 6/12/24 at approximately 4:38 p.m., a pressure wound policy and treatment order policy was requested, however facility failed to provide a copy.

Based on interview and document review the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed, who was cognitively impaired and arrived at an outpatient appointment unaccompanied and was noted to be disorientated and exhibiting aggressive behaviors. Findings include: R1's quarterly Minimal data set dated [DATE], indicated R1 had a diagnosis of Alzheimer's Disease and had severely impaired cognition. Further, R1's MDS revealed R1 exhibited physical and verbal behavioral symptoms. R1's care plan as of 6/11/24, indicated R1 had impaired cognition or impaired though process related to Alzheimer's disease and was exhibited by forgetfulness, confusion and often refusals of care. R1 required assistance by staff for all activities of daily living (ADLs) which included bed mobility, dressing, toileting, and transfers. Further, R1's care plan revealed R1 would exhibit behaviors of resistive to cares and screaming at others and directed staff to provide consistency in care and maintain consistency in timing of ALDs, caregivers, and routine. R1's progress note dated 6/5/24, indicated a nurse from the orthopedics clinic called the facility and stated R1 was not orientated to person and could not verify was he was. After the facility verified R1's identity, R1's vitals were obtained, and his blood pressure was noted to be 80/50 and had a temperature of 99.5. Orthopedic nurse stated R1 was being transferred to the emergency department for further assessment. On 6/12/24 at 8:40 a.m., R1 was observed sitting in his wheelchair in his room. R1 could not recall going to an orthopedic appointment at the clinic independently. On 6/12/24 at 11:16 a.m., registered nurse (RN)-A stated R1 had impaired cognition exhibited by confusion and would get ornery and would swing, grab, and hit at staff. RN-A stated R1 would not be able to make his own medical decisions and his daughters would go with to all appointments. Further, RN-A stated if a resident had impaired cognition, confused, and were not able to be accompanied by either a relative or friend to an appointment the resident would not go to the appointment and facility would find alternative ways such as if the outpatient service could be provided at the facility. On 6/12/24 at 11:33 a.m., nursing assistant (NA)-A stated R1 was confused, couldn't understand staff, and have a fluent conversation with staff as his answers would not be appropriate to questions. NA-A stated due to R1's cognition and behaviors such as hitting and kicking, R1 would not be safe to independently go out into the community by himself. On 6/12/24 at 11:51 a.m. family member (FM)-A stated R1's had a scheduled orthopedic appointment for an injection to R1's knee and the nurse from the clinic called FM-A and reported R1 was confused and could not recall his last name, date of birth, or the reason for his appointment. FM-A stated the facility staff were aware family would not be there as FM-A was not in the state and FM-A was told staff were not able to attend the appointment with R1, but FM-A was unsure why. FM-A confirmed R1 had went to the appointment unaccompanied and without an advocate there for him. On 6/12/24 at 1:06 p.m., RN-B stated R1 was frequently confused, and short-term memory and safety awareness were impaired. RN-B stated R1 had two daughters who were Power of Attorney and would assist in any medical decisions. Further, RN-B stated R1 would not be safe to be unaccompanied out in the community as he could injury himself or someone else if something set him off due to R1 exhibiting some physical aggression. RN-B confirmed on 6/5/24, R1 had an appointment and was being transported by Medi-van (transportation service company) unaccompanied. RN-B stated as a floor nurse they assist with getting the resident ready for the appointment and get any paperwork ready that may be needed, but the floor nurse would not have been the one to schedule the appointment, transportation, or contacting a family or friend to assist the resident with the appointment as that would be role of the health information staff. On 6/12/24 at 1:22 p.m., health information (HI)-A stated she would schedule all appointments for the residents on the unit R1 was currently residing on. HI-A stated she was not responsible for assessing and determining if a resident was safe and appropriate to attend an appointment unaccompanied. HI-A stated she would contact the first emergency contact listed for the resident and if a resident would go unaccompanied HI-A stated she would consult with the nurse manager on the unit especially if the resident exhibits behaviors. Further, HI-A stated R1 had an orthopedic appointment that was scheduled, and HI-A spoke with one of R1's daughters, unsure which one, in person and had asked if the daughter was accompanying R1 to the appointment which daughter stated she was not. HI-A did not consult with R1's nurse manager about the appointment. On 6/12/24 at 2:20 p.m., RN-C stated facility process for resident appointments was the HI staff would notify family and ask if transportation would need to be arranged and give the resident a green slip of paper that would have detailed information regarding the appointment including time, where, and what they will have done. RN-C stated if the resident was cognitively impaired, and family was unable to accompany the resident to the appointment the facility would attempt to arrange the appointment for when family would be available to accompany the resident or if the clinic was familiar with the resident and their doctor was aware of the resident then the resident would be able to go to the appointment unaccompanied. Further, RN-C stated R1 had some confusion, safety awareness was non-existent, and R1 had exhibited physically aggressive behaviors towards staff. RN-C stated FM-A made an orthopedic appointment for R1 and had asked the facility to set up transportation for R1. RN-C stated the facility was not aware family was not accompanying R1 to the appointment and RN-C had not contacted the clinic to inform them about R1's behaviors. In addition, RN-C stated R1 will no longer be able to go to appointment unaccompanied as the facility learned from the mistakes. On 6/12/24, at 4:15 p.m., director of nursing (DON) stated if a resident could advocate and was alert and orientated, they would be able to go to an appointment unaccompanied, however, if the resident was not then they would require to be accompanied by family or friend. If a family or friend was unable to accompany a cognitively impaired resident, then the facility would attempt to arrange services for in house at the facility. DON stated R1 had impaired cognition and had a diagnosis of dementia, and R1's behaviors had been challenging and violent at times. Further, DON stated she was aware R1 had went to an orthopedic appointment unaccompanied by family but was not aware until the nurse from the clinic called the facility to speak with the nurse on his unit. DON stated if HI staff were aware family was not accompanying R1 then the appointment should have been canceled or in urgent situations DON stated she would accompany a resident. In addition, DON stated she had not investigated the incident and has not discussed where the facility's process had failed with HI staff or R1's nurse manager. On 6/12/24, at approximately 4:15 p.m., policy regarding appointments and/or supervision was requested but not provided.

Based on observation, interview, and document review, the facility failed to follow physician orders for a non-pressure related wound, to promote healing, for 1 of 3 residents (R1) who were reviewed. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], identified R1 had diagnoses which included heart failure, diabetes mellitus and depression. R1 was cognitively intact and did not exhibit behaviors of rejection of care. Further, R1's MDS identified no skin concerns. R1's care plan dated 1/3/24, revealed R1 required staff assistance for activities of daily living such as ambulation, transfers, dressing, hygiene, and toileting. R1 exhibited behavior symptom of scratching to point of bleeding related to possible anxiety. R1 had actual skin impairment due to picking of skin and lichen simplex chronicus (skin condition caused by chronic itching and scratching). R1's Skin Observation dated 12/2/23, revealed a new wound noted to right upper posterior inner thigh. Wound was noted to be an upside-down triangle shape measuring approximately 2 centimeters (cm) by 3 cm and 0.5 cm deep. R1's wound was cleansed and Mepilex was applied. R1's Order Summary Report dated 1/3/24, indicated R1 had an order for posterior buttock wounds and scrotal wounds directing staff to cleanse wounds with wound cleanser and pat dry, wipe away loose debris, sprinkle with stoma powder, brush off excess, then apply Calmoseptine ointment or Triad hydrophilic wound filler to cover the areas with reapplication 2 times per day with AM and at bedtime cares. This order had a start date of 1/2/24. R1's Nursing Home note from wound care doctor dated 12/28/23, indicated R1 was being seen for follow-up regarding skin picking wounds. R1 was hospitalized from 12/23/23 until 12/28/23 related to orthostatic hypotension. During hospitalization R1 was also noted to have a new wound on his buttocks right and scrotum. On 1/4/24 at 10:24 a.m., licensed practical nurse (LPN)-A was observed to wash hands in R1's bathroom and apply gloves. R1 was standing in the middle of his room and holding onto his walker. LPN-A did not offer R1 to lay on his bed to complete wound treatment. LPN-A kneeling on the floor stated she noted no open sores on R1's buttocks or scrotum. LPN-A stated she was cleansing the general area with water, dried the area, and applied Calmoseptine ointment. Again, LPN-A stated there were no open wounds or redness noted. R1 stated it hurts and stated there were open sores in the area. LPN-A removed gloves and assisted R1 with pulling up his pants. LPN-A exited R1's room. LPN-A failed to use wound cleanser or stoma powder during treatment as ordered. On 1/4/24 at 10:34 a.m., LPN-A stated R1 required assistance with all ADLs and was incontinent of bowel and bladder. LPN-A stated she was aware of R1's wounds on buttocks and scrotum following his recent hospitalization . Further, LPN-A again confirmed she did not see any open wounds while completing R1's wounds treatment but was doing the treatment as preventative in the general area where the wounds were noted in the treatment order. LPN-A stated she would complete R1's wound treatment while he was standing because R1 won't lay in bed. In addition, LPN-A stated she had completed R1's treatment following his return from his hospitalization and prior to observation on 1/4/24 but had not seen a wound on his bottom. LPN-A also stated she did not use wound cleanser, as ordered, due to it not being available. On 1/4/24 at 11:40 a.m., registered nurse (RN)-A stated R1 was noted to have moisture associated friction wounds on the right and left buttocks. RN-A stated R1 was compliant with laying in bed for wound treatments to be completed and incontinence cares to be completed thoroughly, otherwise he prefers to be in his recliner. RN-A stated licensed nurses were expected to complete all wound care while R1 was lying in bed because when R1 was standing his skin would fold down and staff would not be able to see the wounds. In addition, RN-A stated bariatric resident would be at risk for wounds, especially if they were not mobile and had skin folds, staff would be expected to be thoroughly assessing those folds. On 1/4/24 at 12:49 p.m., RN-A assists R1 to his bed and assists with lifting R1's feet up onto the bed and directs R1 to roll onto his right side. When asked to describe the wounds, RN-A stated the wound on R1's left buttock appeared to be friction related, red/pink wound bed, small amount of drainage, and an area that appears to be scabbed over. RN-A stated on R1's right buttock there was a Mepilex bandage, which she removed, and described the wound as weird edged, V-shaped, with healed areas, minimal discharge and wound bed appeared pink. Further, RN-A stated wounds appeared to be clean, and no signs of worsening or infection noted, as well as confirmed there was no ointment or powder noted on wounds which would indicate LPN-A did not appropriately complete R1's treatment as ordered. RN-A confirmed wound cleanser was available and staff would be expected to ensure all supplies are in the resident's room per physician order in treatment, prior to starting the treatment. In addition, RN-A stated staff would be expected to have R1 lay in bed on his right side while performing wound care treatment. On 1/4/24 at 2:19 p.m., director of nursing (DON) stated bariatric residents are at high risk for skin concerns and staff would be expected to be assessing, cleaning, and drying high risk areas such as skin folds. DON staff would be expected to have R1 lay in bed to at least complete his wound care and do a real thorough assessment. Further, DON stated if a licensed nurse was completing a treatment order and did not observe a wound or couldn't find the wound the treatment was for the licensed nurse would be expected to find their supervisor or nurse manager to seek clarification. In addition, if the licensed nurse completing treatment could not locate a wound supply that was part of the order, the nurse would be expected to check the supply closet and notify supervisor if there were any supplies needed. Review of facility policy titled Wound Dressing Change revised 12/4/23, directed staff to check physician's order and position resident for comfort and to accommodate dressing change. Purpose of policy and procedure was to promote wound healing and help wound remain free of infection.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease and Prevention (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 3 of 5 residents (R32, R36, R49) reviewed for pneumococcal immunizations. Findings include: R32's significant change Minimum Data Set (MDS) dated [DATE], identified R32 was [AGE] years old and had diagnoses that included hypertension, Alzheimer's disease, and Parkinson's disease. R32's Minnesota Immunization Report dated 12/20/23, identified R32 had not received a pneumococcal immunization. R32's electronic health record (EHR) failed to identify if R32 had received pneumococcal immunization education and/or a declination. R36's quarterly MDS dated [DATE], identified R36 was [AGE] years old and had diagnoses that included a history of traumatic brain injury, seizer disorder, and transient cerebral ischaemic attack (temporary blockage of blood flow to the brain). R36's Minnesota Immunization Report dated 12/20/23, identified R36 had received a pneumococcal polysaccharide vaccine (PPSV23) on 5/16/17. R32's electronic health record (EHR) failed to identify if R32 had received pneumococcal immunization booster education and/or a declination. R49's significant change MDS dated [DATE], identified R49 was [AGE] years old and had diagnoses that included renal insufficiency and diabetes. R49's Minnesota Immunization Report dated 12/20/23, identified R49 had not received a pneumococcal immunization. R32's electronic health record (EHR) failed to identify if R49 had received pneumococcal immunization education and/or a declination. During an interview with the director of nursing (DON) on 12/19/23 at 3:07 p.m., the DON stated resident immunizations were reviewed upon admission. The Health Information Management (HIM) reviewed the resident's immunization record and entered the information into the resident's EHR. The unit manager would then review the resident's EHR to determine what immunizations were recommended to be administered. The resident would receive education and the administration or declination would be documented in the resident's EHR. The DON was aware new pneumococcal immunization booster recommendations were available and had created a spreadsheet to begin the process, but had not completed a review of resident immunization records nor offered pneumococcal immunizations. The facility policy Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19 revised 9/21/23, identified resident would be provided the opportunity to receive immunizations as they fit into the resident's healthcare goals. Upon admission, each resident and/or resident representative would receive the Vaccination Information Statement (VIS) for influenza and pneumococcal vaccines. If the resident and/or resident representative chose not to be vaccinated after discussion of benefits, staff were to document declination.

Based on observation, interview and document review, the facility failed to use the ordered wound care to promote wound healing for 1 of 1 resident (R37) reviewed for pressure ulcers. Findings include: R37's significant change Minimum Data Set (MDS) dated [DATE], identified R37 was at risk for pressure ulcers and had a stage II pressure ulcer. R37's care plan revised 12/11/23, identified R37 had a coccyx pressure ulcer. The care plan directed to educate R37/R37's family as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility; good nutrition and frequent repositioning; avoid positioning R37 on her back, R37 was resistive to repositioning; reposition every 2 hours while in bed and every 1 hour when in chair, encourage R37 to eat protein foods; and notify nurse of any new areas of skin breakdown. R37's Order Summary Report dated 12/2/23, identified right buttock wound: cleanse with wound cleanser and pat dry. Apply silver alginate (an antimicrobial ointment) to cover wound and some of the intact skin. Secure with Mepilex border 3x3. Change every other day. If dressings do not stay in place, may change back to Triad hydrophilic wound filler at least two times day application. R37's Treatment Record dated December 2023, identified nursing applied silver alginate and a Mepilex dressing on 12/2/23, 12/4/23, 12/6/23, 12/8/23, 12/10/23, 12/12/23, 12/14/23, 12/16/23 and 12/18/23. The medical record failed to identify if the dressing failed to stay in place. R37's nursing progress notes dated 12/2/23 at 6:43 a.m., identified R37 was evaluated by the wound care provider and new wound care orders were transcribed. R37 was signed off from wound care unless hospice requested additional follow up. R37's failed to identify documentation R37's dressing would not stay in place, if nursing had requested a change in wound treatment order and/or if the provider had been informed. R37's Wound Data Collection V2 identified the following: - On 12/2/23, R37's wound was assessed. The wound was cleansed and stoma power and Triad were applied. - On 12/4/23, R37's wound was assessed. The wound was cleansed and Triad cream was applied. R37's wound was left open to air. - On 12/5/23, R37's wound was assessed. Triad was applied and R37 was offloaded. - On 12/6/23, R37's wound was assessed. Triad was applied and R37 was offloaded. - On 12/10/23, R37's wound was assessed. Triad was applied and R37 was offloaded. - On 12/12/23, R37's wound was assessed. The document did not identify the treatment provided. - On 12/13/23, R37's wound was assessed. The document did not identify the treatment provided. - On 12/14/23, R37's wound was assessed. Triad was applied and R37 was offloaded. - On 12/15/23, R37's wound was assessed. Triad was applied and R37 was offloaded when she allowed. - On 12/16/23, R37's wound was assessed. Triad was applied. - On 12/17/23, R37's wound was assessed. Triad was applied and R37 was offloaded. - On 12/19/23, R37's wound was assessed. Triad was applied. - On 12/20/23, R37's wound was assessed. Triad was applied and R37 was offloaded. During an observation on 12/19/23 at 11:38 a.m., registered nurse (RN)-A and nursing assistant (NA)-A provided incontinence care to R37. R37 was rolled onto her left side, her incontinence brief was unfastened, and her right buttock wound was exposed. The wound was open to air and a white colored substance covered the surrounding skin. NA-A washed the wound with a warm, wet washcloth and dabbed the area dry with a towel. RN-A then applied ointment to the wound and stated it was Triad. A Mepilex wound dressing nor silver alginate were applied. During an interview on 12/19/23 at 1:45 p.m., RN-A stated there was no normal dressing for R37's wound. The Mepilex wound dressing was tried, but kept coming off. RN-A stated she was unsure if the Mepilex wound dressing not adhering to R37's skin had been communicated to the hospice or wound care provider. When RN-A reviewed R37's wound order, RN-A stated the order was scheduled for every other day and would not show on R37's treatment record for 12/20/23, because it was an off day. RN-A did not review R37's wound care order prior to applying Triad and was going by memory. There was no documentation in R37's EHR regarding the use of Mepilex for R37. Documentation was important to ensure order accuracy and to allow the ordering provider to be able to adjust orders as needed. During an interview on 12/20/23 at 1:47 p.m. RN-B stated staff tried Mepilex wound dressings, zinc oxide and/or Triad ointment for R37's wound. It really depended on how it looked that day what treatment RN-B would use. The facility's medical providers were very liberal with wound care orders and were at the facility every week. Because of this, staff could just ask for what they wanted when it came to wound care. During an interview on 12/20/23 at 2:31 p.m., the director of nursing (DON) stated she would always expected staff to refer to the wound care orders and not go by memory. This was important to ensure staff were doing the correct care according to the physician's orders. Upon review of R37's wound care order, the DON stated because the order read staff could use Triad if the Mepilex wound dressing did not work for R37, nursing should have contacted either the wound care provider or the hospice to have the order updated. Additionally, the DON expected nursing staff to document the wound care treatment and, also, document failed treatments. During an interview on 12/20/23 at 3:43 p.m., RN-C stated she did not know why staff had not documented the silver alginate and Mepilex wound dressing did not work. Hospice should have been informed as well. RN-C expected staff to review R37's treatment order and even print out the treatment record to review to bring with them, if needed. Staff were expected to always follow the wound care order because, in R37's case, the wound care provider was the subject matter expert. Documentation allowed the provider to fully assess R37 for the best possible treatment. If a treatment was not working for a wound, the wound care provider needed to know all available information to adjust their plan. The facility policy Pressure Ulcer/Wound Care Resource Packet revised 5/30/23, identified the Pressure Ulcer/Wound Care Resource Packet was designed to provide staff with the resources and tools needed to provide care and services for residents who were at risk for skin breakdown or had skin integrity issues. Based on the comprehensive assessment of a resident, the facility must ensure that a resident having pressure sores received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene/ and glove use was maintained during dressing change of a pressure ulcer to prevent infection for 1 of 3 resident (R52) reviewed with pressure ulcers Findings include: R52's significant change Minimum Data Set, dated dated dated [DATE], identified R52 had intact cognition, and was at risk for pressure ulcers. R52 has no current pressure ulcers and was on a turning and repositioning program. R52 was receiving hospice services. Diagnoses identified were medically complex conditions including cancer. The facility Matrix completed by the facility upon entrance to the facility on [DATE], identified R52 had a stage 3 pressure ulcers (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. May include undermining or tunneling.) R52's undated Order Summary report identified a order for wound care coccyx and right buttocks. Apply a small amount of Triad cream to wound bed only, cover with adhesive dressing every two days, with a start date of 2/24/23. R52's care plan dated 3/2/23, identified R52 had a pressure ulcer on the on coccyx. Interventions included the following: Reposition resident every hour from right to left (avoid resident laying on his back, Monitor location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to health care provider. R52's wound notes identified the following: - 2/22/23 identified, a sacral wound measuring 1.5 centimeters (cm) x 1.5 cm x 0.1 cm. There was a new open area on coccyx that was not present during the day shift. Area was red with a slight split in the skin. Upon re-check with more staff to assist with rolling it was noted that this area is now open. Resident refuses to reposition and slides down in the bed. Resident refuses to have the leg area of the bed up to prevent slipping down. Resident was very difficult to turn as R52 was pushing back so measurements and assessment are limited at this time. - 2/26/2, identified coccyx wound 2 cm x 2 cm x 0.0 cm. Due to resident refusal to reposition and continued pressure on coccyx area. -3/2/23 identified coccyx wound 1.8 cm x 1.8 cm x 0.2 cm. Pressure ulcer wound looks like the bed has slough but unable to wipe any away - 3/4/23 wound noted identified sacral wound 2 cm x 2 cm. no depth was noted. Wound bed was 100% slough. On 3/8/23, at 8:12 a.m. R52's dressing change was observed with registered nurse (RN)-A and RN-B. RN-A and RN-B both performed hand hygiene and put on gloves. R52's dressing was exposed. RN-B removed the old dressing to R52's coccyx and cleansed the pressure ulcer with saline wound spray and 4 inch (in) x 4 in. gauze. The pressure ulcer was measured and was 1 cm x 1.5 cm., the pressure ulcer had minimal drainage and lacked and signs and symptoms of infection. The was no redness of the skin around the wound and it was intact. RN-B did not remove their gloves and perform hand hygiene. With contaminated gloves RN-B proceeded to place Triad ointment on the wound bed of the pressure ulcer and then covered the pressure ulcer with a Mepilex 3 in x 3 in foam bordered dressing. During interview on 3/8/23, at 8:31 a.m. RN-B stated she should have removed her gloves and performed hand hygiene after measuring the pressure ulcer and prior to using the cream and placing the clean dressing, to prevent cross contamination. The pressure ulcer was not currently infected and hospice had started an antibiotic for preventative measure. The pressure ulcer had no signs and symptoms of infection. The facility's Wound Dressing Change policy dated 11/2/22, identified during a dressing change staff were to; 1. Perform hand hygiene and put on gloves. 2. Removed soiled dressing and discard. 3. Remove dirty gloves, perform hand hygiene, and put on clean gloves. 4. Assess and measure the wound, then cleanse the wound as ordered. 5. Remove dirty gloves, perform hand hygiene, and put on clean gloves. 6. Apply new dressing to the wound and adhere in place. 7. Clean up work area, remove dirty gloves and perform hand hygiene.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 1 of 10 residents (R17) observed to receive medication during the survey. A total of 2 or 25 opportunities were in error resulting in a facility medication error rate of 8 % (percent). Findings include: R17's quarterly Minimum Data Set, dated dated dated [DATE], identified R17 had diagnoses that included renal insufficiency, diabetes mellitus and osteoarthritis. R17 's physician orders dated 2/28/22, included orders for the following: levothyroxine 112 micrograms (mcg) mouth (po) daily, losartin 25 milligram (mg) 1/2 tablet po daily, omeprazole 40 mg po daily, furosemide 40 mg po daily, sennosides-docusate tablet 8.6 mg-50 mg daily, vitamin D3 1000 international units (iu) daily, potassium 20 milliequivalents (meq) 1 tab po twice a day and magnesium oxide 400 mg po twice a day. On 3/8/23, at 7:56 a.m. registered nurse (RN)-C was observed to set up R17's morning medications for administration. RN-C set up the following medications levothyroxine 112 mcg, losartin 25 mg 1/2 tablet , omeprazole 40 mg, furosemide 40 mg, sennosides-docusate tablet 8.6 mg-50 mg daily, vitamin D3 1000 international units (iu) daily. RN-C did not set up the magnesium oxide 400 mg or potassium 20 meq's. RN-C stated the magnesium and potassium were not available to administer and she would need to call the pharmacy. Due to both medication being ordered for twice a day R17 would miss her morning dose and would be a medication error. During an interview on 3/8/23, at 3:55 p.m. the director of nursing (DON) stated when a resident was due for a medication and it was not available the nurse would be expected to call the pharmacy to receive the medication. If the resident was not going to receive their medication in a timely manner, the nurse would be expected to check the emergency medication kit to see if a dose was available. If a dose was not available, a call would be expected to be made to the provider to inform them of the missed dose and to check if any follow up needed to be done. The facility's policy Medications: Acquisition, Receiving, Dispensing, and Storage dated 3/2/23, identified if a medication was not available from the pharmacy, the facility would need to contact the prescriber to determine if a different medication was needed or to determine the time frame acceptable to wait for the medication.

Based on interview and document review, the facility failed to ensure abuse and/or vulnerable adult (VA) training was completed annually as directed by facility policy for 4 of 5 employees (NA-A, NA-B, RN-A, RN-B) reviewed. This had potential to affect all 61 residents who were currently residing in the facility at the time of survey. Findings include: Nursing Assistant (NA)-A's Success Center training transcript printed on 1/20/23, revealed NA-B had not completed an abuse training course since 3/22/21. NA-B's Cornerstone training transcript printed on 1/20/23, revealed NA-B had not completed an abuse training course since 11/28/20. Registered nurse (RN)-A's Success Center training transcript printed on 1/20/23, revealed RN-A had not completed an abuse training course since 9/26/21. RN-B's Success Center training transcript printed on 1/20/23, revealed RN-B had not completed an abuse training course since 3/31/21. During an interview on 1/20/23, at 3:04 p.m. registered nurse (RN)-A indicated abuse training was assigned to each employee through an online education system, however RN-A stated, I don't have time for the computer training and RN-A could not recall the last abuse training they completed. During an interview on 1/20/23, at 4:02 p.m. NA-A stated they were expected to complete annual abuse training courses on the online education system but was unsure when they completed the training course. During an interview on 1/20/23, at 4:51 p.m. director of nursing (DON) stated all employees were expected to complete annual abuse training. DON indicated they monitor the employee training reports annually and DON would follow-up with employees to ensure all employees complete the required training, however this had not been done. DON stated the importance of employees completing abuse training annually was to ensure employees would know how to respond to abuse allegations. During an interview on 1/20/23, at 5:30 p.m. review of employee training transcripts for NA-A, NA-B, RN-A, RN-B with administrator and DON, confirmed annual abuse training had not been completed. Review of facility policy titled Abuse and Neglect dated 10/13/22, indicated employees upon hire and annually would be provided education and training on abuse and neglect.

Based on interview and document review the facility failed to implement intervenitons for fall prevention for 1 of 1 residents (R51) reviewed for falls. Findings include: R51's quarterly minimum data set (MDS) dated [DATE], indicated R51 was cognitively impaired, did not ambulate and required assistance from two staff with activities of daily living (ADL's) including transfers, toileting and personal hygiene. R51's diagnoses included weakness and [CONDITION(S)] (a disease which affects brain structure or function and causes altered mental state and confusion). R51's care plan dated 7/8/21, indentifed R51 was at risk for falls related to confusion, pain and weakness. The care plan directed staff to implement interventions which included to ensure R51 had a touch pad call light placed on the edge of the bed when resident was in bed. R51's incident report dated 10/17/21, identified at 8:20 p.m. R51 was found on the floor and leaning against the wall. R51's call light was within reach but the touch pad call light was hanging on the bed rail and not been placed on the bed. The report further indicated the nursing assistant stated she forgot to place the touch pad call light under R51 when she had assisted him to bed earlier that evening. During interview on 10/21/21, at 9:15 a.m. registered nurse (RN)-C stated R51's touch pad call light was supposed to be placed next him on the edge of the bed. The touch pad call light was placed at the edge of the bed to alert staff the resident was moving. -At 10:17 a.m. nursing assistant (NA)-C and RN-D were interviewed together. NA-C stated R51 had a touch pad call light that was supposed to be placed on the edge of the bed. Touch pad call light's were used to alert staff when the resident was moving and were not used to prevent a resident from falling. RN-D stated touch pad call light's were used to help prevent a resident from falling by alerting staff when a resident was moving so the staff were able to assist the resident prior to self transferring. -At 12:18 p.m. NA-A stated since R51's admission to facility R51 was supposed to have a touch pad call light on the edge of the bed when he was in bed. The alarm was used to alert staff that the resident was moving so staff could attend to the resident prior to self transferring. On 10/17/21, she assisted R51 to bed and forgot to place the touch pad call light on the bed next to R51. Later that evening R51 was found on the floor. - At 3:13 p.m. the director of nursing (DON) stated NA-A assisted R51 to bed the evening of 10/17/21. NA-A forgot to place the touch pad call light under R51. R51 had not turned on the call light, self transferred and fell , staff were not following his care plan. The touch pad call light were used to alert staff a resident was moving and were not used to prevent falls from happening. The facility Fall Prevention and Management policy revised 9/17/21, identified the risk of falling for residents in long-term care locations substantially increases due to decreased mobility, frailty, muscle weakness, gait disturbance and disease progression. After a fall, a resident may experience lifestyle changes due to impaired function, decrease mobility and lost independence. It is the facilities obligation to provide the safest environemnt possible for the residents trusted to the facilities care. The policy directs staff to identify fall risk factors, care plan appropriate interventions (including personalizing all areas), communicate fall risks and interventions per the 24-hour report, care plan and kardex, daily stand-up meeting, and/or fall committee meetings, as well as communicate any identified environmental changes and/or referral needs.

Based on observation, interview and document review the facility failed to ensure hand hygiene was performed during personal cares and after touching their personal protective equipment (PPE) for 1 of 3 residents (R46) observed during personal cares. Findings include: R46's quarterly minimum data set (MDS) dated [DATE], indicated R46 was cognitively impaired and required assistance with activities of daily living including personal cares. On 10/20/21, at 8:04 a.m. nursing assistant (NA)-B was observed completing morning cares for R46. NA-B washed R46's peri area with a wet wash cloth and then placed the dirty wash cloth in the wash basin on the table next to the bed. NA-B's face mask slid down below the tip of her nose. With same dirty, wet gloved hand, NA-B reached and pulled her own face mask up over her nose and stated her face mask slipped down. NA-B completed R46's cares, removed the soiled gloves and did not complete hand hygiene. NA-B then proceeded to fasten R46's brief and pull up their pants. NA-B exited R46's room and did not perform hand hygiene. - At 8:28 a.m. NA-B re-entered R46's room and did not perform hand hygiene and put on a clean pair of gloves. Using both hands NA-B emptied R46's catheter urine into a receptacle, clamped catheter tubing, stood and with same dirty gloved hands pulled up her own face mask and stated I just touched my mask with that hand, that was gross. NA-B entered the bathroom, emptied urine receptacle, removed their gloves and washed their hands with soap and water. NA-A adjusted R46's catheter tubing and bag. NA's face mask slid down to the tip of her nose again. NA-B stood, reached up and adjusted her dirty face mask by pulling it up over her nose and then wheeled R46 out of the room and down the hallway. NA did not use hand sanitizer upon exiting residents room. During interview on 10/20/21, at 8:43 a.m. NA stated she did not perform hand hygiene after providing peri care to R46, prior to or after adjusting her face mask up, or prior to exiting R46's room. Staff were expected to use hand sanitizer every time they remove gloves, between dirty and clean procedures and upon entering or exiting a residents room. During interview on 10/21/21, at 3:13 p.m. the director of nursing (DON) stated staff were expected to perform hand hygiene before entering a residents room, before putting on and taking off gloves, prior to/after dirty to clean tasks, and upon exiting a residents room. Staff were expected to wash hands their when they were visible dirty. The Hand Hygiene and Handwashing policy revised 4/6/21, indicated regular handwashing with soap and warm, not hot, water is one of the best ways to remove germs, avoid getting sick and prevent the spread of germs to others. The policy directed staff to wash hands or use alcohol-based hand rub during patient care.

Based on interview and document review the facility failed to notify the physician and family of a change of condition for 1 of 3 residents (R1) reviewed who were discharged . This resulted in actual harm for R1 who was discharged to a lower level of care and subsequently transferred to the hospital the day of discharge, where R1 expired. Findings include: R1's undated, Admission Record indicated he admitted to the facility with [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated he had moderate cognitive impairment and required extensive assistance from two staff for activities of daily living. The MDS indicated R1 displayed no behaviors and had not received oxygen therapy prior to or since admission to the facility. A physician Nursing Home Note dated [DATE], indicated R1 was seen via video visit by medical doctor (MD)-A. The note indicated at times R1 complained of dizziness and shortness of breath believed to be related to chronic [MEDICAL CONDITION]. The note further identified a [DIAGNOSES REDACTED]. Staff asked about potential for use of O2 for shortness of breath but because saturation levels had not dropped it was determined O2 was not needed at that time. There was no evidence of [MEDICAL CONDITION] exacerbation. An addendum to the note, undated, indicated R1 had [MEDICAL CONDITION] and was O2 dependent. Saturation levels ran in the ,[DATE]% range. The MD provided a recommendation for R1 to be on O2 around the clock (continuous) to maintain O2 levels at or above 90%. A facility Progress Note dated [DATE], indicated R1's oxygen (O2) saturation was 60 - 70 % ( average ,[DATE]%) on room air. R1 had thick brown phlegm in his throat, he was coughing up and was placed on 2 liters of O2 with no improvement in O2 sats after four minutes. O2 was increased to 6 liters to maintain saturation levels of 89 - 91%. R1 coughed up large amounts of brown, sticky phlegm for about 45 minutes. Lung sounds were diminished but clear. After coughing R1 was able to maintain O2 levels above 95% on 2 liters O2. R1's O2 Saturation Summary indicated on [DATE], R1 had a saturation level of 71% on room air at 7:00 a.m. No further O2 levels were documented until 10:00 p.m. when R1's O2 saturation level was 89% while O2. R1's Progress Note dated [DATE], indicated R1 was holding saliva in his mouth and would not swallow. The nurse attempted to suction R1 with no results. R1 had faint crackles in bases of lungs. A PT (physical therapy) Daily Treatment Note dated [DATE], indicated the therapist notified a nurse and nurse manager, about O2 saturation levels in the 70's on three liters of supplemental oxygen. The therapist increased R1's oxygen to ,[DATE] liters. R1's saturation levels only increased to 80%. R1's Progress Note dated [DATE], indicated R1 was seen by nurse practitioner (NP)-A by telehealth video. The facility nurse had reported abnormal lung sounds, deterioration of condition and requested orders for O2 and a wheel chair. A Documentation of Face to Face Encounter for Medicare Clients dated [DATE], written by NP-A indicated R1 was seen for a wheel chair and home oxygen. The note indicated R1 required as needed O2 to keep saturation levels above 88%. The encounter note indicated a [DIAGNOSES REDACTED]. R1's Progress Note dated [DATE], identified R1 was resting in bed until being assisted into a wheel chair at 3:30 p.m. R1 was restless but weak, audible tracheal gurgling heard. R1 was encouraged to cough and deep breathe and able to clear. O2 was on at 2 liters. Resident was brought to the front entry. After R1 was brought to the entrance and was outside, writer returned to the unit. R1's Discharge Summary dated [DATE], identified a health conditions of [MEDICAL CONDITION] O2 sats (saturation) drop. However, the summary did not identify R1's current lung condition status. An untitled hospital record dated [DATE], indicated upon arrival to the emergency room R1's blood pressure was ,[DATE] (average range ,[DATE] - ,[DATE]). The note indicated he was ill-appearing and looked toxic, vitals were not stable and he was unresponsive. The notes indicated R1 was in septic shock from presumed bacterial pneumonia and had severe, life threatening lactic acidosis (lactic acid is a substance that can build up in your body if you are not getting enough oxygen). The notes identified evidence or organ damage due to [MEDICAL CONDITION] (infection in the blood) including acute [MEDICAL CONDITIONS] (a decreased level of oxygen in all or part of your body) and hypercapnia (too much carbon [MEDICATION NAME] in your bloodstream). On [DATE], at 1:34 p.m. the assisted living facility (ALF) RN stated when R1 arrived at the ALF he was not very responsive. The ALF RN stated when she completed the admission assessment she reviewed the discharge documentation from the facility and it did not include an assessment or documentation of R1's condition when he left the facility so she had no baseline for him. The ALF RN stated R1's initial blood pressure was low, his heart rate was in the 40's ( average range ,[DATE] ) and O2 saturation was in the high 80's. She stated later in the evening staff rechecked R1's vitals and his blood pressure was 50's/30's, O2 was in the 70's and staff were unable to detect a pulse on their equipment. R1 was then sent to the emergency room for further evaluation and passed away the next day. During interview on [DATE], at 3:39 p.m. NP-A stated she had seen R1 via video on [DATE], his condition had deteriorated since she last saw him on [DATE]. NP-A reviewed R1's medical record and identified he was seen by NP-B on [DATE], and did not have an O2 order at that time. When asked about the face to face visit related to the O2 order on [DATE], NP-A stated the facility had called her on [DATE], and she was unable to complete the visit until later in the day so the facility called MD-A who then amended his note from the [DATE], visit. NP-A stated the order for the O2 was written by MD-A before she saw R1. Further, NP-A indicated she only saw R1 to fulfill a Medicare requirement for the face to face and did not identify she completed an actual assessment of R1's lung status. During interview on [DATE] at 8:57 a.m. registered nurse (RN)-A who was the unit nurse manager, stated, I think his sats (saturation levels) dropped the Sunday before he discharged . RN-A stated MD-A and NP-A were both notified when R1 began to decline; however she had notified the medical providers only about R1's repeated falls. When asked about R1's overall decline, RN-A stated she did not think any medical interventions were implemented and stated RN-A stated she talked to MD-A and NP-A about the need for oxygen upon discharge from the facility, but stated she had not updated them regarding the saturation levels dropping into the 70% range and was not sure if any of the nurses had called and updated R1's medical providers. Further, the addendum on the physician's note dated [DATE], was added on [DATE], following her request for O2. At 9:32 a.m. family member (FM)- A stated the facility had not contacted them and told them R1 needed O2. FM-A stated when R1 arrived at the assisted living facility his blood pressure was really, really low and he was sent to the emergency department. FM-A stated R1 was admitted to the intensive care unit and died from double pneumonia, organ failure [MEDICAL CONDITION]. At approximately 10:00 a.m. physical therapist (PT)-A stated the day R1 discharged from the facility he had worked with R1 and R1's O2 saturation had dropped to 70% on two liters of O2. PT-A stated he reported it to the nurse on the floor who said RN-A was aware and they had been in contact with the physician. PT-A said the way it was communicated to him he thought it was something that was continually being monitored. At 10:20 a.m. NP-B stated she had last seen R1 on [DATE], due to his multiple falls. NP-B stated she went on vacation and when she returned R1 had died . NP-B stated R1 had not required the use of O2 and his vitals signs had been stable. NP-B stated, honestly, I don't believe anyone was notified of the change of condition for R1. At 11:29 a.m. MD-A stated on [DATE], he was trying to arrange for durable medical equipment for R1's discharge and had been speaking with RN-A. MD-A did not complete a face to face evaluation as MD-A stated he had not been aware of the decreased O2 saturation level. Further, if he was made aware of the change in R1's condition he would not have okayed him for discharge to the assisted living and would have sent R1 to the emergency department for further evaluation. On [DATE], at 10:48 a.m. the DON stated R1 had been declining throughout his stay at the facility however, she she would have expected staff to let the physician know of the decline in lung status and staff should have reported the saturation levels in the 70's. A facility policy related to notification of change of condition was requested but none received.

Based on interview and document review the facility failed to assess and monitor a change in lung condition for 1 of 3 residents (R1) reviewed for a change of condition. This resulted in actual harm for R1 who was discharged to a lower level of care and subsequently transferred to the hospital the day of discharge, where R1 expired. Findings include: R1's undated, Admission Record indicated R1 admitted to the facility with [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated he had moderate cognitive impairment and required extensive assistance from two staff for activities of daily living. The MDS indicated R1 had not received oxygen therapy prior to or since admission to the facility. R1's care plan dated [DATE], identified a self performance deficit related to weakness, impaired mobility and deconditioning. The care plan directed staff to provide assistance of one staff to complete bathing, toileting and personal hygiene needs. The care plan lacked nursing interventions related to assessment or monitoring R1's [MEDICAL CONDITION]. R1's Oxygen (O2) Saturation Summary dated [DATE] - [DATE], indicated R1 did not use supplemental O2 from [DATE] to [DATE]. The summary indicated on [DATE], R1's saturation levels were maintained at 89 - 98 % on room air (average range 90%-100%), without the need for supplemental O2. A physician Nursing Home Note dated [DATE], indicated R1 was seen via video visit by medical doctor (MD)-A. The note indicated at times R1 complained of dizziness and shortness of breath believed to be related to chronic [MEDICAL CONDITION]. The note further identified a [DIAGNOSES REDACTED]. Staff asked about potential for use of O2 for shortness of breath but because saturation levels had not dropped it was determined O2 was not needed at that time. There was no evidence of [MEDICAL CONDITION] exacerbation. An addendum to the note, undated, indicated R1 had [MEDICAL CONDITION] and was O2 dependent. Saturation levels ran in the ,[DATE]% range. The MD provided a recommendation for R1 to be on O2 around the clock (continuous) to maintain O2 levels at or above 90%. A facility Progress Note dated [DATE], indicated R1's oxygen (O2) saturation was 60 - 70% on room air. R1 had thick brown phlegm in his throat, he was coughing up and was placed on 2 liters of O2 with no improvement in O2 sats after four minutes. O2 was increased to 6 liters to maintain saturation levels of 89 - 91%. R1 coughed up large amounts of brown, sticky phlegm for about 45 minutes. Lung sounds were diminished but clear. After coughing R1 was able to maintain O2 levels above 95% on 2 liters O2. The medical record lacked further assessment of R1's symptoms. R1's O2 Saturation Summary indicated on [DATE], R1 had a saturation level of 71% on room air at 7:00 a.m. No further O2 levels were documented until 10:00 p.m. when R1's O2 saturation level was 89% while O2. The medical record lacked evidence of ongoing monitoring or further assessment. R1's Progress Note dated [DATE], indicated R1 was holding saliva in his mouth and would not swallow. The nurse attempted to suction R1 with no results. R1 had faint crackles in bases of lungs. No further assessment was identified. A PT (physical therapy) Daily Treatment Note dated [DATE], indicated the therapist notified a nurse and nurse manager about R1 having O2 saturation levels in the 70's on three liters of supplemental oxygen during therapy. The therapist had increased R1's oxygen to ,[DATE] liters. R1's saturation levels only increased to 80%. R1's Progress Note dated [DATE], indicated R1 was seen by nurse practitioner (NP)-A by telehealth video. The note indicated the facility nurse reported abnormal lung sounds, deterioration of condition and requested orders for O2 and a wheel chair. The note was written by registered nurse (RN)-A. R1's Progress Note dated [DATE], indicated R1 was resting in bed until being assisted into a wheel chair at 3:30 p.m. R1 was restless but weak, audible tracheal gurgling was heard. R1 was encouraged to cough and deep breathe and able to clear. O2 was on at 2 liters. R1 was brought to the front entry and outside at which point the writer returned to the unit. The medical record again lacked evidence of further assessment or physician notification prior to discharging R1 from the facility. R1's Discharge Summary dated [DATE], identified a health conditions of [MEDICAL CONDITION] O2 sats (saturation) drop. However, the summary did not identify R1's current lung condition status or any further assessment of R1's lung condition. An untitled hospital record dated [DATE], indicated upon arrival to the emergency room R1's blood pressure was ,[DATE] (average range ,[DATE] - ,[DATE]). The note indicated he was ill-appearing and looked toxic, vitals were not stable and he was unresponsive. The notes indicated R1 was in septic shock from presumed bacterial pneumonia and had severe, life threatening lactic acidosis (lactic acid is a substance that can build up in your body if you are not getting enough oxygen). The notes identified evidence or organ damage due to [MEDICAL CONDITION] (infection in the blood) including acute [MEDICAL CONDITIONS] (a decreased level of oxygen in all or part of your body) and hypercapnia (too much carbon [MEDICATION NAME] in your bloodstream). On [DATE], at 1:34 p.m. the assisted living facility (ALF) RN stated when R1 arrived at the ALF he was not very responsive. The ALF RN stated when she completed the admission assessment she reviewed the discharge documentation from the facility and it did not include an assessment or documentation of R1's condition when he left the facility so she had no baseline for him. The ALF RN stated R1's initial blood pressure was low, his heart rate was in the 40's ( average range ,[DATE] ) and O2 saturation was in the high 80's. She stated later in the evening staff rechecked R1's vitals and his blood pressure was 50's /30's, O2 was in the 70's and staff were unable to detect a pulse on their equipment. R1 was then sent to the emergency room for further evaluation and passed away the next day. During interview on [DATE], at 3:39 p.m. NP-A stated she had seen R1 via video on [DATE], his condition had deteriorated since she last saw him on [DATE]. NP-A reviewed R1's medical record and identified he was seen by NP-B on [DATE], and did not have an O2 order at that time. When asked about the face to face visit related to the O2 order on [DATE], NP-A stated the facility had called her on [DATE], and she was unable to complete the visit until later in the day so the facility called MD-A who then amended his note from the [DATE], visit. NP-A stated the order for the O2 was written by MD-A before she saw R1. Further, NP-A indicated she only saw R1 to fulfill a Medicare requirement for the face to face and did not identify she completed an actual assessment of R1's lung status. During interview on [DATE], at 8:26 a.m. nursing assistant (NA)-A stated R1 did not always use oxygen and stated the O2 use had started only a few days before he discharged . At 8:57 a.m. RN-A, the unit manager, stated R1 had not used oxygen when he came to the unit and stated, I think his sats (saturation levels) dropped the Sunday before he discharged . RN-A stated she talked to MD-A and NP-A about the need for oxygen upon discharge from the facility, but stated she had not updated them regarding the saturation levels dropping into the 70 % range and was not sure if any of the nurses had called and updated R1's medical providers. RN-A did not identify why she did not discuss R1's dropping O2 saturations with MD-A. Further, the addendum on the physician's note dated [DATE], was added on [DATE], following her request for O2. At 9:32 a.m. family member (FM)- A stated the facility had not contacted them and told them R1 needed O2. FM-A stated when R1 arrived at the assisted living facility his blood pressure was really, really low and he was sent to the emergency department. FM-A stated R1 was admitted to the intensive care unit and died from double pneumonia, organ failure [MEDICAL CONDITION]. At approximately 10:00 a.m. physical therapist (PT)-A stated the day R1 discharged from the facility he had worked with R1 and R1's O2 saturation had dropped to 70% on two liters of O2. PT-A stated he reported it to the nurse on the floor who said RN-A was aware and they had been in contact with the physician. PT-A said the way it was communicated to him he thought it was something that was continually being monitored. At 10:20 a.m. NP-B stated she had last seen R1 on [DATE], due to his multiple falls and was not related to R1's lung status. NP-B stated she went on vacation and when she returned R1 had died . NP-B stated at the time of her last visit R1 had not required the use of O2 and his vitals signs had been stable. NP-B stated, honestly, I don't believe anyone was notified of the change of condition for R1's lung status. At 11:29 a.m. MD-A stated on [DATE], he was trying to arrange for durable medical equipment for R1's discharge and had been speaking with RN-A. MD-A did not complete a face to face evaluation as MD-A stated he had not been aware of the decreased O2 saturation level. Further, if he was made aware in the change in R1's lung condition he would not have okayed him for discharge to assisted living and would have sent R1 to the emergency department for further evaluation. On [DATE], at 10:48 a.m. the director of nursing (DON) stated R1 had been declining throughout his stay at the facility. The DON stated over the weekend prior to his discharge he was requiring O2 when he couldn't clear his mucous but it was periodic. The DON stated R1 did not display a drastic change in his vital signs and his O2 saturations levels were not real low. She stated she felt it was just a slow decline. The DON stated she was aware the day of discharge they were evaluating R1's need for O2 and said the reports she received was R1 was doing what he had been doing for weeks and was regularly using O2. The DON stated It was a slow and consistent decline in my opinion, but stated she would have expected staff to report the saturation levels in the 70's and to let the physician know of the decline. The facility policy Change In Condition Evaluation - CICE dated [DATE], directed staff to begin the CICE and collect pertinent clinical data prior to contacting the physician when a resident experienced a change of condition and continue to monitor the resident and update the CICE evaluation as appropriate. Upon completion of the evaluation, a notification hyperlink will turn red if there is information that needs to be communicated to the provider. R1's medical record lacked a CICE form related to a change in condition in lung status.

Based on, interview and document review, the facility failed to comprehensively assess pressure ulcers and initiate appropriate interventions to promote healing and minimize the risk for pressure ulcer worsening for 3 of 6 residents (R66, R54 and R437) reviewed for pressure ulcers. This resulted in actual harm for R66, who had multiple/recurring facility acquired pressure ulcers. Finding Include. R66's [DIAGNOSES REDACTED]. R66's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R66 was cognitively intact and required extensive assist of 1 staff for bed mobility, transfer, dressing, toilet use, personal hygiene, and extensive assist of 2 for ambulation. The MDS also indicated R66 was at risk for the development of pressure ulcers and required a pressure reducing device in his chair along with a turning/repositioning program. R66's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 4/26/18, indicated R66 was admitted to the facility after hospitalization for a fall with left humerus fracture and rib fractures. That CAH indicated R66's current [DIAGNOSES REDACTED]. R66 was also at risk for pressure ulcers due to weakness, limited mobility, impaired balance and pain. He was occasionally incontinent of bladder and frequently incontinent of bowel. He used a wheelchair for mobility. R66's Care Plan provided on 2/7/19, indicated R66 had the potential for pressure ulcer development related to immobility and directed staff to assist R66 to turn/reposition at least every two hours, use pillows for support/comfort and provide a wheelchair cushion. The Care Plan also directed staff to notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily cares. R66's Braden Scale for Predicting Pressure Sore Risk dated 1/6/19, indicated R66 was at risk for pressure ulcer development. R66's Skin Observation dated 1/3/19, completed by licensed practical nurse (LPN)-C identified R66 had needle sticks from accu checks (glucometer testing for blood glucose) and insulin, and his legs had scratches from itching. The observation did not identify any open areas to R66's coccyx. On 2/5/19, at 9:18 a.m. R66 stated he had a history of [REDACTED]. R66 stated staff put salve on the area when they changed his incontinent brief and stated it was better right now but had been open in the past. On 2/6/19, at 9:10 a.m. nursing assistant (NA)-J entered R66's room to provide cares and was pushing a sit to stand lift. NA-J assisted R66 from his wheelchair to bed utilizing the lift. A pressure relieving cushion was noted in R66's wheelchair. R66 stated he was going to rest before [MEDICAL TREATMENT] later that day. NA-J stated R66 had problems with open areas on his bottom and indicated the areas were located on either side of his coccyx. NA-J stated R66's bottom was usually open on the left side but stated when she'd assisted him with his bath this past Monday (2/4/19), she noticed it was open on both sides. NA-J stated she had not gotten R66 up that morning, so was not sure whether the areas were still open. NA-J stated they put ointment on the area and tried to assist R66 with repositioning every two hours however, R66 often sat up the whole day, especially on non-[MEDICAL TREATMENT] days. On 2/7/19, at 9:33 a.m. R66 stated he'd had a shower that morning. R66 stated he'd always had a sore on his bottom and gave the surveyor permission to observe his buttocks. NA-F present at the time, was observed to assist R66 to stand utilizing a sit to stand lift and lowered R66's pants so his coccyx area could be visualized. Open areas were observed on either side of R66's coccyx. NA-F called registered nurse (RN)-H to the room and RN-H verified R66 had an area to the left of his coccyx which was superficially open and looked chafed, and also had small excoriated areas to the right of the coccyx. RN-H palpated the area around R66's coccyx and R66 stated it was sore and flinched when touched. RN-H stated she had not received or conducted a nursing assessment of the wounds, and stated she had not been aware of the open areas prior to this observation. R66 was transferred to bed. During interview with LPN-B at 9:48 a.m. on 2/7/19, LPN-B stated no one had reported to her that R66 had open areas on his bottom. At that time, LPN-B and RN-H verified R66's medical record did not contain an assessment or any documentation related to R66's wounds. At 9:51 a.m. on 2/7/19, RN-H reentered R66's room, applied hand sanitizer and donned gloves. RN-H assisted R66 to lower his pants and lay on his left side. RN-H then measured and described R66's wounds. RN-H stated there was an open area measuring 0.3 x 0.2 cm (centimeters) to the right of R66's coccyx. Above the area was an area RN-H described as scabbed which measured 0.5 x 0.5 x 0 cm. To the left of R66's coccyx was an area measuring 0.4 x 0.5 cm. RN-H described this area as very superficially open and indicated there was no granulation. RN-H asked R66 if he would be willing to try an air bed. R66 stated he used to have an air bed, but could not tolerated it due to back pain. Following the assessment, RN-H stated at 10:01 a.m., staff should have notified her of these open areas. RN-H also stated R66's skin was peeling off all over and indicated there was moisture in the crease of R66's skin. RN-H also stated she didn't think the areas were related to pressure, but felt they were from shearing. RN-H stated all areas were blanchable except the scabbed area. During interview with NA-J at 11:28 a.m. on 2/7/19, NA-J stated she'd reported to LPN-C about R66's open areas after his bath last week. During a follow up interview with RN-H at 12:53 p.m. on 2/7/19, RN-H verified LPN-C had been the nurse working when R66 had his bath last week. RN-H said LPN-C should have assessed the open areas or reported the information on to ensure someone conducted the assessment. At 2:41 p.m. on 2/7/19, the director of nursing (DON) verified R66's open areas should have been assessed when first identified so assessment could have been conducted and treatment could have been initiated. R54's admission record indicated the resident who had previously resided at the facility and been discharged in (MONTH) (YEAR), had been re-admitted [DATE]. R54's Nursing Admit Re-Admit Data Collection form dated 12/19/18, indicated R54's lower extremities had 1-2+ [MEDICAL CONDITION] to right foot, and 2-3+ [MEDICAL CONDITION] on left foot. The report also described R54 as having dry, flaking, red skin on feet. An admission MDS dated [DATE], indicated R54 was at risk for pressure ulcers. However, the MDS indicated R54 had no current pressure ulcers, venous or arterial ulcers, or other ulcers, wounds or skin problems including foot problems. R54's Pressure Ulcer CAA dated 12/27/18, indicated R54 required extensive assistance for bed mobility, was at risk for pressure ulcers, and required regularly scheduled repositioning. R54's [DIAGNOSES REDACTED]. R54's care plan dated 12/19/18, indicated R54 had the potential for pressure ulcer development related to deconditioning, history of falling and not being able to move self. The care plan directed staff to turn and reposition the resident every 2 hours, and to notify the nurse immediately of any new areas of skin breakdown including redness, blisters, bruises or discoloration. On 2/4/19, at 7:51 p.m. R54 was interviewed and stated he thought he might have an open area on his left big toe because it really hurts. R54's Skin Observations completed 1/14/19, 1/21/19, 1/28/19 and 2/4/19, did not identify or address any concerns with the resident's left great toe. When interviewed on 2/6/19, at 7:43 a.m. LPN-A stated she was not aware of any treatments or concerns to R54's left great toe. On 2/6/19 at 8:05 a.m., NA-E and NA-D were observed providing care for R54. When questioned about the resident's skin condition, both NA's stated R54 had no current skin issues. The surveyor asked the NA's to check the resident's left great toe and a scabbed area was observed. Both NA's stated that they apply lotion and socks to feet on a daily basis. During interview with LPN-A at 11:31 a.m. on 2/6/19, LPN-A stated she'd spoken with RN-I and they agreed the sore on R54's left toe likely occurred before R54 was admitted to the facility. At 11:37 a.m., RN-I stated she had looked at R54's toe and had completed an incident report and wound assessment. RN-I stated she would contact the physician for directions. At 12:02 p.m. on 2/6/19, the DON was interviewed and stated she was not aware of the sore on R54's left great toe. A Wound RN assessment dated [DATE], indicated R54 had a wound, non-pressure to the left great toe tip measuring 1 centimeter (cm) x 1 cm. Wound characteristic was identified as 100% eschar (necrotic tissue that appears black, brown or tan, adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than the surrounding tissue). On 2/7/19, at 1:14 p.m. the DON looked through R54's previous admission record, and spoke to the nurses who had worked with R54 during the previous admission. They confirmed there had previously been an area that was being treated to R54's left great toe. The DON stated R54 had previously been discharged from the nursing home on 6/26/18. The facility's Pressure Ulcer policy revised 1/2017, indicated a resident who had a pressure ulcer would receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. The policy also indicated residents would receive appropriate assessment and services to promote and maintain skin integrity. The facility's Skin Assessment, Pressure Ulcer Prevention and Documentation Requirement procedure revised 4/2016, indicated if a pressure ulcer was identified, the registered nurse should record the type of wound and degree of tissue damage. The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics. The procedure also indicated the physician/practitioner would be notified of the ulcer and resident's condition to obtain orders for treatment and the resident/family would be notified of the ulcer, orders and planned interventions. The procedure further indicated the interdisciplinary team should determine any modifications necessary to the resident's plan of care and the pressure ulcer/dressing would be monitored daily and assessed/evaluated at least weekly. R437's Admission Records/face sheet dated 1/21/19, indicated R437 had [DIAGNOSES REDACTED]. R437's A physician order [REDACTED]. In addition, a physician order [REDACTED]. The physician order [REDACTED]. R437's care plan dated 1/24/19, indicated R437 had [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in a left lower leg wound and and staff were to maintain contact precautions during wound care. On 2/6/19, at 11:16 a.m. registered nurse (RN)-J was observed to apply PPE (personal protective equipment) including gown and gloves, and entered R437's room to perform dressing changes. RN-J removed dressing supplies from a chest of drawers in R437's room. The supplies consisted of an unopened [MEDICATION NAME] package, 2x2 gauze, 4x4 gauze, aerosol saline wound wash, [MEDICATION NAME] (self-adherent absorbent bordered foam dressing) and scissors. RN-J was observed to remove a dressing from R437's left forearm, then changed gloves, cleansed the wound, changed gloves again and opened a new [MEDICATION NAME] dressing and cut the dressing to fit over the left arm wound. RN-J then placed the scissors on the bed. RN-J proceeded to cover the [MEDICATION NAME] with a [MEDICATION NAME] dressing. RN-J collected supplies and proceeded to provide wound care to two wounds on the right arm, one on the elbow and one on the forearm. RN-J donned fresh gloves and removed the dressing from the right elbow. RN-J changed gloves, cleansed the wound, changed gloves again, and picked up the scissors off of the bed and cut an [MEDICATION NAME] dressing to fit the wound. RN-J then placed the [MEDICATION NAME] and scissors on a newspaper next to an empty urinal before applying the [MEDICATION NAME], covered by a [MEDICATION NAME] dressing to the right elbow. RN-J then removed a dressing from the right forearm, changed gloves and cleansed the wound. RN-J picked up the scissors and cut an [MEDICATION NAME] to fit the wound. RN-J then placed the scissors and remaining [MEDICATION NAME] on the newspaper, and applied the precut [MEDICATION NAME] followed by [MEDICATION NAME] to the forearm wound. At approximately 11:35 a.m., RN-J applied new gloves, placed a disposable sheet under R437's left leg and removed a dressing from the left lower shin. After removing the dressing, RN-J changed gloves and cleansed the wound before again changing gloves. RN-J again used the scissors to cut a piece of [MEDICATION NAME] to cover the wound. RN-J set the scissors on the disposable sheet and applied the [MEDICATION NAME] and covered the wound with a [MEDICATION NAME] dressing. While still wearing her gloves, RN-J then reached under her PPE and removed a pen from her uniform pocket and initialed and dated each of the four newly applied dressings before putting the pen back into her uniform pocket. RN-J then placed the scissors and the unused portion of [MEDICATION NAME] into R437's top drawer. At no time was RN-J observed to clean the scissors. At 11:46 a.m., RN-J covered R437, removed the gloves and gown, entered R437's bathroom, washed hands with soap and water then the resident's exited room. During interview with RN-J at 11:50 a.m. on 2/6/19, RN-J stated the scissors in the room were dedicated to R437. However RN-J verified being unsure whether the scissors had been cleaned previous to use. RN-J stated she would normally clean scissors after the dressing change however, confirmed she had not. In addition, RN-J verified she had retrieved a pen from her uniform pocket, under her PPE, and verified she had replaced the pen under the PPE when done. RN-J verified the pen should be considered contaminated. On 2/7/19, at 10:08 a.m. RN-C confirmed the scissors should have been cleansed before and after the dressing changes by utilizing an alcohol wipe. RN-C also stated staff who were doing a dressing change should have a disposable sheet laid out, or a surface that had been cleaned, to keep dressing supplies on during the dressing changes. RN-C confirmed a dedicated pen should have been the room to date and initial dressing. RN-C stated staff should not obtain supplies by reaching under their PPE. On 2/7/19, at 10:48 a.m. the director of nursing (DON) and RN-A stated the scissors should have been disinfected with a germicidal cleansing wipe. The DON stated she would expect the staff to establish a clean area to place their dressing supplies while performing wound care. The DON also stated dedicated dressing supplies, including scissors and pens, should be available in the resident's room. The DON confirmed the nurse should not have retrieved the pen from her uniform pocket, reaching under the PPE with her gloved hands. The facility's Personal Protective Equipment policy dated (MONTH) 2012, indicated personal protective equipment was considered appropriate only if it does not permit blood or other potentially infectious materials to pass through to, or reach, the employee's work clothes. A policy related to disinfecting wound care supplies was requested and not provided.

Based on interview and document review, the facility failed to ensure opioid pain medication to control moderate to severe pain was administered timely for 2 of 4 residents (R9, R1) reviewed for pain control. R9 experienced actual harm when the facility failed to administer scheduled pain medication timely in an attempt to control the resident's pain. R1 experienced actual harm when the facility failed to administer as needed opioid pain medication when the resident's pain was not managed. Findings include: R9's medical record was reviewed. R9's face sheet indicated [DIAGNOSES REDACTED]. R9's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R9 had severe cognitive impairment. The MDS also indicated R9 received scheduled pain medications and as needed pain medication. R9's care plan last reviewed on [DATE], indicated R9 was receiving [MEDICATION NAME]/[MEDICATION NAME] due to spinal stenosis (narrowing of a passage). R9's signed physician order [REDACTED]. R9's (MONTH) (YEAR), Medication Administration Record [REDACTED]. On [DATE], at 7:05 a.m. R9 had put his call light on. At 7:24 a.m. R9's call light had not been answered. The investigator entered the room and observed R9 lying in bed on his back. R9 was asked what his request had been. R9 stated he was having pain. At 7:34 a.m. nursing assistant (NA)-S entered R9's room and stated she was taking R9 for a bath. At 7:35 a.m. NA-U entered R9's room and at 7:37 a.m. the call light was turned off. At 7:39 a.m. NA-S and NA-T brought R9 to the tub room. At 7:53 a.m. NA-S and NA-T brought R9 to his room after the bath. At 8:08 a.m. NA-U entered R9's room. At 8:08 a.m. NA-U and NA-S came out of R9's room with the mechanical lift.An interview was conducted with R9 on [DATE], at 8:33 a.m. as he was seated in a rock-n-go chair (a chair that rocks and the seat back will recline). Registered Nurse (RN)-I asked R9 to rate his pain on a scale of ,[DATE] with ten being the worst pain. R9 stated his pain was better now and stated it was a five. After RN-I left the table, R9 stated when he was lying in bed his back pain was at an eight. R9 stated he had to wait to long for his call light to be answered. R9 stated very often there was a call light wait time and this was common. An interview was conducted with RN-I on [DATE], at 8:43 a.m. RN-I was working on the medication cart on the 200 wing. RN-I stated R9 had a physician's orders [REDACTED]. RN-I stated he had not given R9 any pain medication yet today. RN-I was informed by the investigator that R9 had complaints of pain at 7:24 a.m. and had his call light on since 7:05 a.m. RN-I stated he did not know that R9 needed a pain medication. On [DATE], at 8:52 a.m. RN-I administered [MEDICATION NAME]/[MEDICATION NAME] ,[DATE] 1.5 tablets to R9. (2 hours & 27 minutes after R9 put on his call light). An interview was conducted with NA-S on [DATE], at 8:52 a.m. NA-S stated they rolled R9 over in bed to apply the sling for the mechanical lift. NA-S stated R9 told her his back hurt. NA-S stated she had not reported the back pain to RN-I as she knew R9 had a scheduled pain pill at 8:00 a.m. An interview was conducted with the director of nursing services (DNS) on [DATE], at 7:37 a.m. The DNS stated it would be her expectation that the NA would let the nurse know right away when a resident tells them they are in pain. The DNS stated the nurse could then administer a scheduled pain medication or an as needed pain medication. The DNS further stated the 8:00 a.m. scheduled pain medicaiton for R9 could be administered one hour before and one hour after the scheduled time. R1's medical record was reviewed. R1's face sheet indicated she was diagnosed with [REDACTED]. R1's care plan initiated on [DATE], indicated R1 had an alteration in her gastrointestinal status related to [MEDICAL CONDITION] with metastases to the liver and malignant ascites (abnormal buildup of fluid in the abdomen). R1 had nausea and vomiting related to the disease process. R1 had acute/chronic pain/discomfort related to chronic pai[DIAGNOSES REDACTED]. Interventions included to notify the health care provider or hospice if interventions were unsuccessful. Evaluate the effectiveness of pain interventions in ,[DATE] minutes. Attempt non-pharmacological interventions such as repositiong, distraction, and relaxation. R1 had a physician's orders [REDACTED]. R1 had a physician's orders [REDACTED]. R1 had a physician's orders [REDACTED]. R1 had a physician's orders [REDACTED]. R1 had a physican's order dated [DATE], for [MEDICATION NAME] sulfate (MS) solution 20 milligrams/milliliter (ml) give .25 ml every three hours as needed for pain which equaled 5 mg. R1 had a physician's orders [REDACTED]. R1 had a physician's orders [REDACTED].R1's significant Minimum Data Set ((MDS) dated [DATE], indicated R1 was cognitively intact and was receiving hospice services. R1 was on scheduled and as need pain medication. R1 indicated frequent pain with an intensity of 9 on a scale of ,[DATE] with 10 being the worst pain. According to R1's (MONTH) (YEAR), Medication Administration Record [REDACTED]. Licensed Practical Nurse (LPN)-B documented the results as unknown. R1 did not receive any additional pain medication until LPN-B administered MS 5 mg at 12:24 p.m. for pain rated at a 6. LPN-B documented the results as unknown. R1's medical record lacked documentation as to what unknown meant. On [DATE], at 6:30 p.m. LPN-Y administered MS 5 mg for pain rated at a 7. LPN-Y documented the results as ineffective. At 8:14 p.m. LPN-Y administered [MEDICATION NAME] 10 mg orally for pain rated at a 7 with effective results. R1's medical record lacked documentation as to why the [MEDICATION NAME] was not administered until 8:14 p.m. when the MS was not effective at 6:30 p.m. R1's medical record also lacked documentation of a pain scale when LPN-Y documented the results as effective R1's nursing progress notes dated [DATE], at 9:30 p.m. indicated R1 was in bed most of the shift, with multiple complaints of pain noted. MS as ordered not sufficient in pain management. Updated hospice standing orders. R1's nursing progress notes dated [DATE], at 9:36 p.m. by LPN-Y indicated the MS was increased to MS 20 mg/ml .5 ml every hour as needed for pain which equaled 10 mg. According to R1's (MONTH) (YEAR), Medication Administration Record, [REDACTED]. LPN-B documented the results as unknown. At 10:59 a.m. LPN-B administered [MEDICATION NAME] 10 mg for pain rated at a 10 that was effective. At 11:00 a.m. LPN-B administered MS 10 mg for pain rated at a 10 which was documented as effective. R1's medical record also lacked documentation as to why pain medication was not administered at 9:14 a.m. when it was available to be given according to the physician's orders [REDACTED]. With increased MS and [MEDICATION NAME], R1's pain not easing below a 7 per her description. An ice pack was applied to her abdomen. R1 asked when the doctor was seeing her. LPN-B explained it was the weekend and the clinic was closed and her primary physician does not make rounds at the facility. R1 was angry stating that people had told her the doctor would be coming to see her. R1 was swearing. On [DATE], at 2:29 p.m. RN-Z administered MS 10 mg for pain rated at a 7. RN-Z documented the results as ineffective. RN-Z administered MS 10 mg at 4:55 p.m. for pain rated at a 7. RN-Z documented the results as ineffective. R1's medical record lacked documentation as to why the MS was not given within an hour when the effects of the doses at 2:29 p.m. and 4:55 p.m. were ineffective. R1's nursing progress notes dated [DATE], at 8:12 p.m. indicated R1 vomited 20 ml of brown emesis. R1 refused to eat/drink throughout the shift. R1 reported being very nauseated and medication was ineffective at this time. According to R1's MAR indicated [REDACTED]. R1 refused any medications due to nausea.According to R1's (MONTH) (YEAR), Medication Administration Record, [REDACTED]. LPN-B documented the results as effective. R1's nursing progress notes dated [DATE], at 8:48 a.m. indicated R1's pain medication was effective after the MS with a pain score of 8. R1's medical record lacked documentation as to why the MS was not given within an hour when the pain scale remained at an eight. R1's medical record lacked any nursing progress notes for [DATE]. According to R1's (MONTH) (YEAR), Medication Administration Record, [REDACTED]. LPN-AA documented the results as effective. R1 received [MEDICATION NAME] 10 mg at 12:43 p.m. for pain rated at a 10. LPN-AA documented the results as unknown. LPN-AA administered MS 10 mg at 2:02 p.m. for pain rated at a 10 with the results as unknown. R1's medical record lacked documentation as to why the MS was not given at 12:43 p.m. when the [MEDICATION NAME] was administered with a pain scale of 10. R1's nursing progress notes dated [DATE], at 1:50 p.m. documented by LPN-AA indicated R1 had complaints of nausea all day. Had one coffle ground emesis. With pain medications, pain was a 7 out of 10. Ice pack top abdomen. According to R1's (MONTH) MAR, she only received as needed nausea medication at 5:27 a.m. on [DATE]. According to R1's medical record she died on [DATE], at 3:45 p.m. An interview was conducted with LPN-B on [DATE], at 11:12 a.m. LPN-B stated if pain medications were not effective they would call hospice to get the order changed. An interview was conducted with the DNS on [DATE], at 3:41 p.m. The DNS stated they struggled with R1's pain management. R1 would not tell the staff she was having pain. R1 would call her family, who would call hospice, who called the facility. An interview was conducted with LPN-B on [DATE], at 2:33 p.m. LPN-B stated after she administered a pain medication she would check back with R1 within an hour. LPN-B stated the only reason she could think of for documenting unknown for pain effectiveness was that R1 was not in her room and possibly in the coffee shop. An interview was conducted with LPN-AA on [DATE], at 1:30 p.m. LPN-AA stated after she administered a pain medication she would check back with R1 within an hour. LPN-AA stated she thought R1's family was present and did not want R1 awakened so unknown was documented for pain effectiveness. LPN-AA stated the computer system did not prompt her to document a progress note when documenting unknown. An interview was conducted with the DNS on [DATE], at 2:04 p.m. the DNS verified that hospice was not contacted after [DATE], for guidance when R1 was experiencing nausea and vomiting and unable to take pain medications orally. The facility's pain management and pain interventions policy revised [DATE], indicated residents would be as comfortable as possible to promote well-being.

Based on interview and document review, the facility failed to provide immediate emergency care (life-sustaining treatment and cardiopulmonary resuscitation(CPR)) when 1 of 1 residents (R1) had a change in condition, stopped breathing, had no pulse, and died . Staff did not immediately initiate CPR, in accordance with the resident's advanced directives when R1's vital signs ceased. Findings include: R1's medical record indicated that R1 was admitted to the facility's TCU Station 6 on [DATE] after being hospitalized for [REDACTED]. R1 had extreme weakness and deconditioning due to the lengthy and complex hospital stay. The hospital's transfer orders indicated that R1's advance directive was DNR/DNI (do not resuscitate/do not intubate). The hospital's transfer orders for R1's medications, oxygen, diet, lab, therapies, wound treatment, and advance directive were authorized by R1's facility physician on [DATE]. Nursing staff transcribed this information into R1's electronic medical record (EMR) on [DATE]. The Advance Directive in R1's EMR indicated DNR. R1's admission nursing assessment, dated [DATE], indicated that R1 needed rehabilitative therapies to re-gain her prior level of independent function so she could return home. R1 was alert and oriented with clear speech. R1 could use a front-wheeled walker but needed hands-on assistance from staff when walking, due to R1's unsteady gait. R1 needed assistance from one staff for all activities of daily living as a result of R1's weakness. The progress notes, dated [DATE], indicated that a facility social worker assisted R1 with completion of a POLST (physician's orders [REDACTED]. The progress note indicated R1 "wants CPR and life-sustaining treatment."The POLST, dated [DATE], was signed by R1, the facility social worker, and R1's attending physician on [DATE]. The POLST indicated that R1 wanted (A): CPR, (B): Life-sustaining treatment (intubate, cardiovert, provide medically necessary care to sustain life, transport to ER), (C): Interventions and Treatment (Use intravenous/intramuscular antibiotic treatment and tube feeding). On [DATE], nursing staff transcribed R1's POLST order into the EMR. The line in the EMR where R1's Advance Directive was designated indicated "Do Not Resuscitate (DNR), MN POLST (A): CPR/Attempt Resuscitation. When not in cardiopulmonary arrest, follow orders in B and C." The progress notes, dated [DATE] at 8:00 p.m., indicated that staff found R1 lying in bed, unresponsive. R1 did not respond to a sternal rub. Staff re-positioned R1 in bed. R1 had respirations of 2 -3 per minute. R1 had a weak thready pulse. Staff checked the EMR for R1's advance directive wishes and observed that R1 was DNR. Staff stayed with R1 until R1's vital signs ceased at 8:29 p.m. Staff contacted R1's family member, who questioned the validity of the advance directive for DNR. Staff re-checked R1's EMR and then observed R1 also had an advance directive for CPR. Staff contacted the nurse manager regarding the two differing orders for R1's advance directive, one for DNR and one for CPR. Staff were directed to start CPR. 911 was called. Staff started CPR (time not documented) and continued CPR for 10 minutes, until emergency personnel arrived and assumed R1's emergency care. Emergency personnel discontinued CPR at 9:00 p.m. and R1 was pronounced dead. R1's death certificate indicated that R1's immediate cause of death was cardiac [DIAGNOSES REDACTED] and chronic diastolic heart failure. The time of death on the death certificate was 8:30 p.m. on [DATE]. Nursing Assistant (NA)/(J) was interviewed on [DATE] at 2:11 p.m. NA/(J) stated that she was assigned to R1's care on Station 6 during the evening shift of [DATE]. NA/(J) was in R1's room numerous times between 2:00 p.m. and 8:00 p.m. to see if R1 needed anything because R1 wasn't feeling good. R1 was complaining of a stomach ache. Except to go to the bathroom, R1 didn't walk at all on [DATE]. R1 stayed in bed all shift, but was alert and conversant per usual. NA/(J) assisted R1 to the bathroom around 7:15 p.m. At approximately 8:00 p.m., NA/(J) came out of another resident's room and saw R1's call light on. NA/(J) went immediately into R1's room. R1 was slumped crooked in the bed. It looked as though R1 had been sitting on the edge of the bed because R1's legs were dangling toward the floor and R1 was slumped backwards across the bed. NA/(J) called out R1's name but R1 did not respond. NA/(J) ran to get a nurse. RN/(E), who was the nearest nurse, came to R1's room immediately. NA/(J) and RN/(E) re-positioned R1 in the bed to elevate R1's head. R1 couldn't hold her head up so the head of R1's bed was elevated. RN/(E) told NA/(J) to go get the vital-sign cart and tell RN/(F) to check R1's Code status (advance directive). RN/(E) was interviewed on [DATE] at 3:10 p.m. RN/(E) stated she was working on Station 6 on [DATE]. RN/(F) was also working on Station 6. RN/(F) was assigned to R1's care. Around 8:00 p.m., RN/(E) responded to R1's room when NA/(J) notified her that R1 was unresponsive. RN/(E) went to R1's room and observed R1 lying across the bed with her feet dangling toward the floor. R1's eyes were open. RN/(E) called out R1's name but R1 did not respond. R1 did not appear to be breathing. RN/(E) shook R1's arm and performed a sternal rub, with no response from R1. RN/(E) and NA/(J) re-positioned R1 into a semi-fowlers position, with R1's head elevated. R1 then gasped for breath. RN/(E) yelled out to the hallway that she needed to know what R1's advance directive was. RN/(F) responded that R1 was DNR. RN/(E) sent NA/(J) to get the vital sign cart, which has an electronic blood pressure cuff, heart rate monitor, and pulse oximeter. RN/(F) came into R1's room, applied oxygen, and assumed R1's care. The three LPNs who were assigned to work on Station 5 on [DATE] had all come over to Station 6 to provide assistance. RN/(E) left R1's room and called R1's family to report R1's change in condition. R1's family answered the phone immediately. RN/(E) told the family that staff were keeping R1 comfortable, consistent with R1's advance directive for DNR. R1's family wanted to know why R1 wasn't being sent to the hospital. R1's family told RN/(E) that R1 would never have agreed to DNR. Several minutes later, RN/(F) came out of R1's room and said R1 had died . RN/(E) called R1's family again to report that R1 had passed away. When RN/(E) got off the phone with R1's family the second time, LPN/(I) was re-checking R1's EMR. LPN/(I) and RN/(E) then discovered that R1's EMR had two advance directives entered on the same line, one for DNR followed by one for CPR. Neither were dated. Due to the contradictory advance directives, LPN/(H) called RN Manager/(C), at home, for direction. RN Manager/(C) told the staff to start CPR. LPN/(H) called 911. RN/(E) and LPN/(I) started CPR. Approximately 6 minutes had elapsed since RN/(F) told the nurses that R1 had died . RN/(E) and LPN/(I) performed CPR for ten minutes, until emergency personnel arrived and took over R1's emergency care. RN/(F) was interviewed on [DATE] at 3:05 p.m. RN/(F) stated that she was assigned to R1's care on Station 6 from 3:00 p.m. to 3:30 a.m. on [DATE]. RN/(F) normally works on Station 6 and was familiar with R1. On [DATE], RN/(F) was in R1's room five times between 3:00 p.m. and 8:00 p.m. R1 wasn't feeling good. R1 had vomited twice and didn't eat dinner. RN/(F) had given R1 [MEDICATION NAME] around dinnertime, which alleviated R1's vomiting. Around 8:00 p.m., RN/(F) was assisting another resident in a room next to R1. RN/(F) left the other resident's room and was going down the hallway when RN/(F) heard RN/(E) yell out for R1's advance directives. RN/(F) immediately went to the medication cart in the hallway where RN/(F)'s laptop computer was located. RN/(F) quickly checked R1's advance directive, which indicated DNR. RN/(F) noticed only the DNR order, which was the first entry on the line for advance directive. RN/(F) did not notice the POLST order for CPR, which was the second entry on the same line for advance directive. RN/(F) grabbed a stethoscope and went to R1's room. RN/(E) told RN/(F) that R1 was breathing only 2 -3 times per minute. RN/(F) applied oxygen to R1. RN/(E) left R1's room when RN/(F) began to assess R1. RN/(F) observed that R1 was in bed in a semi-fowlers position. R1 was unresponsive. R1's hands, face, and toes were cold. R1 was not breathing. RN/(F) could not hear or feel R1's pulse. RN/(F) could not obtain a blood pressure with the electronic blood pressure cuff. LPN/(H), who had arrived in R1's room, took R1's blood pressure several times with a manual blood pressure cuff. R1's blood pressure was not obtainable. LPN/(H) checked R1's pulse and respirations. LPN/(H) said R1 had a weak thready pulse and respirations of 2 - 3 per minute. LPN/(G), who had arrived in R1's room, also checked R1's carotid pulse and listened to R1's heart sounds. LPN/(G) said R1 had a weak thready pulse and barely audible heart sounds. LPN/(G) and LPN/(H) left R1's room and went to the nurse's station. RN/(F) stayed with R1 for another ten minutes and continued to monitor R1's vital signs. RN/(F) attempted to obtain R1's blood pressure several times with the manual blood pressure cuff. R1 had no blood pressure. R1 had no heart sounds. R1 had no pulse or respirations. RN/(F) checked the time and it was 8:29 p.m. RN/(F) determined that R1 had died . RN/(F) went to the nurse's station, where several of the Station 5 and 6 nurses were congregated. R1's EMR was open on the computer at the nurse's station. Staff were looking at the advance directive. RN/(F) then observed the contradictory orders for R1's advance directive, one for DNR and one for CPR. LPN/(H) was on the phone with RN Manager/(C) regarding the discrepancy with R1's advance directives. RN Manger/(C) wasn't sure how to proceed and indicated the DON should be called for clarification. RN/(F) stated there wasn't time to call the DON, that staff needed to start CPR immediately if staff were going to follow R1's POLST order for CPR. RN Manager/(C) told nurses to start CPR on R1. RN/(F) checked her wrist watch. It was 8:33 p.m. RN/(F) ran to get the crash cart. RN/(E) and LPN/(I) went to R1's room and started CPR. RN/(F) took the crash cart to R1's room and remained in the room with RN/(E) and LPN/(I), who performed CPR for 10 minutes until emergency responders arrived. During the 10 minutes that facility nurses did CPR, R1 had no pulse and no respirations. Emergency personnel performed CPR for another 20 minutes, during which time R1 remained pulseless and breathless. Emergency personnel discontinued CPR around 9:00 p.m. R1 was not revived. Family member/(K) was interviewed on [DATE] at 9:02 a.m. Family member/(K) stated she spoke to R1 by telephone on [DATE] around 7:00 p.m. R1 didn't mention anything about not feeling well that day. About an hour after Family member/(K) spoke to R1, a facility nurse called Family member/(K) and said that R1 had a sudden decline and was breathing only 2 -3 times per minute. Family member/(K) asked the nurse to send R1 to the hospital and the nurse said,"we can't do that" because R1 has a DNR order. Family member/(K), who is R1's Power-of Attorney, questioned the DNR order and requested to over-ride the DNR order, consistent with wishes for life-sustaining treatment that R1 had expressed to Family member/(K). Family member/(K)'s request to over-ride the DNR order, request to have R1 transferred to the hospital, request that staff attempt CPR, and request to speak with R1 by telephone were all denied by the facility nurse. About ten minutes after Family member/(K) spoke to the facility nurse the first time, the nurse called again to inform Family member/(K) that R1 had passed away. RN Manager/(C) was interviewed on [DATE] at 8:02 a.m. RN/Manager/(C) stated that she oversees operation of TCU Station 6. On [DATE] at 8:33 p.m., TCU staff called RN Manager/(C) at home regarding the contradictory advance directives in R1's EMR. RN Manager/(C) directed TCU nurses to follow the most current order, which was R1's POLST for life-sustaining treatment and CPR. RN Manager/(C) told TCU nurses to start CPR on R1. RN/Manager/(C) later learned that R1 was not revived. The next day RN Manager/(C) conducted a root cause investigation to determine how the discrepancy with R1's advance directive occurred. RN Manager/(C) stated that she had entered R1's original hospital transfer orders into R1's EMR, which included R1's advance directive for DNR. Two days later on [DATE], another TCU nurse updated R1's EMR with R1's POLST for life-sustaining treatment and CPR, but the nurse did not delete the order for DNR. As a result, R1's EMR had two conflicting orders on the same line where Advance Directive is designated, the first order said DNR followed by a second contradictory order that said CPR. When R1's POLST was signed by the physician on [DATE] and entered into the EMR, RN Manager/(C) failed to double-check that R1's advance directive was accurate in R1's EMR. RN Manager (C) did not follow up and double-check this information for four days, [DATE], [DATE], [DATE], and [DATE]. The facility's policy for Advance Directives, revised [DATE], indicated "physician's orders [REDACTED].g., resuscitate or do not resuscitate, whether to hospitalize, whether antibiotics are to be used, etc. If a resident who has an advance directive informs a staff member he or she has changed his or her decision, the resident's wishes for different measures will be followed and the physician will be contacted for updated orders." The facility's policy for Advance Care Planning and completion of POLST, initiated [DATE] and revised [DATE], indicated "The facility will provide all residents the opportunity for Advance Care Planning and to complete a POLST document to communicate their wishes regarding treatments. The POLST will be sent to the primary care physician for signature. Once the POLST is returned, it will be given to nursing so the orders can be processed in the EMR. Nursing will be responsible for removing any old orders related to advance care planning, POLST, and Code Status. If a resident's POLST document is updated, this will replace the previous POLST document." The facility's policy for Cardiopulmonary Resuscitation (CPR), revised [DATE], indicated "In the event of a [MEDICAL CONDITION], residents that desire to have CPR performed will receive that service. Cardiopulmonary Resuscitation (CPR) certification is mandatory for all licensed nursing staff...who will perform CPR unless: 1) the resident has a do not resuscitate (DNR) order 2) the resident has obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) 3) the initiation of CPR could cause injury or peril to the rescuer."

Based on documentation and interviews the facility failed to ensure a resident identified at risk for developing pressure ulcers received the necessary care and services to prevent the development of a pressure ulcer for 1 of 1 residents (Resident #1). Findings include: Resident #1's medical record was reviewed and established that Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set, dated dated dated [DATE], indicated that Resident #1's cognition was severely impaired. She needed the assistance of two staff and a total body mechanical lift with bed mobility and transfers. A positioning assessment dated [DATE], revealed that Resident #1's Braden score was at twelve (high risk for developing a pressure ulcer). Resident #1's tissue tolerance showed that she was able to tolerate sitting up for two hours and lying without redness for three hours. On September 25, 2011, documentation established Resident #1 ' s skin was intact. A care plan updated November 22, 2011, directed staff to reposition Resident #1 every 3 hours while in bed and every 2 hours while in her wheelchair. Resident #1's skin was to be observed daily with cares. Resident #1 was to have a skin check done on bath day by a licensed nurse. A Nursing Orders document dated October 2011 and November 2011 was reviewed on December 6, 2011, and revealed that Resident #1 was to have a skin check every week on bath day by licensed staff. Resident #1 had no documentation that skin checks were done during October 2011. One skin check was initialed on November 3, 2011 as being done. A Nursing Orders document reviewed for the month of November directed staff to check Resident #1's coccyx area every day. On November 29 and 30, 2011, employee (C) LPN initialed that she checked Resident #'1 coccyx area. Employee (C) did not document a description of Resident #1 ' s coccyx area. A Nursing Documentation form dated December 3, 2011, revealed that Resident #1 had a stage II open area over coccyx. No further assessment or documentation of the wound was completed. Interdisciplinary Progress Notes were reviewed from September 7, 2011, through December 6, 2011, with no documentation of Resident #1's coccyx area. Employee (A)/ RN was interviewed on December 6, 2011, at 11:45 a.m., and stated that staff told her of Resident #1's red macerated tissue area over coccyx on November 25, 2011. No assessment of the wound was completed. Employee (A)/ RN was interviewed on December 6, 2011, at 3:45 p.m. and stated that she did not find documentation related to Resident #1's coccyx area. Employee (A) indicated that staff should be assessing and charting Resident #1's skin changes and condition. Employee (B)/ LPN was interviewed on December 20, 2011, at 9:00 a.m. and indicated that she observed the red area on Resident #1's coccyx on November 21, 2011. Employee (B) stated that Resident #1's coccyx area was " raw " and red looking and approximately dime size. Employee (B) did not document any skin assessment. A review of Resident #1 ' s care plan lacked any documentation related to her skin changes. Employee (B) indicated that she instructed the NA's to place dry gauze over the red area. Employee (C)/ LPN was interviewed on December 19, 2011, at 1:00 p.m. and indicated that on December 3, 2011, she saw and charted that Resident #1's had a stage II open area over her coccyx. No further assessment of the wound was completed. Employee (C) stated that she and other staff should have been assessing and documenting Resident #1's skin condition. Employee (H)/ NA was interviewed on December 6, 2011, at 10:30 a.m. and indicated that he received report to position Resident #1 on her side and put 2 x 2 gauze over the top of the open coccyx area to keep it dry and prevent feces from getting to the area. Employee (H) was asked to do this prior to November 24, 2011, but unable to recall the exact date. The facility's procedure for Pressure Ulcers: Skin Assessment and Prevention, dated January 2011, directed the registered nurse to record the type of wound and the degree of tissue damage. The procedure directed the licensed nurse to record the location of the area, the measurements and the ulcer/wound characteristics.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment/services to prevent the development of a decline in range of motion unless determined to be unavoidable for 1 of 3 residents (R47) in the sample identified with a limitation in range of motion. R47 had sustained harm related to the development of a right hand contracture. Findings include: R47 had not received the necessary treatment/services in an attempt to prevent a right hand contracture identified on 10/15/10. R47 was admitted to the facility 7/26/2002, and [DIAGNOSES REDACTED]. The most recent 11/18/10, quarterly Minimum Data Set (MDS) indicated R47 had short and long term memory impairments with severe impaired decision making. R47 was identified as requiring extensive assistance with bed mobility, transfers, toileting, and was non-ambulatory. R47 was identified as requiring total assistance with dressing, eating, and personal hygiene. The annual MDS dated [DATE], indicated R47 required extensive assistance with eating, but did participate. From the time of the quarterly MDS dated [DATE], R47 was identified to require total assistance with eating. The 11/24/10, plan of care identified R47 had a self-care deficit and potential for impaired mobility related to [MEDICAL CONDITION]'s chorea and dementia, and directed staff to provide total assist with activities of daily living. R47 was noted to frequent chorea movements. The care plan lacked interventions to help maintain and minimize the risk of decreases in range of motion, except for repositioning. The physician progress notes [REDACTED]." However, the record lacked any documentation addressing the identified right finger contracture and increased resistance of the right arm after it was identified. On 12/1/10, at 9:20 a.m. R47 was observed in her reclining chair in the dining room as NA-A fed her breakfast. R47 held both of her hands in a clenched position. At 9:50 a.m. RN-A/Unit manager stated the resident was not able to open her right hand totally. The RN attempted to open R47's right hand and the 2nd and 3rd fingers were not able to be extended. At that time, the RN stated R47 had a contracture in the right hand. At 10:10 a.m. NA-A stated she thought it had been about two weeks since R47 was able to open her right hand, and the RN was aware of the contracture. She stated the NAs were not providing any range of motion services for R47. On 12/1/10, at 11:30 a.m. RN-A and RN-B stated the resident had the right hand contracture when the MDS was completed on 11/18/10, but it was not identified and coded on the document. At this time, RN-A also stated a referral had just been sent to physical therapy to have R47's right hand evaluated. They verified no services or treatment were in place related to the right hand contracture.