Every finding on record at Good Samaritan Society - International Falls

Based on observation, interview, and document review, the facility failed to ensure shaving preferences were assessed and provided for 1 of 5 residents (R8) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Findings include:R8's annual Minimum Data Set MDS dated [DATE], identified R8 had severe cognitive impairment and diagnoses that included dementia. R8 required substantial/maximal assistance for personal hygiene.R8's medical record lacked evidence his shaving preferences were assessed.R8's care plan revised 12/2/25, identified R8 had an ADL self-care performance deficit related to right shoulder pain, dementia, and a traumatic brain injury exhibited by need for assist with ADL's. The care plan directed staff R8 required assist of one staff to complete personal hygiene. However, the care plan failed to address R8's shaving preferences.During an observation on 1/13/26 at 8:58 a.m., R8 was up, dressed for the day and sitting in his wheelchair at a table in the dining room. R8 had an approximately 1/4 inch beard growth. During an observation on 1/13/26 at 9:28 a.m., nursing assistant (NA)-A and NA-B assisted R8 to toilet and lie down in bed. NA-A nor NA-B offered R8 shaving.During an observation on 1/13/26 at 2:10 p.m., R8 was lying in bed and was covered with blankets to his chest. R8 continued to have an approximately 1/4 inch beard growth. During an interview on 1/13/26 at 2:21 p.m., NA-A stated residents were only shaved on their bath days due to staffing and it's just too hectic down here.During an interview on 1/13/26 at 5:01 p.m., licensed practical nurse (LPN)-A stated residents were shaved on their bath days or if the resident requested to do it. If a resident was unable to request, shaving would only occur on their bath days. During an interview on 1/13/26 at 5:10 p.m., family member (FM)-A stated R8 always shaved every day, and she tried to have to staff shave R8 at least every other day. I don't like it, but I have a hard time to get anyone to do it.During an interview on 1/14/26 at 10:15 a.m., registered nurse (RN)-A stated staff were not expected to shave male residents every day, but it depended on the resident's preference. RN-A stated she was unaware of any resident that wanted to be clean shaven every day and shaving usually happened on shower days. If family wanted a resident shaved more often, staff should be doing that and directed in the resident's care plan. The facility policy Activities of Daily Living revised 12/1025, identified Any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming and personal and oral hygiene. Based on the resident's comprehensive assessment, the center will ensure the resident's ability in activities of daily living (ADL) does not decline except when unavoidable for reasons of disease progression, deterioration of physical condition associated with disability or refusal of care/treatment by the resident or legal representative. Evidence of any of these reasons will be reflected in the medical record. ADLs are those necessary tasks conducted in the normal course of a resident's daily life. Included in these are the following: general personal, daily hygiene/grooming: care of hair, hands, face, shaving, applying makeup, skin, nails and oral care.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was provided following personal cares for 2 of 5 residents (R5, R8) observed during the provision of activities of daily living (ADLs).Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 had severe cognitive impairment with a diagnosis of dementia. R8 required substantial/maximal assistance for personal hygiene.R8's care plan revised 12/2/25, identified R8 had an ADL self-care performance deficit related to right shoulder pain, dementia, and traumatic brain injury exhibited by the need for assist with ADL's. R8 required assist of one staff for personal hygiene. R8 required stand aide with assist of 1 and a riser on the toilet for toileting. R5's quarterly (MDS) dated [DATE], identified R5 was cognitively aware and had diagnoses that included hemiplegia and hemiparesis (left sided weakness). R5 required substantial/maximal assistance with toileting.R5's care plan revised 7/27/25, identified R5 had an ADL self-care performance deficit related to previous cerebral vascular accident (CVA) (stroke) with left sided hemiplegia/hemiparesis, osteoarthritis, contractures to left wrist and left foot, pain and weakness. R5 was usually continent of bowel and bladder, with occasional urge incontinence. R5 worse a pull-up incontinent brief. R5 will inform staff of need to toilet, requires staff assistance of 1 with sit to stand mechanical lift. Staff provide peri hygiene and assist with pants.During an observation on 1/13/26 at 9:28 a.m., NA-A and NA-B put on gowns, gloves and surgical masks upon entering the room. NA-A nor NA-B used hand sanitizer prior to putting on their gloves. NA-A drained R8's catheter bag.At 9:38 a.m., NA-A and NA-B to stand using a mechanical lift. NA-A pulled down R8's pants and incontinent brief and stated R8 had a small bowel movement. R8 was wheeled to the toilet and, while standing in front of the toilet in the mechanical lift, NA-A cleaned the feces from R8's skin.At 9:40 a.m., NA-A cleaned R8's catheter tubing with a disposable wipe.At 9:42 a.m., R8 sat down on the toilet because he started to have a bowel movement. NA-B gave R8's his call light. NA-A continued to wear the same gloves. At 9:44 a.m., NA-B removed their gloves and gown and did not perform hand hygiene and left R8's room.At 9:48 a.m., NA-B returned to R8's room and put on a gown and gloves. R8 was raised off the toilet and NA-A cleaned the feces from R8's skin with a disposable wipe.At 9:55 a.m., R8 was assisted to lie down in bed. NA-A and NA-B removed their gowns and gloves and exited R8's room. Neither washed their hands and/or used hand sanitizer. At 9:59 a.m., NA-A entered R5's room with the mechanical lift without washing her hands or using hand sanitizer. NA-A applied gloves and transferred R5 from her wheelchair to the toilet using the mechanical lift.At 10:03 a.m., NA-A was observed to assist R5 with cleaning her perineum with a disposable wipe, then pulled up R5's pants and assisted R5 to transfer back into her wheelchair.At 10:05 a.m., NA-A removed her gloves but did not wash her hands or use hand sanitizer before exiting R5's room. During an interview on 1/13/26 at 10:08 a.m., NA-A stated she should have washed her hands the second she took off her gloves after R8's perineal cares so I don't spread germs around the room. Also, NA-A stated she should have either washed her hands or used hand sanitizer before entering R5's room. During an interview on 1/14/26 at 10:15 a.m., registered nurse (RN)-A stated staff should have washed hands after doing bowel movement incontinence cares or any peri-care before moving on to clean areas. Additionally, staff were expected to either wash hands or used hand sanitizer before moving on to the next resident. The facility policy Hand Hygiene revised 11/13/25, identified the purpose of the policy was to establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings. All employees in patient care areas (unless otherwise noted in their policy will adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene.1. Entering Room2. Before Clean Task3. After Bodily Fluid/Glove Removal4. Exiting Room5. Zones: Patient zone and Health-care zones.

Based on interview and document review, the facility failed to promptly notify the ordering primary care provider of an abnormal laboratory result for 1 of 5 residents (R4) reviewed for unnecessary medications.Findings include: R4's significant change Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact and required maximal assistance with dressing and moderate assistance with toileting, grooming and transfers. Diagnoses included atrial fibrillation (irregular heartbeat), anemia, depression, long term use of anticoagulants and dysphagia (difficulty swallowing). P4's Elder Care 60 Day Regulatory Visit dated 11/17/25, identified P4 was being seen for regular routine rounds with orders to draw yearly comprehensive blood count with differential (CBC), basic metabolic panel (BMP), thyroid stimulating hormone (TSH). prothrombin time (PTT) and a ferritin level (which indicated the amount of iron stored in the body). P4's medical record lacked documentation of lab work drawn, or results of any blood tests. P4's physician medication orders identified P4 received ferrous sulfate (an iron supplement) 325 milligrams every morning for anemia. During interview on 1/13/26, at 11:31 a.m. registered nurse (RN)-B stated there was an order to draw lab work for P4 in November. The medical center's laboratory staff came weekly to draw resident's labs. RN-B obtained the laboratory results in the residents shared one chart and printed them. If lab work was normal, she put it in the facility scanning pile to be scanned by activity staff. If there were abnormal laboratory results RN-B would call the resident's primary care provider and document that in the resident's progress notes. RN-B was unable to locate P4's laboratory results from lab work in November or documentation of lab work in P4's progress notes. RN-B was able to locate the ordered laboratory results in P4's shared one chart and printed the results to be scanned into P4's medical record. P4's laboratory results completed on 11/18/25, identified a blood sample was obtained to complete a CBC, BMP, PTT, TSH and ferritin level. An abnormal ferritin level was identified with a high value of 574-unit nanograms per milliliter (ng/ml) with normal reference range of 5 to 204 ng/ml. R4's progress notes 11/18/25 to 1/13/26 and rounding provider visit notes on 11/25/25 and 12/17/25, lacked documentation of review of lab results obtained on 11/18/25, or provider notification of the abnormal ferritin level. During interview on 1/13/26, at 11:53 a.m. RN-A stated it was not the facility's practice to document labs drawn or lab results into the resident charts. The nurse managers printed off the lab results from the resident's shared one chart and put them in to be scanned into the resident's facility chart after reviewing the results. It would be difficult to determine if the lab results had been reviewed or if the primary care provider had been notified of abnormal results. Sometimes RN-A called the provider, or the provider called the facility to address abnormal labs. RN-A was unable to find provider documentation of the lab results from lab work obtained 11/18/25 and stated it would be important to know the provider was aware of any abnormal lab work and she was unable to find documentation R4's lab elevated ferritin level had been reviewed by the provider. During interview on 1/14/26, at 10:44 a.m. the director of nursing (DON) stated the facility's practice was to have nurse managers go into the resident's shared one chart and obtain lab results as the results rarely got sent to them automatically. If lab work had abnormal results, the nurse manager should let the provider know. The nurse managers should be documenting the lab results in the resident's medical record, and the DON did not feel that was currently being done. For P4's elevated ferritin level, the facility should have called the provider to ensure the abnormal level was addressed. The facility's policy Laboratory Services dated 12/1/25, identified laboratory services would be done only when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist. Findings would be reported to the medical provider who ordered the test in a timely fashion. Laboratory results would be noted by a licensed nurse and scanned int the resident's medical record.

Based on interview and document review, the facility failed to develop action plans for identified areas of monitoring and failed to identify and implement at least one process improvement project (PIP) This had the potential to affect all 50 residents who resided in the facility. Findings include: The Quality Assurance, Action Committee Meeting Minutes dated 7/11/24, identified the team had reviewed the following topics: -infection control. -emergency operation plan and facility assessment. -dietary concerns -therapy staffing changes -documentation of assessments and coding -resident council complaints -life style enrichment -human resources -life safety and environment The data failed to identify any facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality Assurance, Action Committee Meeting Minutes dated 8/22/24, identified the team had reviewed the following topics: -nursing services -resident council complaints -safety and emergency preparedness -employee action committee results -financial stewardship, -action plans from survey, [NAME] reports and/or corporate compliance. The data failed to identify any facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality Assurance, Action Committee Meeting Minutes dated 10/31/24, identified the team had reviewed the following topics: -incidents and safety -infection control -medication regimen review -QAPI plan priorities -staff quality concern trends -hand hygiene compliance -survey readiness -resident and family concerns -survey results The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. Although the facility listed out areas they were collecting data on there was a lack of information on whether the items were PIPS that required an action plan. Further, the facility could not provide evidence of any PIP project they were working on that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis. When interviewed on 11/25/24, at 4:15 p.m. registered nurse (RN)-D stated she was responsible for the facility's QAPI program. RN-D received monthly audits from corporate and the facility was required to do them. Each month the audits would have a different focus. RN-D also gathered data for QAPI through focused chart reviews and track and analyzing incident reports. RN-D had social services report complaints and grievances to the QAPI committee as well. RN-D also collected data from review of resident council minutes and interactions with residents and families on a day-to-day basis. The facility did have significant issues with staffing in the beginning of the year and the main focus had been on staffing and staff retention. Now that had improved, and they could focus on other issues. Infection control and review of infections were addressed at every QAPI meeting; however, RN-D had not fully addressed the facility's response to their recent COVID-19 outbreak. That was on her agenda to discuss at the next meeting. RN-D stated performance improvement projects (PIPS) were new to her. She had just taken over QAPI and had not received much training on PIPS. RN-D was just trying to redirect everything in a format she could work with, and her next project was to figure out what type of PIP to work on. RN-D stated she needed to learn how to do the PIPS. During interview on 11/25/24, at 4:30 p.m. the director of nursing (DON) stated RN-D ran the QAPI program. The DON was not aware the facility did not have any developed PIPS in place. The DON stated there should be performance improvement projects in place and she would have helped identified areas to implement PIPS if she had been aware there were none. The facility's Quality Assurance and Performance Improvement policy dated 10/9/23, identified at a minimum one performance improvement project would either be in development, ongoing or completed annually utilizing the improvement model adapted by the location. Performance improvement project activity would be monitored for progress and sustainability. Performance improvement activities would focus on high risk, high volume, or problem prone areas. Would consider incidence, prevalence, and severity of problems in that area and would lead to immediate correction of any identified problem that directly or potentially threatened the health and safety of residents. The QAPI committee was responsible for tracking and trending performance, systematically analyzing and prioritizing quality deficiencies, develop action plans, and monitor for effectiveness and sustainability.

Based on observation, interview and document review, the facility failed to develop and implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting infections and communicable disease along with a monthly analysis; and failed to conduct COVID-19 testing of staff and residents per Centers for Disease Control (CDC) guidelines. In addition, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 1 resident (R205) reviewed with pressure ulcers; and failed to wear a mask during a peripherally inserted central catheter (PIIC) line dressing change for 1 of 1 resident (R206) reviewed with a PIIC. These deficient practices had the potential to affect all 50 residents residing in the facility. Findings include: Surveillance and Analysis: The Monthly Report of Resident Infections in Location dated August 2024, identified unit, resident name, room number, admitted , infection type, body system, criteria met yes or no, onset C (community) or F (facility), symptoms, onset date, infection risk factors, precautions type and date resolved. The report identified two COVID-19 cases, one dental abscess, one conjunctivitis (pink eye), one case of shingles, one pneumonia, three cellulitis, two osteomyelitis (bone infection), eight urinary tract infections (UTI) and one resident without an identified infection who demanded antibiotic drops. However, the report failed to identify if the infections were provided treatment, if any, nor did the report identify a resident with symptoms of a viral infection. The Monthly Infection Summary dated August 2024, identified all identified infections received treatment with an antimicrobial. The Monthly Infection Control Report dated August 2024, identified the total number of infections, the infection rate (infections/1000 resident days), antibiotic orders utlization (orders/1000 resident days) and antibiotic days of therapy (days of therapy/1000 resident days). For the month of August the following information was listed: - total number of nosocomial (healthcare acquired) infections 14 - infection rate: 8.85 percent (%) - antibiotic orders utlization: 13.28% - antibiotic days of therapy: 119.5 ordered, 114.5 actual The August 2024 Infection Control Reports identified the facility had 17 infections (14 facility acquired and 3 community acquired), 14 met McGreer's Criteria, 3 did not meet McGreer's Criteria and the facility antimicrobial usage rate was higher than the enterprise as a whole (13.28% versus 5.92%). The Monthly Report of Resident Infections in Location dated September 2024, identified unit, resident name, room number, admitted , infection type, body system, criteria met yes or no, onset C (community) or F (facility), symptoms, onset date, infection risk factors, precautions type and date resolved. The report identified two eye infections, three cases of COVID-19, two cellulitis and one chronic obstructive pulmonary disease (COPD) exacerbation. However, the report failed to identify if the infections were provided treatment, if any nor did the report identify a resident with symptoms of a viral infection other than COVID-19. The Monthly Infection Summary dated September 2024, identified all but three cases of COVID-19 received antimicrobial treatment. The Monthly Infection Control Report dated September 2024, identified the total number of infections, the infection rate (infections/1000 resident days), antibiotic orders utlization (orders/1000 resident days) and antibiotic days of therapy (days of therapy/1000 resident days). For the month of August the following information was listed: - total number of nosocomial (healthcare acquired) infections: 7 - infection rate: 5.3% - antibiotic orders utlization: 3.3% - antibiotic days of therapy: 27.9 The September 2024 Infection Control Reports identified the facility had 17 infections (14 facility acquired and 3 community acquired), 14 met McGreer's Criteria, 3 did not meet McGreer's Criteria and the facility antimicrobial usage rate was higher than the enterprise as a whole (33.2% versus 17.6%). The facility failed to provide a written summary of the analysis of actual/potential infections in the facility. The Monthly Report of Resident Infections in Location dated October 2024, identified unit, resident name, room number, admitted , infection type, body system, criteria met yes or no, onset C (community) or F (facility), symptoms, onset date, infection risk factors, precautions type and date resolved. The report identified nine cases of COVID-19, one cellulitis, one pneumonia, and four UTI. However, the report failed to identify if the infections were provided treatment, if any nor did the report identify a resident with symptoms of a viral infection other than COVID-19. The Monthly Infection Summary dated October 2024, identified all but the cases COVID-19 received antimicrobial treatment. The Monthly Infection Control Report dated October 2024, identified the total number of infections, the infection rate (infections/1000 resident days), antibiotic orders utlization (orders/1000 resident days) and antibiotic days of therapy (days of therapy/1000 resident days). For the month of August the following information was listed: - total number of nosocomial (healthcare acquired) infections: 17 - infection rate: 11.22% - antibiotic orders utlization: 6.6% - antibiotic days of therapy: 38.9 The September 2024 Infection Control Reports identified the facility had 17 infections (14 facility acquired and 3 community acquired), 14 met McGreer's Criteria, 3 did not meet McGreer's Criteria and the facility antimicrobial usage rate was lower than the enterprise as a whole (5.4% versus 8.85%). The facility failed to provide a written summary of the analysis of actual/potential infections in the facility. The Monthly Report of Resident Infections in Location dated November 2024, identified unit, resident name, room number, admitted , infection type, body system, criteria met yes or no, onset C (community) or F (facility), symptoms, onset date, infection risk factors, precautions type and date resolved. The report identified two COVID-19 cases, three cellulitis, one osteomyelitis (bone infection), and three urinary tract infections (UTI). However, the report failed to identify if the infections were treated with an antimicrobial. No further information for November 2024 was provided. During an interview on 11/19/24 at 12:57 p.m., registered nurse (RN)-D stated she was responsible for the facility's Infection Prevention Program. RN-D reviewed antibiotics ordered and rounds/observation of what the staff were doing, including hand hygiene audits. RN-D updated the surveillance log everyday Monday through Friday. At the end of the month, RN-D completed all the reports that were needed for Quality Assurance. RN-D did not usually list residents with cold symptoms and/or sniffles on the surveillance log. Now that you say that I should be tracking it. During an interview on 11/21/24 at 3:06 p.m., the DON stated the facility needed to create a better tracking system to track staff and resident illness to prevent the transmission of illness. A facility policy related to infection surveillance, tracking and trending was requested but not received. STAFF TESTING The Centers for Disease Control (CDC) website Infection Control Guidance: SARS-CoV-2 (COVID-19) dated 6/24/24, identified a single new case of COVID-19 infection in any health care provider (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. Perform testing for all residents and HCP identified as close contacts or on the affected unit. Testing was recommended at day 1, day 3 and day 5, where day of exposure is day 0. If additional cases were identified, testing should continue on affected units or facility-wide every 3 to 7 days until there were no new cases for 14 days. A facility untitled spreadsheet dated 6/18/24 through 11/14/24, identified employee name, positive test date, symptoms onset date, last day worked, unit(s) assigned/worked, precautions (return to work (RTW) dated and instructions) and symptoms. The spread sheet identified nine employees with onset positive dates which included: nursing assistant (NA)-C on 9/28/24, NA-D on 10/10/24, NA-E on 10/12/24, N A-L on 10/13/24, NA-F on 10/13/24, NA-G on 10/15/24, registered nurse (RN)-C on 10/15/24, NA-H on 10/18/24, NA-I on 10/23/24, NA-J on 11/2/24 and NA-K on 11/14/24. An undated facility COVID Testing Roster, identified staff name, test #1 results/date, test #2 results/date, test #3 results/date and symptoms. However, the roster failed to identify which staff were required to test or when. Review of the staff schedule 9/27/24 through 11/25/24, identified two registered nurses (RN), one trained medication aide (TMA), and 17 nursing assistants (NA) did not test according to CDC guidance during the breakout period. Additionally, one RN and 4 NAs were not listed on the COVID Testing Roster. During an interview with RN-D and the DON on 11/21/24 at 2:47 p.m., RN-D stated, if a staff member tested positive for COVID-19, RN-D sent an electronic communication to all staff working on the unit where the positive staff member last worked to notify them, they needed to test that day. RN-A spoke with dietary and activities staff, so they knew to test as well. RN-A then put a COVID-19 Testing Roster including all staff out on the unit. Staff were tested by the nurse working on the unit and marked off on the roster. However, RN-D did not identify any staff on the roster who were required to test. Review of the COVID-19 Testing Roster with the staff schedule, identified staff that did not test according to CDC guidance. The DON stated she believed the untested staff were casual staff that did not regularly work at the facility. Many tested while at home and called results into the facility, but there was no documentation of the result. RN-D stated the casual staff just didn't come into the facility to test. Additionally, the DON stated she believed the registered nurses also tested but forgot to document their results. The DON stated staff and residents were sick of COVID-19 and testing nonchalantly because they were not taking COVID-19 as seriously. It was frustrating. The facility needed to create a better tracking system to track staff and resident testing. Staff were expected to test before their shift and the facility needed to implement a system to do that. Additionally, the DON stated she needed to be informed of staff who refused to test so the DON can address it with the staff member. It was a system failure. RESIDENT TESTING A facility untitled spreadsheet dated 9/27/24 through 11/5/24, identified resident name, positive test date, symptom onset date, isolation period, out of isolation date, symptoms, and treatment (if any). The spread sheet identified 14 resident names with positive test results: R44 on 9/27/24, R39 on 9/30/24, R16 on 9/30/24, R42 on 10/2/24, R31 on 10/13/24, R4 on 10/13/24, R40 on 10/13/24, R1 on 10/13/24, R6 on 10/15/24, R33 on 10/15/24, R14 on 10/18/24, R26 on 10/21/24, R19 on 11/4/24 and R36 on 11/5/24. A facility COVID Testing Roster for residents was requested but not received. A facility list of residents tested due to symptoms was requested but not received. R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R36 was [AGE] years old and had diagnoses that included hypertension. R36's nursing progress note dated 11/5/24 at 12:54 p.m., identified R36 was seen during rounds this morning by the nurse practitioner (NP). Discussed R36's complaints regarding moods, pain, and general complaints of not feeling well. The NP discussed with R36 and R36 was agreeable to increasing dosage of Abilify (an antipsychotic medication). Received order via fax to increase dose from 2 milligram (mg) per day to 3 mg per day for 2 weeks and then, if tolerating, increase to 4 mg daily at HS for mood stability. Order entered. However, the note failed to identify what R36's complaints of not feeling well were and/or if R36 was tested for COVID-19. R36's nursing progress note dated 11/5/24 at 8:53 p.m., identified R36 tested positive for COVID-19. R36 was increasingly confused and restless, R36 was walking in hallway to get something to drink. R36 was assisted into bed and 15-minute checks were initiated. During an interview on 11/21/24 at 9:02 a.m., TMA-A stated symptoms of COVID-19 included sore throat, runny nose, congestion, all the symptoms a cold has and fevers. Whenever a resident showed symptoms like that, they should be tested because often it's COVID-19. Usually, the nurse on the unit collected the test and, if negative, the resident was tested again in two days. If symptoms resolved and the original test was negative, the second test did not need to be collected. When the facility was in a COVID-19 outbreak, staff needed to test every other day to make sure COVID-19 did not spread throughout staff, residents, and visitors. During an interview on 11/21/24 at 9:19 a.m., NA-W stated symptoms of COVID-19 included sore throat, cough, body aches, fever and then sometimes not a fever. Everyone was different, especially the elderly. During the facility's COVID-19 outbreak, NA-W stated she noticed many residents became incontinent of bowel and that was the first sign something was wrong. R36 had a cough, fever and just really bad body aches. During an interview on 11/21/24 at 9:38 a.m., RN-A stated R36 was tested for COVID-19 on 11/4/24 due to facility outbreak testing and was negative. On 11/5/24, R36 complained of body aches and headache. That was kind of R36's initial complaints and later also complained of a sore throat. RN-A stated she did not test R36 for COVID-19 when R36 complained of symptoms nor placed R36 into isolation because RN-A was focused on R36's pain. RN-A stated she was unsure when a resident should be placed into isolation for exhibiting symptoms because RN-A relied on RN-D to tell her. During an interview on 11/21/24 at 9:58 a.m., RN-D stated she was told R36 was tested for COVID-19 due to exhibiting symptoms but was unaware R36 had complained of COVID-19 earlier in the day nor had reviewed R36's chart. During an interview on 11/20/24 at 6:55 p.m., RN-D stated an COVID-19 outbreak was one or more positive case. The facility's first outbreak started on 9/27/24 and ended 10/21/24. Then the facility had another COVID-19 outbreak that started 11/4/24 and ended 11/15/24. An outbreak ended when residents and staff made it passed their isolation period and the facility had done 3 rounds of testing with no more positives on days 1, 3 and 5. The facility only needed to test 3 times and if no more positives, the outbreak was over. If there was another positive, the outbreak testing restarted until the facility had 3 consecutive tests without any further cases. RN-D did not keep any type of tracking of resident COVID-19 testing. The test was documented in the residents' electronic treatment administration record (ETAR). If a resident was positive, a nursing note would be documented as well. - On 9/27/24, R44 tested positive for COVID-19 at 10:30 a.m. RN-D stated that was day 1 and all residents and staff who had not had COVID-19 in the past 30 days on that unit were tested that day, then residents were tested again three days later. - On 9/30/24, two residents tested positive on another unit and this threw off the facility's testing plan. The facility added an extra two days of testing to ensure COVID-19 was not spreading more. COVID-19 outbreak testing was halted on 10/4/24. - On 10/10/24, NA-D worked a partial shift in two units. The first unit, NA-D wore a mask because there were positive cases but when she moved to the other unit removed her mask. RN-D stated she was unaware NA-D was working in two units because the facility did not typically do that. On 10/10/24, RN-D implemented masking on all units, however, outbreak testing did not begin until 10/13/24. RN-D stated she should have kept a paper record of all resident and staff testing to ensure she was able to track testing. Tracking of testing would ensure all staff and residents were tested according to CDC guidance. R36's medical record failed to identify when R36 was placed into transmission-based precautions. During an interview on 11/21/24 at 3:08 p.m., the DON stated the residents were tested on days one, three and five and stopped testing positive on 10/4/24. The facility halted COVID-19 outbreak testing. Any new resident testing positive would have restarted the cycle of every two-day testing. The COVID-19 Confirmed Case Checklist updated 8/31/23, identified when a case of COVID-19 had been suspected/confirmed in the location: Isolate (suspected or confirmed case): The DON and Infection Preventionist determine isolation period: - The day of the positive test or symptom onset (whichever is sooner) is day zero. - Asymptomatic or mild to moderate illness: Isolate Day O through day 1 O - Severe to critical illness or residents with immunocompromising conditions: isolate up to 20 days. Test-based strategy may be used starting on Day 10, 2 negative tests 48 hours apart are needed to discontinue prior to day 20. - Confine resident to their room. Door should remain shut if safe. Pull privacy curtain. Isolate in a private room, if possible. - Initiate Airborne and contact transmission-based precautions. - Station with PPE including N95 respirator, eye protection, gowns and gloves available immediately outside of resident room. - Assign employees to care for the positive resident. - Implement source control masking in common spaces on affected units. - Look back two days from start of symptoms or positive test, whichever was sooner, to identify all residents, staff and visitors as able who had close contact or higher risk exposure with this resident. - Initiate outbreak testing via contact tracing or broad-based testing - Test all Employees and Residents determined to be close contacts/higher risk exposures on Day 1, Day 3, and Day 5 following the exposure. - Contact trace any additional identified positives. - If unable to conduct contact tracing, move to broad based testing of all employees and residents on a unit/hall or facility on Day 1, Day 3, and Day 5 - If the outbreak becomes uncontained, move to testing of all employees and residents every 3-7 days until no new cases of COVI D-19 are identified for 14 days. Choosing a test - Either Antigen or NAAT can be used. Antigen testing is preferred for symptomatic people and for people who have recovered from COVID-19 infection in the prior 31-90 days. - People should not be included in outbreak testing through contact tracing or broad-based testing for 30 days following the onset of their COVID-19 illness unless new symptoms develop, in which case antigen test should be used. - Instruct symptomatic employees to get tested immediately, prior to working. - Instruct positive employees to stay home. Surveillance and Mitigation Plan for SNFs updated 4/26/23, identified if symptomatic residents test negative with an antigen test, they should be placed into transmission-based precautions, and in a single room, if possible, but not cohorted with a known positive resident until a confirmation test with a PCR is received or confirmation with another negative antigen test 48 hours later. 41575 EBP: R205's admission MDS dated [DATE], identified R205 had moderate impaired cognition. R205 had one stage three pressure ulcer and one unstageable ulcer present on admission. In addition, the MDS identified R205 had infection of foot and required pressure ulcer care and application of dressings to his feet. Diagnoses included dementia, anxiety, and diabetes. R205's care plan dated 11/20/24, identified R205 had an unstageable pressure ulcer to his left second toe and stage three pressure injury to his right great toe. Staff were directed to monitor location, size and treatment of skin injury and report abnormalities to the provider, provide supplemental protein, vitamins, and minerals to support healing and notify nurse of any new skin breakdown or concerns. During observation on 11/20/24 9:55 a.m. licensed practical nurse (LPN)-A entered R205's room to change the dressing on his foot after applying alcohol-based hand sanitizer (ABHR). LPN-A gathered dressing supplies from R205's closet and put on gloves. LPN-A removed R205's sock on right foot. No dressings were visible and the wound on right great toe was left open to air. The wound was approximately three centimeters in diameter and was a stage two wound with a crater like appearance. LPN-A dabbed the wound with a 4x4 sponge. LPN-A changed gloves and applied iodosorb ointment with a cotton tipped swab into the wound bed. LPN-A covered the wound with a Band-Aid and put a sock and soft tennis shoe slipper onto R205's foot. LPN-A removed her gloves, put away supplies and washed her hands before exiting the room. There was no signage or personal protective equipment (PPE) cart outside of R205's room to indicate he was on enhanced barrier precautions. During interview on 11/20/24, at 1:45 p.m. LPN-A stated the infection preventionist (IP) determined and setup enhanced barrier precautions (EBP) when it was needed for residents. Staff identified when they needed to implement enhanced barrier precautions to care for a resident when a PPE cart and signage was located outside a resident's door. R205 has never needed EBP since his admission and so she just used gloves for the dressing change to his foot. LPN-A knew EBP were needed for resident with catheters or wounds but not exactly sure when they were required. LPN-A just relied on the IP nurse to let staff know when EBP was needed to care for residents. When interviewed on 11/21/24, at 11:15 a.m. registered nurse (RN)-C stated she did not know why R205 was not on EBP. The IP nurse had told staff it was not needed because R205's wounds were not significant enough to need precautions. The IP nurse reviewed resident conditions even before they were admitted and determined what type, if any, precautions were needed for their care. The staff followed what they were told by the IP nurse. When interviewed on 11/21/24, at 11:50 a.m. the IP nurse stated R205 had a chronic wound and EBP was not required when the wound was chronic in nature. R205 was admitted with the wounds on his feet. The wounds were rapidly healing and R205 did not have a history of skin conditions, so she did not feel EBP was needed. During observation on 11/25/24, at 10:45 a.m. a PPE cart and EBP signage was noted posted outside of R205's room, with instruction for staff to wear gown and gloves with any care or prolonged contact with R205. A facility policy on enhanced barrier precautions was requested, however none were received. The Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, indicated wound care was included as a high-contact resident care activity and was generally defined as the care of any skin opening requiring a dressing. This generally included residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers. Mask Use: R206's admission MDS dated [DATE], identified R206 had intact cognition. R206 was admitted with diabetic foot ulcer, open lesions on foot and application of dressings to feet. The MDS indicated antibiotics were administered daily. R206's care plan dated 11/25/24, identified R206 was on antibiotics for osteomyelitis with a peripherally inserted central catheter (PICC) in left arm. Antibiotics were ordered twice a day for six weeks. Staff were directed to monitor intravenous (IV) site in left arm every shift for symptoms of infection. The care plan also identified R206 was to be on enhanced barrier precautions due to her wounds and the presence of the PICC line. Staff were directed to don gown and gloves when performing high contact activities such as dressing, grooming, repositioning, wound care, and device care and use. The PICC dressing was to be changed weekly. During observation on 11/19/24, at 2:55 p.m. RN-C and RN-E entered R206's room after applying alcohol-based hand sanitizer (ABHR) and gloving and gowning. RN-E, with clean gloves and gown on, proceeded to carefully remove the transparent adhesive dressing covering the PICC line insertion site. RN-E was not wearing a mask during the procedure. RN-E removed her gloves and washed her hands. RN-E opened the PICC line sterile dressing change packet , setup a sterile field barrier sheet and put on the sterile gloves. RN-E put on a sterile mask and began cleaning the PICC line insertion site with the enclosed chlorhexadine swab. RN-C put on a pair of sterile gloves to assist RN-E. RN-C took the sterile paper measuring tape and measured R206's upper arm, leaning over the PICC line insertion site to do so. RN-C then applied the sterile transparent adhesive dressing to cover the PICC line insertion site. Both nurses disposed of used supplies removed gloves and washed hands and exited room. During interview on 11/19/24, at 3:15 p.m. RN-C stated she was not wearing a face mask when assisting RN-E with the PICC line dressing change and she should have been. When interviewed on 11/21/24, at 8:40 a.m. RN-E stated she had never received training on PICC line dressing changes from the facility, except for the mentoring that was observed on 11/19/24, while doing the procedure. RN-E verified she was not wearing a mask when removing the dressing covering the PICC line insertion site. RN-E stated she should have been wearing a face mask during the procedure. During on 11/21/24, at 11:55 p.m. the director of nursing (DON) stated it was the facility's expectation to perform PICC line dressing changes using sterile technique and procedures. The facility policy Peripherally Inserted Central Catheter dated 4/1/24, directed staff to perform hand hygiene and put on a face mask when performing a PICC line dressing change.

Based on interview and document review the facility failed to review and update the facility assessment to incorporate the minimal staff requirements; and all resources and conditions to care for the resident populations. This had the potential to affect all 50 residents who resided in the facility. Findings include: The Facility assessment dated [DATE], identified the need to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment listed resident count, activities of daily living (ADL) assistance needed, behavioral symptoms and active diagnoses. The facility utilized an interdisciplinary approach to meet the needs of residents across all shifts, including nights and weekends. The scheduler would check the schedule and divide staff based on the acuity of the facility assessment. The facility assessment failed to include information on the staffing levels needed for specific shifts, such as day, evening, and nights based on resident population and acuity. The facility assessment failed to identify residents who required oxygen supplementation and identify the minimal equipment and supplies needed to care for oxygen dependent residents. The facility assessment lacked evidence of assessment of resident population with diagnosis of PTSD. During interview on 11/25/24, at 2:10 p.m. the administrator stated the facility assessment had been completed by the previous administrator and he had not reviewed the assessment. Minimum staffing was based on the facility census. The bare minimum staffing would be one nurse and aide on each wing during the day and evening shift and one aide on each wing and a nurse float for the overnight shift. There should be something in the facility assessment that addressed minimum staffing needs. The administrator was unsure how detailed oxygen needs of residents would need to be documented in the facility assessment, but he was aware PTSD was required to be covered in the assessment. A policy on the facility assessment was required, however none was received.

Based on observation, interview and document review, the facility failed to provide timely repositioning for 1 of 1 resident (R203) reviewed for pressure ulcers. Findings include: R203's admission Minimum Data Set (MDS) dated [DATE], identified R203 had severe cognitive impairment and did not have identified behaviors. R203 required substantial to maximum assistance with rolling side to side and sitting up. R203 was dependent with toileting and transfers and was always incontinent of bowel and bladder. R203 was at risk for pressure ulcer development and was admitted with a stage two unhealed pressure ulcer. A turn and reposition program was in place as well as a pressure reducing device for R203's bed. Diagnoses included malignant neoplasm of the sinus and brain, palliative care, moderate protein-calorie malnutrition, and pressure ulcer stage two of the sacral region. R203's care plan dated 10/31/24, identified R203 was dependent with most activities of daily living and was bedfast all or most of the time. R203 had actual impairment to skin integrity. Staff were directed to use extra caution with transfer and bed mobility to avoid injury to R203 skin, keep skin clean and dry and to turn and reposition R203 every two hours and as needed. R203's Braden Skin Assessment 10/31/24, scored 13 which identified a moderate risk for pressure ulcer development. During continuous observation on 11/20/24. 4;30 p.m. to 7:10 p.m. R203 was awake, lying on her back in bed, dressed in a hospital gown. A pillow was positioned under R203's right foot. No other positioning devices were in use. R203's head of the bed was raised at 25-degree angle. -at 4:50 p.m. there was no change in R203's position. -at 5:22 p.m. there was no change in R203's position. -at 5:37 p.m. homemaker (HMK)-A entered the room to record R203's supper meal choices. HMK-A raised R203's head of the bed to a 35-degree angle and exited the room. HMK-A made no attempt to move, shift R203's weight or reposition R203. -at 5:45 p.m. licensed practical nurse (LPN)-C entered R203's room and raised the head of the bed to an upright sitting position of 45 degrees. LPN-C administered medications and exited the room. LPN-C did not turn, shift R203's weight or reposition R203 before exiting the room. -at 5:50 p.m. R203's call light was put on. LPN-C and unidentified NA entered room. R203 indicated the call light was on by accident and nothing was needed. Both staff exited the room after turning off call light. Neither staff attempted to turn, reposition or move R203. R203 remained seated fully upright in bed. - 5:57 p.m. R203 turned on her call light. R203 remained seated fully upright in bed. R203 had slid down in the bed and her head was hanging heavily to her right side with her chin in her chest. -at 6:11 p.m. R203 had not changed position. R203's head of the bed remained in full upright position. R203 was in slouched position in bed, leaning to her right side, with her chin in her chest. The call light remained on with steady green light over the door. -at 6:30 p.m. R203 had not changed position. The head of the bed remained in fully upright position. R203 has slouched further down in the bed with her head positioned halfway from top of bed to middle of bed. R203 leaning to her right side with her chin in her chest. The call light remains on. -At 6:45 p.m. there is no change in position. -At 6:56 p.m. R203's head of the bed remained fully elevated at 45-degree angle.R203 was leaning heavily to her right side with her chin touching her chest and slouched down to the middle of the bed. The call light remained on. -At 7:06 p.m. NA-M and NA-N entered R203's room and lowered R203's head of the bed and turned and repositioned R203. R203 was not incontinent of bowel or bladder. R203's peri area had dry, intact skin. Coccyx wound healed with no redness noted. NA-M stated she had been told R203 had been turned and repositioned at 4:30 p.m. NA-M knew R203 was to be checked and/or changed and repositioned every two hours. NA-M and NA-N had been walking by and noticed R203 was leaning so far over to the right and nearly falling out of bed, so they went in to reposition her. NA-M had noticed R203's light was on, and she had wondered why, which is why she walked down the hall to check. When interviewed on 11/21/24, at 12:05 p.m. the director of nursing stated it was the facility's expectation staff were to check and change residents every two hours if the care plan directed them to do so. The long call wait time would need to be looked in to. The facility policy Activities of Daily Living dated 12/4/23, identified any resident who was unable to carry out activities of daily living would receive necessary services to maintain good nutrition, grooming, personal and oral hygiene.

Based on interview and document review the facility failed to establish a process for antibiotic review in order to determine appropriate indications for use of an antibiotic for 1 of 1 resident (R15) reviewed for antibiotic use. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had diagnoses that included renal insufficiency, diabetes, Alzheimer's disease, and dementia. R15 was always continent of bowel and bladder and required supervision or touching assistance with personal hygiene. The Monthly Report of Resident Infections in Location dated November 2024, identified R15 had a urinary tract infection with an onset date of 11/2/24. Symptoms included gross hematuria and flank pain related to kidney stones. However, the report failed to identify if R15 was treated with an antibiotic and/or if a urinalysis or urine culture were obtained. R15's Order Summary Report dated 11/2/24, identified R15's was prescribed cefdinir (an antibiotic) 300 mg capsules give 1 capsule by mouth two times a day for acute cystitis with hematuria for 10 days. R15's nursing progress note dated 11/2/24 at 8:58 a.m., identified R15 was transferred to the emergency department (ED) due to abdominal pain. - At 2:15 p.m., R15 returned from the ED with new orders for cefdinir 300 mg two times a day for 10 days. R15 had acute cystitis with hematuria (a conditions where a person develops cystitis (inflammation of the bladder) with the presence of blood in the urine) and ureterolithiasis (kidney stones). R15's urine culture dated 11/24/24, identified mixed microflora (mixed microflora in urine culture typically indicates the culture yielded two or three different organisms, which may be considered colonization rather than infection.) During an interview with registered nurse (RN)-D on 11/19/24 at 1:35 p.m., RN-D stated she was responsible for the infection control program in the facility and tracked all antibiotic use. R15 was evaluated in the ED for kidney stones. R15 returned from the ED with an order for cefdinir to treat a UTI even though that wasn't a typical treatment for kidney stones. R15's urine culture identified mixed microflora and the culture was reviewed by the ED medical provider and determined it was a contaminated urine sample. However, by the time the culture returned, the antibiotic treatment was almost completed. - At 1:42 p.m., RN-D stated the facility used McGreer Criteria to determine if an antibiotic was warranted. However, RN-D stated McGreer Criteria was a steep level and residents had horrible infections by the time they reached the point of meeting criteria. The facility did review antibiotic orders during the morning meetings Monday through Friday, but RN-D stated she could not speak to what the nursing staff did at the unit level. RN-D stated the primary rounding providers were very involved in antibiotic stewardship and conducted 48-hour timeouts (an antibiotic timeout prompts a reassessment of the continuing need and choice of antibiotic when the clinical picture is clearer and more diagnostic information is available) on all UTI and generally did not order antibiotic treatment unless necessary. However, the ED providers ordered antibiotics for everything. The ED had a huge rotating schedule of providers and that was why the facility received orders for kidney stones, chronic obstructive pulmonary disease (COPD) exacerbation and other illnesses not normally treated with antibiotics. RN-D had spoken with the medical director regarding concerns with orders prescribed by ED providers, but the topic had not gone past talking about it. RN-D stated she did not know who she would talk to at the hospital about antibiotic stewardship concerns and had not attempted. During an interview on 11/25/24 at 3:46 p.m., the director of nursing (DON) stated antibiotic stewardship was reviewed with each case because each case was different. When a resident returned from the ED with an order for an antibiotic, the provider was frequently no longer at the facility to review lab results with by the time the facility received results. The ED providers worked 7 days on and 7 days off and it was just difficult to speak with them. The DON stated she could not speak to any discussion that had been had with the hospital regarding antibiotic stewardship concerns or who to reach out to for concerns with lab results, but guessed the hospital would direct staff to reach out to the primary provider. The staff should be following McGreer Criteria to determine antibiotic treatment was appropriate and, for contaminated urine samples, another sample should have been collected with the intention to stop the antibiotic treatment. When R15 returned from the ED, there should have been follow up to determine if the antibiotic should have been stopped. The facility policy Definitions of Infection - For Surveillance Purposes Only, Infection Control, R/S LTC dated 11/1/23, identified the facility used McGreer Criteria for UTI: Resident without indwelling catheter: At least one of the following signs or symptoms from these sub-criteria: - Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostrate. - Fever or leukocytosis and at least one of the following localizing urinary tract sub-criteria: - Acute costovertebral angle pain or tenderness - Supra-pubic pain - Gross hematuria - New or marked increase in incontinence. - New or marked increase in urgency. - New or marked increase in frequency. - In the absence of fever or leukocytosis, then two or more of the following localizing urinary tract sub-criteria must be present: - Supra-pubic pain - Gross hematuria - New or marked increase in incontinence. - New or marked increase in urgency. - New or marked increase in frequency. And One of the following: - At least 105 colony-forming units (cfu)/milliliter (ml) of no more than two species of microorganisms in a voided urine sample - At least 10^2 cfu/ml of any number of organisms in a specimen collected by an in-and-out catheter. Comments: UTIs should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine culture result. A diagnosis of UTI can be made without localizing symptoms if a blood culture isolate is the same as the organism isolated from the urine and there is no alternate site of infection. In the absence of a clear alternate source of infection, fever, or rigors with a positive urine culture result in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as a UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source. Urine specimens for culture should be processed as soon as possible, preferably within one or two hours. If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated. Refrigerated specimens should be cultured within 24 hours.

Based on interview and document review, the facility failed to ensure adverse event monitoring was completed for 2 of 5 residents (R22, R37); and failed to monitor adverse behaviors for 1 of 5 residents (R37) reviewed for unnecessary medication use and were taking a psychotropic medication. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment and exhibited behaviors of verbal abuse to others four to six times per week and physical behaviors of hitting, scratching, pacing and wandering, one to three times per week. R22 also rejected care four to six times weekly. The MDS identified R22 had received antidepressant medications daily. Diagnoses included chronic myeloid leukemia, anxiety, post-traumatic stress disorder (PTSD) and dementia. R22's signed Order Summary Report, dated 11/21/24, identified R22's current ordered medications and treatments at the nursing home. These included orders for: venlafaxine (to treat depression) 75 mg daily. The summary listed an order which directed Nurse to monitor for the following symptoms: weakness, dizziness, sudden changes in strength or mobility, nausea or vomiting, unusual bleeding, bruising, black or tarry stools, extreme fatigue. Swelling, redness and/or pain in upper or lower extremities, yellowing of the skin or eyes, swelling of the face, mouth, tongue, legs, ankles or feet, or sudden weight gain. R22's care plan dated 10/11/24, included interventions of report to nurse signs and symptoms of confusion, mood change, change in behavior, or ability to help with activities of daily living, suicidal ideation, constipation, shuffle gait, rigid muscles, diarrhea, appetite loss, weight loss, nausea and vomiting and fatigue. R22's Medication Administration Record (MAR), dated 11/2023, included the order for venlafaxine and identified R22 received the medication, as ordered, on a daily basis. However, the MAR and Treatment Administration Record (TAR) lacked evidence of an order to monitor for adverse effects of the medications. R22's medical record lacked evidence R22 was being assessed or evaluated for adverse effects as ordered by the physician. During interview on 11/21/24, at 11:11 a.m. registered nurse (RN)-C stated R22 did have an active order to monitor for side effects and so the order should be on the resident's MAR or TAR to monitor. The MAR and TAR usually pulled from the resident orders but in R22's case, it had been entered incorrectly and did not get pulled over. It was the facility policy to monitor high risk psychotropic medications for side effects every shift and document it was completed on the TAR. R37's quarterly MDS dated [DATE], identified R37 had intact cognition and no behavioral symptoms were identified. The MDS indicated R37 received antidepressant, and antianxiety medications daily. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, atrial fibrillation (irregular heartbeat), and kidney disease. R37's signed Order Summary Report, dated 11/25/24, identified R37's current physician ordered medications and treatments at the nursing home. These included orders for lorazepam (an antianxiety) 0.5 mg at bedtime, and Lexapro (an antidepressant) 10 mg daily. R37's care plan with last revision date 8/13/24,identified R37 had depression and included interventions to help R37 meet this goal including consult with pharmacist, administer the medication as ordered, and monitor for complications and side effects such as confusion, mood change, change in behavior, or ability to help with activities of daily living, suicidal ideation, constipation. Staff were also directed to monitor and report if noted increased anger, labile mood or agitation, feeling threatened or thoughts of harming others, and possession of objects that could be used for weapons. R37's MAR dated 11/2023, identified the orders for lorazepam and Lexapro and recorded R37 received the medications, as ordered, on a daily basis. However, the MAR and TAR lacked evidence staff monitored for adverse effects of the medications. The MAR and TAR failed to identify behavioral symptoms to monitor, and track. R37's medical record lacked evidence R37's behaviors were monitored, assessed, and reviewed to justify the daily medication administration. During joint interview on 11/21/24, at 11:59 a.m. with the director of nursing (DON) and RN-D, RN-D stated it was the facility's practice to monitor psychotropic medications every shift and staff were to document it was completed on the resident's TAR. The DON stated R37 should have symptoms of anxiety and depression monitored every shift. During telephone interview on 11/25/24, at 3:49 p.m. the consultant pharmacist (CP) stated when charts were reviewed monthly the CP did check to ensure the facility was monitoring for side effects as well as adverse behaviors. The facility had been short staffed and had just resumed monthly behavior monitoring meetings. During the meetings the facility staff and CP reviewed each residents' psychotropic medications and behavior monitoring. The CP also looked at each resident's chart individually and had made the recommendation to be sure to have specific individualized targeted behaviors for each resident and not just general. The CP was working on reviewing psychotropic medications and behavior monitoring and had planned to review the wing where R37 and R22 resided later in the week. She was not sure why she had not made recommendations to monitor side effects for the two residents or adverse behaviors for R37. Those were things the CP reviewed when she reviewed the resident charts monthly. The facility policy Psychotropic Medications dated 12/6/23, identified throughout the administration of psychotropic medications, mood and behavior documentation must continue in order to monitor the effect the medication has on the behaviors, as well as monitoring for side effects. Staff were directed to monitor for effectiveness and potential adverse consequences of the medications.

Based on interview and document review, the facility failed to ensure adverse event monitoring was completed for high-risk medications 2 of 5 residents (R22, R37) reviewed for unnecessary medications. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment. Diagnoses included chronic myeloid leukemia and dementia. R22's signed Order Summary Report, dated 11/21/24, identified R22's current ordered medications and treatments at the nursing home. These included orders for: Gleevec (to treat myeloid leukemia) 400 milligrams (mg) daily, nurse to monitor for side effects and notify MD as needed. The summary listed an order which directed Nurse to monitor for the following symptoms: weakness, dizziness, sudden changes in strength or mobility, nausea or vomiting, unusual bleeding, bruising, black or tarry stools, extreme fatigue. Swelling, redness and/or pain in upper or lower extremities, yellowing of the skin or eyes, swelling of the face, mouth, tongue, legs, ankles or feet, or sudden weight gain. R22's care plan dated 10/11/24, identified R22 consumed a non-cytotoxic oral chemotherapy with a goal to remain free of complications related to chemo therapy side effects. Interventions included drawing blood work as ordered, administering the medication as ordered, and monitor for chemotherapy complications and side effects. R22's Medication Administration Record (MAR), dated 11/2023, identified the order for Gleevec and recorded R22 received the medication, as ordered, on a daily basis. However, the MAR and Treatment Administration Record (TAR) both lacked evidence of monitoring for adverse effects of the medications. Further, R22's medical record was reviewed and lacked evidence R22 was being assessed, or evaluated for adverse effects as ordered by the physician. During interview on 11/21/24, at 11:11 a.m. registered nurse (RN)-C stated R22 did have an active order to monitor for side effects to his chemotherapy medication and so the order should be on his MAR or TAR to monitor. The MAR usually pulled from the resident orders but in R22's case, it had been entered incorrectly and did not get pulled over. It was the facility policy to monitor high risk medication for side effects every shift and document it was completed on the TAR. RN-C had just discussed the need to monitor labs with residents on certain medications. Lab work was not part of the standing orders and they relied the primary physician to order labs as needed and so it frequently was missed. R37's quarterly MDS dated [DATE], identified R37 had intact cognition and no behavioral symptoms were identified. The MDS indicated R37 had consumed anticoagulant and diuretic medications daily. Diagnoses included chronic obstructive pulmonary disease (COPD), atrial fibrillation (irregular heartbeat), and kidney disease. R37's signed Order Summary Report, dated 11/25/24, identified R37's current physician ordered medications and treatments at the nursing home. These included orders for furosemide (a diuretic) 40 mg daily, potassium (a supplement) 10 milliequivalents daily, and methimazole (to treat hyperthyroid) 2.5 mg daily. R37's care plan with last revision date 8/13/24, identified R37 received diuretic therapy. Interventions included monitor for side effects based on clinical standards of practice and to monitor for symptoms of dehydration and encourage adequate fluid intake. R37's medical record lacked evidence annual lab work was completed to monitor for adverse effects and/or therapuetic drug levels of the high risk medications. R37's MAR, dated 11/2023, identified the orders for furosemide, methimazole and potassium and recorded R37 received the medications, as ordered, on a daily basis. However, the MAR and TAR both lacked evidence staff were monitoring for adverse effects of the medications. Further, R37's medical record was reviewed and lacked evidence R22 had annual blood work to assess, or evaluate for adverse effects, effectiveness of hyperthyroid treatment and monitoring for therapeutic dosages. During interview on 11/21/24, at 11:11 a.m. registered nurse RN-C stated R37 should have had lab work done to monitor for dehydration related to her diuretic medications as well as potassium level and hemoglobin to check for the need for supplementation related to the diuretic medications and history of anemia. RN-C had just discussed this with the DON that some residents should have routine lab work done every six months to a year. Some of the physicians were on top of their residents to order labs and others were not. During joint interview on 11/21/24, at 11:59 a.m. with the director of nursing and RN-D, RN-D stated it was the facility's practice to monitor for adverse events with high risk medications every shift and staff were to document it was completed on the resident's TAR. During telephone interview on 11/25/24, at 3:49 p.m. the consultant pharmacist (CP) stated when charts were reviewed monthly the CP did check to ensure the facility was monitoring for side effects. The CP reviewed each resident charts individually for side effects. When a resident was receiving diuretic or thyroid medications, lab work was something the facility would want to look at. R37 should have lab work drawn and the CP was not sure why there had not been a recommendation to do so in the past year. The facility policy Medication Drug Regimen Review dated 2/28/24, identified the drug regimen review was a process that included medication reconciliation and review of all medications a resident was taking to identify and prevent potentially significant medication issues. A policy to monitor for side effects of medications was requested, however, none was received.

Based on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified and communicated to the facility the need for monitoring for potential adverse events for high- risk medications for 2 of 5 residents (R22, R37); and failed to identify the need to monitor for adverse behaviors for psychotropic medications for 1 of 5 residents (R37) reviewed for unnecessary medications. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment and exhibited behavior of verbal abuse to others four to six times per week and physical behaviors of hitting, scratching, pacing, and wandering, one to three times per week. R22 also rejected care four to six times weekly. The MDS identified R22 had received antidepressant medications daily. Diagnoses included chronic myeloid leukemia, anxiety, post-traumatic stress disorder (PTSD) and dementia. R22's signed Order Summary Report, dated 11/21/24, identified R22's current ordered medications and treatments at the nursing home. These included orders for: Gleevec (to treat myeloid leukemia) 400 milligrams (mg) daily, nurse to monitor for side effects and MD as needed, and venlafaxine (to treat depression) 75 mg daily. The summary listed an order which directed Nurse to monitor for the following symptoms: weakness, dizziness, sudden changes in strength or mobility, nausea or vomiting, unusual bleeding, bruising, black or tarry stools, extreme fatigue. Swelling, redness and/or pain in upper or lower extremities, yellowing of the skin or eyes, swelling of the face, mouth, tongue, legs, ankles or feet, or sudden weight gain. R22's medical record lacked evidence R22 was being assessed or evaluated for adverse effects as ordered by the physician. R22's PharMerica Physician Recommendations dated 8/23/24, identified R22 was receiving venlafaxine and donepezil daily. The consultant pharmacist (CP) identified donepezil could cause side effects for aggression and agitation. A recommendation was made to increase venlafaxine and consider reducing R22's donepezil. During interview on 11/21/24, at 11:11 a.m. registered nurse (RN)-C stated R22 did have an active order to monitor for side effects to his chemotherapy medication and so the order should be on his MAR to monitor. The MAR usually pulled from the resident orders but in R22's case, it had been entered incorrectly and did not get pulled over. It was the facility policy to monitor high risk medication and psychotropic medications for side effects every shift and document it was completed on the MAR or the TAR. RN-C had just discussed the need to monitor labs with residents on certain medications. Lab work was not part of the standing orders, and they relied on the primary physician to order labs as needed and so it frequently was missed. Pharmacy reviews were conducted monthly and review of recommendations January 2024 through November 2024, identified no further concerns or recommendations. The pharmacy reviews lacked evidence the CP identified the need and made the recommendation to the facility to monitor for psychotropic medication adverse effects as ordered. R37's quarterly MDS dated [DATE], identified R37 had intact cognition and no behavioral symptoms were identified. The MDS indicated R37 had consumed antidepressant, anticoagulant and diuretic medications daily. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, atrial fibrillation (irregular heartbeat), and kidney disease. R37's signed Order Summary Report, dated 11/25/24, identified R37's current physician ordered medications and treatments at the nursing home. These included orders for furosemide (a diuretic) 40 mg daily, lorazepam (an antianxiety) 0.5 mg at bedtime, methimazole (to treat hyperthyroid) 2.5 mg daily and Lexapro (an antidepressant) 10 mg daily. A hospital discharge summary dated 11/28/23, identified R37 had been hospitalized and treated for anemia with a hemoglobin of 6.4. R37's hemoglobin on discharge was 10.3 and medications changes were made to discontinue coumadin and to start aspirin 325 mg instead. R37's medical record lacked evidence R22 had annual blood work to assess, or evaluate for adverse effects, effectiveness of hyperthyroid treatment and monitoring for therapeutic dosages. R37's PharMerica Physician Recommendations dated 7/29/24, identified R37 received Lexapro and lorazepam daily with a recommendation to the physician to review the medications and consider a gradual dose reduction (GDR). The physician refused the recommendation due to R37 was stable with current dose. Pharmacy reviews were conducted monthly and review of recommendations January 2024 through November 2024, identified no further concerns or recommendations. The pharmacy reviews lacked evidence the CP identified the need and made the recommendation to the facility to monitor for psychotropic medication side effects as ordered or to track and monitor adverse behaviors for which the medications were ordered. During interview on 11/21/24, at 11:11 a.m. RN-C stated R37 should have had lab work done to monitor for dehydration related to her diuretic medications as well as potassium level and hemoglobin to check for the need for supplementation related to the diuretic medications. RN-C had just discussed this with the director of nursing (DON) that some residents should have routine lab work done every six months to a year. Some of the physicians were on top of their residents to order labs and others were not. A joint interview was conducted with the DON and RN-D on 11/21/24, at 11:59 a.m. RN-D stated it was the facility's practice to monitor high risk and psychotropic medications every shift and staff were to document it was completed on the resident's TAR. The DON stated R37 should have symptoms of anxiety and depression monitored every shift. RN-D stated they never received recommendations from the pharmacist regarding need for lab work related to a resident's medications. RN-D commented it would be another check to ensure things were not missed and a good resource for the facility. During telephone interview on 11/25/24, at 3:49 p.m. the CP stated when charts were reviewed monthly the CP did check to ensure the facility was monitoring for side effects as well as adverse behaviors. The facility had been short staffed and had just resumed monthly behavior meetings, which the CP attended. The CP had been looking at each residents' charts for side effects and behavior monitoring and had told the facility to be sure to have specific behaviors to monitor on residents receiving psychotropic medications. The CP had made recommendations to try to reduce medications but felt the recommendations were not considered because the psychiatric clinic would keep adding on more medications. The CP felt R37 should have some lab work drawn. Sometimes the resident or family would refuse but the CP was unsure why a recommendation to check lab work was not made for R37. The facility policy Consultant Pharmacist Services Provider Requirements dated 1/2023, identified regular and reliable pharmacist services were to be provided to residents of the facility. The consultant pharmacist would provide pharmaceutical care services.

Based on interview and document review, the facility failed to comprehensively assess for trauma informed care to identify potential triggers and avoid potential re-traumatization for 1 of 1 resident (R22) reviewed who had a history of trauma. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment and exhibited behavior of verbal abuse to others four to six times per week and physical behaviors of hitting, scratching, pacing and wandering, one to three times per week. R22 also rejected care four to six times weekly. Diagnoses included chronic myeloid leukemia, anxiety, post traumatic stress disorder (PTSD) and dementia. R22's care plan with last revision date 10/11/24, identified R22 had impaired cognition and impaired thought process as well as behavior symptoms of hitting staff, name calling, throwing objects, sexual comments and unpredictable behaviors related to impaired cognition, anxiety and PTSD. Interventions included approach with soft tone of voice, let him know comments are inappropriate, redirect, use humor, divert attention about talking about his home or grandchildren. However, R22's care plan lacked individualized trauma-informed approaches or interventions and identification of triggers to avoid potential re-traumatization. R22's order summary report dated 11/21/24, identified R22 received Depakote 125 milligrams (mg) two times per day for post traumatic stress disorder. R22's telehealth psychiatric visit note dated 8/12/24, identified R22 had PTSD and a family member identified R22 served in the Vietnam war and had flashbacks of the war. R22's medical record lacked a comprehensive assessment for R22's PTSD, potential triggers and interventions. When interviewed on 11/19/24, at 1:00 p.m. family member (FM)-A reported R22 served in Vietnam and had a career as a fire chief. R22 had taken care of dismembered people and traumatic injuries that never seemed to bother him; however, R22 was taking the medication Depakote for PTSD. A joint interview was conducted with nursing assistant (NA)-B and trained medication assistant (TMA)-A on 11/20/24 at 2:00 p.m NA-B stated when she talked with R22 he would bring up his service and mention how he was near others who got blown up and/or how his general treated him. R22 did not seem anxious or upset when discussing these things with her. NA-B see how R22 could get upset with certain people depending on how R22 was spoken to. TMA-A stated he knew R22 would get angry if others mentioned they were in the service but did not serve in war. R22 would comment to them they did not know anything if they had not been in war and make angry comments. When interviewed on 11/21/24, at 8:15 a.m. registered nurse (RN)-C stated the diagnosis of PTSD should be assessed and care planned. R22's was not assessed or have a care plan related to R22's PTSD. It would be important to have the PTSD addressed on R22's plan of care to alert staff to what his triggers were. During interview on 11/21/24, at 12:00 p.m. the director of nursing stated it would be important to assess and care plan a diagnosis of PTSD with interventions for staff to avoid known triggers, if any. On 11/24/24, at 10:45 a.m. R22 was observed sitting in recliner in his room fully dressed and watching television. R22 stated he had lost several of his fingers during a work accident while working at the local paper mill. R22 stated he served three years in Vietnam and then was the local fire chief and ran the fire department for the town in which he lived for many years before he eventually retired. R22 did not elaborate on his service in Vietnam or the fire department. The facility policy Trauma Informed Care dated 11/16/23, identified a trauma assessment was required within five days of admission and as needed. The interview would focus on understanding the resident's experience. Staff were directed to document how trauma was currently affecting the resident. Individualized care plan interventions were required to avoid re-traumatization.

Based on observation, interview and document review, the facility failed to provide assistance with toileting for 1 of 1 resident (R203) reviewed for activities of daily living and who were dependent on staff for their care. Findings include: R203's admission Minimum Data Set (MDS) dated [DATE], identified R203 had severe cognitive impairment and did not have behaviors. R203 required partial to moderate assistance with eating. R203 was dependent with toileting and transfers and was always incontinent of bowel and bladder. Diagnoses included malignant neoplasm of the sinus and brain, palliative care, moderate protein-calorie malnutrition, and pressure ulcer stage two of the sacral region. R203's care plan dated 10/31/24, identified R203 was dependent with most activities of daily living and was bedfast all or most of the time. R203 was incontinent of bowel and bladder. Staff were directed to check and change every two hours and as needed. During continuous observation on 11/20/24 from 4:30 p.m. to 7:10 p.m., R203 was awake, lying on her back in bed, dressed in a hospital gown. A pillow was positioned under R203's right foot. No other positioning devices were in use. R203's head of the bed was raised at 25-degree angle. -at 4:50 p.m. there was no change in R203's position. -at 5:22 p.m. there was no change in R203's position. -at 5:37 p.m. nursing assistant (NA)-N entered the room to record R203's supper meal choices. NA-N raised R203's head of the bed to a 35-degree angle and asked R203 what she would like for supper. NA-N told R203 she would return with a couple of pudding choices for her supper and then exited the room. NA-N did not check R203 for incontinence. -at 5:45 p.m. licensed practical nurse (LPN)-C entered R203's room and raised the head of the bed to an upright sitting position of 45 degrees. LPN-C administered medications and exited the room. LPN-C did not check R203 for incontinence before exiting the room. -At 5:50 p.m. R203's call light was put on. LPN-C and an unidentified NA entered room. R203 identified the call light was on by accident and nothing was needed. Both staff exited the room after turning off call light. R203 was not checked for incontinence or need for toileting and remained seated fully seated upright in bed. - At 5:57 p.m. R203 turned on her call light. R203 was seated in bed. the head of the bed was in an upright position. R203 had slid down in the bed and her head was hanging heavily to her right side with her chin in her chest. -At 6:11 p.m. R203 had not changed position. R203's head of the bed remained in full upright position. R203 was in slouched position in bed, leaning to her right side, with her chin in her chest. The call light remained on with steady green light over the door. -At 6:30 p.m. R203 had not changed position, the head of the bed remained in fully upright position. R203 has slouched further down in the bed with her head positioned halfway from top of bed to middle of bed. R203 leaning to her right side with her chin in her chest. The call light remained on. -At 6:45 p.m. there was no change in position. -At 6:56 p.m. R203's head of the bed remained fully elevated at 45-degree angle. R203 was leaning heavily to her right side with her chin touching her chest and slouched down to the middle of the bed. The call light remained on. -At 7:06 p.m. NA-M and NA-N entered R203's room and lowered R203's head of the bed and checked R203 for incontinence. R203 was dry and did not require a brief change. During interview on 11/20/24, at 7:10 p.m. NA-M stated they just checked R203 for incontinence and she was dry. NA-M stated she had been told R203 was checked at 4:30 p.m. NA-M knew R203 needed to be checked and/or changed and repositioned every two hours. NA-M and NA-N were walking by and noticed R203 was leaning so far over to the right and nearly falling out of bed so they went in to reposition her. NA-M noticed R203's light was on and wondered why, which is why she walked down the hall to check. During interview on 11/25/24, at 2:30 p.m. NA-N stated she remembered going into R203's room on 11/20/24 and offering her supper. R203 refused supper but then NA-N offered pudding and R203 had agreed. NA-N stated she had not checked or changed R203 for incontinence at that time. When interviewed on 11/21/24, at 12:05 p.m. the director of nursing stated it was the facility's expectation staff were to check and change residents every two hours if the care plan directed them to do so. The facility policy Activities of Daily Living dated 12/4/23, identified any resident who was unable to carry out activities of daily living would receive necessary services to maintain good nutrition, grooming, personal and oral hygiene.

Based on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 1 of 5 residents (R27) reviewed for unnecessary medications. Findings include: R27's quarterly MDS dated [DATE], identified R27 had severe cognitive impairment. Diagnoses included Alzheimer's, non-Alzheimer's dementia, diabetes, and depression. The MDS identified R27 received an antianxiety medication. R27 medication administration report (MAR) for the month of October 2024, identified R27 received Trazodone (an antidepressant) for generalized anxiety disorder, restlessness, and agitation. The MAR/orders did not identify R27 was receiving an antianxiety medication during the MDS lookback period. During an interview on 11/25/24 at 3:14 p.m., registered nurse (RN)-B identified she did the most recent MDS for R27. When RN-B went over the medications for R27, RN-B reviewed medications by what they were used for and not specifically the class of medication. R27's was receiving an antidepressant to help with anxiety, and it was entered on the MDS as an antianxiety medication and not an antidepressant. RN-B stated it was important to ensure the MDS was accurate, so staff had the accurate data to care for R27. During an interview on 11/25/24 at 4:00 p.m., the director of nursing (DON) stated she would expect the MDS for R27 would be complete and accurate to enable others working with R27 to get a complete picture of care required for them. The facility's MDS 3.0 Resident Assessment Instrument (RAI) dated 8/27/24, identified each team member would review the electronic medical record and determine if there is accurate documentation which supported coding for the MDS.

Based on observation, interview and document review, the facility failed to ensure an electric wheelchair was maintained in working order for 1 of 1 resident (R23) reviewed for accommodation of needs. Findings include: R23's annual Minimum Data Set (MDS) dated [DATE], identified R23 had intact cognition and used a motorized wheelchair. R23 was independent with mobility once seated in his motorized wheelchair. Diagnoses included paraplegia, dependence on wheelchair and autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system). R23's care plan dated 3/15/24, identified R23 had limited physical mobility related to paraplegia from spinal cord injuries and weakness evidenced by R23's need for specialty wheelchair. The goal was for R23 to remain independent with locomotion in the facility. Interventions included use of motorized wheelchair in the facility. On 11/19/24, R23 was lying in bed watching television. A manual high back wheelchair was stored in the shower area of R23's room and a motorized wheelchair was positioned against the wall in the room. R23 stated lightning hit the nursing home building a few months ago and fried his motorized wheelchair. R23 did not know why the facility had not attempted to repair the chair for him. R23 was told he needed a new battery and that is all he had heard about it. The nurse reported the problem to maintenance and maintenance told R23 they were going to look into getting him a battery for the wheelchair and that was two to three months ago. The manual wheelchair the facility provided R23 to use was uncomfortable for him and he was unable to sit up straight when he was seated in it or recline the wheelchair back. R23 had autonomic dysreflexia and when he had a spell he would pass out and needed to be reclined back immediately. R23 was able to sit fully upright and to recline when needed in his motorized wheelchair. R23 owned the motorized wheelchair but felt it was the facility responsibility to repair because he knew it quit working when the building had been hit by lightning. His chair had been plugged in at the time and made a loud beeping noise and then did not work again after that. R23's medical record was reviewed and lacked evidence the facility had made any effort to assess, evaluate or discuss the broken motorized wheelchair with R23. During interview on 11/20/24, at 10:49 a.m. nursing assistant (NA)-A stated R23 did not use his motorized wheelchair. The facility had been hit by lightning about two and 1/2 months ago and R23's motorized wheelchair would not take a charge after that. R23 used the manual wheelchair when he would get out of bed, for special things like haircut or celebrations. When interviewed on 11/20/24, at 10:53 a.m. trained medication aide (TMA)-A stated R23's motorized wheelchair did not work, and it needed a new battery. TMA-A did not know who was helping R23 fix his wheelchair, he just knew it has not worked for at least a month. When interviewed on 11/20/24, at 11:00 a.m. registered nurse (RN)-C stated she was aware R23's motorized wheelchair was not working as the battery would not charge. RN-C stated she reported the issue to maintenance. RN-C was upset when she came back from her vacation and found R23's motorized wheelchair had not been fixed. R23's motorized wheelchair absolutely should be repaired. A joint interview was conducted on 11/20/24 with the director of nursing (DON) and maintenance staff (M)-A. The DON stated she was not aware R23's motorized wheelchair was not working and R23 had a right to have his motorized wheelchair in working order. M-A stated he was made aware of R23's wheelchair not working, and M-A told R23 to use the chair more and run down the battery before recharging it, as it was developing a memory. M-A was not aware the motorized wheelchair did not take a charge at all. R23 had mentioned something about a lightning strike but that had just messed up the facility's television programming and had not interfered with the facility's electrical equipment. The occupational therapist had stated any maintenance or repairs would have to go through R23 and/or his family but he was not sure if anyone had discussed the issue with R23. On 11/21/24, at 10:00 a.m. M-A stated he tried a different charger with no success and now was looking into obtaining a different battery to try. M-A stated R23 had told him the chair had been plugged in during the lightning strike and had made a loud beeping sound, the damage could have been caused by the lightning strike, it was hard to tell. The facility's Accommodation of Resident Need policy dated 9/16/24, identified the resident had a right to reside and receive services with reasonable accommodation of resident needs and preferences. The facility should adapt or individualize things such as desires and unique needs such as furniture that enhances the resident's ability to maintain their independence.

Based on observation, interview and document review, the facility failed to ensure two insulin pens were labeled with the resident name for 1 of 1 resident (R154) observed to receive insulin. Findings include: R154's Admission Record dated 11/25/24, identified R154 was admitted to the facility on [DATE]. R154's Diagnosis Report dated 11/25/24, identified R154 was a Type 2 diabetic. R154's Order Summary Report dated 11/25/24, identified the following: 11/13/24, R154 was prescribed insulin lispro (Humalog) (a short acting insulin) with the following instructions: - insulin lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit/milliliter (ml) Inject as per sliding scale: if 0 - 160 = 0 UNITS; 161 - 190 = 1 UNIT; 191 - 220 = 2 UNITS; 221 - 250 = 3 UNITS; 251 - 280 = 4 UNITS; 281 - 310 = 5 UNITS; 311 - 340 = 6 UNITS; 341 - 370 = 7 UNITS; 371 - 400 = 8 UNITS; 401 - 999 = 9 UNITS, subcutaneously three times a day for Type 2 diabetes. Give sliding scale dose in addition to scheduled dose. - Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML give 25 Units before breakfast daily plus sliding scale; give 22 Units before lunch daily plus sliding scale; and give 21 Units before supper daily plus sliding scale. - 11/13/24, R154 was prescribed Toujeo Max SoloStar Subcutaneous Solution Pen-injector 300 unit/ml (insulin glargine) (a long acting insulin) inject 84 unit subcutaneously one time a day for Type 2 diabetes. During an observation on 11/19/24 at 8:59 a.m., licensed practical nurse (LPN)-A administered Humalog insulin and Toujeo to R154. Neither the Humalog kwik pen or the Toujeo pen had a label identifying the pens belonged to R154. During an interview on 11/19/24 at 9:02 a.m., LPN-A stated the medication pens did not come with a label from the pharmacy but the boxes did. The boxes of medication were kept in the fridge in the medication room. When asked how she knew the pens belonged to R154, LPN-A stated R154 was the only diabetic resident on the unit who received injectable medication. The medication pens were stored in the top drawer of the medication cart and everyone just knew they belonged to R154. I guess I could put her [R154] initials and room number on it. During an interview on 11/19/24 at 9:22 a.m., registered nurse (RN)-A stated all medication pens should be labeled when they come from the pharmacy. If not, staff should put a sticker with the resident's information on it. RN-A stated she was unaware R154's medication pens were unlabeled but would put a sticker on them. There was only one diabetic resident on the unit and R154 was just admitted to the facility on [DATE]. RN-A stated a medication pen without a label was an infection control issue because staff shouldn't use a medication pen on the wrong resident. Also, R154 paid for that mediation, and it should be labeled with R154's name. During an interview on 11/25/24 at 3:44 p.m. the director of nursing (DON) stated she expected all medication pens to come from the pharmacy labeled or staff should place a resident sticker on the pen identifying who the pen belonged to. The facility policy Medication Ordering and Receiving from Pharmacy Provider Medications and Medication Labels dated 1/2023, identified each prescription medication would be labeled to include: a. Resident's name b. Specific directions for use, including route of administration c. Medication name d. Strength of medication e. Prescriber's name f. Date medication is dispensed g. Quantity dispensed h. Expiration or end-of-use date, if not dispensed in original manufacturer packaging i. Name, address, and telephone number of dispensing pharmacy J. Prescription number k. Accessory/precautionary labels indicating storage requirements and special procedures. Example: Shake well, Take on empty stomach, one hour before or 2 hours after meals, Do not crush. l. Dispensing pharmacist's initials m. Lot number of medication dispensed, if not dispensed in original manufacturer packaging, where required by state law n. Any other information required by state and federal Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels are returned to the dispensing pharmacy for re-labeling or destroyed in accordance with the medication destruction policy.

Based on observation, interview and document review, the facility failed to consistently post the census on the nurse staff posting; failed to identify when the posting changed due to call ins; and failed to retain the nurse staff posting for 18 months. This had the potential to affect all 50 residents residing in the facility and/or visitors who may wish to view the information. Findings include: During an observation on 11/19/24 at 7:09 a.m., the staff posting was in a display case at the front entrance at the persons in charge list. The posting was dated Friday 11/15/24, and identified the census was 51 and listed the following staff scheduled working hours per shift for each nursing job class. However, the posting failed to identify the staff actually worked hours due to call-ins, vacations and/or staff shortages. The facility provided a print out that reflected staff timecard punches, however, an actual working staff schedule that reflected call-ins, staff shortages and/or vacations was requested, but not received. The nurse staff postings dated 10/8/24 through 11/15/24, were reviewed and identified the following dates were missing: 10/9/24 through 10/16/24, 10/18/24 through 10/20/24, 10/22/24, 10/25/24 through 10/27/24, 11/2/24, 11/3/24, 11/7/24, 11/9/24 through 11/12/24. Additionally, the nurse staff postings failed to identify if corrections had been completed to reflect staffing changes, including call ins. During an interview on 11/20/24 at 9:55 a.m., household coordinator (HC)-A stated she was responsible for the staff schedule and the nurse staff posting. HC-A posted the nurse staff posting in the display case at the front entrance Monday through Thursday when she was at the facility. HC-A printed the nurse staff posting on Thursday for the weekend and the charge nurse was responsible to post it. HC-A stated the facility had consistent staff shortages, especially on the evening shift. HC-A stated she had never thought of updating the nurse staff posting to reflect call-ins and/or changes in staffing numbers and was unsure how long the nurse staff postings should be retained, possibly a year. During an interview on 11/25/24 at 2:01 p.m., the director of nursing (DON) stated the nurse staff posting should be kept for 18 months and should be posted daily. The DON stated she was unaware the nurse staff posting should be updated to show changes in actual working staff, but it would allow residents and visitors to determine numbers of staff in the building. During an interview on 11/25/24 at 2:28 p.m., the administrator stated his expectation was have the census recorded and posted daily on the nurse staff posting form. A policy regarding the nurse staff posting was requested but not received.

Based on interview and document review the facility failed to ensure adequate supervision to reduce the risk of falls for 1 of 3 residents (R1) who had a history of falls with serious injury. This resulted in actual harm for R1 who fell and sustained a laceration to her head and a subdural hematoma (pool of blood between the brain and its outermost covering). In addition, the facility failed to develop a sustainable plan for ongoing supervision. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she was dependent on staff for transfers. The MDS indicated R1 did not have a fall since the prior assessment. R1's care plan dated 10/29/23, identified a communication problem related to dementia and a self care deficit. The care plan indicated R1 used a wheel chair with assistance from staff for locomotion and transferred using a mechanical lift. The care plan indicated R1 had a fall on 12/19/23, resulting in a subdural bleed. The care plan directed the use of a video monitoring device to observe movement when R1 was alone in her room, bed in lowest position and directed staff to remove the leg rests on her wheel chair when she was not being transported in the chair. R1's Kardex (care guide) dated 12/18/23, identified the following interventions: - Anti-thrust cushion with a calf rests. - Grippy tape at bedside and in front of chair. - When in wheel chair R1 must be in line of staff site. When not being pushed in wheelchair leg foot rests should be removed. A facility Fall Scene Huddle Worksheet dated 12/19/23, indicated at 4:45 p.m. R1 was found on the floor in the dining room. R1 was unable to state what she was trying to do. The worksheet indicated she had been brought to the dining room by staff approximately five minutes prior to the fall. The worksheet further indicated the wheelchair brakes were not locked. An untitled facility incident report dated 12/19/23, indicated a visitor reported to staff that R1 had fallen in the dining room and was bleeding. R1 was on the floor in the dining room next to her wheelchair and dining room table with a gash above her left eye brow. Predisposing factors indicated, not applicable. An undated, untitled review of the incident indicated on 12/19/23, R1 had an unwitnessed fall in the dining room and indicated R1 had mutliple falls since admission to the facility. Prior incidents included falls on 2/13/23 and 4/19/23, that resulted in injuries. R1 had shown an improvement in transfer ability and had recently been changed to a stand to pivot transfer. Contributing factors included the nursing assistant (NA) left R1 alone in the dining room. Advanced Alzheimer's disease with history of impulsive behavior, recent improvement in walking and transferring and discontinuation of Gabapentin may have contributed to R1 deciding to stand and walk unassisted. Plan for staff to monitor every 15 minutes as able, review of Kardex and paying attention to safety concerns, not locking wheelchair brakes at the table and not bringing residents who require supervision with eating to the table until staff are able to assist them. R1's facility Progress Notes indicated on 12/19/23, staff was alerted by a visitor that R1 was on the floor in the dining room bleeding. R1 had a laceration on the right side of her head above her brow. Called ambulance. 12/19/23, Notified by hospital staff R1 had a subdural bleed and also nicked an artery that was sewn up along with seven to eight staples. 12/20/23, notified R1 would be returning to facility on comfort care. 12/21/23, R1 readmitted to the facility following two night hospital stay after fall resulting in injury. 12/21/23, staff and family discussed R1's fall on 12/19/23. R1 was brought to the dining room for dinner and two minutes later she stood up and began walking along the table. As soon as she let go of the table R1 fell striking her head on the floor. R1 was alone in the dining room at the time as the two staff members were assisting others. Family expressed frustration with R1's fall and wanted to discuss interventions. Family asked why R1 did not have alarms and writer explained the reasons these devices were no longer allowed. Family thought R1 should have a chair and a bed alarm due to her high fall risk. Also discussed was having a lap buddy (designed to provide anterior posture support while safely securing the resident in a seated position) on her wheelchair to distract her from standing. Writer explained in detail what were considered restraints. Family still requested writer get a physician's order for the lap buddy and stated they would sign a consent. Other interventions discussed: R1 would be checked on every 15 minutes as staff were able, R1 would no longer be brought and left alone at dining room table, motion sensor placed in room and family requested video monitoring device in room. Progress Notes dated 12/22/23 through 1/17/24, identified multiple attempts by R1 to stand up from her wheel chair. Emergency Department (ED) Provider Notes dated 12/19/23, indicated R1 was brought to the ED after a fall out of her wheelchair at the nursing home. R1 had a large laceration over her left temporal area. Computed Tomography (CT) identified a fairly extensive left subdural hematoma that extended along the temporal lobe. Procedures included a laceration repair of R1's forehead that included 11 sutures and closed with staples. After CT results were reviewed, call was placed to hospital in Duluth to discuss case with trauma surgeon. Trauma surgery would not perform any procedure on R1 to relieve pressure or evacuate bleeding due to her being on Plavix (blood thinner) and physician stated any procedure may make the bleeding worse. Conversation with family to forgo transfer to higher level of care and admit for comfort cares. During interview on 1/18/24 at 4:30 p.m., NA-A stated when R1 fell on [DATE], she got R1 up for dinner around 4:30 p.m. NA-A said she had five other residents to get up so she brought R1 to the table and put the wheel chair brake on. NA-A stated she left R1's foot pedals on while she was at the table and said she was not aware she was supposed to remove them. NA-A said after leaving R1 at the table she went to another room and when she came out R1 was on the floor. On 1/18/24 at 5:21 p.m., family members (FM)-A and FM-B were interviewed. FM-A stated this last fall, we were afraid we were going to lose her [R1]. FM-A said the facility did not want them to look at the video and said R1 was on blood thinner and bleeding horribly and said she had internal stitches and external staples. FM-A said the prognosis was not good because R1's brain was so full of the brain bleed. FM-A said they chose to put R1 on comfort care. FM-B said they had concerns, not just about the falls but the staffing. FM-B said they were at the facility every day for about two hours. FM-A said right after the fall it, shook things up but said, I already see it sliding back. FM-B stated in regard to R1's fall, I think the bottom line is it comes down to staffing. During interview on 1/19/24 at 9:09 a.m., licensed practical nurse (LPN)-A stated when R1 fell on [DATE], she had left the unit to get something and said the NA's must have been in rooms. LPN-A said a visitor found R1 and said R1 was lying flat on her back. LPN-A said the foot pedals were still on the wheel chair and the wheelchair looked like it had been pushed back and R1 was next to the table. LPN-A stated the staffing was pretty short on evenings and weekends and said it was not reasonable to be able to watch everyone. LPN-A said a video monitor was implemented while R1 was in bed but said R1 did not fall when in bed. During interview on 1/19/24 at 9:19 a.m., NA-B stated R1 used to walk but refused to use a walker so staff kept an eye on her. NA-B said R1 was pretty stable at that time. NA-B said R1 had a pretty bad fall a while back and then she required a wheelchair and a mechanical lift for transfers. NA-B said R1's fall interventions included keeping the bed in the lowest position and keep a flat pad call light next to her to alert staff of movement in bed. NA-B said when R1 was in the wheelchair staff were supposed to sit with her and keep an eye on her but said it was not uncommon for her to be the only NA on the unit. During interview on 1/19/24 at 9:30 a.m., NA-C stated R1 thought she could walk by herself and had nothing to hold onto then fell . NA-C stated staff tried to make sure R1 had something in her hands and said she had a blanket with busy items. NA-C stated since R1's fall on 12/19/23, someone had to be with her at all times when she was out of bed. NA-C said a lot of times the unit was staffed with just herself and a nurse and said I cannot reasonably stay with her with one person and said even with two NA's it was hard. During interview on 1/19/24 at 1:13 p.m., registered nurse (RN)-A stated on 12/19/23, a NA who did not always work on the unit brought R1 to the dining room at around 4:40 p.m. RN-A said the home maker on the unit left to go get food and R1 stood up. RN-A stated they reviewed the video footage and R1 had pushed herself up and tipped over sideways to her left side. RN-A said the very first person who saw R1 was another resident, then a visitor came out of a room and started yelling. RN-A stated a week before R1's fall her Gabapentin had been discontinued and R1 had been more awake and alert since. RN-A stated they had placed a video camera in R1's room and the nurse kept the monitor on the cart at all times. RN-A said they had been doing 15 minute checks but determined it was not sustainable. RN-A stated she told the NA's R1 should be the last person up and staff should not bring her to the table until someone was ready to feed her but said a lot of times there was just one NA on the unit. RN-A said staff can't keep her in their sight line and said if there was only one NA, I don't know how they could properly supervise her. Every time staff needed a two person transfer or an alarm went off the nurse got pulled away from the cart. During interview on 1/19/24 at 12:02 p.m., RN-B stated the video camera was implemented because family wanted 15 minute checks and that was not manageable. When asked about the addition of the video camera in the room in relation to R1's fall in the dining room, RN-B said I don't know. RN-B stated staff were not able to adequately supervise R1 and said if a NA was in a room and the nurse was in a med room there was no one to watch R1. RN-B stated R1's falls typically occurred in the evenings before family arrived or after family left. During interview on 1/19/24 at 1:00 p.m. the interim administrator stated one of the issues in the facility was the ability to afford good staff and said a wage increase had been approved and they were hoping that would help. The interim administrator stated they had contacted staffing agencies to try to find staff for the facility. The interim administrator stated he identified the current staffing levels did not meet the needs of the residents. A facility policy related to fall interventions was requested but not received.

Based on interview and document review, the facility failed to ensure the resident [NAME] of Rights were provided verbally and ongoing for residents of the facility for 2 of 2 residents (R22, R43) interviewed during resident meeting. This deficient practice had the potential to affect all 48 residents residing in the facility. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had no cognitive impairment. R43's quarterly MDS dated [DATE], identified R43 had no cognitive impairment. During an interview on 10/17/23 at 1:03 p.m., R22 and R43 stated they did not know what the Residents' [NAME] of Rights was. R22 thought she received a paper when she was admitted to the facility, and possibly had it in a drawer in her room. R43 did not recall ever receiving anything about it. Neither recalled a resident council meeting where the [NAME] of Rights was discussed either. During an interview on 10/18/23 at 8:08 a.m., social services designee (SSD) stated she conducted the resident council meetings with residents and had been doing that for approximately a year. The Residents' [NAME] of Rights was provided to the residents during admission and the booklets were always available at the suggestion box for residents. SSD did not review the rights with residents during resident council because she thought it just needed to be available to residents. During an interview on 10/18/23 at 3:21 p.m., the director of nursing (DON) stated residents and families were given a handbook during the admission process, but it was not verbally discussed with them. It was something that could be done during resident council. The facility Resident's Right for Skilled Nursing facilities revised 10/4/16, identified the resident has the right to be informed of his or her rights and of all rules and regulations governing the resident conduct and responsibilities during his or her stay in the facility. The facility policy Notification of Changes in Resident Rights revised 1/18/23, identified the facility would promptly notify the resident and, if known, the resident's legal representative or interested family member when there was a change in resident rights under federal or state law. The policy failed to identify if the facility staff provided ongoing communication to residents about their rights.

Based on observation, interview and document review, the facility failed to ensure laundry services were conducted in a manner to promote sanitary conditions. This had the potential to affect all residents who ultilized bedspreads. Findings include: On 10/17/23 at 8:55 a.m., a jumbled pile of bedspreads was piled onto a rolling office chair with the edges of the bedding touching the floor. Housekeeping (HSKG)-A stated the bedspreades were left that way the evening prior and would need to be re-washed. HSKG-A was not the normal laundry staff member and was covering for the day. On 10/17/23 at 5:27 p.m., The jumbled pile of bedspreads remained on the rolling office chair, and several had fallen onto the floor. HSKG-A stated the last load of linens for the day were being folded and would be delivered to the units for use. HSKG-A stated I'll just be honest. If you hadn't walked in, I would have just folded them [the bedspreads] and put them in the cupboard, but I'll rewash them now. During an interview on 10/18/23 at 3:17 p.m., the director of nursing (DON) stated she expected environmental services to launder linens and put them back into supply for use the same day. If something touched the floor, it needed to be rewashed and treated appropriately. During an interview on 10/18/23 at 4:19 p.m., registered nurse (RN)-A stated she was responsible for the facility's infection prevention (IP) program. RN-A had not conducted any audits of the laundry. When items touched the floor, it would need to be rewashed. A facility laundry policy was requested but not received.

Based on interview and document review, the facility failed to The facility failed to provide adequate supervision by appropriately trained staff when a home maker (HM-A) staff assisted a resident, not utilizing care planned interventions and resulting in a fall with fracture. This had the potential to affect all residents in the facility that required assistance from staff for ambulation. In addition, the facility failed to implement care planned interventions for 1 of 3 residents (R3). The immediate jeopardy began on 6/20/22, when an unlicensed/non-certified (HM-A) staff assisted R1 to the bathroom while not utilizing care planned interventions resulting in a fall with fracture. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 4:00 pm. on 6/28/22. The immediate jeopardy was removed on 6/29/22, but noncompliance remained at the lower scope and severity of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. R1's Admission Record indicated he admitted to the facility on [DATE], with diagnosis that included cognitive deficits and repeated falls. R1's quarterly Minimum Data Set, dated dated dated [DATE], identified moderately impaired cognition. R1's care plan dated 3/4/22, indicated he was able to ambulate with assitance from one staff and a gait belt. A report to the state agency dated 6/21/22, indicated on 6/2/22, R1 had attended an activity off the unit and needed to use the bathroom. HM-A assisted R1 to a public bathroom and left him alone. About a minute later HM-A heard R1 fall and start to yell so she entered the bathroom and found R1 on the floor. R1 complained of pain rated 10/10 to his right shoulder and was sent to the emergency room where he was diagnosis with a right shoulder fracture. The resident had been assisted by a staff, but it was a HM who was not certified nursing assistant. The report indicated it was unlikely HM-A had used a gait belt when assisting R1 to the bathroom as directed by his care plan. A Progress Note dated 6/22/22, indicated the facility high risk committee met to review R1's fall. Fall intervention included NA staff only to assist with ambulation and must wear a gait belt. During interview on 6/27/22, At 4:15 p.m. the administrator stated falls were reviewed daily. The administrator stated immediate interventions were reviewed at that time. The administrator stated during the review the team looked at if the care plan had been followed at the time of the fall and if the care plan needed updating. The administrator stated when they discussed R1's incident the team determined they needed to talk to the staff and stated the HM role was newer to the facility. The administrator stated assisting residents to the bathroom was not part of HM-A's job as she was not trained to provide toileting assistance. The administrator stated the facility did not have a clear description of the HM's role in the facility and acknowledged HM-A would not have known which residents she could or could not assist. The administrator stated HM-A would not have known the level of assistance R1 required as she had not been trained to use the Kardex (nursing assistant care guide). The administrator stated herself and the DON were planning to do some education later in the week so HM staff would know who they could help and in what way. The administrator stated the HM's needed education on how they could transfer and use of the Walkie-talkies to communicate with the NA's. The administrator stated, following the incident on 6/20/22, HM-A continued to work with residents but had not received any additional training or guidance related to her position and stated she had just connected with HM-A that morning. The administrator stated at the time of the incident HM-A was the only staff member at the activity. The DON who was also present stated the HM's received on-boarding training and one to one with other HM's on the floor. The administrator stated she had reviewed HM-As file and said HM-A did not have and training related to safe resident handling. Review of HM-A's Job Description Summary, signed 10/21/21, indicated tasks such as food preparation and dining, assist with meals and snacks, provides water, housekeeping and laundry but the job description summary also reflected the Nursing Assistant provides assistance with basic health care needs including daily actives that may include but not limited to bathing, toileting, grooming Assists the resident in transferring, repositioning, and walking using the correct and appropriate transfer techniques and equipment and also provides range of motion and passive exercises. On 6/27/22, at 5:01 p.m. HM-A stated she had assisted R1 to the bathroom and confirmed she had not used a transfer/gait belt. HM-A stated other staff asked her to bring people to activities all the time and she had been doing what she was asked to do. HM-A stated at the time of the incident she was not aware she wasn't supposed to bring R1 to the bathroom. HM- stated she did not have access to the Kardex. HM-A stated after speaking with the administrator earlier today she sort of knew who she could assist. On 6/28/22, at 9:50 a.m. nursing assistant (NA)-A and NA-B were interviewed. NA-B stated the HM's role was to clean, get food and do activities on the units. NA-B stated the NA's brought residents to the of unit activities so the NAs could stay on the unit with the residents who did not attend. NA-A stated she was not aware of any residents on the unit that could not be escorted off unit by a HM. On 6/28/22, at 10:02 a.m. HM-B stated she was able to escort residents to activities but could not use a lift. HM-B stated she was not aware of anyone she could not escort to an activity. HM-B stated typically it was only HM's in the off site activities and said she did not usually carry a Walkie-talkie. On 6/28/22, at 10:07 a.m. HM-C stated she helped with meals, cleaned rooms and assisted residents to activities. HM-C stated if a resident used a walker they could escort them to an activity. HM-C stated there was typically only one HM in the off site activities. A facility policy Competency and Mandatory Education Requirements dated 10/15/19, identified competence as the ability of an individual to perform a skill or a job properly. Ongoing measurement of competency is a process and an expectation of the employee. [NAME] is responsible to provide processes for ongoing education and competency achievement. The immediate jeopardy began on 6/20/22 was removed on 6/29/22, at 2:55 p.m. when it was verified through interview and document review the facility had assesses supervision needs and policies related to care needs, updated job description for HM's and educated all staff on the scope of practice for the HM role in relation to resident care/supervision. In additional the facility educated staff on the use of the resident care guides and implemented a system to alert certified/licensed staff of resident needs when supervised only by HM's. R3's Admission Record indicated she admitted to the facility on [DATE], with diagnosis that included dementia and a history of falls. R3's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she required limited physical assistance from staff for transfers and ambulation. R3's care plan dated 4/9/22, identified a self care deficit. The care plan indicated a risk for falls related to confusion and a history of falls including a history of falls with fractures prior to admission to the facility. The care plan directed staff to ensure proper footwear, place a stop sign outside door and close door when R3 was not in her room, and indicated R3's wheel chair had been equipped with anti-roll backs for safety and fall prevention. Progress Note dated 3/4/22, indicated the high risk committee met to discuss R3's fall that occurred on 2/25/22. The note indicated R3 attempted to stand and ambulate independently and fell in the dining room. The note indicated anti-roll backs were placed on R3's chair for safety and a stop sign was placed on her room door. A Falls Tool dated 6/20/20, indicated R3 had three or more falls in the past three months. The tool indicated R3 received two high risk medications and was moderately cognitively impaired. During observation on 6/27/22, at 1:52 p.m. R3 was seated in a wheel chair at a table in the common area of the unit. No anti-rollbacks were observed on her chair. R3's room was observed and the door to her room was open and no stop sign was placed on the door. At 1:56 p.m. NA-C stated R3 required limited assistance and stated R3 had not fallen in quite some time. NA-C stated R3's fall interventions included a fall mat and a motion sensor. At 2:00 p.m. licensed practical nurse (LPN)-A stated staff kept and eye on R3 and tried to be aware of her movements. LPN-A verified R3 was seated in her own wheel chair and verified there were no anti-roll backs on the chair. NA-C stated the stop sign should have been placed across R3's door when she was out of the room and said staff did not want her in her room alone. At 4:15 p.m. the administrator stated falls were reviewed daily. The administrator stated immediate interventions were reviewed at that time. The administrator stated during the review the team looked at if the care plan had been followed at the time of the fall and if the care plan needed updating. The administrator stated typically the registered nurse would follow up on implementation of interventions but stated it was everyone's responsibility. The administrator said she had not been aware R3 had a stop sign for her door. A facility policy related to following the plan of care was requested but not received.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19. The facility failed to ensure hospital returns were quarantined according to guidelines along with utilization of gowns in a manner to reduce the spread of infection for 2 or 2 residents (R2, R4) who were on isolation or quarantine. In addition, the facility failed to ensure staff wore the appropriate eye protection while in the patient care areas. These deficient practices resulted in an immediate jeopardy (IJ) situation for all 35 residents residing in the facility during the COVID-19 Focused Infection Control Survey. The IJ began on 10/20/20, when the facility removed R2's quarantine precautions 10 days after readmission to the facility following a hospitalization . R2 subsequently tested positive for COVID-19. R4's quarantine and transmission based precautions (TBP) were also removed 10 days following readmission to the facility. In addition, the facility failed to ensure TBP including gown use and eye protection were implemented according to the CDC guidelines for those on isolation and quarantine, in an effort to prevent cross contamination to other staff and subsequently residents. On 11/5/20, at 5:23 p.m. the administrator, director of nursing (DON) and infection preventionist (IP) were notified of the IJ. The IJ was removed on 11/6/20, at 3:51 p.m. when the facility implemented actions to reduce/ prevent the spread of COVID-19 within the facility. However, noncompliance remained at the lower scope and severity, widespread, which indicated no actual harm with potential for more than minimal harm that was not IJ (Level F). Findings include: The CDC guidance Coronavirus Disease 2019 (COVID-19) People at Increased Risk dated 9/11/20, identified the risk for severe illness from COVID-19 increased with age, with older adults at the highest risk. Severe illness means a person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. On 11/4/20, at 12:00 p.m. upon entrance to the facility the DON stated the facility had one resident, R2, who was on isolation and TBP following a positive COVID-19 test on 10/27/20. R2 resided on the Voyageur wing which also housed residents negative for COVID-19. The Keptom wing was set up as the facility's COVID-19 wing but due to only one resident being positive the facility could not staff a separate wing for one resident. On 11/4/20, at 2:00 p.m. the administrator indicated the facility did have a wing that was being allocated as the COVID-19 wing for positive COVID-19 residents. The administrator stated the facility had decided not to move their one positive COVID-19 resident to that wing because of staffing concerns. The administrator indicated they felt they had things controlled where the resident was and it would be a risk to move R2. QUARANTINE AND GOWN USE: The CDC Responding to Coronavirus (COVID)-19 in Nursing Homes updated 4/30/20, identified a facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. All recommended personal protective equipment (PPE) should be worn during care of residents under observation and should include a facemask/respirator, eye protection, gloves and gown. Further, Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. The CDC Using Personal Protective Equipment (PPE) updated 8/19/20, identified gowns should be donned (put on) prior to entering the resident's room. The gown should be doffed (removed) while standing in the resident's room, if disposable it should be thrown away and if it was washable it should be bagged for laundry. R2's quarterly Minimum Data Set ((MDS) dated [DATE], identified R2 had severe cognitive impairment and required assistance of one to two staff with activities of daily living (ADL's) including bed mobility, transfers, personal hygiene and locomotion on the unit. [DIAGNOSES REDACTED]. R2's progress note(s) from 10/10/20 through 10/27/20, identified the following: -10/9/20, R2 was sent to the area hospital where he was admitted to the hospital. -10/10/20, R2 was subsequently transferred to another hospital, out of the area, for further follow up. R2 was discharged back to the facility, following a procedure and a brief observational time. -10/20/20, R2 was taken off quarantine and droplet precautions, per the facility policy. (Removing precautions 4 days early was a potential for him to comingle with other residents and for staff to not protect themselves with gowns during cares.) -10/26/20, R2's family was notified R2 was running a fever of 100.2 degrees Fahrenheit (F). -10/27/20, R2 had a temperature of 100.4 degrees (F) and family was notified R2 had tested positive for COVID-19. Further, R2 was placed back on isolation precautions. During observation on 11/4/20, at 1:35 p.m. R2's room had an infection control cart containing PPE and hand sanitizer outside the room along with a sign identifying R2 was on droplet precautions. R2's door was not closed as recommended by the CDC. During interview on 11/5/20, at 8:33 a.m. licensed practical nurse (LPN)-C stated R2 had a positive COVID-19 test on 10/27/20, and was placed on isolation precautions for 10 days. LPN-C stated they had been removing quarantine and TBP after 10 days for everyone who was under observation for potential exposure, following a hospital stay. -At 9:09 a.m. registered nurse (RN)-A stated R2 was transported to the hospital and returned on 10/10/20, R2 was placed in quarantine and TBP for 10 days from 10/10/20 through 10/20/20. On 10/23/20, R2 was again transported to an outside medical appointment and returned the same day. RN-A did not identify if R2 was wearing a mask when he left his rooom after precautions were lifted. R2 was again placed on quarantine and TBP following his appointment. R2 however, developed a fever on 10/26/20, and subsequently tested positive for COVID-19. R2 currently remained on isolation and TBP. During observation on 11/5/20, at 9:56 a.m. nursing assistant (NA)-E had on a facemask and walked to R2's room, donned a clean washable isolation gown, gloves and a face shield. NA-E entered R2's room and shut the door. NA-E as not observed to exit R2's room. At 10:17 a.m. LPN-C donned gloves, reached into R2's room and took a used contaminated washable isolation gown off the back of R2's door. While standing in R2's doorway with gloved hands, LPN-C donned the previously used contaminated washable isolation gown, donned a face shield from the bin hanging on R2's door, entered the room and closed the door behind her. During interview on 11/5/20, at 10:29 a.m. LPN-C stated there were hooks behind R2's door and on the wall. LPN-C stated she retrieved a clean washable isolation gown and after using the isolation gown, LPN-C hung the isolation gown on one of the hooks, instead of placing it in a hamper for washing. Further, LPN-C would continue to use the same (contaminated) isolation gown throughout the entire shift. The staff were instructed by the facility to reuse the washable isolation gowns for their entire shift. LPN-C did not know if the facility had any disposable gowns but had plenty of the washable isolation gowns. At 3:37 p.m. NA-F stated the staff reuse the washable isolation gowns. Each staff obtained a clean washable isolation gown and after using it they were to hang it on a hook on the back of the door. They continued to use the same washable isolation gown the entire shift on the same person. NA-F was working part of two shifts so NA-F removed her gowns from the isolation rooms she had used on the day shift. When NA-F started the evening shift she would start with clean washable isolation gowns again and then reuse them the rest of the evening shift. Further, the staff were instructed on reusing the washable isolation gowns by facility administration. The hooks were usually labeled but today there were two gowns hanging on unlabeled hooks behind R2's door. During observation on 11/5/20, at 3:59 p.m. LPN-B exited R2's room with a contaminated washable isolation gown. LPN-B doffed the isolation gown and then reached into R2's room and hung the contaminated washable gown on an unlabelled hook in R2's room. During interview on 11/5/20, at 4:02 p.m. LPN-B stated when entering R2's room she retrieved and donned the yellow isolation gown that she previously worn that day and hung on the hook in R2's room. Upon exiting R2's room she hung the same used gown on the same unlabelled hook. Further, LPN-B stated she would reuse the gown for the entire shift and then place in a red bag for laundering at the end of their shift. She was uncertain if other staff used her gown. Approximately a week and a half ago staff were instructed on how to don and doff PPE and how to hang the washable isolation gowns. R4's quarterly MDS dated [DATE], identified R4 was cognitively intact and required extensive assistance of two staff for ADL's including bed mobility, transfers, dressing, toileting, and personal hygiene. [DIAGNOSES REDACTED]. R4's progress note(s) from 10/15/20 through 10/26/20, and identified the following: -10/15/20, R4 was transported and admitted to the local hospital for a medical condition. -10/17/20, R4 was subsequently transferred to another hospital for further follow up. -10/26/20, R4 returned to the facility, following further medical treatment and was placed on TBP on 10/26/20. During observation on 11/4/20, at 1:35 p.m. R4 was sitting at the far end of her bedroom. At 3:11 p.m. RN-A donned a clean washable isolation gown from the isolation bin hanging on the outside of R4's door. RN-A obtained and donned a clean face shield that was hanging from infection control bin, then entered R4's room. During observation on 11/5/20, at approximately 8:15 a.m. there was no longer an isolation cart outside of R4's room and no droplet precautions sign on door. A bedside table with a pump bottle of hand sanitizer was outside the room. R4's door was closed. During interview on 11/5/20, at 8:18 a.m. LPN-A stated when first going into an isolation room for their shift she would don a washable isolation gown. She would put on gloves, either eye goggles for COVID-19 negative residents or a face shield if COVID-19 positive residents, and a face mask. When exiting the room would doff and throw away gloves and then doff and hang the used contaminated washable isolation gown on the hooks behind the residents door. The gown that was hung would be used for the remainder of the shift. When interviewed on 11/5/20, at 11:30 a.m. the IP stated all hospital returns and new admissions were quarantined for 10 days, as long as they were asymptomatic. The IP found the quarantining information in the facility policy regarding quarantine zones. Residents that were symptomatic or tested positive were placed in the red zone; those that were exposed and under quarantine were placed in the yellow zone and hospital returns were placed in the gray zone, those in the gray zone only required 10 days of quarantine. Further, the facility was using washable isolation gowns. Because they were reusable the staff were to hang the washable isolation gowns on hooks behind the resident's door. They were to use one gown per resident per shift. Upon exiting the room, staff would mark their hook and hang the washable isolation gown on the hook to reuse for each subsequent encounter on their shift. At the end of the shift staff were to remove the washable isolation gowns and double bag them for laundering. There was a potential staff would forget to mark their hook or contaminate themselves when reusing the isolation gowns. The decision to hang and reuse the washable isolation gowns for the shift was made by the nursing and administration staff. The facility had been previously using disposable gowns but are now using reusable gowns and updated their practice. Further, the IP did not know why they were not laundering the gowns after every use and identified the facility was not short on gown supplies. The IP stated she thought the facility was in conservation mode and did not want to run out of isolation gowns, if their was a large outbreak; however, the facility isolation gowns were reusable after they had been washed. On 11/5/20, at 4:47 p.m. the facility administrator, DON and the IP were interviewed. The DON stated the staff would get a clean washable isolation gown for each resident upon entering a quarantine room, the first time of their shift. The staff would label the hook and place the used isolation gown on the hook. At the end of the shift the gown would be laundered. The IP stated the facility's practice changed about two weeks ago, and were previously sharing the used washable isolation gowns. The IP indicated there were three gowns hanging in the quarantine rooms and staff would share those gowns for that resident, through out their shift. The IP indicated the staff did not like sharing the gowns and so the facility had went to labeling the hooks at that point. The IP stated the staff were never instructed they should obtain a fresh gown with each resident encounter. The facility was not aware they could prioritize gown use for those on observation for COVID-19. The facility Cohorting Plan for SNFs (Skilled Nursing Facilities) updated 10/12/20, identified new admissions to the facility would be placed in the gray zone if they tested negative by a point of care analyzer or [MEDICATION NAME] card test. Further, staff should wear PPE including surgical masks, eye protection, gown and gloves as needed while taking care of the residents in the gray zone. Residents should be kept in the gray zone for 14 days as long as they remained asymptomatic. The policy did not identify quarantine for observation status only could end at 10 days for any resident on observation status regardless of zone. The CDC Strategies for Optimizing the Supply of Isolation Gowns updated 10/9/20, identified the facility could prioritize gown use for those under observation. Gowns should be prioritized for the following activities: During care activities where splashes and sprays are anticipated, which typically includes aerosol generating procedures; During the following high-contact patient care activities that provide opportunities for transfer of pathogens to other patients and staff via the soiled clothing of healthcare providers, such as: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. EYE PROTECTION: The CDC's guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic updated 11/4/20, identified healthcare personnel working in resident areas should wear eye protection in addition to a facemask. On 11/4/20, at 3:01 p.m. NA-F was observed wearing eye goggles on the top of her head while assisting an unidentified resident with a snack and drink. NA-F was within 6 feet (ft) of the unidentified residents. NA-F stated she could not see when wearing eye protection and then placed the eye goggles correctly on her face. On 11/4/20, at 5:07 p.m. NA-D was observed wearing prescription eye glasses and had eye goggles on the top of her head and not over their eyes in a resident care area. NA-D stated she could not see to chart if she was wearing the eye protection because they were tinted and hard to see out of. During interview on 11/4/20, at 5:11 p.m. RN-A stated staff should wear eye goggles when in contact with residents for 15 minutes. If staff go into an isolation room they should wear the face shield and upon leaving the room they should disinfect it and don their own eye protection. During observation on 11/4/20, at 5:17 p.m. NA-D was walking out of a resident's room wearing prescription eye glasses and eye goggles; however, the eye goggles were low on her face. The goggles were towards the end of her nose and below the level of prescription eye glasses, not covering the sides of their eyes. During interview on 11/5/20, at 9:30 a.m. NA-G stated staff were supposed to wear eye goggles if they were in direct contact with residents for 15 minutes or more. NA-G was uncertain if prescription eye wear was okay. Some of the staff were told by administration that it was okay to only wear prescription glasses as long as they covered the eyes. Further, if staff wore prescription glasses they should not have to wear eye protection over them although staff probably should wear eye protection when they go into a positive COVID-19 resident room. NA-G was uncertain if there was a policy for that or not, and did not identify if they had received education regarding eye protection. When interviewed on 11/5/20, at 11:42 a.m. the IP stated she had told all staff to wear goggles in resident care areas and when entering an isolation room they had wear a faceshield. it was an infection concern if prescription glasses are not being cleaned properly between residents rooms, eye protection prevents the spread of COVID-19 and she recommends all staff wear eye protection at all times when on the units and to wear a face shield when in an isolation room. The facility policy Emerging Threats- Acute Respiratory Syndromes Coronavirus (COVID) - Enterprise revised 4/30/20, identified eye protection that covered both the front and sides of the face should be used in resident areas. The IJ that began on 11/5/20, was removed on 11/6/20, at 3:51 p.m. when it could be verified through observation, interview and document review the facility had reviewed and revised facility procedures and practices to reduce/ prevent the spread of COVID-19 within the facility. These interventions included placing R4 back on quarantine; implementing and educating staff on 14 day admission/ readmission quarantine practices regardless of COVID-19 status, completed risk assessments to determine which residents were high risk exposes due to the deficient practice; revising gown procedures and educated staff on using one gown per resident interaction, along with following the CDC guidance for optimizing gown use for residents on observation/quarantine status; reinforced education with staff to ensure appropriate eye protection was worn in all resident care areas; along with implementing a system to monitor staff for adherence to the expected procedures and practices.

Based on observation, interview and document review, the facility failed to provide supervision for 1 of 1 resident (R11) who utilized a motorized wheelchair in the community and was identified as being unsafe. This resulted in an immediate jeopardy (IJ) for R11 who was observed to navigate the electric wheelchair into the line of traffic causing traffic to slow down, stop, or maneuver around R11. The facility also failed to provide supervision for 1 of 1 resident R12 when outside smoking during inclement weather resulting in frost bitten hands. This failure resulting in actual harm for R12 due to the skin injury. In addition, the facility failed to provide assistance with full body mechanical lifts as directed by the manufacturer guidelines for 1 of 3 residents (R5) who was observed to be transferred via a full body lift with one nursing assistant (NA) and one homemaker (HM) staff. The IJ began on 8/6/19, when an unknown community member (CM) called for emergency assistance (911) after noticing R11 in the community displaying signs of a possible medical emergency, while off of the facility grounds. The facility administrator and director of nursing (DON) were notified of the 8/6/19, incident by the direct care staff. The facility administrator and DON were notified of the IJ on 1/30/20, at 4:46 p.m. The IJ was removed on 2/4/20, at 3:48 p.m. but noncompliance remained at the lower scope and serenity level of an G actual harm sustained by R12. Findings include: R11's annual Minimum Data Set ((MDS) dated [DATE], indicated R11 had [DIAGNOSES REDACTED]. The MDS also indicated R11 was alert and orientated, required total assistance with transfers, was unable to ambulate, and required supervision on and off of the nursing unit. R11's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE], indicated R11 required assistance for ADL's, displayed balance concerns during transitions and was not steady. R11 had chronic pain, muscle spasms, spastic [MEDICAL CONDITION] (paralysis affecting one side) contracture of her leg and neck, and utilized a motorized wheelchair for all locomotion on and off of the nursing unit. R11's Occupational Therapy (OT) Therapist Progress and Discharge Summary dated 8/20/19, indicated R11 had cervical (neck) contractures which resulted in limited ability to move her head to the right as R11's neck was contracted in a downward (toward chin) position. R11 was deemed not safe while in the community. R11 had been educated on the risk/benefits of utilizing a motorized chair in the community at which time R11 had verbalized her understanding of the risk/benefits, and declined further OT restorative therapy. R11's Care Plan dated [DATE], indicated R11 utilized a motorized wheelchair and OT had assessed R11 to be safe on the facility property, but was unsafe to use off property. R11 had been educated on the risks and benefits and was able to make decisions independently. R11's Care Plan dated 5/2/18, indicated R11 utilized tobacco safely and smoked off facility property. R11's clinical record contained a Release from Responsibility When Resident is Away from Facility (unaccompanied) form dated 1/8/20. The release indicated, This is to acknowledge that I, (R11) a resident of [SOCIETY] accept full responsibility for myself, my actions and any consequences resulting therefrom while I am away from said facility and hereby release, hold harmless and agree to indemnify the Good Samaritan Society it's staff and said facility from all responsibility for any ill effects during or resulting from the period I am away from the facility. The form was signed by R11 and registered nurse (RN-A). R11's Progress Note (PN) dated 8/6/19, at 4:03 p.m. indicated a concerned citizen had called 911 after finding R11 in town, in her electric wheelchair. R11 apparently displayed signs and symptoms of dehydration (exact symptoms not identified in the record), the police called a community transportation bus company and R11 was returned to the facility. R11 displayed an increased pulse of 112 beats per minute. R11 was seen on routine physician rounds. R11's pulse returned to [AGE]. The note indicated the administrator and director of nursing (DON) were informed of the situation. According to the National Weather Service, the temperature in [ENTITY], [STATE] on 8/6/19, was 82 degrees Fahrenheit with 51% humidity. On 1/29/20, at 9:53 a.m. an anonymous reporter stated R11 was not safe in the community, unattended. The reporter also stated facilty residents could leave the property unattended regardless if they were safe or not, because they had signed a release of responsibility form. -At 12:26 p.m. R11 was observed seated in an electric wheelchair equipped with a slow moving sign (orange reflective triangle) on the back of the chair. The chair was not equipped with side mirrors or a high posted flag. R11 was dressed with a hat, winter coat with the hood up over her head, gloves on, and a blanket over her legs. R11 did not turn her head to look side to side for oncoming traffic/hazards. R11 maneuvered the electric wheelchair throughout the Voyager's neighborhood living room area, reached the community telephone, and placed a called. Following the call, R11 proceeded to maneuver out of the living room, pushed the electric handicapped door button, opened the door, exited the Voyager's neighborhood and entered into the facility main entrance area. R11 did not sign out prior to leaving the neighborhood. At 12:36 p.m. R11 opened the facility main entrance doors and maneuvered out to the facility parking lot, and headed west on [LOCATION]. -At 12:40 a.m. community member (CM)-A was observed entering the facility. CM-A identified R11 by name and reported R11 goes all over town in her chair. CM-A stated R11 utilized the main driving lanes due to the snow/snow banks and CM-A has had to assist R11 when she was stuck in the snow with her chair. CM-A stated, A while ago, she found R11 in the [ENTITY] (community fitness center) parking lot yelling for help because her electric wheelchair kept spinning in the snow so she pushed R11's chair so that it could get some traction and move. CM-A stated, People really have to pay attention to what (R11) is doing because she will get stuck in the snow when out in the road. -At 1:00 p.m. R11 was observed seated in the parking lot of a local fitness center approximately a half mile from the facility. R11 stated she was waiting for her family to come out so she could take them to lunch. R11 stated she did not want to enter the business. R11 remained outside until 1:12 p. m. at which time the business staff had indicated R11's family was not there, however, R11 stated she wanted to wait around a bit longer and then would head back to the facility. At 1:18 p.m. the national weather cell phone application indicated the temperature of [ENTITY] was 20 degrees Fahrenheit without a wind. -At 1:20 p.m. R11 crossed [LOCATION] which was a two lane road covered with ice and snow and with some exposed tar patches in the driving lanes. R11 did not turn her head side to side to look for oncoming traffic or any hazards prior to crossing the road. R11 maneuvered the wheelchair down the middle of the driving lane with the flow of traffic heading to a frontage road. Two passing cars slowed down when they had seen R11, and another car, driving in the same direction as R11, came to a complete stop due to R11 being in the line of traffic. R11 again did not turn her head or look for oncoming traffic/hazards as she turned down the snow covered frontage road next to [STATE] [LOCATION] and continued to maneuver down the center of the lane. The west side sidewalk was impassable due to snow coverage and 4-6 foot high snowbanks on both sides of the road. R11 stopped in the middle of the road, lit a cigarette, paused and continued to travel down the road. One car followed behind R11 for approximately 1/2 block and came to a complete stop to allow R11 to turn east on [LOCATION], a two lane road. R11 was not observed to turn her head or look for traffic or hazards. While crossing [LOCATION], three cars stopped to allow R11 to cross the street as she maneuvered down the middle of the road. One car followed R11 off of the frontage road, one car headed east towards HWY 71, and one headed west on [LOCATION] and all stopped to allow R11 to cross the road -At 1:29 p.m. R11 stopped at the stop lights at the intersection of [LOCATION] and [LOCATION] and waited to cross the highway. [LOCATION] was a five lane road (two lanes going both north and south and one turning lane). When the stop light turned green, R11 began maneuvering across the highway. When the light turned red, R11 had made it past the four lanes but not the turning lane and the traffic at the stop light waited for R11 to finish crossing the road. Once she had crossed the highway, R11 entered Keenan Drive, a two lane road, and headed east. Keenan Drive was a wide road with two lanes of traffic and 6-8 foot bicycle lanes on both sides of the road, along with a walking path on the north side of the road. The walking path and the edges of the road were inaccessible due to snow coverage, 4-6 foot high snowbanks also lined the roads. The traffic on Keenan Drive slowed, stopped and also swerved around R11 as she maneuvered down the middle of the road on her way back to the facility. At 1:36 p.m. R11 entered the facility parking lot and returned to the facility. -At 3:36 p.m. trained medication assistant (TMA)-B stated R11 was to sign herself out each time she left the facility. Upon review of the sign out log, TMA-B confirmed R11 had not signed out when she left the facility, but stated R11 was allowed to leave the facility unattended. -At 4:02 p.m. R11 was observed in bed, dressed in a hospital gown, and tucked under the covers. R11 stated she would not be getting out of bed until 1/30/20. When asked, R11 stated she had to leave the facility property to smoke and that she would either go outside to smoke or to go to the store uptown. R11 stated, I go all over town, whenever I want and frequently visited local businesses along [LOCATION], [LOCATION], as well as family members homes. The businesses identified by R11 ranged from 0.5 miles to two miles away from the facility. R11 stated she informed the staff members when she was leaving the facility, but did not have to tell them where she was going. R11 stated she did not have a working cell phone and did not have the ability to call for help, if needed. -At 4:10 p.m. registered nurse (RN)-A stated per facility policy, all residents who chose to smoke were required to leave the property when smoking. RN-A stated she was aware that R11 was deemed unsafe to navigate alone in the community, but R11 had signed a release of responsibly form, and was able to make her own decisions, therefore she was allowed to do so. RN-A confirmed R11 had a history of [REDACTED]. In addition to getting stuck in the snow, RN-A stated the electric wheelchair was also at risk of running out of power leaving R11 stranded and no way to communicate if she had trouble. RN-A verified the facility had received phone calls from community members who were concerned about R11 while off the facility property, but the staff did not have the ability to go and get R11 if/when she had difficulty when in/out in the community, therefore R11 had been instructed to call a community transport bus to provide her transportation back to the facility, if needed. RN-A stated R11 was encouraged to stay on the facility property, but she did not comply. In addition, RN-A stated the staff were responsible to ensure R11 was appropriately dressed for the weather when she went out. RN-A also stated household lead (HL)-A was looking into obtaining a reduced rate or free cell phone for R11 to use when she was out in the community, but was unaware if the phone had been obtained yet or not. RN-A stated all facility staff including the administrator were fully aware of R11 leaving the facility and having difficulties such as becoming stuck in the snow or becoming dehydrated during the summer months while in the community. In addition, the staff and adminstrator were also aware of community members calling the facility to report concerns related to R11 having difficulties when in the community during both the summer and winter months. However, upon review of R11's clinical record, RN-A confirmed R11's record lacked documentation related to the concerned phone calls received or about the known difficulties R11 had when unattended in the community. -At 4:27 household lead (HHL)-A stated about 3-4 weeks ago, the interdisciplinary team (IDT) had discussed obtaining a cell phone for R11 for her use when out in the community, unattended. However, HHL-A stated she had not had time to look into the matter further. HHL-A confirmed R11 had a cell phone which she used within the facility to communicate with family/friends when connected to the internet, however, the phone did not function when out of internet range. -At 4:37 p.m. RN-A confirmed he had not completed a comprehensive safety assessment of R11 while out in the community. Both RN-A and HHL-A confirmed R11's 8/19, OT evaluation indicated R11 was not safe in the community unattended. -At 5:17 p.m. family member (FM)-D stated she was aware R11 left the facility unattended. FM-D stated R11 was under sixty years of age, enjoyed the freedom of utilizing the electric wheelchair around the community and would go all over town in the summer in her chair, but in the winter it was a little sketchy. FM-A stated she wished R11 had a cell phone to call for help and was working on obtaining one for her. FM-D stated R11 had limited neck mobility which prevented her from performing full visual safety checks to look for oncoming traffic but even-so, did not wish for R11 to be restricted with going into the community as it was her right to do so, her time of freedom. FM-D stated R11 would be very upset if she did not have the ability to utilize her electric wheelchair in the community and FM-D did not want R11 to lose the right to do so. FM-D could not recall the facility expressing any type of concerns related to R11's safety in the community and stated she was aware R11 was not safe driving in traffic and if she (R11) gets hit by a car, that's her deal. On 1/30/20, at 9:08 a.m. nursing assistant (NA)-B stated last week, R11 reported she had been stuck in the snow by the stop lights ([LOCATION] and Keenan Drive) and unknown community members had pushed her out. NA-B stated R11 had been informed of winter blizzard conditions but R11 still left the facility property. NA-B confirmed community members had called the facility to report safety concerns related to R11 being stuck all over town, and the facility does not respond to those calls. NA-B stated both the facility administration and the DON were fully aware of R11's safety concerns when out in the community, unattended. -At 9:44 a.m. occupational therapist (OT)-A stated she had assessed R11's wheelchair mobility on multiple occasions in the past and determined R11 was safe to maneuver the electric wheelchair in the facility, however, she was not safe to do so out in the community. OT-A verified the facility had been notified by community members on multiple occasions of R11 having difficulties with mobility when in the community. OT-A stated on multiple occasions, R11 had received training related to street safety, how to improve range of motion, and how to make better choices, however, R11 was not cognitively able to implement the instructions she had been trained on. OT-A confirmed the last time she had assessed R11's wheelchair safety was during the summertime at which time R11 had been deemed unsafe to be in the community unattended. OT-A stated R11 had not been assessed when out in the community during the winter months, but did not feel R11 would be safe during the winter conditions either. On 1/30/20, at 10:0 a.m. R11 was observed seated in her electric wheelchair, dressed in a winter coat, hats, gloves, hood and blanket. R11 stated she had to go to [ENTITY] to pick up some potting soil. R11 proceeded to leave the neighborhood, exited the main entry doors and began maneuvering downtown. R11 did not sign herself out of the facility. R11 maneuvered from the parking lot westbound on Keenan Drive which was snow packed. There were 4-6 foot high snowbanks were on both sides of the road and the walking path was impassible. R11 maneuvered down the middle of the road heading towards [LOCATION]. At the [LOCATION] intersection, R11 stopped in the middle of the road and waited for the traffic light to change. While waiting, two vehicles had made right hand turns and another vehicle went straight. All three vehicles went around and passed on the side of R11. When the light turned green, R11 began moving forward, however, the light was red before R11 could cross all 5 traffic lanes. The traffic at the light waited for R11 to cross the road. Once fully across, R11 proceeded on to [ENTITY]. -At 10:19 a.m. R11 entered the [ENTITY]/County Market parking lot. The lot was snow-packed with patches of tar exposed in the traffic lanes. A snowbank at the corner of Valley Circle Drive and County Market parking lot was greater than 10 feet high which obscured the [ENTITY] parking lot. R11 was not visible to traffic exiting [LOCATION] and entering the parking lot. R11 maneuvered down the middle of the parking lot traffic lane southbound to [ENTITY]. While maneuvering, three vehicles passed R11 on the left, two on the right side, and five slowed down. R11 entered [ENTITY]. At 10:30 a.m. the National Weather Cell Phone application indicated the temperature of [ENTITY] was 21 degrees F without a wind. -At 10:50 a.m. R11 left the [ENTITY] store and maneuvered down the middle of the lane, north towards Valley Circle Drive. R11 stopped at the stop sign at the corner of Valley Circle Drive and [ENTITY] parking lot. The snowbank next to the road obscured R11 from the oncoming traffic's view. R11 was not observed to turn her head or look for traffic as she entered Valley Circle Drive. -At 10:53 a.m. R11 traveled east on Valley Circle Drive towards [LOCATION]. The traffic stopped as R11 approached the road. R11 stopped at the light in the middle of right turn lane as one car turned to the right and one car crossed the highway. R11 was between the two cars as she maneuvered her electric wheelchair with the cars as they proceeded on. The light had turned red prior to R11 making it to the other side of the Hwy. The northbound cars waited for R11 to cross the road before moving. R11 maneuvered west on Keenan drive and continued down the middle of the lane all the way to the edge of the facility property. Once on the road in front of facility, R11 moved out of the lane of traffic and maneuvered along the snow covered edge of the road. Traffic was again observed to stop, slow and swerve around R11 in order to avoid hitting her. R11 entered the facility parking lot, stopped an unknown community member and requested assistance. The community member adjusted R11's full body mechanical lift sling straps which were wrapped around the wheelchair controls making it difficult for R11 to steer the wheelchair. R11 thanked her for the assistance and headed into the facility. -At 11:10 a.m. R11 entered the facility and informed RN-C she had difficulties making sure the straps of the lift sling were out of the way of the wheelchair controllers. R11 reported she had picked up the potting soil for her plants. The facility's 1/30/20, resident Sign Out sheet lacked indication R11 had signed out/left from the facility. -At 12:44 p.m. the director of admissions and household lead (DAHHL), DON and the interim administrator (joined by phone) were interviewed. The DAHHL stated R11 had signed a release of responsibility therefore could leave the facility on her own because the facility was no longer liable for R11's actions. The DAHHL stated R11 had been educated on the risks and benefits for leaving the facility unattended, but R11 was able to make her own choices. The DAHHL stated [CTY] social service had called in the past and had talked to R11 about street safety. R11 was aware of the dangers of being unattended, yet she went out anyway. The DAHHL stated when she was not working, she had personally observed R11 out in the community maneuvering in the line of traffic, but again reiterated, it was R11's right to do so. The DAHHL confirmed R11's clinical record did not contain documention related to the repeated calls from concerned community members regarding R11's safety. The interim administrator verified R11 had signed a release of responsibility form, local law enforcement were aware of R11 being out in the community alone, as well as the county social services and believed the facility had done everything within their power to keep R11 safe. The interim administrator stated it was R11's choice to go out unattended. When asked, the DAHHL confirmed R11 did not have a cell phone on her person in order to call for assistance when away from the facility, however, stated HHL-A was working on obtaining one, but she was not sure where HHA-L was in the process of that. The DAHHL stated she was aware emergency services (911) had been called in the past to assist R11 when she was in the community and had difficulties and again reiterated that R11 had the right to leave as she wished, but was to sign out when the left. When asked, the DAHHL and interim adminstrator both denied receiving calls from concerned community members regarding R11's safety when observed in the community. The interim administrator confirmed R11's wheelchair did not have a high warning/alert flag nor mirrors in place and verified the facility had not provided R11 with a phone to utilize when out in the community unattended. -At 1:12 p.m. the DAHHL stated R11 did not wish to be escorted when out of the facility and the facility did not have staff to provide escort services for just one resident. The DON stated R11 was very impatient at times and would not tolerate one on one supervision while in the community. The DAHHL and the DON confirmed neither of them had discussed the option of supervision with R11 because the facility did not have enough staff in order to provide one to one supervision. -At 2:33 p.m. the DAHHL provided an email communication dated 8/13/19-8/19/19, between the former DON, RN-A, HHL-A, DAHHL, and the administrator. The emails revealed the following communication: -8/13/19, at 4:11 p.m. a social worker from [CTY] visited the DON regarding R11. The county had received multiple reports/concerns brought forth to them via law enforcement about R11's safety/condition in the community. The administrator, DON and HHL met with social services, and reviewed R11's care plan. The IDT team met and were going to see about a free cell phone for R11 and free/reduced community bus tickets. The email indicated law enforcement may visit with R11. -8/13/19, at 4:13 p.m. RN-A responded via email and indicated R11 had been evaluated by OT-A in the past who did not feel R11 would benefit from further therapy. -8/14/19, at 6:05 a.m. the DON replied that it would be addressed at the IDT meeting that day. However, R11's clincial record lacked documentation of this meeting having occurred or what was discussed. A second email string dated 8/19/20, included the following communication: -At 3:12 p.m. RN-A reported to the administrator, the DON, and the DAHHL, that the facility receptionist had notified RN-A of R11 being across the street in her wheelchair, on the sidewalk and sleeping with a cigarette in her mouth. -At 3:23 p.m. the DON replied that she had driven by R11 and she was okay. -At 3:27 p.m. RN-A replied that he did not think this was something the facility needed to worry about. -At 3:29 p.m. the DON thanked the receptionist for brining it to the attention of the team. -At 3:45 p.m. the receptionist replied that she was responding to a person who called in the concern about R11. The receptionist asked if she was to communicate each time a call from the community had came into the facility. The receptionist noted R11 and another resident (R10) had been identified by the community members with concerns. It is not rare that I get up to at least three calls or drop ins from a concerned citizen regarding our peeps (residents) on the road/sidewalk. -At 3:50 p.m. the DAHHL replied and directed that all concerns in this nature were to be filtered to her and to identify them as a Suggestion/Concerns and she determine what to do with them from there. In her absence, the household leads were to be informed. The administrator did not respond to the aforementioned email communications. On 1/30/20, at 2:33 p.m. the DAHHL stated she had reviewed R11's clinical record and did not identify any further documentation related to any concerns regarding R11's safety when out in the community, unattended. The undated Instruction Sheet for the Resident Sign-Out Sheet directed the resident and/or responsible person accompanying the resident out of the facility to identify the location as to where the resident was going. If the writer felt uncomfortable with the resident leaving the location either accompanied or unaccompanied, the staff were to fill out a Release from Responsibility When Resident is Away from the Facility Accompanied/Unaccompanied form. The Absence (Temporary) from Center policy dated 9/2016, directed all residents who left the facilty to log in and out of the facility. The Motorized Mobility Devices policy dated 11/2019, indicated residents were able to use motorized wheelchairs. Safety considerations were identified but not limited to: -Use of protective gear such as a helmet, knee and/or elbow pads, bicycle gloves, -Use of a rearview mirror. -Use of a horn. -Use of a safety flag. -Use of reflective tape on the scooter and/or clothing -Use of a reacher device to grab items. On 1/30/20, 4:46 p.m. the administrator, the DAHHL, and the DON were informed of the IJ related to lack of supervision for R11 while in the community. The facility was aware R11 had limitations in neck range of motion, utilized a motorized wheelchair when in the community, was not able to follow traffic rules, and was unable to maneuver on safe ways such as sidewalks due to the snow coverage, and had a history of [REDACTED]. R11 was in immediate jeopardy of being involved in a car accident or sustaining weather related injuries. The IJ that began on 8/6/19, was removed on 2/4/20, at 3:48 p.m. when the facility had completed the following interventions; -R11 was assessed for safety factors in the community -R11 was provided a manual wheelchair to be escorted in by staff outside of the facility. -Community rides were arranged for R11 to continue to be allowed to go into the community. -R11 was involved with the decisions in her change of care. -R11's electric wheelchair was equipped with adaptive devices including a mirror and flag. -Reviewed and/or revised policies and procedures related to motorized wheelchair use and educated all staff. -Established an auditing system to ensure compliance, resident safety. R12's admission MDS dated [DATE], indicated R12's [DIAGNOSES REDACTED]. The MDS also indicated R12 had moderate cognitive impairment, required limited to extensive assistance with all activities of daily living and supervision on and off of the nursing unit while in the wheelchair. R12 had been discharged from the facility. R12's Pressure Ulcer Care Area Assessment (CAA) dated [DATE], identified the pressure ulcer and surgical amputation site. No other skin issues were identified. R12's Nursing Admit Re-Admit Data Collection form dated 12/31/19, indicated R12 had bilateral leg amputations, a [DEVICE] on the right amputation site and a stage three ulcer on her coccyx. The assessment indicated R12 had bruises on her hands from intravenous (IV) sites. The assessment did not identify any other type of skin complications on R12's hands. The National Weather Service Application indicated the temperature in [ENTITY], [STATE] from 12/31/19 - 1/8/20, ranged from 30 degrees Fahrenheit (F) to minus 29 degress F. R12's Progress Note dated 1/7/20, at 12:33 p.m. indicated R12 had been taking off her mittens while outside so she could light cigarettes. R12 had blisters on her hands from pushing the wheelchair. Dressing were placed on both hands before going outside and when resident came in, the dressing on the left hand was removed. R12's clinical record lacked clear indication as to when the blisters had developed. R12's Physican Progress Note dated 1/7/20, indicated R12 had been outside of the facility to smoke cigarettes and presented with many open and closed blisters to bilateral hands. R12 was diagnosed with [REDACTED]. The nurse practitioner ordered [MEDICATION NAME] (medicated cream) to be applied to R12's hands along with dressings to cover the wounds. R12's Tobacco assessment dated [DATE], indicated R12 was a current smoker, was cognitively intact, and had difficulty with independent wheelchair locomotion and had gotten stuck (in the snow) in parking lots. The assessment did not identify interventions to ensure safe smoking while R12 was off facility property or smoking unsupervised in inclement weather. R12's Care Plan dated 1/8/20, indicated R12 had sustained frostbite on her fingers on 1/7/20. The plan directed the staff to educate R12 on causative factors and measures to prevent skin injury. Monitor the areas and identify optional causative factors and eliminate/resolve where possible. The care plan lacked interventions to ensure R12's safety while off facility property during inclement weather. R12's Wound Data Collection dated [DATE], indicated R12 had frostbite wounds on her hands as follows: -Right middle finger measured 2.3 centimeter (cm) x 1.3 cm. with serous (clear) drainage. -Right thumb measured 0.4 x 0.4 cm wound with serosanguineous (pink/blood and clear) drainage. -Left thumb measured 4.2 x 1.5 cm wound with serosanguineous drainage. -Left index finger was noted to have a 2.6 x 2 cm wound with serosanguineous drainage. -Left index finger was noted to have a 1.0 cm x 1.0 cm wound with serosanguineous drainage. -Left hand, palm, peri thumb was noted to have a 2.0 cm x 1.5 cm wound with serosanguinous drainage. R12's Wound Data Collection dated 1/11/20, indicated R12 had the following areas on hands: -Left hand (palm) multiple popped blisters on hand, ring finger, pointer finger, thumb, along palm of hand in two places and on back of thumb. Measurements of each area were not identified. The wounds were identified to have sanguinous (bloody) drainage. On 1/31/20, at 7:51 a.m. the director of nurses (DON ) reviewed R12's clinical record and confirmed the record lacked indication as to when R12 first presented with frostbite and a comprehensive assessment had not been completed. The DON stated she would ask registered nurse (RN)-A. -At 9:15 a.m. RN-A confirmed R12 had developed frostbite on her hands while at the facility. Upon review of the record, RN-A confirmed the clinical record lacked documentation as to

Based on observation, interview and document review, the facility failed to provide range of motion (ROM) services in order to maintain and/or prevent loss of ROM ability for 4 of 4 residents (R5, R13, R14, R15) who were reviewed for range of motion. This failure resulted in actual harm when R5's leg contracture had worsened. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5's [DIAGNOSES REDACTED]. The MDS also indicated R5 had severe cognitive impairment, required extensive assistance with all activities of daily living (ADL), was unable to ambulate, and had functional limitations of upper and lower extremities on one side. R5's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/7/19, indicated R5 was unable to independently reposition self in the wheelchair or bed. R5 was unable to propel the wheelchair. The CAA did not address R5's ROM ability. R5's Care Plan dated 6/6/19, indicated R5 required restorative interventions to maintain her current level of function in bed mobility, eating, dressing, toilet use, and personal hygiene. The plan directed staff to provide R5 passive range of motion (PROM) up to seven days a week with evening cares to all extremities: 10 repetitions each, 1 set finger, wrist, elbow and shoulder flexion/extension. Knee and hip flexion/extension and hip abduction/adduction. Ankle dorsal flexion/plantar flexion. R5's Occupational and/or Physical Therapy discharge summary at the time of the initiation of the passive range of motion program were requested but none were provided. Review of R5's Documentation Survey Report v2 (restorative nursing documentation) indicated the following information: November 2019- R5 had participated in the restorative program 2 of 30 opportunities. December 2019, R5 participated in the program 4 of 21 opportunities. January 2020, R5 had partitioned in the program 1 of 31 opportune. R5's Restorative Nursing Documentation dated [DATE], indicated R5 was to participate in a restorative program and verified she displayed functional limitation in ROM on one side. The review indicated R5's ROM was unchanged from previous assessments and identified left side upper and lower limitations. On 1/30/20, at 7:13 a.m. nursing assistant (NA)-A and NA-B were observed to assist R5 with morning cares. R5 was wearing a nightgown as she was resting in bed with a pillow in between her knees. When NA-A removed the pillow, R5 was noted to be resting in a fetal like position. R5's knees were bent with her ankles approximately 1-2 inches from her buttocks. R5's left foot was rotated inward. NA-A rubbed lotion on R5's bent legs which did not straighten. NA-B stated R5 had a ROM program for her upper and lower legs, however, the staff did not have the time to provide the exercises. NA-B attempted to stretch R5's legs. NA-B straightened R5's right leg to an approximate 95 degree angle. The left leg did not extend past a 90 degrees. R5 stated, Ow while NA-B attempted to stretch her legs. R5's right arm was noted to be bent at the elbow, her hand opened, and the right shoulder moved approximately two inches outward from her torso. NA-B removed R5's arm from the night gown, slipped the gown over R5's head and removed the left arm. The left moved approximately two inches outward from her torso. The elbow moved into a 90 degree position, and R5 held her left hand in a fisted position. R5 made facial grimaces when NA-B fully opened the left hand. NA-A and NA-B stated R5 had declined in ROM status as her legs were more contracted and the staff had more difficulty providing perineal cares. -At 8:01 a.m. RN-C stated the staff had been working very hard, however, the facility did not have enough staff to ensure all cares were provided including restorative services. RN-C stated she was aware ROM restorative services were not consistently provided for the residents because there was not enough staff. On 1/31/20, at 9:15 a.m. RN-A was observed to assess R5's ROM. RN-A stated R5 was to wear a splint in the left hand, however, R5 did not like to wear it, therefore it was not used. RN-A attempted to move R5's shoulders and confirmed R5 did not have full ROM in either shoulder. RN-A moved R5's legs and stated the left leg was unchanged from past assessments, however, the right leg was more contacted than in the past. RN-A confirmed R5 had declined in her ROM ability. -At 2:12 p.m. RN-C confirmed R5's right leg contracture had gotten worse and stated it was difficult to complete perineal cares as R5's legs were stiff and did not move. RN-C stated the facility did not have a restorative aide, and the NA's did not have time to complete restorative program services. RN-C stated the restorative program had been discussed at the quality improvement meetings, but the facility had not developed a plan to ensure restorative programs were provided in accordance to the individualized care plans. -At 3:12 p.m. trained medication assistant (TMA)-B stated the facility did not have enough staff to care for the residents and the ROM programs were not being completed. TMA-B stated R5 had become harder to move as her legs were bent all of the time and she was more difficult to provide assistance with bed mobility and to complete incontinence cares because she was so stiff. In addition, TMA-B stated R5 had more difficulty standing. TMA-B stated the staff want to complete restorative programs, but they just did not have enough time. R13's [DIAGNOSES REDACTED]. R13's quarterly MDS dated [DATE], indicated R13 had severe cognitive impairment, required extensive to total assistance with all activities of daily living (ADL), one staff assist for locomotion of wheelchair, did not ambulate, and had functional limitation in ROM to both lower extremities. R13's ADL Functional/Rehabilitation Potential CAA was requested and not provided. R13's Care Plan dated 3/12/14, indicated R13 had a need for restorative intervention due to ADL self-care performance deficit/limited physical mobility related to [DIAGNOSES REDACTED]. Staff were directed to complete the nursing rehabilitation program identified at exercises #2 through #6. R13's Physical Therapy (PT) Plan of Care signed 11/12/18, indicated staff reported weakness and joint stiffness of R13's lower extremities (LE) affecting her ability to assist with bed mobility and LE dressing. R13 was at increased risk for pain, debility, and further loss of motion. R13 previously denied participation in a restorative maintenance program, however was now willing to participate based on loss of movement and independence. R13 required skilled PT for the development of a program for which the staff would assist with for LE ROM and strengthening exercises to support mobility and self-care. R13 discharged from PT with a program in place to increase LE ROM and strength and to help improve R13's ability to assist with LE dressing and with transfers. R13's Occupational Therapy (OT) Plan of Care signed 4/30/19, indicated R13 demonstrated joint stiffness in bilateral hands, as well as weakness and impairment in fine motor coordination. Patient/staff have been instructed to apply resting hand splint to alternate hands at night for bilateral hand contracture management. R13's Documentation Survey Report identified the following restorative program services: #2: trunk lateral flexion, PROM. Stand on R13's left side, reach around R13 side to place your hands on R13's right shoulder, and pull R13 towards you so R13 bends sideways at her trunk. Repeat 10 times, hold for 2 seconds, 10 sets. Up to 3 times per week. #3: PROM - perform PROM to bilateral LE. Focus on the hip, knee, and ankle joints. 2 sets of 10 to each joint, up to 3 times per week. #4: Perform PROM on the right upper extremity. Focus on the shoulder, elbow, wrist, and finger joints. 10 reps, 2 sets up to 3 times per week. #5: Apply splint to left hand at bedtime and naps. Place all 5 fingers on top of splint and secure both Velcro straps over wrist and forearm at bedtime every other day. #6: Apply splint to right hand at bedtime and naps. Place all 5 fingers on top of splint and secure both Velcro straps over wrist and forearm at bedtime every other day. Review of R13's Documentation Survey Reports indicated Nursing Rehab was provided as follows: November 2019: #2 - out of 13 opportunities: refused x 5, not applicable x2, blank x 6 #3 - out of 13 opportunities: refused x 5, not available/tired x 1, blank x 7 #4 - out of 13 opportunities: refused x 6, blank x 7 #5 - out of 15 opportunities: refused x 12, not applicable x2, blank x 1 #6 - day shift, identified on the form as daily application: out of 30 opportunities: refused x 14, not applicable x 7, blank x 9 #6 - evening shift out of 15 opportunities: refused x 13, not applicable x2 December 2019: #2 - out of 13 opportunities: refused x 3, not applicable x 1, blank x 9 #3 - out of 13 opportunities: refused x2, not applicable x 1, blank x 10 #4 - out of 13 opportunities: refused x2, not applicable x 1, blank x 10 #5 - out of 15 opportunities: refused x 10, not applicable x 4, blank x 1 #6 - day shift, identified on the form as daily application: Out of 31 opportunities: refused x 11, not applicable x 9, blank x 11 #6 - evening shift- out of 16 opportunities: refused x 12, not applicable x 3, blank x 1 January 2020: #2 - out of 13 opportunities: refused x 4, yes x 1, blank x 8 #3 - out of 13 opportunities: refused x 3, N/A x 1, yes x 1, blank x 8 #4 - out of 13 opportunities: refused x 3, N/A x 1/tired, yes x 1, blank x 8 #5 - out of 16 opportunities: refused x 11, not applicable x 2, yes x 1, blank x 3 #6 - day shift: out of 31 opportunities: refused x 7, not applicable x 8, blank x 16 (identified on the form as daily application). #6 - evening shift: out of 15 opportunities: refused x 12, not applicable x 3 On 1/30/20, at 12:33 p.m. NA-A & NA-B were observed to assist R13 into bed and provide personal cares. Once cares were completed, both NA's exited the room. A splint had not been applied to either of R13's hands. -At 3:49 p.m. R13 was in bed, sleeping. No splint noted on either hand. On 1/31/20, at 7:09 a.m. R13 was observed lying in bed, asleep. No splint observed on either hand. -At 7:14 a.m. NA-B was observed assisting R13 with morning cares. R13 held the right arm close to her body and NA-B had to lift the arm in order to wash underneath it. R13 was able to lift the left arm per self. When NA-B opened the left hand extending fingers to approximately 90 degrees or halfway, R13 stated that's really sore. Both hands were held in fisted positions. R13 stated my arms are really weak. NA-B stated R13 used to only require one person to provide cares, but has declined and needs two staff to turn from side to side as R13 was no longer able to help. When asked, NA-B stated R13 did not have any hand splints on this morning and NA-B could not locate the splint within R13's room. NA-B stated due to staffing, he did not have time to provide ROM exercises/programs, as directed, for any resident. NA-B stated on many occasions, management had been made aware the staff's inability to provide the services, but nothing changed. Upon completion of the cares, NA-B stated he was the only NA working on the unit and did not have time to provide R13's ROM exercises. NA-B exited the room without providing the service. -At 8:10 a.m. R13 was observed in the dining room, seated in a wheelchair. R13's right arm hung loosely (flaccid) and both hands were in fists. -At 9:20 a.m. RN-A demonstrated R13's ROM abilities. R13 was able to open both hands and extend fingers approximately 50% open. RN-A stated most of the time, R13 refused to wear hand splints which had not been communicated to OT in order for a new evaluation to be conducted. When asked, RN-A stated he could not say for sure if R13 had experienced a decline in hand ROM ability as he had not been provided sufficient time in order to complete a timely thorough ROM assessment due to being short staffed and having to work most of his shifts on the floor. RN-A stated the staff had reported to him regarding the inability to provide restorative nursing services as directed, due not enough staff. RN-A stated he had reported this concern to management. -At 9:56 a.m. R13 was lying in bed, asleep. No splints observed on either hand. R14's [DIAGNOSES REDACTED]. R14's quarterly MDS dated [DATE], indicated R14 had moderate cognitive impairment, required extensive with ADLs, occasionally ambulated in own room, and had no functional limitation in ROM. R14's ADL Functional/Rehabilitation Potential CAA dated 5/25/19, indicated R14 required assistance with all ADL's and also had balance concerns with transitions. R14's Care Plan dated 6/28/18, indicated R14 had a need for restorative intervention due to cognitive deficits related to slow mentation and confusion. The staff were directed to: 1. Provide active range of motion (AROM) sit to stand with walker. Have resident stand up with walker, with contact guard assist (CGA) and gait belt 30 seconds. Up x2. Up to 3x a week. 2. Elastic band triceps with yellow band - start by holding the yellow band across his chest with unaffected arm. Next have him pull downward with the other arm so that the elbow goes from a bent position to a straightened position. Complete on right and left sides; up to 2 sets, up to 15 times, 3x per week. Review of R14's Documentation Survey Reports indicated Nursing Rehab was provided as follows: November 2019: #1 - out of 13 opportunities: refused x 1, not applicable x 7, yes x 4, blank x 1 #2 - out of 13 opportunities: refused x 5, not applicable x 6, yes x 1, blank x 1 December 2019: #1 - out of 13 opportunities: refused x 3, not applicable x 3, not available x2, yes x 4 #2 - out of 13 opportunities: refused x 6, not applicable x 4, not available x2, yes x 1. January 2020: #1 - out of 13 opportunities: refused x 3, not applicable x 5, not available x 1, yes x2, blank x2. #2 - out of 13 opportunities: refused x 5, not applicable x 5, not available x 1, blank x2. On 1/31/20, at 9:59 a.m. RN-A stated it was recommended that R14 ambulated to the bathroom with the walker, but he declined. RN-A stated R14 had two different restorative programs which included AROM sit to stand with walker and elastic band exercises, both were to be provided up to 3x per week. When asked what not applicable (N/A) meant when documented, RN-A stated it meant the service was not provided however, the staff should not have been documenting that. After reviewing the task sheets, RN-A confirmed R14 had not received the services as directed. On 1/31/20, at 1:39 p.m. NA-B demonstrated R14's Nursing Rehab exercise #1. NA-B was unable to locate a walker for R14 and borrowed one from another resident. R14 was able to perform the standing exercise without difficulty. However, NA-B stated the staff did not have enough time to provide R14's exercises as directed because the staff just did not have the time to do so. NA-B stated the staff would briefly stand R14 when in the bathroom but had not provided exercises for many months due to not enough time/staff. On 2/5/20, at 8:53 a.m. Occupational Therapist (OTR) stated a resident's restorative program should be continued unless a referral had been sent due to a decline or refusal of program. OTR stated R13 should be on a current restorative program, but was aware that many resident programs were not being provided as instructed by therapy and have also shared concerns about this lack of service with the administrative team, on many occasions. OTR also stated she had been informed that nursing staff had been discontinuing restorative programs for individual residents when either the resident refused or the staff did not have time to complete the services. OTR stated the staff should not just stop a resident's restorative program without consulting with a therapist first. R15's quarterly MDS dated [DATE], identified R15 to be cognitively intact and had [DIAGNOSES REDACTED]. The MDS indicated R15 required extensive assist of two staff for bed mobility, dressing and personal hygiene, was totally dependent on staff for transfers and toilet use and required assist of one staff for locomotion in the wheelchair. The MDS also indicated R15 did not ambulate and did not have functional limitation in range of motion in upper extremities (shoulder, elbow, wrist, hand) but did have bilateral impairment of lower extremities (hip, knee, ankle, foot). R15's ADL Functional/Rehabilitation Potential CAA dated 7/10/19, indicated R15 had weakness in bilateral lower extremities, was unable to independently bring self to standing position, balance concerns during transitions and required use of total mechanical lift with high back sling and assist of two staff for transfers. The CAA also indicated R15 to have a history of TIA affecting physical functioning, chronic back and leg pain and weakness in bilateral lower extremities. From 10/23/19, through 11/21/19, R15 received physical therapy for left foot muscle spasms and pain, and had discharge instructions to continue home exercise program (HEP) with occasional guidance from staff as needed. R15's Care Plan, printed 2/4/20, indicted R15's need for restorative intervention due to ADL self-care performance deficit/limited physical mobility related to weakness, and history of [MEDICAL CONDITIONS]. Staff were directed to complete nursing rehabilitation exercises three times per week to include active range of motion (AROM)as follows: #1 - bicep curls with 2 pound free weight each hand x 15 reps #2 - pulleys out to sides (snow angels) #3 - pulleys straight up (climbing ladder) x 20 repetitions (reps) #4 - seated marching, hold for 10 seconds x 20 times. Review of R15's Document Survey Report-V2 indicated the following: November 2019: #1 - out of 13 opportunities: refused x 4, not applicable x 7, yes provided x 2, blank x 0 #2 - out of 13 opportunities: refused x 0, not applicable x 2, resident not available x 1, yes provided x 0, blank x 10 #3 - out of 13 opportunities: refused x 0, not applicable x 2, resident not available x 1, yes provided x 0, blank x 10 #4 - identified as daily: out of 30 opportunities: refused x 4, not applicable 20, yes x4, blank x 2 December 2019: #1 - out of 13 opportunities: refused x 0, not applicable x 9, resident not available x4, #2 - out of 13 opportunities: refused x 2, not applicable x 1, resident not available x 3, blank x 7 #3 - out of 13 opportunities: refused x 2, not applicable x1, resident not available x 3, blank x7 #4 - identified as daily, out of 31 opportunities: refused x 5, not applicable x 17, resident not available x 8, yes x1 January 2020: #1 - out of 13 opportunities: refused x 4, not applicable x7, yes x2 #2 - out of 13 opportunities: refused x 3, not applicable x1, blank x9 #3 - out of 13 opportunities: refused x 3, not applicable x1, blanks x9 #4 - identified as daily: out of 31 opportunities: refused x6, not applicable x21, yes x3, blank x1 February 2020: #1: out of 2 opportunities: provided x1, not applicable x1 #2: out of 2 opportunities: refused x1, blank x1 #3: out of 2 opportunities: refused x1, blank x1 #4: out of 4 opportunities: yes x1, not applicable x2, blank x1 On 1/30/20, at 9:50 a.m. NA-D verified R15's restorative program had not been implemented as directed. -at 9:57 am, NA-L confirmed R15's restorative program had not been implemented and stated there was not enough time or staff to complete it. On 2/4/20, at 8:49 a.m. OT-A verified R15 was on a restorative program and should have been provided the services, as directed. OT-A stated OT assessed the residents, trained the NA's on the individual program at which time the nursing staff were responsible to implement the program and would notify OT when there was a functional decline so the resident could be reassessed. -at 9:48 a.m. RN-B verified R15 was currently on restorative program and had been on the same program since 2017, but was uncertain if the program had been updated since then. RN-B stated R15 did at times refuse his therapy however, the NA's were expected to offer and provide the restorative services as directed but also knew the staff did not have the time to provide the service. On 1/31/20, at 10:47 a.m. director of nursing (DON) stated the facility did not have specific restorative staff and expected the NAs to provide the restorative services to all the residents' as ordered and to document as such. The facility's ROM and Ambulation Policy revised 10/2017, indicated this program was to provide the residents with as full ROM as possible, to improve or maintain joint mobility and functional independence, and prevent contractures. The policy also reflected the Federal Regulation which indicated a resident who entered the location without a limited ROM did not experience reduction in ROM unless the resident's clinical condition demonstrated that a reduction in ROM was unavoidable and a resident with a limited ROM received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM