Every finding on record at Good Samaritan Society - Maplewood

Based on interview and document review, the facility failed to ensure quarterly care conferences were provided or offered for 1 of 1 resident (R61) reviewed for care planning.Findings include:R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 was cognitively intact and did not exhibit rejection of care behavior. R61's diagnosis included major depressive disorder, anxiety, chronic pain, and diabetes.R61's progress note dated 5/21/25, indicated a conference occurred without R61 or a resident representative for R61 were in attendance. Invited resident, expressed again does not want to participate in care conferences. Informed resident that facility still has to inform/invite for each care conference even if refuses. Resident verbalized understanding.R61's electronic medical record (EMR) lacked evidence any other care conference was offered, provided, or refused after 5/21/25.During interview on 8/11/26 at 8:09 a.m., R61 stated she did not always know what the plan was and could not remember attending or being offered a care conference in a long time.During interview on 8/12/26 at 2:45 p.m., social worker (SW)-A stated care conferences were documented in the EMR as a care conference note type in progress notes. SW-A verified and stated there were no care conferences documented in R61's EMR since May of 2025. SW-A stated it did not make sense that R61 would not have had a care conference since then and they should be completed quarterly. Further, R61 was due for a care conference in March and June of 2026, and that family member (FM)-A would have been invited to attend.During interview on 8/12/26 at 3:02 p.m., FM-A stated she had not been invited to or attended a care conference in over a year and did not really know what was going on with R61's care. FM-A further stated she felt like she was not being kept in the loop and that it was very frustrating.During follow up interview on 8/12/26 at 3:17 p.m., SW-A stated she thought R61 had been appropriately offered care conferences but had refused them.During interview on 8/13/26 at 3:59 p.m., director of nursing (DON) stated would expect quarterly care conferences would be completed and offered and if the resident declined to participate, the EMR would have evidence of the refusal. DON further stated care conferences were important to keep the resident and/or family members updated on the resident's plan of care. Facility policy Comprehensive Care Plan and Care Conferences dated 12/29/25, indicated, Social worker or designated employee will.Invite residents and their representative [with resident's permission] at least two weeks in advance of the care conference.If resident and/or representative is not invited to the care conference, an explanation must be included in the medial record.

Based on observation, interview, and document review, the facility failed to ensure resident assessments were accurate for 1 of 1 resident (R61) reviewed for dental.Findings include:R61's annual Minimum Data Set (MDS) dated [DATE], indicated R61 was cognitively intact and required setup or clean-up assistance with oral hygiene. R61's MDS did not identify any oral or dental concerns. Obvious or likely cavity or broken natural teeth was not checked 0-Not checked [No]. R61's diagnoses included diabetes and chronic pain syndrome. R61's care plan revised 7/27/26, indicated R61 had activities of daily living (ADLs) self-care performance and that R61 had her own teeth, some with crowns. R61's HealthDrive (HD- an outside source for medical and dental support for long term care facilities) note dated 12/30/25, indicated R61 had ten missing teeth and three fractured teeth. R61's HD note dated 5/26/26, indicated R61 was scheduled for dental appointment, but declined due to not feeling well. R61's electronic medical record (EMR) lacked evidence of any other dental appointments. R61's quarterly MDS nursing assessment dated [DATE], indicated, Obvious or likely cavity or broken natural teeth.Not checked [No]. During observation and interview on 8/11/26 at 8:19 a.m., R61 had several teeth missing. R61 had obvious missing teeth on her upper front gumline and several scattered along her lower gumline. R61 stated she had a lot of missing teeth and at least one broken tooth on the upper and back right side. R61 stated she was hoping to get a plate for the upper front and to have the broken tooth fixed or extracted. During interview on 8/13/26 at 8:50 a.m., licensed practical nurse (LPN)-A stated quarterly or annual nursing assessments were often completed by nursing staff. LPN-A stated the MD nurse (MDS-RN) would place a nursing order to display on the resident's treatment administration record (TAR) when the assessment was due. LPN-A stated the assessment should be a face to face assessment. During interview on 8/13/26 at 8:58 a.m., MDS-RN stated she entered a nursing order for the assessments per the required schedule and would expect nursing to complete the assessments accurately. MDS-RN stated she relied on the data from the nursing assessments and other documentation to code the MDS and an inaccurate assessment could cause the MDS to be coded inaccurately. MDS-RN stated an inaccurate assessment could also affect the residents care plan and ultimately the care they received. During interview on 8/13/26 at 3:59 p.m., director of nursing (DON) stated would expect nursing assessments to accurately reflect the resident's status. Facility policy Dental and Oral Care, Dental Health Assessment, Dental Services dated 3/3/26, indicated the purpose of dental assessments was to ensure early identification and evaluation of any dental/oral health problems for treatment by a dentist or other professional to begin as early as necessary.

Based on observation, interview, and document review, the facility failed to ensure that the required personal protective equipment (PPE) was used for 1 of 1 resident (R73) reviewed for Contact Precautions.Findings include:R73's MDS dated [DATE], identified R73 was admitted on [DATE], was cognitively intact, and diagnoses that included congestive heart failure, heart disease, kidney problems, and recurrent Clostridioides difficile (C. difficile, a highly contagious infection spread by contact).R73's care plan dated 8/4/26, identified R73 required Contact Precautions and a private room due to C. difficile infection.R73's nursing progress note dated 8/10/26 at 9:53 p.m., identified R73 had active C. difficile infection.R73's nursing order dated 8/11/26, indicated R73 could be removed from isolation precautions.R73's nursing progress note dated 8/12/26 at 8:37 a.m., identified Contact Precautions were discontinued on 8/11/26, with 8/10/26 identified as the last full day of isolation.During observation on 8/10/26 at 6:02 p.m., Contact Precautions signage was posted outside R73's room and indicated all people entering the room were required to wear a gown and gloves. PPE supplies were located across the hall from R73's room.During an interview on 8/10/26 at 6:06 p.m., R73 stated staff did not always wear a gown when entering the room but usually wore gloves. R73 stated caregivers wore a gown and gloves when providing direct care.During an observation on 8/10/26 at 6:10 p.m., RN-C entered R73's room with medications without wearing a gown or gloves and touched the bedside table and interior surface of the room door. During an interview on 8/13/26 at 9:00 a.m., RN-C stated staff determine what required PPE is used by reviewing signage outside residents' rooms. RN-C verified that R73 was on Contact Precautions for C. difficile infection, as indicated by signage posted on R73's door. RN-C stated staff wear a gown and gloves when providing direct care to residents on Contact Precautions but wear only gloves when delivering medications or entering resident's rooms for non-care-related tasks. RN-C confirmed she did not wear a gown or gloves when entering R73's room because she was only delivering medications.During an interview on 8/14/26 at 4:40 p.m., the interim director of nursing (DON) confirmed staff were expected to wear a gown and gloves when entering R73's room while Contact Precautions were in place.The facility's Standard, Enhanced Barrier, and Transmission-Based Precautions policy, revised 4/30/26, identified Contact Precautions were required for residents with infections that posed an increased risk for contact transmission. The policy directed staff to put on a gown and gloves before contact with the resident or the resident's environment and to remove PPE before leaving the room.

Based on observation, interview and record review the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 resident (R31) reviewed for respiratory care.Findings include:R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 was cognitively intact and required oxygen therapy. R31's diagnoses included multiple sclerosis and hypoxemia (low blood oxygen level).R31's care plan dated 5/19/26, indicated R31 had shortness of breath (SOB) related to diagnoses and required oxygen therapy. R31's August 2026, treatment administration record (TAR) indicated, Nursing Order: Change oxygen supplies, including oxygen bubbler [container filled with water in-line with oxygen to provide humidification], and tubing. Date and initial every night shift every Wed for routine exchange and maintenance.During observation on 8/10/26 at 5:44 p.m., R31 was in bed, receiving oxygen through a nasal cannula. R31's oxygen PM bubbler was dated 6/4/26. During interview and observation on 8/10/26 at 5:54 p.m., registered nurse (RN)-A stated the oxygen tubing and bubbler was supposed to be changed weekly and confirmed R31's bubbler was dated 6/4/26 and stated it should have been changed since then. RN-A stated if oxygen supplies were not maintained properly, the chance of contracting respiratory infection increased. RN-A stated R31 required oxygen therapy for SOB and was not aware that she experienced any recent respiratory infections. During interview on 8/13/26 at 1:35 p.m., RN-B, who was also the staff educator, expected nurses to follow provider orders as written. During interview on 8/13/26 at 3:59 p.m., director of nursing (DON) stated would expect nurses to follow orders as written and that R31's bubbler should have been changed weekly. Facility policy Oxygen Administration, Safety, Mask Types, dated 7/16/26, indicated all oxygen equipment should be clean, safe, and functional and all disposable pieces changed weekly.

Based on observation, interview, and document review, the facility failed to ensure the resident's fall interventions were in place for 1 of 1 (R9) residents reviewed for falls. Findings include: R9's Quarterly Minimum Data Set (MDS), dated [DATE], indicated diagnoses of dementia and end-stage renal disease (ESRD) required dialysis. R9 had intact cognition but was at risk for falls that required supervision with activities of daily living (ADL's), transfers and used a walker for ambulation. R9's falls assessment, dated 6/15/25, indicated she was a fall risk due to ESRD required dialysis, impulsive behavior, and impaired mobility. R9's nursing and provider orders dated 3/18/25, indicated that R9 was to be up with nursing assistance, reminded to use the call light and wait for staff assistance, and monitored through frequent safety checks each shift.R9's Safe Event Incident report dated 6/4/26, R9 was found sitting on the floor between her drawer and walker. R9 had bleeding from a forehead injury and a skin tear to her jaw and was transferred to the hospital, where she received stitches. the root cause was R9 lost her balance when she walked to her drawer to close it. The intervention following this fall included placement of skid strips next to the bed to prevent falls. R9's care plan, dated 7/8/26, indicated a self-care performance deficit related to actual falls, weakness, and impaired mobility. R9 required assistance from one staff member, a walker, and a gait belt for ambulation. R9 also required assistance from one staff member with transfers, bathing, dressing, personal hygiene, and toilet use. Additionally, R9 had dementia with decreased safety awareness and demonstrated impulsive self-transfers and self-ambulation. Interventions included restorative rehabilitation; education for R9 and family regarding fall prevention and factors that could cause falls; use of assistive devices; placement of skid strips next to the bed to prevent falls; and frequent monitoring of R9 for safety. Additionally, R9 was at risk for falls, the interventions were to provide assistance of one staff with walker during transfers and ambulation. She also had a wheelchair she could use independently. It instructed to remind R9 to use call light, wait for staff assistance, and have staff perform safety checks each shift. During an observation on 8/12/26 at 8:28 a.m., R9's room door was open. R9 was standing in the bathroom. Her walker and wheelchair were located in her room near her bed and not within arms reach. R9 independently ambulated to her wheelchair and sat down. At 8:30 a.m., R9 stood and walked to her walker. She independently ambulated with the walker to the bathroom and brushed her teeth. At 8:32 a.m., an unidentified staff member walked past R9's room but did not enter room. At 8:34 a.m., R9 was observed ambulating in room her room using her walker without staff present. At the same time, an unidentified staff member walked past R9's room, glanced into the room, and continued walking down the hallway. During an observation on 8/13/26 at 7:57 a.m., R9 was seated in a wheelchair in her room. R9 stood, ambulated to a recliner, and self-transferred without staff assistance or her walker which was located by the wall adjacent to the wheelchair. The call light was on recliner arm, and non-skid shoes on. At 8:01 a.m., R9 was observed ambulating in her room from the recliner to the wheelchair without a using her call light, walker or staff present. During an interview on 8/11/26 at 3:24 p.m., R9 that she walked in room by herself, self-transferred and used the bathroom independently. R9 stated that the facility did not have control over her, that she did not need to follow instructions, and that she was going to do what she wanted.During an interview on 8/12/26 at 9:17 a.m., NA-A stated that when a resident fell, staff were to notify the nurse, obtain vital signs, and remain with the resident to assist the nurse. NA-A stated that resident care was provided according to the care plan and written care sheets.During an interview on 8/12/26 at 10:13 a.m., registered nurse (RN)-D stated that when a resident fell, staff were to call for assistance and assess the resident for injuries. If the resident hit their head, neurological checks were to be performed, and the resident was monitored for a change in condition. RN-D stated that staff used a mechanical lift to elevate a resident from the floor when the assessment indicated it was appropriate. Otherwise, the resident was sent to the hospital for further treatment. RN-D stated that staff utilized the care plan and Kardex to provide the necessary care. RN-D further stated that it was important to follow provider orders for resident safety and to ensure appropriate care and progress. RN-D stated that orders were specific to each resident's care and that following the care plan was important for resident safety and autonomy.During an interview on 8/13/26 at 8:02 a.m., NA-B confirmed that R9 transferred independently and that he had observed R9 ambulating in her room without a walker or staff assistance. NA-B stated that he was unaware R9 was a fall risk. He also verified R9 used the bathroom and was walking independently. NA-B stated that he referred to the care plan when providing care to residents.During an interview on 8/13/26 at 8:14 a.m., RN-E stated that R9 was not supposed to self-transfer. RN-E stated that multiple-colored signs were posted on the walls of R9's room instructing her to call, not fall, wait for assistance, and remember to use call light. RN-E stated that R9 had memory loss and required frequent education regarding safety and redirection. RN-E stated RN-E stated that the care plan indicated that R9 was to have skid strips placed. RN-E verified the skid strips were not present on the floor despite the care plan indicating that they were to be used to prevent falls.During an interview on 8/13/26 at 3:25 p.m., the director of nursing (DON) stated that the expectations for staff when a resident had a fall was to assess the resident for injuries and call 911 when necessary. If the fall was not serious, the resident was assessed and moved using a mechanical lift. The provider, family, and supervisor were to be notified. The fall was documented as a safe-event incident report and reviewed during the interdisciplinary team (IDT) weekly leadership meeting. The DON stated that it was important to follow orders to provide current and appropriate care for each resident. The DON stated that the care plan was designed to provide instructions for the individual resident and was updated by the DON and nurse managers. The facility's policy titled Fall Prevention and Management, reviewed on 6/2/26, instructed staff to promote resident well-being by developing and implementing a fall prevention and management program, identifying risk factors, and implementing interventions before a fall occurred. The policy also instructed staff to provide prompt treatment after a fall occurred. A nurse was required to observe the resident and perform a full-body examination to determine whether an injury occurred, continue to monitor the resident's condition, and update the plan as needed. Staff were required to complete a safe-event incident report and fall-scene huddle worksheet and communicate that a fall had occurred to the provider, family, supervisor, during stand-up meetings, at change of shift, and through the 24-hour report.

Based on observation, interview, and document review, the facility failed to monitor urine output for 2 of 3 residents (R1 and R2) and failed to report, monitor, and document urine characteristics for 1 of 1 (R2) resident who was observed for staff emptying catheter bag. In addition, the facility failed to document catheter cares for 3 of 3 residents (R1, R2, and R3) and failed to store a catheter bag in a manner to reduce risk of infection for 1 of 1 resident (R3) who was observed to have a leg drainage bag during the day and larger catheter bag overnight.Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, no mood or behavior concerns, or rejection of care. R1 required setup or clean-up assistance with eating, oral hygiene, personal hygiene; substantial/maximal assistance for upper body dressing, lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying/lying to sitting on bed side, sitting to standing, chair/bed-to-chair transfers; and dependent on staff for toileting hygiene, showering, toilet transfers. R1 had an indwelling catheter and was frequently incontinent of bowel. R1's diagnoses included hypertension, benign prostatic hyperplasia (BPH), renal failure, diabetes mellitus, malnutrition, and glaucoma.R1's hospital Discharge Summary, with admission date of 3/18/26 and discharge date of 3/23/26, indicated R1 was hospitalized for clostridium difficile colitis and catheter-associated urinary tract infection. The urine culture grew E.coli. R1's care plan 4/29/26, indicated R1 had an indwelling catheter due to BPH, a urinary tract infection, and renal insufficiency due to chronic kidney disease. Staff were directed to:-Monitor/document pain/discomfort due to catheter.-Monitor for signs/symptoms (s/s) of discomfort on urination and frequency.-Monitor/record/report to health care provider for s/s urinary tract infection (UTI): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.-May wear leg bag during the day and straight catheter drainage bag at night.-Report unusual observations/conditions to nurse.-Observe and report to nurse s/s of UTI frequency, urgency, foul smelling urine, pain with urination, fever, nausea, vomiting, back pain, lower abdominal pain, blood in urine, cloudy urine, altered mental status, change in level of consciousness, loss of appetite, behavior changes.-Encourage fluid intake.-Assist, supervise, remind R1 to wash hands after toileting and before and after meals.-Monitor/document/report for signs/symptoms of acute renal failure which included urine output. R1's progress notes reviewed between 3/1/26 to 4/26/26, indicated catheter care was provided once on 4/22/26. In review of R1's record there was no indication catheter care had been routinely completed on other days between the review dates of 3/1/26 through 4/26/26. In review of R1's urinary output documented between 4/15/26 to 4/25/26, the record identified inconsistent monitoring to ensure the catheter was patent or free from complications nor did the record include assessments/evaluation of accumulative daily totals of urinary output. The following was documented: -On 4/15/26, the record for urine output at 6:43 a.m. and 1:11 p.m. noted response not required and at 9:59 p.m. urine out was 550 cubic centimeters (cc; metric unit of volume) indicating a daily total of 550 cc's. -On 4/16/26, the record for urine output at 6:33 a.m. was 1,000 cc, 10:51 a.m. was 550 cc, and 9:32 p.m. was 800 cc indicating a daily total of 2,350 cc's. -On 4/17/26, the record for urine output at 6:34 a.m. was 1,000cc, response not required at 2:59 p.m., and 300 cc at 10:59 p.m. indicating a daily total of 1,300 cc's.-On 4/18/26, the record for urine output at 6:51 a.m. was 600 cc's. No other urine output was documented for 4/18/26.-On 4/19/26, the record for urine output at 6:41 a.m. was 2,000 cc and 575 cc at 10:59 p.m. indicating a daily total of 2,575 cc's.-On 4/20/26, the record for urine output at 6:16 a.m. was 700 cc and 2:09 p.m. noted response not required indicating a daily total of 700 cc's.-On 4/21/26, the record for urine output at 9:54 p.m. was 850 cc's. No other urine output was documented for 4/21/26.-On 4/22/26, the record for urine output at 9:55 a.m. was 550 cc and 400 cc at 9:22 p.m. indicating a daily total of 950 cc's.-On 4/23/26, the record for urine output at 6:33 a.m. noted response not required and 500 cc at 6:12 p.m. indicating a daily total of 500 cc's.-On 4/24/26, the record for urine output at 6:10 a.m. was 850 cc and 550 cc at 10:59 p.m. indicating a daily total of 1,400 cc's.-On 4/25/26, the record for urine output at 6:13 a.m. was 400 cc, and no other urine output was documented. R1's physician visit dated 4/24/26 with a faxed time stamp of 4:10 p.m. identified R1 was seen for constipation and ongoing nausea and vomiting. Unable to keep solid food down, tolerates only light breakfast and liquid meals. An abdominal x-ray had been completed with negative for obstruction/constipation. The visit note did not address or mention urinary assessment or catheter related complications other than the mention of historic hospitalization from 3/18/26-3/23/26. R1's progress note dated 4/24/26 at 9:05 p.m. Resident seemed upset and when asked what the problem was. He complained about his foley catheter not changed yesterday. He worries about a bladder infection and hospitalization. R1's progress note dated 4/24/26 at 9:10 p.m. identified R1's vital signs and blood sugar were within normal limit. Am shift reported he had repeated emesis during the shift. No emesis was reported this shift at this time and his appetite was good. R1's progress note dated 4/24/26 at 9:15 p.m. indicated catheter was patent with clear yellow urine with no urinary complaints. R1's progress note dated 4/24/26 at 10:04 p.m. indicated urinary collection bag was not available. Foley was irrigated but resident wanted it changed. R1's record did not identify why the catheter was irrigated, if the irrigation was successful, and if R1 had discomfort as a result of the procedure. R1's progress note dated 4/25/26 at 4:38 a.m. included Resident requested to go to ER this afternoon due to severe abdominal pain after other inventions failed (interventions were not identified). Bladder residual scanned at this time was 26 ml, foley cath draining ok, urine was clear and free of sediments. Late entry progress note dated 4/26/26 at 1:11 p.m. indicated on Sunday 4/26/26 (inaccurate date as evidenced by hospital records) patients foley catheter was changed per his and resident representative request. He was complaining of bladder spasm and stated that the catheter wasn't working right, he was also bypassing urine. Patient reported the catheter was replaced by the overnight nurse. Patient then called his resident representative, and they brought in one from home and demanded that the catheter be changed right away. R1's Hospital Discharge Summary, with admission on [DATE] and discharge on [DATE], indicated R1 had abdominal pain and urine appeared grossly infected. R1's diagnosis was acute pyelonephritis (bacterial infection causing inflammation of the kidneys) associated with bilateral hydronephrosis (both kidneys swollen due to urine backup).During interview on 5/7/26 at 2:10 p.m., NA-C stated they worked with R1, and R1 had complained he could not urinate before he was sent to the hospital on 4/25/26. NA-C stated they observed R1's catheter draining without concern and reported to nursing. NA-C stated nursing assistants documented residents' urinary output and nurses monitored if residents had more or less urinary output. During interview on 5/7/26 at 4:21 p.m., registered nurse (RN)-C stated they sent R1 into the hospital on 4/25/26 for abdominal pain. RN-C stated R1's catheter was changed the previous shift, and R1 had clear urine in his catheter bag. During interview on 5/11/26 at 3:29 p.m. with the interim director of nursing (DON) and RN-D, who was also the nurse manager, continence and urinary charting were reviewed. The DON stated nurse managers reviewed nursing assistant charting to ensure accuracy. RN-D stated nurses on the floor reviewed urinary outputs from catheters at the end of each shift. RN-D stated they could not articulate if there were changes in urinary output, since there were shifts in which no urinary output was documented. Staff were directed to view the care plan for direction to complete catheter care and documented if prompted to in the tasks. R1's care plan and nursing assistant tasks did not direct staff to perform or document catheter cares.R2R2's admission MDS dated [DATE], indicated R2 had intact cognition and required setup or clean-up assistance with eating and personal and oral hygiene and was dependent on staff for toileting hygiene, showering, dressing, bed and wheelchair mobility, and transfers. R2 had an indwelling catheter and was frequently incontinent of bowel. R2 had diagnoses which included atrial fibrillation, heart failure, hypertension, benign prostatic hyperplasia, urinary tract infection, renal failure, arthritis, osteoporosis, and hip fracture. R2 was at risk for pressure ulcers and had a surgical wound.R2's care plan dated 4/15/26, indicated R2 had a catheter related to BPH and urinary retention. The care plan directed the staff to:-Monitor/document for pain/discomfort due to catheter.-Monitor for signs/symptoms of discomfort on urination and frequency.-Monitor/record/report to health care provider for s/s UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.-May wear leg bag during the day and straight catheter drainage bag at night.-Report unusual observations/conditions to nurse. R2's Medication, Nursing, and Treatment Records from March to May 2026, directed staff to complete the following:-Change drainage bag every Friday and as needed if plugged and unable to clear with irrigation.-Change 16 French with 10 cc (cubic centimeter) balloon as needed if dislodged or plugged and unable to clear with irrigation. R2's progress notes dated 3/31/26 to 5/11/26, indicated catheter care was provided once on 4/3/26.R2's Follow Up Question Report for 5/1/26 to 5/11/26, the record identified inconsistent monitoring to ensure the catheter was patent or free from complications nor did the record include assessments/evaluation of accumulative daily totals of urinary output. The following was documented: -On 5/1/26, the record for urine output at 6:39 a.m. was 700 cc, at 11:13 a.m. noted response not required, and 450 cc at 9:56 p.m. indicating a daily total of 1,150 cc's.-On 5/2/26, the record for urine output at 6:05 a.m. was 700 cc for a daily total of 700 cc's. -On 5/3/26, the record for urine output 700 at 6:38 a.m. was 700 cc and at 10:18 p.m. was 400 cc indicating a daily total of 1,100 cc's -On 5/4/26, the record for urine output at 6:21 a.m. was 700 cc, at 1:52 p.m. noted response not required, and 700 cc at 9:58 p.m. indicating a daily total of 1,400 cc's. -On 5/5/26, the record for urine output at 5:02 a.m. noted response not required, 650 cc at 10:33 a.m., and 300 cc at 9:25 p.m. indicating a daily total of 950 cc's. -On 5/6/26, the record for urine output at 1:36 p.m. was 450 cc and at 10:35 p.m. was 450 cc indicating a daily total of 900 cc's. During observation and interview on 5/7/26 at 2:10 p.m., NA-C wore gloves and gown to empty R2's catheter bag. The urine had a foul smell and a darkish yellow orange color. NA-C was about to dump the urine in the toilet when surveyor asked about the urine appearance. NA-C stated the urine was a deep yellow, did not articulate further, and dumped urine into toilet. NA-C washed R2's catheter tube and penial area with a soapy washcloth in the morning. Nursing assistants documented residents' urinary output and nurses monitored if residents had more or less urinary output. During interview on 5/7/26 at 4:21 p.m., RN-C stated staff did not report any current urinary concerns to her for any resident during her shift, which included R2. RN-C stated it was important for staff to tell nursing about urinary concerns, so nursing could assess dehydration or urinary tract infections and have testing like a urinalysis and/or culture ordered. Review of R2's record on 5/7/26 did include documentation of the noted darkish yellow/orange urine and foul odor nor a corresponding comprehensive assessment. Further no notation of catheter cares provided. R2's urine output record did not include urine output for the day shift; On 5/7/26, the record for urine output at 10:22 a.m. was 650 cc and at 10:28 p.m. was 350 cc for indicating daily total of 1,000 cc's. During interview on 5/8/26 at 2:17 p.m., NA-A stated they worked with R2. NA-A stated they did not have concerns with R2's urine output and would chart R2's output. NA's would alert nurses If residents with a urinary catheter had no output, blood in the urine, fever, confusion, or anything unusual. During observation and interview on 5/8/26 at 4:18 p.m., NA-B stated they had not emptied R2's catheter since the evening shift started and was not sure how much was emptied from the day shift. NA-B stated they had not heard of any concerns with R2's urine. NA-B stated they washed R2's penial area and catheter tubing with soap and water in the morning and evening. NA-B documented urinary output each time the catheter was emptied and would report to a nurse if urine was red, pink, thick, or had a strong smell. NA-B entered R2's room and emptied R2's urine from catheter bag in a clear graduated container. R2's urine had a yellowish hue, tannish white particles, and a longer thick substance in the tubing as urine was emptied. NA-B stated they would report the urine appearance to the nurse and dumped the urine into the toilet.Review of R2's record on 5/8/26 did not include documentation of R2's urine integrity (yellowish hue, tannish white particles, and a longer thick substance) nor evident corresponding comprehensive assessment was completed. R2's progress note dated 5/8/26 included urinary catheter intact. R2's urine output was documented as at 6:51 a.m. noted response not required and at 10:38 p.m. was 550 cc indicating a daily total of 550 cc's. No urine output was recorded for the day shift. Further no notation of catheter cares were completed and provided. R2's urine output on 5/9/26 was left blank indicating R2 did not have any urine output. R2's progress note dated 5/9/26 indicated R2's urinary catheter was changed per as needed for urinary retention order. The note did not include urine characteristics. R2's urine output on 5/10/26 identified urine output at 6:15 a.m. was 450 cc, at 2:17 p.m. was 200 cc, and at 10:59 p.m. noted response not required for a daily total of 650 cc. R2's progress notes dated 5/10/26 indicated R2's urinary catheter change was noted as effective, and Skilled Evaluation note indicated urinary catheter intact. The notes did not include urine characteristics R2's urine output on 5/11/26, at 6:23 a.m. was 800 cc, 550 cc at 12:50 p.m., and 700 cc at 10:59 p.m. indicating a daily total of 2,050 cc's. During interview on 5/12/26 at 10:29 a.m., RN-A stated R2's urine usually looked yellow. RN-A stated nursing assistants should report if urine looked deep yellow, foul smelling, or had particles and had not heard of any recent concerns with R2's urine. During interview on 5/8/26 at 2:52 p.m., NA-F stated they checked catheter bags for emptying needs at the beginning of their shift because sometimes the catheter bags were full, and NA-F was unsure if the morning shift emptied or not. NA-F would round on residents with urinary catheters throughout their shift and emptied when the catheter bags were full. NA-F stated they wrote down the urine amount emptied on their paper and documented the total urine output amount at the end of the shift.During interview on 5/8/26 at 3:17 p.m., RN-A stated signs and/or symptoms of urinary tract infection (UTI) included irritating, fever, burning and everyone had different UTI symptoms. RN-A stated they would assess urine, push fluids, ask providers for a urinary analysis and/or urinal culture, and document if they noticed signs and/or symptoms of a UTI. RN-A stated nursing assistants charted urinary output for residents with a catheter and let the nurses know of urinary concerns, such as lack of output. RN-A stated they observed urinary conditions throughout their shift.During interview on 5/8/26 at 3:55 p.m., RN-B stated signs and/or symptoms of UTI included confusion, pain, cloudy or red urine. RN-B stated they would assess the catheter site and ensure catheter patency if they suspected any catheter related infection. RN-B stated staff documented urine and catheter concerns in progress notes. During interview on 5/11/26 at 3:29 p.m. with the interim director of nursing (DON) and RN-D, who was also the nurse manager, continence and urinary charting were reviewed. The DON stated nurse managers reviewed nursing assistant charting to ensure accuracy. RN-D stated nurses on the floor reviewed urinary outputs from catheters at the end of each shift. RN-D stated they could not articulate if there were changes in urinary output related to the shifts in which no urinary output was documented. The nursing assistants were expected to report to nursing about urinary concerns or lack of output. Nurses were expected to chart urinary concerns and monitor in a skilled note, progress note, or other clinical monitoring assessment. RN-D reviewed R2's notes and indicated the notes did not note any outside findings besides the catheter change. Staff were directed to view the care plan for direction to complete catheter care and documented if prompted to in the tasks. R2's care plan did not direct staff to complete or document catheter cares. R3R3's admission MDS dated [DATE], indicated R3 had moderate cognitive impairment and an indwelling catheter. R3 was dependent on staff with most activities of daily living and had diagnoses which included coronary artery disease, heart failure, neurogenic bladder, multiple sclerosis, and malnutrition.R3's indwelling catheter care plan dated 1/28/26, directed staff to:-Monitor/document for pain/discomfort due to catheter.-Monitor for signs/symptoms of discomfort on urination and frequency.-Monitor/record/report to health care provider for s/s UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.-May wear leg bag during the day and straight catheter drainage bag at night.-Report unusual observations/conditions to nurse.R3's care plan did not direct staff to complete or document catheter cares.R3's Medication, Nursing, and Treatment Records from March to May 2026, directed staff to complete the following:-Change drainage bag every Friday and as needed if plugged and unable to clear with irrigation.-Change foley catheter every 30 days.-Change 22 French with 5 cc (cubic centimeter) balloon as needed if dislodged or plugged and unable to clear with irrigation. R3's progress notes dated 3/1/26 to 5/10/26 did not indicate catheter cares were completed except on 4/27/26 and 5/1/26.During observation and interview on 5/7/26 at 12:54 p.m., a catheter bag was between two towels on a dry shower chair. NA-E placed gloves on and observed the catheter. NA-E lifted the drainage bag to observe, and the top of the catheter bag tubing, the connector port, touched the shower curtain railing. The connector port did not have a cap on it, and the catheter bag had a noticeable amount of clear yellow urine.During a follow-up interview on 5/12/26 at 11:09 a.m., NA-E stated they cleaned the outside of the overnight catheter bag with an alcohol wipe or soapy towel before storing for later use. NA-E was unsure how to rinse out the inside of the overnight catheter bag.During observation and interview on 5/12/26 at 10:56 a.m., NA-D verified there was no cap on the connector port of R3's catheter bag which was stored between two towels on a dry shower chair. NA-D verified the presence of clear yellow urine in the stored, overnight catheter bag.During interview on 5/12/26 at 10:29 a.m., RN-A stated they used to cap the connector ports of catheters bags stored during the day for later use and used to rinse out catheter bags with vinegar and water and was unsure about current cap use and rinsing practices for catheter bags.During interview on 5/11/26 at 3:29 p.m. with the interim director of nursing (DON) and RN-D, who was also the nurse manager, continence and urinary charting were reviewed. Staff were directed to view the care plan for direction to complete catheter care and documented if prompted to in the tasks. R3's care plan and nursing assistant tasks did not direct staff to perform or document catheter cares. RN-D stated facility competency directed the staff to rinse a catheter bag. The DON and RN-D could not articulate a facility practice to cap the connector port tubing on catheter bags which were to be stored during the day or overnight for exchanges from leg to overnight/overnight to leg catheter bags.Facility policy Catheter: Care, Insertion, and Removal, Drainage Bags, Irrigation, Specimen- AL, R/S, and LTC dated 3/2/26, directed staff to complete catheter care in the morning and bedtime and as needed. Catheter care included:-inspect urine collection for color, clarity, and quantity.-observe urethral meatus and surrounding tissue for inflammation, encrustations, swelling, or discharge, and ask the resident if burning or discomfort is present.-provide perineal care with soap and water, peri-wash as directed or disposable wipes.-secure the catheter with the catheter securement device and secure the drainage bag and tubing below the level of the bladder. The policy directed staff to clean leg bags and straight drainage bag with warm soapy water or one part white vinegar and three parts water solution or an appropriate commercial solution by pouring solution into the bag, soak the bag for 30 minutes, drain the solution from the bag, rinse with warm water, hang to dry covered with a clean towel, and cover/cap the tubing once the bag is dry. The policy directed staff to store tubing caps in designated bag or container when not in use and clean with alcohol pad before recapping tubing. The policy directed staff to record urine volume where appropriate. The policy directed staff to note amount and character of urine and report any signification observations to licensed nurse (blood, mucus, low urine output).

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBPs) and infection control measures were followed for 1 of 1 resident (R2) reviewed for urinary catheters.Findings include:Centers for Disease Control and Prevention defined EBP as the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug-resistant organism; microorganisms, such as bacteria, which are resistant to one or more antimicrobial drugs) to staff hands and clothing.R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition and required setup or clean-up assistance with eating, personal hygiene, and oral hygiene and was dependent on staff for toileting hygiene, showering, dressing, bed and wheelchair mobility, and transfers. R2 had an indwelling catheter and diagnoses which included atrial fibrillation, heart failure, hypertension, benign prostatic hyperplasia (BPH), urinary tract infection, renal failure, arthritis, osteoporosis, and hip fracture.R2's care plan dated 4/15/26, indicated R2 had a catheter due to BPH and urinary retention.R2's physician Order Summary Report with order dated 3/31/26, directed staff to follow enhanced barrier precautions due to R2's foley catheter and incision.During an observation on 5/8/26, at 2:17 p.m. R2's signage by his door informed staff R2 required enhanced barrier precautions which directed staff to wear gloves and a gown for high-contact resident care activities. The sign indicated Device care use: central line, urinary catheter, feeding tube, tracheostomy were high-contact resident care activities.During interview on 5/8/26 at 2:17 p.m., nursing assistant (NA)-A stated they wore gloves but no gown to empty R2's catheter. NA-A reviewed the enhanced barrier precautions sign on R2's door and stated they only had to follow gowning and gloving guidance if the resident was in isolation, had a wound or infection, or when the nurses changed a catheter.During observation and interview on 5/8/26 at 4:18 p.m., NA-B wore gloves and no gown and emptied R2's urine from catheter bag in a clear, triangular container. NA-B wiped the emptying port with a paper towel and placed the port back into the protective holder. NA-B reviewed the sign on R2's door and stated they did not have to wear a gown to empty R2's catheter, but the nurses had to wear a gown and gloves when they changed R2's foot dressing.During interview on 5/8/26 at 2:52 p.m., NA-F stated they wore gloves but not a gown to empty catheter bags.During interview on 5/11/26 at 3:29 p.m., registered nurse (RN)-D, who was also the nurse manager, expected staff to wear a gown and gloves when emptying urine from a catheter bag and use an alcohol swab to clean the emptying port. RN-D stated EBP provided infection protection for staff and residents.During interview on 5/12/26 at 1:58 p.m., the interim director of nursing (DON) expected staff to wear a gown and gloves when emptying urine from a catheter bag.Facility policy Standard, Enhanced Barrier, and Transmission-Based Precautions, All Service Lines-Enterprise dated 4/30/26, directed staff to wear a gown and gloves to complete high-contact resident care activities, which included urinary catheter care.Facility policy Catheter: Care, Insertion, and Removal, Drainage Bags, Irrigation, Specimen- AL, R/S, and LTC dated 3/2/26, directed staff to clean drainage port with alcohol wipe and replace the drainage port in the holder after urine was emptied from catheter bag.

Based on interview and document review, the facility failed to ensure medications were available for administration per physician order for 2 of 3 residents (R1 and R2) reviewed for medication errors.Findings includeR1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, no mood or behavior concerns, or rejection of care. R1 required setup or clean-up assistance with eating, oral hygiene, personal hygiene; substantial/maximal assistance for upper body dressing, lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying/lying to sitting on bed side, sitting to standing, chair/bed-to-chair transfers; and dependent on staff for toileting hygiene, showering, toilet transfers. R1 had an indwelling catheter and was frequently incontinent of bowel. R1's diagnoses included hypertension, benign prostatic hyperplasia (BPH), renal failure, diabetes mellitus, malnutrition, and glaucoma.R1's Discharge summary dated [DATE], indicated R1 admitted to the hospital 3/18/26 for clostridium difficile colitis and catheter-associated urinary tract infection. Discharge medications included fidaxomicin (an antibiotic used to treat diarrhea and kill bacteria or prevent bacterial growth) 200 mg (milligrams) by mouth twice daily for seven days for clostridium difficile bacteria. R1's hospital Medication Administration Record (MAR) dated 3/23/26 identified R1 was administered fidaxomicin at 8:00 a.m. indicating an evening dose was required.R1's admission physician orders included the order for fidaxomicin twice daily however, identified the start date for administration was on 3/24/26 and not 3/23/26.R1's medication administration record (MAR) included the physician order for fidaxomicin and identified a start date of 3/24/26 at 8:30 a.m. The MAR identified R1did not receive the 3/23/26 evening dose. Additionally, the MAR identified the 8:30 a.m. dose was not administered and marked as drug not available. The MAR identified the remaining doses were administered as scheduled.R1's progress notes 3/23/26 to 3/31/26, identified R1 returned to the facility on 3/23/26 and started antibiotic.In review of R1's record there was no indication the physician was notified R1 missed two doses of the antibiotic and did not identify actions that were taken for the unavailable medication.R2R2's admission MDS dated [DATE], indicated R2 had intact cognition and required setup or clean-up assistance with eating and personal and oral hygiene and was dependent on staff for toileting hygiene, showering, dressing, bed and wheelchair mobility, and transfers. R2 had an indwelling catheter and was frequently incontinent of bowel. R2 had diagnoses which included atrial fibrillation, heart failure, hypertension, benign prostatic hyperplasia, urinary tract infection, renal failure, arthritis, osteoporosis, and hip fracture. R2 was at risk for pressure ulcers and had a surgical wound. R2 received one injection during the seven days of the MDS data collection period and had an anticoagulant, diuretic, and opioid.R2's Discharge Medication Orders dated 3/31/26, included ergocalciferol 1.25 milligrams (mg) (50000 unit) capsule by mouth once every week for 12 doses for vitamin D deficiency.R2's medication administration record (MAR) April 2026, included ergocalciferol oral capsule was given 4/7/26 and 4/14/26, and the medication was not available on 4/21/26 and 4/28/26.R2's Medication Record May 2026, included ergocalciferol oral capsule was not available on 5/5/26.In review of R1's record there was no indication of the pharmacy was notified of the missing medication, nor the physician notified the medication was not available for administration on 4/21/26, 4/28/26, and 5/5/26.During interview on 5/8/26 at 3:55 p.m., RN-B indicated if the medication was not available staff were supposed to call the pharmacy right away for medications which were not available to give, and the pharmacy would promptly deliver the medicationDuring interview on 5/11/26 at 3:29 p.m., the interim director of nursing (DON) and RN-D, who was also a nurse manager, reviewed R1's medical documents. They verified R1 re-admitted to the facility on [DATE], and fidaxomicin should have been available for administration per the physician order. R2's record was reviewed and verified ergocalciferol was documented as not available. They expected nurses to write a progress note when medications were not available and document taken actions. RN-D expected the pharmacy and the physician be notified if there were issues with medication availability. DON stated there was a risk for extended infection when antibiotics were not given as ordered.Facility policy Medication Errors- R/S, LTC dated 3/2/26, identified omission of medication as a medication error. An omission was defined as the failure to administer an ordered dose to a resident by the time the next dose was due, assuming there was no prescribing error.No other medication related policies and procedures were received.

Based on observation, interview, and documentation, the facility failed to assess and monitor non-pressure skin conditions for 2 of 3 residents (R1 and R2) reviewed for skin management.R1R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, no mood or behavior concerns, and no rejection of care. R1 required setup or clean-up assistance with eating, oral hygiene, personal hygiene; substantial/maximal assistance for upper body dressing, lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying/lying to sitting on bed side, sitting to standing, chair/bed-to-chair transfers; and dependent on staff for toileting hygiene, showering, toilet transfers. R1 had an indwelling catheter and was frequently incontinent of bowel. R1's diagnoses included hypertension, benign prostatic hyperplasia (BPH), renal failure, diabetes mellitus, malnutrition, and glaucoma.R1's care plan undated, indicated R1 had diabetes mellitus and directed staff to wash feet daily with mild soap and water, dry thoroughly, and may use a light dusting of powder or lotion but not between toes. Staff were to check all body for breaks in skin and treat promptly as ordered by health care provider, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness and report abnormalities to nurse. R1's care plan indicated R1 had cellulitis to right lower extremity and directed staff to remind resident not to scratch skin and monitor healing. R1's care plan indicated R1 had potential for pressure ulcer development due to weakness and impaired mobility. Staff were directed to educate family/resident as to causes of skin breakdown, inform family/resident of any new area of skin breakdown, provide gel foam cushion in wheelchair and pressure reducing mattress on bed, and notify nurse immediately of any new areas of skin breakdown, such as redness, blisters, bruises, and discoloration noted during bath or daily care.R1's Treatment Record March 2026, directed staff to:-2/3/26 to 3/9/26, wound care to right foot every Tuesday and Friday. Wound VAC (vacuum-assisted closure; type of therapy which uses a device to decrease air pressure on a wound) at negative 125 mmHg pressure. Cleanse with saline and pat dry. Supplies included medium black foam.-3/10/26 to 4/3/26, wound VAC to right foot wound at negative 125 mmHg pressure. Wound care every Tuesday and Friday. Cleanse with saline and pat dry. Apply Cavilon No Sting Barrier around wound. Apply drape around incision. Cut strip of drape and apply to skin if bridge needed. Cut foam to fit incision. Cover foam with drape to obtain tight air seal. Cut quarter size opening where suction pad to be place. Apply suction pad.R1's Treatment Record April 2026, directed staff to:-4/5/26 to 4/9/26, cleanse right foot wound three times per week, Tuesday, Thursday, and Sunday, with normal saline or five-minute Vashe soak (medical technique used to clean wound with a solution), pat dry with non-sterile gauze, cut Hydrofera Blue READY (antibacterial foam dressing) and transfer to size of wound, cover with gauze, and secure with roll gauze and tape. The order directed staff to apply Hydrofera Blue with shiny side facing up if there was a shiny side. On 4/12/26, the order had additional direction to cover with ABD pad (an absorbent abdominal dressing) if needed for increased drainage.-Cover open area on buttocks with Mepilex (soft, absorbent silicone foam bandage) every three days on day shift, which started 4/21/26 and was discontinued on 4/23/26.-On 4/23/26, staff were directed to cleanse sacrum/buttock wound every shift and as needed for incontinence episode. The wound was to be cleansed with preferred cleanser and barrier cream was to be applied for moisture-associated skin damage. R1's progress notes dated 4/19/26, indicated [R1] stated [left] butt hurts and looked at it and it appears as an open lesion or pressure sore. The notes indicated measurements not documented as part of this assessment. The nurse wrote a note in Dr. Board to order treatment for it and added it [to] the wound rounds.R1's verbal order dated 4/20/26, directed staff to cover open area of buttocks with Mepilex every day shift every three days.R1's progress notes dated 4/21/26 and 4/22/26, did not include new information related to R1's buttocks.R1's progress note dated 4/23/26 at 1:29 p.m., indicated the skin issue of the buttocks was evaluated. The area was identified as moisture-associated skin damage and acquired in-house. The area was measured as 5.41 cm (centimeters) by 4.11 cm and described as scabbed with fragile, dry/flaky, and intact surrounding tissue. The area was cleansed with normal saline, generic wound cleanser and barrier cream was applied.R1's Wound Evaluation and Management Summary dated 4/23/26, directed staff to apply house barrier cream every shift/three times a day and as needed if saturated, soiled, or dislodged for 30 days. The sacrum wound was classified as moisture associated skin damage with mild pain, scab, and open areas of exposed dermis. The wound size was 5.41 by 4.11 cm. During interview on 5/8/26 at 3:17 p.m., RN-A stated they addressed skin concerns according to the prompts of the medication and treatment record. RN-A recalled R1's wound to foot but not other skin concerns. RN-A stated if they had new wound concerns, they measured the area and updated the provider, wound team, and family. During interview on 5/11/26 at 3:29 p.m., the interim director of nursing (DON) and RN-D, who was also a nurse manager, reviewed R1's medical documents. They expected nursing to use descriptive words to describe a new skin concern and avoid words such as pressure. Measurements were required if the skin concern was open. R2R2's admission MDS dated [DATE], indicated R2 had intact cognition and required setup or clean-up assistance with eating and personal and oral hygiene and was dependent on staff for toileting hygiene, showering, dressing, bed and wheelchair mobility, and transfers. R2 had an indwelling catheter and was frequently incontinent of bowel. R2 had diagnoses which included atrial fibrillation, heart failure, hypertension, benign prostatic hyperplasia, urinary tract infection, renal failure, arthritis, osteoporosis, and hip fracture. R2 was at risk for pressure ulcers and had a surgical wound.R2's Clinical admission assessment dated [DATE], indicated R2 had a bruise above right elbow which measured 1 cm (centimeter) in length.R2's Skin Issues assessment dated [DATE], indicated R2 had bruise above right elbow and bruise at genital area with additional location information which described bruise as on his scrotal area and inner thigh. The assessment indicated overall wound characteristics improved.R2's care plan dated 4/15/26, indicated R2 had potential for pressure ulcer development and had a pressure ulcer related to weakness, impaired mobility, pulmonary edema, and acute kidney injury. The care plan instructed staff to assess, record, and monitor wound healing and report improvement and declines to the health care provider.R2's Treatment Records April to May 2026 indicated:-4/7/26, skin check every evening shift on Tuesdays and complete skin assessment. Report any skin insults or new skin injury to nurse manager or wound team.-4/16/26, left calf wound: cleanse wound daily and as needed for loose and/or saturated dressing with saline or wound cleanser, apply silver calcium alginate cut to fit wound, cover with ABD, and secure with kerlix.-4/17/26 to 4/23/26, left dorsal foot/left heel: apply betadine daily every day shift for wounds.-4/23/26 to 5/5/26, left dorsal foot/left heel: cleanse wounds daily and as needed with saline or wound cleanser, apply betadine, cover with ABD, and secure with kerlix and tape.-4/30/26, nursing skin check every Tuesday evening and document in the assessment tab.-5/5/26, left dorsal foot/left heel/left calf: cleanse wounds every day shift and as needed for loose/saturated dressing with saline or wound cleanser, apply xeroform to wound beds, cover with ABD and secure with kerlix and tape.R2's progress notes, which included skin issue and skilled evaluation assessment notes, indicated:-3/31/26 at 5:03 p.m., bruising above right elbow issue present on admission. The note indicated a new skin issue described as a bruising to R2's genital, scrotal and inner thigh area. The note indicated the bruising was present on admission and was improving.-4/1/26 at 3:03 p.m., genital bruising on scrotal area and inner thigh issue present on admission. Bruising above right elbow issue present on admission. The note indicated a new skin issue described as a surgical wound on R2's left lateral thigh. Sutures were noted, and measurements not documented as part of this assessment.- 4/1/26 to 5/10/26, indicated skin issue has not been evaluated for R2's genital bruising, bruising above right elbow, and surgical wound of the left lateral thigh.During observation and interview on 5/7/26 at 1:14 p.m., R2 reported no concerns about their cares. R2 had a dressing wrapper around his left foot and had no other visible skin concerns.During a follow up interview on 5/12/26 at 1:58 p.m., the DON expected staff to monitor R2's non-pressure skin concerns through weekly skin assessments.The facility policy Skin Assessment Pressure Ulcer Prevention and Documentation Requirements- Rehab/Skilled, Therapy & Rehab dated 3/30/26, directed staff to accurately document observations and assessments of residents. The policy directed staff to record the location of the area, the measurements, and the ulcer/wound characteristics if a pressure ulcer was identified. The policy indicated skin tears, abrasions, and bruises were not intended to be recorded on the Skin Issues assessment. The policy directed staff to monitor bruises, contusions, skin tears, and abrasions weekly and document any changes and/or progress toward healing on the Skin Check assessment and on resident's care plan.

Based on interview and record review, the facility failed to ensure residents who required dialysis receive such services that were consistent with professional standards of practice for three out of five (R1, R5, R7) residents when the facility failed to assess the residents before and after dialysis. The facility failed to ensure licensed nurses had appropriate education to care for and assess residents who received dialysis for 26 out of 34 licensed nurses. Findings include:R1's hospital medical records dated 11/15/25 indicated R1 would be transferred to the facility after surgical repair of hip fracture after a fall at home. R1's additional diagnoses included end stage renal disease on dialysis and anemia in chronic kidney disease. The medical records indicated R1 would continue receiving hemodialysis through left arm fistula at an outside provider on Monday's, Wednesday's, and Friday's. R1's treatment administration record (TAR) dated 11/18/25 to 11/21/25 did not identify dialysis ongoing monitoring for complications before and after dialysis treatments. R1's progress notes from 11/18/25 to 11/21/25 indicated R1 attends dialysis on Monday, Wednesday, and Friday, dialysis access was on R1's AV fistula to left arm. On 11/19/26 indicated R1 was out to dialysis. No other data regarding R1's dialysis monitoring was documented. R1's care plan dated 11/19/25 indicated R1 needed dialysis related to end stage renal disease. R1's interventions were the nurse would not draw blood in arm with graft on her left upper extremity. The nursing assistants would not take R1's blood pressure on arm with graft in her left upper extremity. The nurse would monitor, document, and report to the healthcare provider as needed for signs and symptoms of bleeding, hemorrhage, bacteremia, and septic shock. The nurse would monitor, document, and report to the health care provider as needed for signs and symptoms of renal insufficiency included changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds. The nurse would encourage R1 to go to his scheduled dialysis appointments. The nurse would monitor, document, and report to the healthcare provider signs and symptoms of depression and obtain an order for a mental health consult if needed. R1's minimum data set (MDS) dated [DATE] indicated R1 had active diagnoses of end stage renal disease and dependence on renal dialysis. R1's medical record did not indicate nurses completed a Clinical Monitoring-Dialysis UDA on 11/19/25. R5's progress notes dated 1/1/26 to 3/24/26 included R5's diagnosis of dependence on renal dialysis.-On 2/21/26 indicated diagnosis related to R5's skilled nursing stay included fluid overload, unspecified, indicated R5 was to continue dialysis per schedule. No other data regarding R5's dialysis monitoring was documented.-On 2/16/26 R5 was at dialysis.-On 2/13/26 R5 returned to the facility from dialysis, no new orders, vital signs normal, R5 was stable.-On 2/11/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis. R5 returned from dialysis with no new orders, denied shortness of breath, no sign, or symptoms of discomfort.-On 2/9/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis. R5 returned from dialysis with no new orders, denied shortness of breath, no sign, or symptoms of discomfort.-On 2/7/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis.-On 2/6/26 R5 returned from dialysis with no new orders.-On 2/5/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis.-On 2/4/26 Malnutrition diagnoses included receives dialysis 3x/week. R5 is weighed pre/post at dialysis. Noted variable hospital weights of 240 pounds (lbs), 260 lbs, 262 lbs, 268 lbs, 279 lbs. Unclear what is accurate. Initial weight here was incorrect, and writer struck out this wt. Noted post-dialysis weight of 258 lbs on 1-28-26. Used this weight in Section K of the admission MOS. Expect slight weight fluctuation in between dialysis runs.-On 2/2/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis. R5 returned from dialysis with no new orders, denied shortness of breath, no sign, or symptoms of discomfort.-On 1/30/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis. Age relates osteoporosis diagnosis includes R5 returned from dialysis today no new orders, denied SOB- No S/S of discomfort noted.-On 1/28/26 R5 returned from dialysis with no new order.-On 1/28/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis. Need for assistance with personal care R5 returned from dialysis today no new orders, denied SOB- No S/S of discomfort noted.-On 1/26/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis. Need for assistance with personal care R5 returned from dialysis today no new orders, denied SOB- No S/S of discomfort noted.-On 1/23/26 diagnoses relevant to the R5's skilled stay included dependence on renal dialysis. Age relates osteoporosis diagnosis includes R5 returned from dialysis today no new orders, denied SOB- No S/S of discomfort noted. R5's provider order dated 1/23/26 indicated R5 was to receive dialysis at an outside dialysis center on Mondays, Wednesdays, and Fridays. R5's dialysis treatment was to start at 2:15 p.m. R5's care plan dated 1/23/26 indicated R5 required dialysis related to end stage renal disease. R5's interventions included the nurse would monitor and document for peripheral edema. The nurse would monitor, document, and report to the health care provider as needed for signs and symptoms of bleeding, hemorrhage, bacteremia, and septic shock. The nurse would monitor, document, and report to the health care provider as needed for signs and symptoms of renal insufficiency included changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds. The nurse would monitor, document, and report to the health care provider as needed for signs and symptoms of infection to the access site including redness, swelling, warmth, or drainage. The nurses or nurses' aides would observe for dry skin and apply lotion as needed. The nurse would monitor, document, and report to the healthcare provider signs and symptoms of depression and obtain an order for a mental health consult if needed. R5's MDS dated [DATE] indicated R5 was admitted to the facility with a primary diagnosis of fractures and other multiple traumas. R5's additional diagnosis included dependence on renal dialysis. The MDS indicated R5 was on dialysis. R5's treatment administration record (TAR) dated 3/1/26 to 3/31/26 did not identify dialysis ongoing monitoring for complications before and after dialysis treatments. R1's medical record did not indicate nurses completed a Clinical Monitoring-Dialysis UDA on 1/23/26, 1/26/26, 1/28/26, 1/30/26, 2/2/26, 2/4/26, 2/6/26, 2/9/26, 2/11/26, 2/13/26, 2/16/26, 2/18/26, 2/20/26, 2/23/26, 2/25/26, 2/27/26, 3/2/26, 3/4/26, 3/6/25, 3/9/26, 3/11/26, 3/13/26, 3/16/26, 3/18/26, 3/20/26, or 3/23/26. R7's progress notes dated 1/1/26 to 3/24/26 included R7's diagnosis of dependence on renal dialysis.-On 3/9/26 was at dialysis. Going to dialysis this morning and only having a cracker and apple juice.-On 3/6/26 R7 was at dialysis.-On 3/2/26 R7 was at dialysis.-On 2/23/26 R7 was at dialysis.-On 2/18/26 R7 was at dialysis.-On 2/16/26 R7 was at dialysis.-On 2/15/26 diagnoses relevant to the R7's skilled stay included weakness, continuedialysis three times per week.-On 2/14/26 diagnoses relevant to the R7's skilled stay included weakness, continuedialysis three times per week.-On 2/12/26 diagnoses relevant to the R7's skilled stay included weakness, continuedialysis three times per week. No c/o pain and returned from dialysis with no new orders. R7's provider order dated 2/9/26 indicated R7 was to receive dialysis at an outside dialysis center on Mondays, Wednesday's, and Fridays. R7 was to use an outside transportation company to bring him from the facility to the outside dialysis center. R7's care plan dated 2/10/26 indicated R7 required dialysis related to end stage renal disease. R5's interventions included the nurse would monitor and document for peripheral edema. The nurse would monitor, document, and report to the health care provider as needed for signs and symptoms of bleeding, hemorrhage, bacteremia, and septic shock. The nurse would monitor, document, and report to the health care provider as needed for signs and symptoms of renal insufficiency included changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds. The nurse would encourage R7 to go to his scheduled dialysis appointments. The nurse would monitor, document, and report to the health care provider as needed for signs and symptoms of infection to the access site including redness, swelling, warmth, or drainage. The nurse would monitor, document, and report to the healthcare provider signs and symptoms of depression and obtain an order for a mental health consult if needed. R7's MDS dated [DATE] indicated R7 was admitted to the facility with a primary diagnosis of medically complex conditions. R7's additional diagnoses included chronic kidney disease stage 3B and dependence on renal dialysis. R7's treatment administration record (TAR) dated 3/1/26 to 3/31/26 did not identify dialysis ongoing monitoring for complications before and after dialysis treatments. R7's medical record did not indicate nurses completed a Clinical Monitoring-Dialysis UDA on 2/11/26, 2/13/26, 2/16/26, 2/18/26, 2/20/26, 2/23/26, 2/25/26, 2/27/26, 3/2/26, 3/4/26, 3/6/25, 3/9/26, 3/11/26, 3/13/26, 3/16/26, 3/18/26, 3/20/26, or 3/23/26. Personnel record review indicated for licensed practical nurse (LPN)-A, LPN-C, LPN-D, LPN-E, LPN-F, RN-A, RN-B, RN-D, RN-F, RN-G, RN-I, RN-J, RN-K, RN-L, RN-M, RN-N, RN-O, RN-Q, RN-R, RN-S, RN-T, RN-U, RN-V, RN-X, RN-Y, or RN-BB, did not have an onboarding orientation checklist that identified dialysis education. During an interview on 3/23/26 at 9:44 a.m., registered nurse (RN)-A stated the only complication she looks for on a dialysis resident is bleeding from the access site. RN-A stated she does not recall having training on residents who receive dialysis treatment. During an interview on 3/24/26 at 9:27 a.m., R7 stated nurses do not check their access site before and after his dialysis treatment. R7 stated the nurse does not complete an assessment when he comes back from dialysis. During an interview on 3/24/26 at 10:08 a.m., the administrator stated licensed nurses do not receive education on residents receiving dialysis treatment at a corporate level but states the nurses may get training when they first start at the facility. During an interview on 3/24/26 at 10:17 a.m., RN-D stated the only complication a resident can have when receiving dialysis treatment is change in vital signs. RN-D stated she takes the resident's vitals before the resident goes to dialysis, but states that she takes vitals on all residents in the morning. RN-D stated that after a resident comes back from dialysis, she will take the resident's vitals but does not complete any other assessment. RN-D stated the only education she received regarding dialysis resident was to take the resident's vitals after they come back from dialysis. During an interview on 3/24/26 at 10:46 a.m., the clinical learning and development specialist (CLDS) stated licensed nurses do not receive education on dialysis residents. The training happens once the nurse is at the facility, and it is specific to each facility whether the nurses get training or not. Once a resident comes back from dialysis treatment, the expectation is that the nurse will complete a dialysis assessment in the resident's chart. The dialysis assessment consists of getting the resident's full set of vitals including weight, pedal pulses, pain levels, checking the shunt and brill, and fluid and food intake and output. If the resident comes back from dialysis with new orders, those orders would be placed in the dialysis assessment. CLDS stated it is the responsibility of the nurse to go into the resident's assessments and complete the dialysis assessment; the dialysis assessment is not an automatic prompted assessment. CLDS stated if the dialysis assessment is not completed and documented, that would indicate to her that the dialysis assessment was not completed. During an interview on 3/24/26 at 12:07 p.m., RN-E stated when a resident returns from dialysis, it is the expectation that the nurse completes a dialysis assessment. RN-E stated if there is not a dialysis assessment in the resident's chart, it would mean to her that the dialysis assessment was not completed. RN-E stated, I know that the facility dropped the ball on educating the nurses. The facility's Clinical Monitoring- Dialysis UDA assessment consists of vital signs including most recent weight, blood pressure-lying, blood pressure- sitting, most recent blood pressure, blood pressure-standing, most recent temperature, most recent pulse, most recent pedal pulse- left, most recent pedal pulse- right, most recent respirations, most recent blood sugar, most recent oxygen saturations, most recent pain level, non-medication pain interventions and effectiveness, pain medications administered and effectiveness, checking the shunt bruit, checking the shunt thrill, fluid intake for current shift, fluid output for current shift, and if the resident's fluid restrictions were maintained. The facility's Dialysis Services policy dated 9/30/25 indicated the Clinical Monitoring- Dialysis UDA assessment is available in the computer system for use in monitoring the resident's receiving dialysis.

Based on interview and record review the facility failed to develop a comprehensive care plan for two out of four residents (R5, R7) when the care plan did not include dialysis services, goals/outcomes, and interventions. Findings include:R5's provider order dated 1/23/26 indicated R5 was to receive dialysis at an outside dialysis center on Mondays, Wednesdays, and Fridays. R5's dialysis treatment was to start at 2:15 p.m. R5 would use a transportation company to bring him from the facility to the outside dialysis center. R5's care plan dated 1/23/26 did not include dialysis services, goals/outcomes, and interventions. R5's MDS dated [DATE] indicated R5 was admitted to the facility with a primary diagnosis of fractures and other multiple traumas. R5's additional diagnosis included dependence on renal dialysis. The MDS indicated R5 was on dialysis. R5's progress notes did not indicate what type of dialysis access he had. R7's provider order dated 2/9/26 indicated R7 was to receive dialysis at an outside dialysis center on Mondays, Wednesday's, and Fridays. R7 was to use an outside transportation company to bring him from the facility to the outside dialysis center. R7's care plan dated 2/10/26 did not include dialysis services, goals/outcomes, and interventions. R7's MDS dated [DATE] indicated R7 was admitted to the facility with a primary diagnosis of medically complex conditions. R7's additional diagnoses included chronic kidney disease stage 3B and dependence on renal dialysis. R7's progress notes did not indicate what type of dialysis access he had. During an interview on 3/23/26 at 9:44 a.m., registered nurse (RN)-A stated she did not recall what type of dialysis R5 received or how he got to the outside dialysis center but would check his care plan to find out. During an interview on 3/24/26 at 10:17 a.m., RN-D stated she did not recall what type of dialysis R7 received or how he got to the outside dialysis center but would check his care plan to find out. During an interview on 3/24/25 at 12:07 p.m., RN-E stated if any facility staff had questions about where a resident received dialysis treatment, how the resident got to and from the outside dialysis center, and what type of dialysis access a resident has, the staff member would look in the resident's care plan. RN-E stated the purpose of a resident's care plan is to let the staff member know the resident was on dialysis and where the resident goes for dialysis. RN-E stated RN-F and RN-G were responsible for creating a resident's care plan. During an interview on 3/24/26 at 12:51 p.m., RN-F stated she was the primary staff member that would make a resident's care plan. RN-F stated when a resident is admitted , the primary nurse working with that resident would make the initial care plan and then RN-F would go back to the resident's care plan, make revisions to the care plan, and then finalize it. RN-F stated the outside dialysis center information, when the resident receives dialysis, and transportation to and from the dialysis center should be on a resident's care plan if the resident is receiving dialysis. During an interview on 3/24/26 at 1:05 p.m., RN-G stated all staff from the interdisciplinary team (IDT) can make changes and finalize a resident's care plan. RN-G stated the outside dialysis center information, when the resident receives dialysis, and transportation to and from the dialysis center should be on a resident's care plan if the resident is receiving dialysis. The policy Care Plan dated 12/1/25 indicated a resident's care plan would emphasize the care and development of the whole person ensuring that the resident would receive appropriate care and services. The care plan would address the relationship of items or services required and facility responsibility for providing those services.

Based on observation, interview, and document review, the facility failed to ensure insulin pens were stored in a manner to prevent cross-contamination in 3 of 3 medication carts on the transitional care unit (TCU). This deficient practice had the potential to affect all residents who required insulin administration via an insulin pen who resided in the facility.Findings include: During observation and interview on 8/27/25 at 10:38 a.m., registered nurse (RN)-E was at the one of three medication carts on TCU preparing medication administration. RN-E removed an insulin pen from a plastic cup in a red tote in the bottom of the medication drawer. The plastic cup contained other insulin pens prescribed for multiple residents, no barrier noted between the pens. RN-E stated this was the way the insulin pens had always been stored after opening and stated they were all in one cup, touching each other without a barrier between. During observation and interview on 8/27/25 at 12:22 p.m., RN-F opened remaining two of three medication carts on TCU. RN-F stated there were several different resident's insulin pens together without a barrier separating the pens. RN-F stated not being aware the insulin pens should not be stored together and touching other resident's pens and that this was how they had been stored since she started working at this facility. During interview on 8/27/25, RN-A stated was not aware of an issue with insulin pens being stored together. RN-A thought they should be stored apart from other types of medication. During interview on 8/27/25 at 1:31 p.m., Infection Preventionist (IP) stated each resident's insulin pens should be separated from other resident pens. IP stated separating the pens with a barrier would prevent possible cross contamination. During interview on 8/27/25 at 1:36 p.m., director of nursing (DON) stated they were not aware insulin pens needed to be stored separated by resident or with a barrier between each resident's pen, but thought it was a good idea. Facility policy Medication: Insulin Administration, Insulin Pens, Insulin Pumps dated 9/5/24, indicated, Contamination of these devices [insulin pens] can occur externally [even in the absence of visible blood].resulting in the potential for transmission of blood borne pathogens when used for multiple people. Facility policy Medications: Acquisition Receiving Dispensing and Storage dated 3/4/25, indicated, All medication will be stored in accordance with manufacturers' recommendations. Refer to [facility] Insulin Administration. policy.

Based on observation, interview, and document review, the facility failed to ensure unpasteurized eggs were fully cooked and prepared in a manner to prevent/decrease the risk of foodborne illness. This had the potential to affect up to 40 residents residing at the facility who ate undercooked eggs weekly. Findings include: A facility invoice for the periods of 8/7/25, 8/14/25, and 8/21/2025 indicated the facility received 115 dozen whole large white eggs on each order. The invoices did not include an indication that these eggs were pasteurized (a process used to eliminate bacteria and disease-producing microorganisms in foods, such as dairy). A Shopping Cart record dated 8/27/25 at 2:00 p.m., indicated the facility had a case of medium shelled pasteurized eggs in their shopping cart. A facility invoice indicated these shelled pasteurized eggs had been delivered on 8/28/25.During an observation and interview on 8/25/25 at 11:41 a.m., an unopened 15 dozen box of eggs was observed in a double-door refrigerator. There were no markings on the box to indicate the eggs had been pasteurized. The dietary manager (DM) stated these eggs were used to make poached eggs and fried eggs every Thursday for the residents' breakfast. The DM confirmed these poached and fried eggs would be undercooked and have runny yolks, but this was the only time eggs were served in this manner. The DM confirmed she was unable to find labeling on the box indicating the eggs were pasteurized, but would find the order invoice, as she thought they were pasteurized. On 8/26/25 at 1:55 p.m., the DM stated she found the order invoices and the eggs in the refrigerator observed on 8/25/25 were not pasteurized. The DM stated the poached and/or fried eggs facility staff had been serving on Thursdays had been unpasteurized for at least the past month but was unable to determine the exact length of time unpasteurized eggs were being served. The DM stated she would complete education with her staff to ensure pasteurized eggs were used when eggs were cooked with a runny yolk and would change the order with her supplier to ensure the facility had pasteurized whole eggs on hand. During an interview on 8/27/25 at 9:38 a.m., cook (C)-A confirmed that she helped cook eggs for breakfast service regularly. C-A stated she knew the difference between pasteurized and unpasteurized eggs, but had just not noticed the eggs were unpasteurized until it was brought up this week. C-A stated kitchen staff had been using the unpasteurized eggs to cook poached eggs with running yolks. C-A stated the fried eggs sometimes had runny yolks, but not always. C-A stated approximately 40 residents consumed the poached or fried eggs on Thursdays. During an interview on 8/28/25 at 10:10 a.m., the director of food and nutrition (DFN), a registered dietician, stated she would expect staff to utilize pasteurized eggs when cooking in a manner that the yolk was still runny because of the risk of foodborne illness associated with undercooked unpasteurized eggs. The DFN stated unpasteurized eggs had been served as poached eggs, and it was possible the yolks of these were running or undercooked, but the facility residents had not had any foodborne illness associated with these eggs. The facility's Food Handling- Food and Nutrition policy dated 6/27/25, indicated hard-cooked eggs were safe for consumption, and runny eggs should not be served unless they were prepared from pasteurized eggs.

Based on observation, interview, and document review, the facility failed to ensure range of motion (ROM) was completed according to therapy recommendations for 1 of 1 resident (R4) reviewed for ROM. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4's cognition was not assessed. R4 had impairment of upper and lower extremities on both sides and was dependent on staff for all mobility, transfers, and all activities of daily living (ADL), R4's MDS indicated R4 had received physical therapy (PT) and occupational therapy (OT) and zero minutes of restorative nursing to include active and passive range of motion (PROM). R4 did not exhibit rejection of care behaviors and had diagnoses including cerebral infarction (stroke), cognitive communication deficit, and quadriplegia (paralysis affecting all limbs). R4's care plan dated 7/30/25, indicated R4 had a need for restorative intervention due to limited mobility and required passive ROM to bilateral upper and lower extremities and neck with restorative nursing. R4's PT treatment encounter note dated 8/13/25, indicated, Patient appears at max functional potential at this time and recommendation for transition from PT to RNP [restorative nursing program] for [NAME] [lower extremity] ROM program and caregiver training completed with both RNP staff and family for successful program with goal to prevent contractures and maintain joint integrity. R4's PT Discharge summary dated [DATE], indicated, Caregiver training completed with daughter/spouse and RNP staff for carryover program on unit for B [bilateral] [NAME] PROM. R4's therapy communication to nursing staff form dated 7/29, indicated, FMP [functional maintenance program] for PROM for [NAME] [lower extremity] exercises at least 3x/wk [three times a week]. An additional therapy communication form dated 7/29/25, indicated, OT FMP: RN [restorative nurse] Please perform PROM for neck & Bilateral UE's [upper extremities] at least 3x/week. R4's nursing care sheet dated 8/25/25, lacked evidence R4 required ROM. R4's 30-day lookback task report printed 8/27/25, indicated ROM on bilateral upper and lower extremities and neck was completed one time, refused twice and not applicable twice. During interview on 8/25/25 at 3:40 p.m., family member (FM)-A stated R4 was supposed to be receiving PROM exercises from staff but that was not happening. R4 indicated, by shaking head side-to-side, staff was not completing PROM. During interview on 8/26/25 on 2:13 p.m., nursing assistant (NA)-A stated residents residing on TCU (transitional care unit) did not typically receive restorative nursing since they were generally still receiving therapy. NA-A stated on occasion the long term care restorative nurse aide (RNA) would ambulate or exercise with TCU residents. NA-A was not aware of any resident on TCU currently receiving restorative nursing. During interview on 8/26/25 at 2:30 p.m., director of PT and OT (DPTOT) stated therapy would notify nursing of restorative nursing recommendations using a therapy to nursing communication form. DPTOT further stated they would expect RNP to be completed as recommended. During observation on 8/27/25 at 7:24 a.m., NA-A and NA-B entered R4's room. NA-A and NA-B placed pillows under each side of R4 and under each arm. R4's head of bed was raised. NA-A offered R4 a blanket to cover her, R4 declined. PROM was not performed or offered. During interview on 8/27/25 at 8:22 a.m., registered nurse (RN)-E stated if therapy recommended RNP for someone on TCU, which was rare, it would be on a communication form and then entered into the chart as an order to be displayed and charted in the TAR (treatment administration record). During interview on 8/27/25 at 8:28 a.m., physical therapy aide (PTA) stated therapy used the communication form to notify nursing of recommended RNP. PTA further stated they completed a communication form for R4 recommending PROM to be completed since PT was discontinued. PTA stated they would expect nursing to follow through on recommendations and for R4 to receive PROM exercises at least three times a week. During interview on 8/27/25 at 10:36 a.m., NA-A stated R4 was not on a RNP and PROM was not being done. NA-A stated OT was working on positioning in R4's wheelchair and nursing focused on repositioning R4 frequently to prevent skin breakdown. During follow up interview on 8/27/25 at 10:47 a.m., RN-E stated if the task was not on the TAR, it was not being done. RN-E stated R4 was not receiving any restorative nursing. During interview on 8/27/25 at 11:48 a.m., RN-B stated they were not aware of anyone currently on RNP on TCU. RN-B stated nursing would have received a communication form from nursing for RNP and the task would be entered as an order to display on the TAR for nursing to complete. RN-B was not aware of a RNP for R4. During interview on 8/27/25 at 12:25 p.m., RN-A stated would receive a communication form from therapy with recommendations would be received. Recommendations would be entered on a RNA task sheet in PCC (point click care) to be documented when completed. RN-A further stated the intervention would be added to the resident's care plan. RN-A stated a RNA was scheduled five days a week so all RNPs could be completed. During interview on 8/27/25 at 1:34 p.m., director of nursing (DON) stated PROM was usually performed by RNA as part of a RNP when the resident was on LTC, and when recommended should be completed while on TCU as well. DON stated R4 should have received PROM as part of a RNP. Facility policy Restorative Nursing Care Implementation and Screening dated 11/27/24, indicated, The goal of restorative nursing care is to attain and maintain the maximum possible independence and/or prevent rapid declines through their interventions for each resident. The policy further indicated, The restorative nurse had the overall responsibility and accountability for the restorative program. In the event the location does not have a designated restorative nurse, the responsibility and accountability remain with the director of nursing services. The policy indicated RNA and other designated and trained staff will provide care under the supervision of the restorative nurse, therapists, or DON. Facility policy Restorative Nursing Documentation dated 7/7/25, indicated, recommendations from therapy for a RNP will be added to a resident's care plan and entered into PCC for documentation.

Based on interview and document review, the facility failed to ensure resident specific advanced directive orders were accurately reflected throughout the medical record for 1 of 1 resident (R75) investigated for advanced directives (AD).R75's face sheet (undated) indicated diagnoses of wedge compression fracture of the T11-T12 vertebra, congestive heart failure (CHF), and chronic kidney disease (CKD). R75's Brief interview of Mental Status (BIMS) assessment dated [DATE], indicated intact cognition. R75's Functional Ability assessment dated [DATE], indicated R75 required assistance from staff with most activities of daily living (ADL) and mobility. R75's physician's orders indicated the following:-[DATE] advanced directive DNR-[DATE] attempt CPR R75's face sheet banner in Point Click Care (computer program) indicated code status (Advance Directive) of Do Not Resuscitate (DNR) and to attempt Cardiopulmonary Resuscitation (CPR). R75's Physician's Order for Life Sustaining Treatment (POLST) dated [DATE], indicated to attempt CPR. During interview on [DATE] at 3:18 p.m. R75 stated he wanted a good faith attempt at life saving measures, if he was found to be unresponsive/emergency situation. He further stated his AD should not be DNR. During interview on [DATE] at 8:57 a.m., registered nurse (RN)-C stated the first place they would look for code status (if a resident became unresponsive) would be on the POLST but it can also be found on the face sheet banner. RN-C verified they would have given him CPR because that is what the POLST indicated, however they further verified the face sheet banner in PCC indicated both CPR and DNR and stated that was confusing and could lead to error. During interview on [DATE] at 9:52 a.m. licensed practical nurse (LPN)-A stated if a resident was found unresponsive, the first place they would look for code status would depend on their location. If they were on their computer, they would look on the face sheet banner in PCC. If they were closer to the POLST book, they would look at the POLST. There are lots of places you could look. LPN-A further stated if there was a discrepancy, they would use the code status on the face sheet banner in PCC because that is the most accurate. During interview on [DATE] at 10:23 a.m., RN-D stated if a resident was found unresponsive, the first place they would look for code status was on the face sheet banner in PCC because that is the most accurate. During a follow up interview on [DATE] at 1:08 p.m., the surveyor showed LPN-A R75's face sheet banner in PCC which indicated both CPR and DNR and asked what they would do in that situation. LPN-A stated they would look at the actual orders and if they contained both orders, then they would get clarification from the nurse practitioner (NP). LPN-A stated she would not give direction to other staff regarding what action to take while she waited for direction from the NP. During interview on [DATE] at 9:56 a.m., the director of nursing (DON) stated if a resident was found unresponsive, the first-place nurses should look for the code status would depend on the nurse's location. If their computer was up and running, they should look on the face sheet banner in PCC, if they are closer to the desk they should look in the POLST book. After reviewing R75's face sheet banner in PC, DON stated as R75 had both DNR and CPR listed, she would look down in the orders and if there still was a discrepancy she would look in On-Base (computer program) to look at the POLST. The DON also stated this could cause a delay in R75 receiving CPR. The facility policy regarding advanced directives dated [DATE], was received but didn't address the first place to look for a resident's code status.

Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was donned (applied) for 2 of 2 residents (R42, R18) who were on enhanced barrier precautions (EBP), and 2 of 2 residents (R55, R111) on transmission based precautions, and failed to ensure appropriate hand hygiene and glove use for 3 of 3 residents (R42, R7, R18). Additionally, the facility failed to take appropriate steps to diagnose and manage a COVID-19 outbreak in accordance with Centers for Disease Control (CDC) guidance. Findings include: According to the Centers for Disease Control (CDC) Infection Control Guidance: SARS-CoV-2 updated [DATE], Infection Control Guidance: SARS-CoV-2 COVID-19 | CDC under the heading, Nursing Homes, indicated the approach to an outbreak investigation could involve either contact tracing (an attempt to find all contacts of a confirmed case in order to test or monitor for infection) or a broad-based approach; however, a broad-based such as unit, floor, or other specific areas of the facility approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected units or facility-wide every 3 to 7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. R55: R55's admission Minimum Data Set (MDS) dated [DATE], indicated R55 had intact cognition. R55's Admission Record form dated [DATE], indicated R55 had COVID-19 on [DATE]. R55's care plan dated [DATE], indicated R55 tested positive for COVID-19 on [DATE]. Interventions included observing for symptoms, monitoring breath sounds, rate rhythm, and use of any accessory muscles, when possible all services brought to resident in room such as rehabilitation, activities, and dining, droplet and contact precautions wear gowns, gloves, N95 masks (if available), and eye protection when changing contaminated linens. R55's care plan dated [DATE], indicated R55 had COVID-19 on [DATE], and interventions included encouraging R55 to wear a mask while staff in the room and when going outside of the room, encourage social distancing as appropriate per MDH (Minnesota Department of Health) and CDC (Centers for Disease Control) recommendations, provide a private room and use airborne/contact precautions, all cares provided in the private room. R55's Order Summary Report dated [DATE], indicated R55 had an order dated [DATE], for airborne and contact precautions for 10 days and all cares and therapies were completed in room. R55's nursing progress notes dated [DATE], indicated R55 was on isolation droplet precautions and all services were being rendered in R55's room. R5: R5's admission MDS dated [DATE], indicated intact cognition. R5's Admission Record form dated [DATE], indicated R5 had COVID-19 on [DATE]. R5's care plan dated [DATE], indicated R5 had COVID-19 on [DATE]. Interventions included to encourage R5 to wear a mask while staff in the room and when going outside of the room. Encourage social distancing as appropriate per MDH/CDC recommendations, provide private room and use contact/airborne precautions. All cares provided in a private room. R5's Order Summary report dated [DATE], indicated R5 had an order dated [DATE], ok for airborne and contact precautions. Patient can be placed in a single room and all meals, care, and therapy provided in the room for 10 days every shift for COVID-19 for 10 days. R5's progress notes dated [DATE], indicated R5 's respiratory infection was potentially a result of COVID-19 and R5 was on isolation droplet precautions and all services rendered in R5's room. R111: R111's admission MDS dated [DATE], indicated intact cognition. R111's Admission Record form dated [DATE], indicated R111 had COVID-19 on [DATE]. R111's care plan dated [DATE], indicated R111 tested positive for COVID-19 on [DATE]. Interventions included to encourage R111 to wear a mask while staff were in the room and when going outside of the room, provide a private room and use airborne/contact precautions, all cares provided in a private room. R111's Order Summary report dated [DATE], indicated R111 had an order dated [DATE], ok for airborne and contact precautions. Patient can be placed in a single room and all cares, meals, and therapy provided in room for 10 days every shift for COVID-19 for 10 days. R111's progress notes dated [DATE] at 7:26 p.m., indicated R111's respiratory infection was potentially a result of COVID-19, was on droplet precautions, and all services rendered were completed in R111's room. R215: R215's admission MDS dated [DATE], indicated intact cognition. R215's Admission Record form dated [DATE], indicated R215 had COVID-19 on [DATE]. R215's care plan dated [DATE], indicated R215 tested positive for COVID-19 on [DATE]. Interventions included, encourage R215 to wear a mask while staff were in the room and when going outside of the room, provide a private room and use airborne/contact precautions, all cares provided in a private room. R215's Order Summary Report dated [DATE], indicated the following orders: [DATE], complete SARS-COV-2 testing on all residents ongoing per CDC. [DATE], notify the provider about any symptoms of hypoxia every shift for COVID. [DATE], ok for airborne and contact precautions, single room isolation for all cares for 10 days every shift for COVID. R215's progress notes dated [DATE] at 2:23 p.m., indicated R215's family member was updated on the recent COVID positive result. R215's progress notes dated [DATE] at 7:46 p.m., indicated R215's respiratory infection is potentially a result of COVID-19 and was on isolation airborne precautions and contact isolation precautions. R4: R4's admission MDS dated [DATE], indicated intact cognition. R4's Admission Record form dated [DATE], lacked information R4 had COVID-19. R4's care plan dated [DATE], indicated R4 tested positive for COVID-19 on [DATE] and was on strict isolation in a private room with airborne and contact precautions. Interventions indicated contact precautions: wear gowns and masks when changing contaminated linens, provide a private room and use contact precautions. The care plan lacked interventions for using an N95 mask. R4's Order summary Report form dated [DATE], indicated the following order: [DATE], complete SARS CoV 2 testing on all residents ongoing per CDC. [DATE], airborne and contact precautions patient can be placed in a single room and all cares, meals and therapy is provided in room every shift for COVID-19 for 10 days. R4's progress notes dated [DATE] at 10:59 p.m., indicated R4's infection was potentially a result of COVID-19 and was on airborne and contact isolation precautions. Facility team sheets dated [DATE], were divided into 4 teams: team 1, team 2, team 3 and team 4. Team 3 included the following residents: R55, R5, R111, R215, and R4 who all tested positive for COVID-19. Additionally, R110, R43, R12 , and R214, were on Team 3. Facility POC COVID-19 Test forms were reviewed and identified the following: R55 tested positive for COVID-19 on [DATE]. R5 tested negative for COVID-19 on [DATE], and [DATE]. Additionally, another test dated [DATE], indicated R5 tested positive for COVID-19. R111 tested positive for COVID-19 on [DATE], no previous tests were located. R215 tested negative for COVID-19 on [DATE], and [DATE]. R4 tested negative for COVID-19 on [DATE], and tested positive for COVID-19 on [DATE]. R110 tested negative for COVID-19 on [DATE], and negative for COVID-19 on [DATE]. R43 tested negative for COVID-19 on [DATE], no previous tests were located. R12 tested negative for COVID-19 on [DATE], and on [DATE]. R214 tested negative for COVID-19 on [DATE]. Facility form, Monthly Report of Resident Infections in Location dated [DATE], indicated the following: R55 had COVID-19 on [DATE], and a productive cough with nasal drainage,, and congestion started on [DATE]. R5 had COVID-19 on [DATE], and had symptoms of a productive cough, nasal drainage with congestion on [DATE]. R111 had COVID-19 on [DATE] and symptoms of a non productive cough started on [DATE]. R215 had COVID-19 on [DATE], and symptoms started on [DATE]. R4 had COVID-19 on [DATE], and symptoms started on [DATE]. During interview on [DATE] at 7:53 a.m., the infection preventionist (IP) stated she worked as the IP every Wednesday, Thursday, and Friday. IP stated if an employee showed up to work with symptoms of a reportable communicable disease, they were tested with a rapid COVID-19 test and if they had signs or symptoms, would be sent home. IP stated they had 5 residents who tested positive for COVID-19, and all were on team 3. IP further stated all staff should wear a surgical mask on the unit and a designated nurse and nursing assistant (NA) would care for those residents with full PPE to include an N95 mask, gloves, gown, and a face shield. IP stated the N95 masks should fit securely to the face with no other mask located inside the N95 and regular glasses were not sufficient because they were not protective. IP further stated a couple staff were sick, one staff person had not worked at the facility and the other one was sent home as soon as they found out the staff person was COVID-19 positive. IP further stated they completed contact tracing and stated she was just finishing up on that on [DATE]. IP stated with contact tracing, they look at someone in contact with a person at 6 feet or less for 15 minutes or more and test on day 1, then 48 hours later, and an additional 48 hours after that. IP stated COVID-19 first started when R55's family member was positive for COVID-19, did not mask, and did not tell staff their positive status. IP further stated the 2nd person was R5 on [DATE], then R111 on [DATE], and then R215 on [DATE], and last, R4 tested positive on [DATE]. IP stated when not working, the director of nursing (DON) or nurse manager will test residents if they have signs and symptoms and will start transmission-based precautions and if a resident had symptoms and tested negative, they would require two negative tests 48 hours apart. IP stated they had four additional residents on team 3 and did not know whether they were tested and verified the residents were R110, R43, R12, and R214 and stated she planned to follow up on those residents [DATE]. IP stated it was a situation where testing should be done on group three if staff were wearing PPE and a designated nurse and NA looked after the individuals. Further, IP stated hand hygiene occurred prior to entering a room and completing a task such as activities of daily living, take off the gloves, wash hands and donn new gloves. Not sanitizing hands can bring bacteria and spread infection if donning gloves without performing hygiene. IP stated residents on enhanced barrier precautions (EBP) had incisions, ulcers, catheters, and signage was placed outside the resident's door and a cart was placed in the hallway. If a resident had COVID-19, they were not on EBP, but were on airborne and droplet precautions. IP expected staff to donn a gown and gloves for EBP and the signage instructed staff what the high-risk areas were including dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care, central lines, urinary catheters, feeding tube, tracheostomy, wound care, and any skin opening requiring a dressing according to the CDC. During interview on [DATE] at 10:55 a.m., registered nurse (RN)-B stated she tested at home and did not have signs or symptoms of COVID-19 and if there was a COVID-19 outbreak, they tested on day 1, 3, and 5 and further stated with this outbreak, all staff would be tested but did not know whether residents would also be tested and stated if they have signs and symptoms, they were tested right away. During interview on [DATE] at 10:57 a.m., nursing assistant (NA)-B stated she tested for COVID-19 this morning and had been testing the last 3 days and was without signs or symptoms. NA-B stated she heard that morning the facility would be testing everyone on the unit and staff due to everyone walking through the floors. During interview on [DATE] at 11:02 a.m., RN-F walked down the hall with four tests for COVID AG cards and stated they were all negative tests for R12, R43, R110, and R214 and stated these residents were on team 3 in the middle of other residents who had COVID. RN-F further stated they test residents and staff, and the test results were placed in a folder. During interview on [DATE] at 2:19 p.m., the director of nursing (DON) stated COVID-19 testing was completed on residents who were symptomatic or had an exposure and they watched for signs and symptoms. DON further stated employees with close contact were also tested and stated the first case of COVID-19 was on [DATE], then [DATE], [DATE], [DATE], and [DATE]. DON further stated they tested the other four residents on team 3 who were negative but did not think they completed testing promptly enough. The DON further stated she expected staff to wear an N95, gloves and a gown along with face shields and staff could not wear regular glasses as an eye protectant to prevent the spread of COVID-19. DON further stated the N95 had to be fitted to the face without a surgical mask underneath. Further, the DON stated she expected staff complete hand hygiene before and after glove use. The DON stated signs for EBP went up on admission and expected gloves and gowns to be worn for any close contact. A COVID-19 Confirmed Case Checklist dated [DATE], indicated when a case of COVID-19 has been suspected or confirmed in the location, the resident is confined to their room, airborne and contact transmission-based precautions are initiated, employees are assigned to care for the positive resident, source control is implemented 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, 3, and 5 and 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 to 7 days until no new cases of COVID-19 are identified for 14 days. 42586 R55's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and a diagnoses of COVID-19. R55 required partial/moderate assistance with ADL's and mobility. R55's physician's order dated [DATE], indicated droplet precautions x 10 days. All cares and therapies in room, every shift for 10 days. R55's care plan dated [DATE], indicated R55 has respiratory infection: tested Positive for COVID on [DATE]. It further indicated the following interventions: -observe for symptoms, e.g., cough, changes in functional ability or activity tolerance, O2 saturations, etc. -monitor/document breath sounds, document rate, rhythm, and the use of any accessory muscles. -when possible, all services brought to resident in room (e.g. rehabilitation, activities, dining, etc.). -DROPLET and CONTACT PRECAUTIONS: Wear gowns, gloves, N95 masks (if available), and eye protection when changing contaminated linens. Bag linens and close bag tightly before taking to laundry. -encourage/assist resident to perform hand hygiene -monitor/document/report new or worsening signs/symptoms of COVID-19 fever of 100.0 or greater, chills, shortness of breath, difficulty breathing, new or change in cough, sore throat, new loss of taste or smell, new sputum production, congestion, runny nose (rhinorrhea), fatigue, muscle or body aches, headache, nausea or vomiting, or diarrhea. -keep door closed for isolation -provide private room if available. R111 (TA) admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnosis of COVID-19. R111 required substantial assistance with mobility, lower extremity impairment on one side, used a walker and a wheelchair, and had a catheter. R111's physician' orders dated [DATE], indicated ok for droplet precautions. Patient can be placed in a single room and all cares, meals, and therapy provided in room for 10 days, every shift for COVID-19 for 10 days. R111's care plan dated [DATE], indicated has infection testing positive for COVID on [DATE] and is in strict isolation droplet and contact precautions. It further included the following interventions: -monitor/document/report to health care provider s/s of delirium: Changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. -when possible, all services brought to resident in room (e.g. rehabilitation, activities, dining, etc.). -CONTACT PRECAUTIONS: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. -educate resident/family regarding preventive measures to contain the infection. -provide private room and use contact precautions. During observation on [DATE] at 5:35 p.m., there was a sign on the outside of R111's and R55's door which indicated: Airborne Precautions everyone must: clean their hands, including before entering and when leaving the room. Put on an N95 or higher level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. Nursing assistant (NA)-F entered R111's room wearing 2 surgical masks, gown, and personal eye glasses. NA-F then exited the room (after having removed the gown) and donned another gown, and entered R55's room, set her meal tray down, removed her gown, and exited the room. During interview on [DATE] at 5:40 p.m. NA-F verified knowing the residents in rooms R111 and R55 were on airborne precautions due to testing positive for COVID-19 and was supposed to be wearing an N95 but was unable too stating I can't breathe with an N95 mask on so I wear 2 surgical masks instead. R55 was also supposed to wear goggles/eye protection but was unable to find any stating sometimes we're short of that. During observation and interview on [DATE] at 5:47 p.m., RN-G went into R111's room wearing an N95 with a surgical mask underneath it, a gown, and no eye protection. RN-G stated they weren't wearing eye protection because they were just giving the resident his pills, but should have been. Staff should wear eye protection every time they go into a residents room who are on airborne precautions. All staff have been fitted for an N95 and shouldn't be wearing a surgical mask underneath it. During observation and interview on [DATE] at 12:28 p.m., nursing assistant (NA)-G entered R111's room wearing an N95 with a surgical mask underneath, a gown, and no eye protection. NA-G stated they had been fitted for N95's and didn't know if it was acceptable to wear a surgical mask underneath it. NA-G further stated he didn't wear eye protection because he wasn't performing cares and was only bringing the resident his meal tray. During interview on [DATE] at 12:35 p.m., registered nurse (RN)-E stated when entering a residents room who is on airborne precautions, staff are required to wear a gown, gloves, N95, and face shield. Anyone who enters the room for any reason needs to wear personal protective equipment (PPE) even if they are not performing cares. All staff have been fitted for an N95 and should not be wearing a surgical mask underneath it. RN-E also verified rooms [ROOM NUMBERS] were airborne precaution rooms due to residents testing positive for COVID-19. During interview on [DATE] at 9:15 a.m., nurse manager registered nurse (RN)-A stated any staff entering a resident's room who is on airborne precautions was required to wear an N95, face shield, gown, and gloves, even if they weren't performing cares. Staff must wear eye protection and not their own personal eye glasses and they must wear the N95 they have been fitted for. A surgical mask should not be worn underneath. If staff are not wearing the appropriate PPE they are putting themselves and other residents at risk of transmission and could expose them to getting COVID-19. 44647 R18 R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had cognitive impairment and diagnoses of heart disease, Alzheimer's Disease, and anxiety disorder. R18's MDS also indicated R18 had pressure injury and was dependent on staff for mobility. R18's care plan revised [DATE], indicated R18 required EBP related to open wounds. Interventions including ensuring staff wore gown and glove when performing high contact care activities including transferring repositioning, and personal hygiene. R18's Kardex printed [DATE], directed staff to don gown and gloves when performing high contact care activities such as dressing, providing hygiene, repositioning, changing linins and personal cares. An observation on [DATE] at 1:13 p.m., R18 was seated in a wheelchair in her room with lunch in front of her. Outside her door to the left was a EBP sign and directed staff to gown and glove when providing high contact care. An observation on [DATE] at 2:03 p.m., nursing assistant- (A) and licensed practical nurse (LPN)-A entered to assist R18 back to bed. Outside of R20's room to the left of the door was an EBP sign that directed staff to gown and glove when providing high contact care. Hand hygiene was performed upon entrance and gloves were donned however NA-A and LPN-A had not donned a gown. R18 was lifted with the Hoyer lift and placed in bed. NA-A removed R18's slippers. NA-A unfastened R18's brief and tucked it down. NA-A provided cares from the front before LPN-A assisted to turn R18 to the side. NA-A removed R18's wet brief. R18's bottom had blanchable redness and skin was intact. NA-A cleaned R18 from the back side and removed gloves. Without performing hand hygiene, R18 applied new gloves and applied barrier cream before placing a clean brief and assisted R18 to roll on their back. LPN-A pulled the brief through and secured. NA-A then removed gloves and without performing hand hygiene donned new gloves. NA-A adjusted R18 to tilt to their right side and covered up. NA-A then removed gloves and tied garbage. Hand hygiene was performed, and NA-A and LPN-A exited the room. An interview on [DATE] at 2:17 p.m., NA-B verified the EBP sign to the side of R18's door. R18 stated they had not noticed the sign and should have worn a gown when providing cares to R18. NA-B also verified they had not performed hand hygiene in-between glove exchanges and was supposed to. When interviewed on [DATE] at 7:536 a.m., the IP expected staff to perform hand hygiene upon when exchanging gloves during cares. This was important to minimize the risk spreading bacteria and risk of infection for the residents. When interviewed on [DATE] at 2:19 p.m., the Director of Nursing (DON) expected staff to perform hand hygiene before and after glove removal. EBP signs were place for residents with any open area, foley, feeding tube, and wounds. Staff were expected to follow EBP when providing close contact cares such as transferring and personal or hygiene cares. 48299 R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact and had diagnoses of heart failure (heart does not pump blood as well as it should), hypertension (high blood pressure), and chronic obstructive pulmonary disease (lung disease which blocks airflow and makes it difficult to breath). R7 required supervision or touching assistance for toileting hygiene and transfers. During observation on [DATE] at 2:00 p.m., nursing assistant (NA)-C placed transfer belt around R7, applied gloves, and assisted R7 to stand from her wheelchair in the bathroom. R7 sat on the toilet and was incontinent of bowel, and NA-C removed and threw away the incontinent product. NA-C unlocked R7's wheelchair and backed out of bathroom, grabbed a clean incontinent product, returned to bathroom, and moved wheelchair closer to resident and locked wheelchair. R7 stood up from the toilet, and NA-C wiped R7's, applied clean incontinent product, pulled up R7's underwear and pants and fixed R7's shirt. NA-C assisted R7 into wheelchair grabbing the transfer belt, removed the transfer belt, wiped the toilet seat, then removed gloves and washed hands. During interview on [DATE] at 2:12 p.m., NA-C stated R7 required limited assistance for activities of daily living (ADLs). NA-C stated staff performed hand hygiene between assisting residents and between changes gloves. NA-C stated glove change and hand hygiene should be completed after dirty tasks and before clean tasks, and verified they did not change gloves during toileting and incontinence cares. NA-C stated glove changes and hand hygiene were important to prevent infection. During interview on [DATE] at 7:53 a.m., the infection preventionist (IP) expected staff to take gloves off and perform hand hygiene after assisting with ADLs, such as incontinence cares, and before touching clean items. This was important to minimize the risk of spreading bacteria and risk of infection for the residents. During interview on [DATE] at 2:19 p.m., the Director of Nursing (DON) expected staff to perform hand hygiene before and after glove removal. 49893 R42 R42's face sheet printed [DATE], indicated diagnoses of pneumonia, heart failure, and diabetes R42's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R42 had moderate cognitive impairment, no upper or lower extremity impairment, uses a wheelchair, dependent on staff for toileting hygiene, bathing, lower body dressing, and substantial assist for personal hygiene and bed mobility. R42 was frequently incontinent of urine and always incontinent of bowel. R42 has moisture associated skin damage (MASD) R42's careplan indicated R42 required enhanced barrier precautions related to open wounds. Interventions included wearing gown and gloves when performing high contact are activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, and/or wound care. R42's Kardex printed [DATE] directed staff to don gown and gloves when performing high contact care activities such as dressing, transferring, bathing, hygiene, changing linens, repositioning, and wound care. During observation on [DATE] at 1:39 p.m., a sign on was noted on the wall outside R42's door indicated EBP with instructions to don gown and gloves for high contact care. Nursing assistant (NA)-A entered R42's room with shower chair and NA-C entered room with mechanical lift. Both NA-A and NA-C arrived wearing gloves however did not don gowns. NA-D removed blankets and pillows from R42's bed. NA-C removed R42's pants. NA-C reached across R42 and assisted with rolling him to his right side. NA-C's scrub top was observed touching R42's bed. NA-D removed R42's incontinence product and placed mechanical lift sling under R42. NA-C and NA-D then rolled R42 to his left side exposing a bandage to R42's buttocks. Center of bandage was noted to be saturated with drainage. NA-C disposed of incontinence product in a garbage bag. Without removing gloves or performing hand hygiene, NA-C and NA-D assisted with transferring R42 from bed to the shower chair. Stool was noted on draw sheet on R42's bed. NA-C and NA-D then removed gloves with NA-D washing hands in bathroom. NA-C left room. NA-D brought R42 to the shower room. NA-D applied gloves however did not don gown. NA-D washed, rinsed, and towel dried R42. With the same gloves, NA-D wrapped R42 in sheet and blanket. NA-D then gathered shower linens placing them in bin. NA-D removed gloves and, without performing hand hygiene, took R42 back to his room. NA-D donned gloves however no gown. NA-D removed soiled linens from R42's bed and applied clean linens wearing the same gloves. NA-C entered room wearing gloves and no gown. NA-D removed gloves and donned new gloves without hand hygiene. R42 was transferred from shower chair to bed. NA-D and NA-C assisted with applying incontinence product and dressing R42. NA-C removed gloves and left the room. NA-D tidied room, removed gloves, opened window shades and put on new gloves. No hand hygiene was performed. NA-D then took bag of dirty linen and shower chair back to shower room. During interview on [DATE] at 2:52 p.m., NA-D confirmed signage outside R42's room indicating EBP. NA-D stated gowns and gloves are to be worn for cares, transferring, dressing changes, and bathing. NA-D also stated hand hygiene should be performed before and after wearing gloves or when hands are dirty. NA-D confirmed they should have worn a gown when transferring and bathing R42 and should have performed hand hygiene after removing gloves. During interview on [DATE] at 2:52 p.m., NA-C stated residents with wounds and catheters require EBP. Gown and gloves are required depending on level of contact, such as changing or helping residents getting dressed. NA-C stated they did not don a gown because they did not notice a sign outside R42's door. During interview on [DATE] at 10:51 a.m., RN-A stated they would expect staff to don gloves and gown for direct care, clothing management, showering, and all other high contact cares for residents on EBP and confirmed staff should have worn gowns when assisting R42. RN-A stated she would expect staff to sanitize hands before donning and after doffing gloves. During interview on [DATE] at 1:04 p.m., the director of nursing stated residents are evaluated for EBP on admission. All residents with incisions, wounds, and medical devices inserted in body are placed on EBP. She would expect staff to wear gowns for close contact with residents and remove gowns before leaving the room. The director of nursing confirmed she would have expected NA-D and NA-C to wear gown and gloves when performing cares and bathing for R42. The director of nursing further confirmed she would expect staff to perform hand hygiene between glove change. A policy tilted Multidrug-Resistant Organisms, MRSA VRE CRE and ESBL, All service Lines-Enterprise dated [DATE] indicated All resident's with any of the following: wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator: regardless of MDRO colonization status are to be placed on EBP. Personal protective equipment (PPE) are used for high-contact resident care activitie [TRUNCATED]

Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to weekly skin assessments which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all 61 residents in the facility. The Certification and Survey Provider Enhanved Reports (Casper)-3 assessment (data was converted to quality measures (QM) to evaluate nursing homes performance) dated 8/11/24, identified the following previous deficiency by month and year. -F686 Treatment/services to prevent/heal pressure ulcers at a scope and severity level of a D. See also F686 Based on interview and document review, the facility failed to ensure weekly skin assessments were completed for 2 of 3 (R3, R12) residents reviewed for pressure ulcer risk. Monthly QAPI meeting minutes dated 5/26/23, indicated performance improvment plan (PIP) for high risk pressure ulcers-current percentage for the month of April 2023 was 9.1%. State was 7.3% and national norm is 9.0%. Continue to see some long term care residents with chronic reoccurring areas that are non-compliant with repositioning/off loading to reduce pressure ulcer risk. Risks and benefits are explained to the residents and documented in point click care (computer program). Although the QAPI minutes provided documentation the facility was working on addressing high risk pressure ulcers, it lacked indication it was addressing missing weekly skin assessments. During interview on 8/22/24 at 3:00 p.m., the director of nursing (DON), stated the facility was working on addressing high risk pressure ulcers by looking at the clinically complex nature of people who were already admitting with pressure ulcers, some of which had wound vacs and trying to promote healing. They also really wanted involvement with a medical doctor, so the facility decided to get Vohera (name of a wound care company) to come in once a week. The DON also stated they address pressure ulcers in their weekly interdisciplinary team (IDT) meetings and how important documentation was. The main issue was getting the nurse to complete the documentation and not put it to the wayside. It is so important to do a skin assessment. We have provided education and the nurse manager RN-A has recently made time in the nurses schedule that is dedicated to completing skin assessments.

Based on observation, interview, and record review the facility failed to ensure 3 of 4 residents (R18, R4, R12) reviewed for skin alterations had weekly skin observations completed. Furthermore, the facility failed to ensure bruising was assessed and monitored for 1 of 3 resident (R12 ) reviewed for bruising and a skin tear was assessed and monitored for 1 of 2 residents (R18) reviewed for pressure injury. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had cognitive impairment and diagnoses of heart disease, Alzheimer's Disease, and anxiety disorder. R18's MDS also indicated R18 was at risk for pressure injury, was always incontinent of bladder and bowel, and was dependent on staff for mobility. R18's care plan revised 4/3/24, indicated R18 had potential for pressure ulcer development related to impaired mobility, weakness, history of falls, and use of a diuretic. R18 further had a known pressure insult of suspected deep tissue injury to both feels. Interventions included to assist to turn/reposition with a goal of every 2 hours, float heels off bed, provide pressure reducing mattress and gel cushion in wheelchair, and notify the nurse immediately of any new skin breakdown. R18's Kardex printed 8/20/24, indicated R18 was a high risk for skin injury and had history of previous skin breakdowns. Staff were directed to notify the nurse of any new areas, redness, blisters, or bruises noted during care activities. R18's medical record lacked indication R18 had a weekly skin observation completed since 7/25/24. R18's nursing and provider orders lacked indication R18 required monitoring or treatment to the right lower extremity skin alteration on the skin. R18's medical record lacked evidence R18's skin tear had been assessed until 8/20/24 (after entrance). An observation on 8/20/24 at 2:03 p.m., NA-A and licensed practical nurse (LPN)-A entered to assist R18 back to bed. R18 had knee high nylon stockings in place and was wearing a nightgown/dress. Under the stockings on R18's right shin, steri-strips were in place to close a skin alteration. LPN-A was not sure what the wound on R18's right shin was from and would check with LPN-B. When interviewed on 8/20/24 at 2:20 p.m., LPN-B stated R18 had fragile skin and was prone to skin breakdown. R18 required frequent position changes and heels elevated. LPN-A stated skin observations were completed on shower days and verified R18 had not had a skin observation documented since 7/25/24. LPN-A was not sure why R18 had steri-strips on the right shin and was not able to find any documentation in R18's record of when or how it happened. There should be an incident report and documentation. LPN-B reviewed the 24-hour nurse book and verified there was not anything listed there either. When interviewed on 8/21/24 at 2:19 p.m., registered nurse (RN)-A stated staff should be completing skin observations and reporting any new skin altercations so the correct follow up was in place. RN-A stated it appeared to be a skin tear and treatment was provided and was following up with staff to find out more details. RN-A verified there was no skin observations completed by staff since 7/25/24 and they should have been completed or documentation of refusal. When interviewed on 8/22/24 at 2:19 p.m., the Director of Nursing (DON) expected staff to complete weekly skin observations weekly with bathing. Nurses should also assess and document any skin alterations when they occur. 42586 R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below the knee, and type II diabetes mellitus with diabetic chronic kidney disease. It further indicated, impairment on one side of lower extremity, required staff assistance with most activities of daily living (ADL) and mobility, had a surgical wound, and no rejection of care behaviors were noted. R4's physician's order dated 6/20/24, indicated to complete skin user data assessment (UDA) or daily skilled note regarding skin condition on bath day-Thursday morning. Please check entire body for any skin insults or new skin injury and report to nurse manager or wound team every day shift every Thursday for skin care. In addition, another physician's order dated 8/13/24, indicated wound care right leg: cleanse the wound using wound cleanser. Apply Vashe-moistened gauze, let sit 10 minutes, then remove and pat dry. Protect the skin around the wound with Cavilon barrier film. Apply medihoney alginate, cut to fit the size of the wound and place directly over wound followed by 4X4 silicone foam adhesive (zetuvit border) is covered for daily dressings. Moisturize legs daily with thick, hypoallergenic, high quality moisturizer (CeraVe, Eucerin, Cetaphil, Vanicream). Apply every day shift every other day for wound care R4's care plan dated 6/18/24, indicated R4 had an amputation of right below knee with the following interventions: -check and document on wound daily for signs/symptoms of infection, drainage, bleeding, any breakdown of skin and impaired circulation (edema or pain). -monitor/document pain management. Document frequency, duration, intensity of pain, phantom pain. Report to health care provider if medications are not effective. -monitor for excessive wound drainage, swelling, redness, etc. -monitor for bleeding and document. R4's medical record lacked any indication of weekly skin assessments. R4's progress notes for July and August 2024, lacked documentation of weekly skin assessments. During interview on 8/21/24 at 2:06 p.m., registered nurse (RN)-C verified there was no documentaton of weekly skin assessments for the surgical incision on R4's right leg and there should have been. The skin assessment should include (at a minimum) a description of the wound in a progress note. R12 R12's significant change Minimum Data Set (MDS) dated [DATE], indicated, intact cognition and diagnoses of displaced bicondylar fracture of right tibia, atrial fibrillation, and chronic kidney disease (CKD). It further indicated R12 required assistance from staff with most activities of daily living (ADL), mobility, and received an anticoagulant on a routine basis. R12's physician's order dated 5/10/24, indicared please complete skin assessment UDA or daily skilled note regarding skin condition on this bath day-Friday PM. Please check entire body for any skin insults or new skin injury and report to nurse manager or wound team every evening shift every Friday for skin care. R12's care plan dated 5/6/24, indicated R12 was on anticoagulant therapy. Report to nurse observations of blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs, etc. It further indicated the following interventions: -monitor resident condition based on clinical practice guidelines or clinical standards of practice related to use of (apixaban). -Teaching: Resident/family/caregiver teaching to include the following: take/give medication at the same time each day; use soft toothbrush; use electric razor; avoid activities that could result in injury; take precautions to avoid falls; s/s of bleeding; avoid foods high in Vitamin K (includes greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussel sprouts, milk, and cheese). -WARNINGS #1: Refer to boxed warnings in the orders or electronic medication administration record (eMAR), or medication reference of choice. R12's medical record lacked any indication of weekly skin assessments. R12's progress notes for July and August 2024, lacked documentation of weekly skin assessments. During observation and interview on 8/19/24 at 1:37 p.m., R12 stated her wheelchair was too narrow and the arm rests were too high. She then showed surveyor a bruise on the inside of her upper right arm which was dark purple in color and appeared to line up with height of arm rest. R12 further stated she was on a blood thinner (Eliquis) and she had reported it to the lady at the front desk. During observation and interview on 8/20/24 at 7:59 a.m., R12 was sitting in her wheelchair in her room. She had a large purple bruise on her inner arm by the elbow (from a hospital blood draw) and another smaller purple bruise next to it that she stated she had bumped on the arm rest of her wheelchair and demonstrated where it matched up. RN-D verified the bruise and stated she wasn't aware of it and it should have been documented in R4's chart and monitored until it was resolved. During interview on 8/22/24 at 9:15 a.m., nurse manager registered nurse (RN)-A stated the nurses were responsible to document and monitor skin alterations such as bruises and scratches. They also need to try to identify where they came from and depending on the answer, may need to fill out an incident report or a progress noted. RN-A further stated skin assessments should be completed weekly and documented in a UDA or progress note stating I would like to see them follow it until it has resolved. RN-A verified R4 had a surgical incision on her right leg and didn't see any weekly skin assessments with a description of the incision which was important because it was hard to monitor what was going on without a description. She also verified R12's last skin assessment was on 8/9/24 and there haven't been any skin assessments since then. During interview on 8/22/24 at 2:19 p.m., the director of nursing (DON) stated skin assessments should be completed by nurses weekly and as needed and documented until resolved. If the skin alteration was a surgical incision, she would expect the nurse to monitor for healing, signs/symptoms of infection, drainage, proper closure, etc. and simply documenting the dressing was intact was not enough to be considered proper documentation A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/24, directed staff notify the nurse immediately about monitor any bruise, contusion, abrasion, or skin tear noted during cares. Furthermore, the policy directed staff to monitor any bruise, contusion or skin tear weekly and update the resident's care plan.

Based on observation, interview, and document review, the facility failed to ensure reclining foot rests functioned appropriately for 1 of 1 resident (R212) and failed to ensure a clean communal shower room which had the potential to affect all residents who used the shower room. Findings include, R212's comprehensive Minimum Data Set (MDS) in progress dated 8/15/24, indicated intact cognition, had coronary artery disease and hypertension (high blood pressure), acute myocardial infarction (heart attack), presence of an aortocoronary bypass graft, and had an encounter for surgical after care following surgery on the circulatory system. R212's physician orders form indicated the following order: 8/16/24, bumetanide 1 milligram (MG) by mouth daily for edema (fluid collecting in body tissues) and shortness of breath. R212's care plan dated 8/12/24, identified R212 took a diuretic. During interview on 8/19/24, at 1:13 p.m., R212 stated she mentioned to a few staff that the recliner chair did not work when trying to put her feet up, the foot rest would not stay in the upright position. R212 stated she mentioned the concern on 8/18/24, and again the morning of 8/19/24. During interview on 8/21/24 at 7:18 a.m., the manager of ancillary services (MOAS)-A stated he becomes aware of repairs thru the use of a maintenance slip or if there is something more severe or if something was urgent, a direct phone call was completed. MOAS-A further stated maintenance slips were used for everything to make him aware. A list of maintenance slips were requested from the past three weeks including completed orders and uncompleted work orders. During interview on 8/21/24 at 7:43 a.m., the MOAS-A provided the maintenance slips and further stated if in a hurry, instructs to fill out a slip, but if it is something like a remote not working, MOAS-A will look at the remote and not necessarily fill out a slip, but if a slip is not filled out, will look at the issue immediately or the same day. The work orders lacked information regarding R212's reclining chair. During interview and observation on 8/21/24 at 11:39 a.m., nursing assistant (NA)-B answered R212's call light and pulled the lever to recline R212 in the recliner chair. The foot rest would not stay in the elevated position. NA-B stated when the back of the chair is pulled back, the chair wouldn't stay in a reclined position and stated a lot of the chairs this style have been doing this since they got them and stated R212 had been wanting a new chair and stated somebody told R212 on 8/20/24, that they could not interchange the chairs, but did not know who told R212 the chairs could not be changed. NA-B further stated R212 mentioned the chair issue to her 8/20/24, but did not talk to maintenance. R212 stated she had swelling in her feet. During interview on 8/21/24, at 11:45 a.m., and 11:47 a.m., registered nurse (RN)-B stated if a recliner chair wasn't functioning, they contacted maintenance who will repair or replace a chair. RN-B stated she was not aware R212's leg rest on the chair was not functioning. RN-B stated MOAS-A was pretty quick and usually came up on the same day of any requests. RN-B further stated R212 had heart surgery and it would be important to elevate her legs for the swelling and edema. At 11:47 a.m., RN-B called and notified MOAS-A that R212's recliner chair was not working and would come up to look at the chair. During interview on 8/21/24 at 2:21 p.m., NA-B stated R212 was able to respond appropriately and could make her needs known. During interview on 8/22/24 at 7:33 a.m., MOAS-A stated the recliners had two springs that held the leg rest up and the manufacturer provided springs in three different tensions and stated the stiffness of the springs were used based on a resident's weight and residents used their legs and the lever to put their legs down, but if they don't have the strength, adjustments are made with a different tension spring. MOAS-A stated he did not know how long R212 had the problem and was first made aware of it around 12:00 p.m., on 8/21/24. During interview and observation 8/22/24 at 10:51 a.m., R212 was able to recline herself in the reclining chair and put the foot rest down and stated it was much better. During interview on 8/22/24 at 12:00 p.m., the director of nursing (DON) stated she expected staff to complete a slip to notify maintenance and further stated she expected staff to contact maintenance and stated she would contact MOAS-A to see if there was a schedule for the shower room and expected housekeepers keep a schedule. 44647 R13's quarterly MDS dated [DATE], indicated R13 was cognitively intact and had diagnoses of heart failure and diabetes. Furthermore, R13's MDS indicated R13 required partial/moderate assistance to shower. When interviewed on 8/19/24 at 12:18 p.m., R13 was seated in their wheelchair in the room. R13 stated there was mold growing in the shower room. R13 stated she had reported it before about a year ago and it was cleaned up and looked great however it was returning. R13 stated it was between the tiles and along the edges of the floor. An observation on 8/19/24 at 12:26 p.m., the lower-level shower room for the odd number hallway was observed. The room had a small ivory/white tiled floor. Grout in between the tiles were whit/light colored in most of the areas. However, several areas of the floor had darker black grout between the tiles. An observation on 8/21/24 at 12:28 p.m., the lower-level shower room for the even number hallway was observed. The room had a small ivory/white tiled floor. There was dark grout in between the tiles under the shower and along the shower floor and wall. When interviewed on 8/21/24 at 12:11 p.m., housekeeper (HSK)-A stated shower rooms were cleaned daily, and maintenance completed any deep cleaning and was not aware of any schedule for deep cleaning. HSK-A stated the shower room on the odd hallways did not get used much and most residents used the even hall shower. HSK-A was aware of the black grout between the tiles and along the wall and stated the mop used did not get in deep and mostly cleaned the surface of the tiles. HSK- stated they have tried to use their fingernail over the mop sponge to try to dig in between the tiles some, but it was hard to get it removed. When interviewed on 8/21/24 at 12:28 p.m., the MOAS-A verified the dark grout on the tile floor in the even number shower room and stated they needed to have a deep clean. MOAS-A further stated there was not a routine deep cleaning schedule and it was just as needed. MOAS-A was not aware of them needing cleaning and was not sure when the last time it was done. MOAS-A was able to confirm the shower rooms have not been deep cleaned in the past 8 months since their return. A policy, Resident Environment, dated 2/2/24, indicated the facility will provide a safe, clean, comfortable environment that allows the residents use of some personal belongings. Resident rooms will be designed and equipped for adequate nursing care, safety and comfort and will ensure full visual privacy for each resident as well as the following, housekeeping and maintenance services and functional furniture appropriate to resident needs.

Based on interview and document review the facility failed to ensure comprehensive care plans were developed for 1 of 1 resident (R50) and failed to ensure non-pharmacological interventions were developed and implemented for 1 of 1 resident (R110) reviewed for psychotropic drug use. Findings include: R50's admission Minimum Data Set, dated dated dated [DATE], indicated severe cognitive impairment, did not have little interest or pleasure in doing things, and did not feel down, depressed, or hopeless, did not have physical, verbal, or other behaviors, had diagnoses of dementia and depression and took an antipsychotic and antidepressant medication. R50's care area assessment (CAA) worksheet dated 7/16/24, indicated R50 took duloxetine (an antidepressant) and aripiprazole (an antipsychotic) for depression and psychotropic drug use would be addressed in the care plan in order to minimize risks. R50's physician orders indicated the following orders: 7/4/24, aripiprazole 20 milligrams (MG) by mouth once daily. 7/4/24, duloxetine 30 mg by mouth every evening, and 60 mg by mouth every morning. R50's orders lacked any monitoring for side effects of duloxetine and aripiprazole. R50's care plan was reviewed and lacked information R50 had a specific care plan for depression, and further lacked any monitoring for side effects of duloxetine and aripiprazole. R50's Pharmacist Medication Review form dated 8/15/24, indicated R50 was on Aspirin 325 mg daily indicated Aspirin was indicated for the prevention and or treatment of a wide variety of cardiovascular condition, and there was general consensus across guidelines that when used for primary or secondary cardiovascular prevention, lower doses of Aspirin have similar efficacy to higher doses, but carry less risk for significant bleeds. Please consider lowering this patient's Aspirin to 81 mg daily. The review lacked information for monitoring for side effects of aripiprazole or duloxetine. R50's Pharmacist Consultant review dated 7/19/24 indicated R50 was on aripiprazole 20 mg daily, please order monthly orthostatic blood pressure monitoring. R50's Pharmacist Consultant review dated 7/4/24 indicated no potential clinically significant medication issues identified at this time. During interview on 8/21/24 at 11:15 a.m., the consulting pharmacist (CP)-A stated antidepressant side effect monitoring included monitoring for central nervous system changes, whether a resident starts falling, weight loss and weight gain and further stated specific manifestations can take a few weeks and did not see any specific orders for R50. During interview on 8/21/24 at 12:03 p.m., registered nurse (RN)-C stated if a resident was on a psychotropic medication, it was added to the careplan and any monitoring for side effects showed up in the medication administration records. RN-C viewed the orders and stated R50 should have monitoring because R50 was on aripiprazole and duloxetine and verified the orders lacked monitoring and further RN-C viewed R50's care plan and verified R50 did not have a care plan related to psychotropics. RN-C also viewed R50's discontinued orders and verified there were no orders for monitoring and stated it should be there and would have to follow up with the director of nursing. During interview on 8/21/24 at 11:49 a.m., nursing assistant (NA)-B stated she would have to ask the nurse to see what kind of medications a resident was on and could also look in the Kardex to see if there were any behaviors to watch for. During interview on 8/22/24 at 12:13 p.m., the director of nursing (DON) stated monitoring was completed weekly and should be part of the documentation and whether the medications are effective and stated monitoring was supposed to be in the nursing orders and checked the care plan and verified the care plan lacked information R50 was on aripiprazole and duloxetine or had any kind of monitoring in place. 42586 R110's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, diagnosis of Bipolar disorders, was independent to supervision with ADL's and received an antispsychotic on a routine basis. R110's care area assessment (CAA) worksheet for psychotropic drug use dated 8/7/24, indicated: R110 received an antipsychotic, antidepressant, and hypnotic medication. Resident for drug induced Parkinsonism, multiple falls, chronic back pain, and myelofibrosis for diagnosis of bipolar disorder. Resident appears to tolerate medication without adverse reaction. Nursing staff observe for mood and behavior, and potential adverse reaction with administration of medication. R110's physician's orders dated 8/1/24, indicated olanzapine oral tablet 15 milligrams (mg). Give 15 mg by mouth at bedtime for psychosis. R110's care plan dated 8/5/24, indicated R110 was on antipsychotic medication therapy related to bipolar and psychosis. It further contained the following interventions: -R110 will be free of any discomfort or adverse side effects from antipsychotic medication use through the review date. -monitor resident condition based on clinical practice guidelines or clinical standards of practice related to use of (olanzapine). -consult with pharmacy, health care provider, etc. to consider dosage reduction when clinically appropriate. -WARNINGS #1: Refer to boxed warnings in the orders or eMAR, or medication reference of choice R110's care plan lacked any indication of non-pharmacological interventions. During interview on 8/22/24 at 9:15 a.m., nurse manager registered nurse (RN)-A stated when a resident comes in as a new admission a baseline care plan was initiated by the admitting nurse, MDS nurse or the DON. After that they continue to develop a more comprehensive care plan which was driven by the admission assessment. As things change, the care plan was continuously updated and the MDS nurse had a huge part in that but all departments are included. RN-A further stated staff should be developing and impletmenting non-pharmacological interventions on the care plan for residents who receive an antipsychotic medication and verified R110's care plan lacked individualized non pharmacological interventions. During interview on 8/22/24 at 2:19 p.m. the director of nursing (DON) stated non pharmacologic interventions should be developed, monitored, care planned and documented for residents who receive an antipsychotic medication. A policy, Care Plan-R/S, LTC, Therapy & Rehab, dated 11/1/23, indicated the purpose was to develop a comprehensive care plan using an interdisciplinary team approach, to provide guidance to the interdisciplinary team (IDT) in developing the initial care plan. The comprehensive care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders.

Based on interview and document review the facility failed to comply with resident rights to refuse treatment for 1 of 4 residents (R1) reviewed when staff proceeded with a urinary straight catheterization while R1 verbally and physically refused the procedure. R1 has had increased anxiety since the straight catheterization procedure. Findings include: R1's Minimal Data Set (MDS) dated [DATE] indicated R1 admitted to the facility on [DATE]. R1's pertinent primary medical conditions indicated on the MDS included anxiety disorder, morbid obesity, metastatic breast cancer, pathological fracture of the left tibia (shin bone) and generalized muscle weakness. R1 had no cognitive deficits. R1 was dependent upon staff with toileting and lower body dressing and transfers. R1 required maximum assistance from staff with upper body dressing and bathing. R1's treatment administration record (TAR) with a start date 10/30/23 at 3:00 p.m., end date 10/31/23 at 4:01 p.m. indicated postvoid residuals (PVRs) (a scan of the bladder to determine the amount of residual urine after voiding) every shift for urine residual greater than 350 cubic centimeters (cc) to use a straight catheter (a soft, thin flexible tube is inserted into the urethra, until urine flows out, the catheter is then removed and discarded) three times. If straight catheterizations were greater than three times, reinsert an indwelling urinary catheter (an indwelling tube that stays in the urethra and bladder for urine voiding). - 10/30/23 evening shift R1 had a PVR of 550 cc's. - 10/30/23 to 10/31/23 night shift R1 had a PVR of 35 cc's. - 10/31/23 day shift R1 had a PVR of 1000 cc's. R1's progress notes from 10/30/23 to 11/30/23 indicated: - 10/30/23 at 12:28 p.m. R1 admitted to the facility from the hospital for skilled services following surgical repair of R1's left tibia. - 10/31/23 at 1:02 p.m. a summary of R1's skilled services indicated R1 was to receive skilled nursing services, physical therapy, and occupational therapy. R1 had anxiety, edema, urinary retention, incisional dressing, and pain was monitored. R1 was sensitive to touch and cares, anxious about what would happen next. Scheduled antianxiety medications helps with R1 conditions. R1 had urinary retention in the hospital. Had PVR orders. R1 attempted to void this morning but was unable, a PVR scan was completed that showed 1000 cc of urine in the bladder. R1 and R1's family member (FM)-A requested an indwelling urinary catheter be placed. Next catheterization, including the hospital straight catheterizations, would be the fourth time. The indwelling urinary catheter procedure was tolerated by R1, returning 1200 cc of clear yellow urine. R1 was comfortable and less anxious. - 10/31/23 to 11/13/23 monitoring of the indwelling catheter was performed with no concerns from R1. - 11/14/23 at 4:25 p.m. R1 complained of pain and burning from the indwelling urinary catheter. An order was obtained for removal. R1's catheter was removed. - 11/30/23 at 3:26 p.m. R1 discharged from the facility. R1's physician order dated 11/1/23 at 9:31 a.m. indicated indwelling urinary catheter, 16 French with 15 cc's in 30 cc balloon, to dependent drainage. Change catheter as needed if dislodged or plugged and unable to clear with irrigation. R1's physician order dated 11/14/23 at 7:00 a.m. indicated okay to remove indwelling urinary catheter if R1 wants. PVR every shift for 72 hours. Straight catheter if residual urine is 350 cc or greater. If straight catheter needed three times reinsert indwelling urinary catheter. Upon interview on 12/15/23 at 8:46 a.m. R1 stated she left the facility after one month due to how she was treated. She stated she has been in pain ever since the staff forced catheterization on her. She was sobbing during interview, having to stop between sentences, saying I'm sorry, I'm sorry, I hurt physically and emotionally. She stated due to having vaginal and leg pain she cannot stop thinking about the facility. She had an appointment with her physician later during that day to discuss her symptoms. I think they damaged me; it hurts to pee. She stated two nurses, and a man were in her room during her stay at the facility, the staff was pulling on her leg trying to insert a catheter. R1 stated she was screaming, stop it is hurting me, I don't need this. She stated her husband was sleeping in her room and he woke and told staff to stop as well. She stated, the man was standing at the end of her bed looking at her parts. She said the women were trying to pull her legs apart as she was trying to close them. R1 stated the staff told her they needed to put the catheter in because it was unhealthy. R1 stated she did tell the nurse manager, registered nurse (RN)-C and RN-D that staff placed a catheter inside her, that she did not want, and they hurt her. Upon interview on 12/15/23 at 11:41 R1's family member (FM)-A stated R1 was yelling stop you are hurting me; you are hurting me. He stated two female nurses were holding her legs apart and a male was there helping. I told them to stop. He stated the staff stated if they could not get the urine out, she could become ill and must go to the hospital. She talks and cries about the trauma that the nurses caused every day since leaving the facility. A police report was filed by FM-A on 11/15/23 for the incident 10/30/23 and the care received at the facility. Upon inquiry on 12/15/23 with the police department at 9:41 a.m. The department did not have a police report on file made by FM-A regarding R1. Upon interview on 12/15/23 at 12:51 RN-E stated the day R1 was admitted on [DATE] was the day they had to straight catheterize her because her bladder scan contained over 350 cc; her bladder contained 550 cc's. She stated RN-B came to her and asked for assistance. RN-B told RN-E that he needed assistance as R1 was refusing the procedure. RN-E stated the procedure was explained to R1; however, she was frantic and did not feel the procedure was necessary. R1 started to cry before staff began procedure. RN-E stated that her and RN-B started the process and R1 started yelling It hurts, it hurts, I don't need this. R1 was lying flat on her back with her knees bent up. RN-E tried to expand R1's legs as much as she could, but R1 was saying her right leg was painful all the time. RN-E stated her role was to hold R1's legs so RN-B could insert the straight catheter. RN-E and RN-B did not get the straight catheter in inserted, we pulled back. RN-E stated she explained to the husband if the staff could not catheterize R1 that she may have to go back to the hospital. RN-B left the room to get another nurse to assist with the procedure. RN-F came into the room and assisted RN-B with holding R1's legs apart. R1 was yelling why do we now have another person in the room. As RN-B and RN-F were holding R1's legs RN-E did get the straight catheter inserted with a return of 574 cc of urine. R1's husband was heard saying that he hoped the procedure would be over soon and he hopes it would never need to be performed again. RN-E stated, We did attempt to try putting it in after she said stop. RN-E stated the procedure from start until finish lasted about 20 minutes. She denied trying any other interventions to try to get R1 to urinate or her own or any other interventions to ease R1's anxiety. She denied calling the nurse practitioner when R1 was refusing for further recommendation. RN-E stated she did not document anything about the procedure in R1's notes as she was not the nurse in charge of R1's cares that night. Upon interview on 12/15/23 at 2:36 p.m. RN-B stated R1 had an order to do a straight catheter procedure if her bladder scan residual showed over 350 cc. R1 was a larger lady who had anxiety, therefore RN-E was asked to assist. On the first attempt to insert the straight catheter R1 was yelling you're ripping me apart. RN-B stated he did not insert the straight catheter yet and R1 was not being touched when she was screaming. R1 was closing her legs, so the insertion was not obtained with RN-E holding her legs and RN-B attempting in insert the straight catheter. RN-B stated he went to get another nurse to assist. R1's husband woke-up and RN-B did not recall what the husband was saying. RN-B stated he did not hear R1 say stop, rather she was yelling you're ripping and putting it in the wrong hole RN-B stated with the help of RN-D they were able to complete the procedure as RN-B and RN-D held R1's legs and RN-E inserted the straight catheter. RN-B stated R1 was saying it was vagina which was hurting not her leg. RN-B stated RN-F did say maybe the staff should pull back due to R1's resistance, but RN-E was about to get the job done, so they proceeded. RN-B stated he did not recall if he wrote a progress note. He denied trying any relaxation interventions, education or notifying the NP for further instructions due to R1's anxiety or an update following the procedure. RN-B stated the entire procedure from start to finish took three minutes. The first attempt took two minutes and the second attempt one minute total time. RN-B stated he was aware that after procedure he was not allowed into R1's room per her request to not have male staff. RN-B stated he still proceeded with the procedure when she was because she was saying just get it in the right hole. Upon interview on 12/15/23 at 2:51 p.m. RN-D stated she worked the morning after R1 was straight catheterized. She stated that she knew R1 was upset about the catheterization and refused her bladder scans the rest of the night. RN-D stated she performed the bladder scan on R1 the following morning and she had 1000 cc's of residual urine in her bladder, which was a dangerous level. RN-D stated R1 was an extremely anxious resident and who was on a lot of anxiety medications and when the medications wore off R1 became anxious and scared. RN-D stated she spent a lot of time with R1 and her husband and explained that she needed an indwelling foley catheter or to be straight catheterized again, but this time she would put in an indwelling foley catheter. RN-D stated she made sure R1 had her Ativan 0.5 milligrams (an antianxiety medication) and R1 and her husband consented to the indwelling foley catheter. She stated she and another nurse (unidentified) placed the straight catheter in without difficulty. Upon interview on 12/15/23 at 2:39 p.m. RN-C the nurse manager stated she was not aware that R1 was yelling stop and yelling out pain during the straight catheterization procedure. In addition, she was not aware that three staff were in her room attempting to perform the straight catheter procedure. She stated 574 cc's is not that much urine, so it was not emergent that staff catheter her. She stated her expectation of staff would have been to stop and to get further direction from the NP. The nurse manager stated, There is no excuse, no means no. Upon interview on 12/15/23 at 3:06 p.m. RN-F stated RN-B requested her assistance with straight catheterization on a resident who was having anxiety. R1 was in her room and was very anxious when RN-F arrived, she was yelling. RN-F stated R1 was thrashing and flailing her legs around saying she was uncomfortable. RN-F did not recall her saying stop but recalled yelling. RN-F heard R1 say that she was not comfortable as RN-F and RN-B were holding back the skin folds of her legs and abdomen. RN-F stated she was uncertain of any interventions RN-B and RN-E providing before asking for her assistance. RN-F stated if resident does not want something done staff does not do it. Upon interview on 12/18/23 at 10:57 a.m. the director of nursing (DON) stated she heard that R1 at first did not want the straight catheter procedure, but then said she would allow it and the husband was present. She stated that she was not aware R1 was yelling. She stated if R1 was yelling, she would expect the staff to stop and come up with another plan. Upon interview on 12/18/23 at 11:21 p.m. the Administrator stated she was not aware of the straight catheter procedure for staff or residents, but if a resident were yelling, she would expect the staff to stop and explain risk and benefits to the resident. A facility policy titled Notification of Changes in residents-rehab/skilled dated 1/18/23 indicated the purpose was to ensure the resident receive prompt notification of changes in residents' rights. The facility provided the Care Providers of Minnesota Combined Federal and Minnesota State [NAME] of Rights version 6/8/19. Under the title Exercise of Rights indicated the facility must ensure the resident can exercise their rights without interference, coercion, discrimination, or reprisal from the facility. Under the title Planning and Implementing Care indicated the right to request, refuse, and/or discontinue treatment. Competent residents have the right to refuse treatment.