Every finding on record at Good Samaritan Society - Woodland

Based on observation, interview and document review, the facility failed to update care plans to reflect contact precautions for 2 of 3 residents (R1, R40) reviewed for transmission-based precautions.Findings include:R1R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, diagnoses included non-pressure chronic ulcer of the right lower leg/extremity (RLE), and multidrug-resistant organism (MDRO - microorganism that is resistant to one or more classes of antibiotics). R1 received interventions including ointment/medication and nonsurgical dressings on two venous/arterial ulcers and was not in isolation or quarantine for active infection during the assessment period.R1's care plan, revised 1/29/25, identified R1 had cellulitis and MDRO in the right lower extremity and was on enhanced barrier precautions (EBP). Staff were to wear PPE including gowns and gloves during high contact cares and to perform hand hygiene.R40R40's admission MDS dated [DATE], identified R40 had moderate cognitive impairment and had diagnoses including methicillin-resistant staphylococcus aureus (MRSA - an infection resistant to methicillin antibiotics). R40 was at risk for pressure ulcers and had open lesions other than ulcers, rashes or cuts. The assessment identified R40 was not in isolation or quarantine for active infection during the assessment period.R40's care plan dated 1/8/26, identified R40 was on EBP due to MRSA and staff were to wear PPE including gowns and gloves during high contact cares and to perform hand hygiene.On 2/9/26 at 7:47 p.m., observed a contact precaution sign on R1's door and R40's door.On 2/11/26 at 3:57 p.m. observed staff put on gowns and gloves prior to entering R1's room.On 2/11/26 at 1:07 p.m., registered nurse (RN)-A stated R1 had lower leg cellulitis that was positive for MRSA. R40 had a lower leg wound that was positive for MRSA. Both residents were at risk and were on contact precautions. Contact precautions should be on R1 and R40's care plans for staff to easily view. On 2/11/26 at 3:12 p.m., nursing assistant (NA)-A stated the residents care plan listed the type of precautions a resident was on. There was also a sign on the resident's door. For both EBP and contact precautions staff wore gowns and gloves. R1 and R40 had both EBP and contact precautions signs on their doors. R1 was on precautions due to skin redness on the leg and R40 was on precautions due to a wound on the lower leg. NA-A stated she was uncertain if R1 and R40 should be on EBP or contact precautions because both signs were on their doors.On 2/11/26 at 3:15 p.m., licensed practical nurse (LPN)-A stated R1 was on precautions for leg cellulitis and R40 was on precautions for a leg wound. NAs looked at the care plan and nurses looked at the medication administration record (MAR) and orders to review the type of precautions a resident had.During interview on 2/11/26 at 3:23 p.m., RN-B, who is also the infection preventionist, and the director of nursing (DON) stated R1 and R40 should be on contact precautions for infections in their wounds. It was important for staff to know what type of precautions a resident was on so they could protect the residents and themselves by wearing the appropriate PPE. Staff should wear gowns and gloves for contact precautions. The type of precautions would be listed in the resident's care plan. RN-B stated R1's care plan listed both EBP and contact precautions, and R40's care plan listed EBP. Both residents had MRSA in their wounds, and both care plans should list contact precautions. MRSA was a major infection, and staff should be aware of the positive infection as well as the appropriate precautions to protect the residents, themselves and other staff. RN-B stated R1 and R40's care plans were not accurate and should have been updated.The facility Care Plan policy identified 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. The plan of care will be modified to reflect the care currently required/provided for the residents.

Based on observation, interview and document review, the facility failed to ensure staff responded to resident request for toileting assistance in a timely manner for 1 of 4 residents (R23) reviewed for falls. This resulted in actual harm for R23 who fell while attempting to transfer independently, resulting in a head laceration which required emergency medical care. The facility implemented corrective action prior to the survey, therefore, the deficient practice was issued at past non-compliance. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], identified R23 had intact cognition. R23 was occasionally incontinent of bladder, continent of bowel and required maximum assistance to transfer and toilet. R23 was unable to ambulate. R23's care plan dated 4/1/25, identified R23 was at risk for falls related to activity intolerance. A goal was listed for R23 to be free of injury. Intervention included to allow R23 to make position changes slowly due to orthostatic blood pressure changes. A second intervention was added on 6/2/25, which directed staff to ensure R23 was wearing appropriate footwear. The care plan identified R23 had a self care deficit and required assistance of one to transfer and toilet. Interventions included to transfer R23 with assist of one and a mechanical stand aid and to toilet every three hours. A progress note on 5/29/25, identified R23 was found lying on the floor of her room next to her recliner. R23 had a large laceration to her forehead and R23 was sent to the emergency room to be evaluated. R23 stated she was going to go to the bathroom when she fell. R23 did not have shoes or gripper socks on at the time. Her call light was utilized prior to her fall and staff reported R23 was told she was next in line for assistance. R23 returned from the emergency room at 11:28 p.m. with eleven sutures to the laceration at the center of her forehead and purple bruising started to appear. R23's Fall Scene Huddle Worksheet dated 5/29/25, identified R23 was found on the floor in her room at 7:55 p.m., after having tried to self transfer. R23's recliner was all the way up in the elevated position and R23 was wearing socks on her feet. R23 was incontinent of urine and stated she had to go to the bathroom. Staff had offered to assist R23 to use the bathroom prior to supper and had declined the need. R23 was last toileted at 2:23 p.m. Nursing assistant (NA)-C last checked with R23 at 6:37 p.m. and notified R23 she would be the next resident to be assisted. The Summary Call Data by Room dated 5/26/25, identified identified R23 had put on her call light at 7:18 p.m. and the call light was turned off 38 minutes later when she was found on the floor. R23's Resident Event Abstract dated 5/29/25, identified an unobserved fall had occurred. R23 had stated she was going to go to the bathroom. R23's call light had been used prior to the fall and staff reported they had told R23 she would be next to be assisted to the bathroom and get ready for bed. On 6/1/25, at 5:10 p.m. R23 was seated in a wheelchair in her room, waiting for supper service. R23 had a laceration on the center of her forehead from her hairline to above her eyebrows that had sutures holding the edges together. Bruising was also noted surrounding the laceration. R23 stated she had fallen a few days before and hit her head on the bedside table. During interview on 6/2/25, at 3:29 p.m. NA-A stated she worked the evening of 5/29/25. She remembered it had gotten really busy with all the resident call lights. R23 had put her call light on but it had just been so busy that evening. During interview on 6/2/25, at 3:30 p.m. NA-B stated R23 would always ring her call light to go to the bathroom and at times staff would tell her they would be back in just a minute and R23 would wait. NA-B had never seen R23 attempt to take herself to the bathroom. When interviewed on 6/2/25, at 3:37 p.m. trained medication assistant (TMA)-A stated R23 would put on her call light when needed to use the bathroom and at times staff would tell her they would be back in a minute and R23 would always wait for staff to return. TMA-A had never known R23 to make self transfer attempts. During interview on 6/2/25, at 4:30 p.m. NA-D stated R23 needed assistance to go to the bathroom and was always continent of urine. R23 would ring her call light when needed to go to the bathroom and sometimes, would wheel to the doorway to look for help to the bathroom, if she was in her wheelchair. NA-D heard R23 had to wait a long time for assistance to the bathroom that evening and finally just tried to go on her own. When interviewed on 6/2/25, at 4:57 p.m. registered nurse (RN)-A stated she was working on the evening R23 had fallen. R23 had put on her call light and the NA went in and told her she would be the next to be assisted to bed and then they found her on the floor. R23's recliner was fully upright and RN-A thought she had been trying to stand and fell. Staff asked her before and after supper if she had wanted to use the bathroom and she had declined. R23 was not able to bear weight and had regular socks on, not gripper socks. RN-A assessed R23's injury and had sent her to the emergency room to be evaluated. During interview on 6/3/25, at 12:00 p.m. the director of nursing (DON) stated she had reviewed the facility video the night of R23's fall and spoken with staff who worked that evening. Staff entered R23's room and told her she was next to be assisted to bathroom and bed; however, staff assisted two other residents to bed first. The DON checked to see who the two residents were that were assisted before R23 and both residents had behaviors of anxiety, hollering out and were a high fall risk, so the staff put them to bed first. In the meantime, R23 had decided she could not wait and attempted to go herself. The DON reviewed the incident with all the NA's involved and provided education that call lights were a priority over putting residents to bed and the importance of toileting residents when they requested it. The DON stated she had also educated staff at shift change to approach R23 more directly when attempting to assist her to the bathroom instead of just asking. When a staff member saw a resident call light on, they were to check in frequently with the resident and/or get on their walkie's when a call light was on and needed to be addressed and request help. The staff on other wings needed to answer call lights and help out. During the fall investigation it was determined the the cause of R23's fall was because the call light was not addressed timely. Staff had checked in with her and told her they would be back to assist but did not get back to her timely. The staff were educated on answering call lights promptly and responding immediately to resident's request to be assisted to the bathroom. The facility' corrective actions were confirmed through a sample of other residents reviewed for falls, including R23, and verbal interviews with staff and management to affirm education was completed. R23's medical record was reviewed and verified R23 had been comprehensively assessed for fall risk, and the IDT review process was being completed since R23's fall. There were no other concerns identified regarding falls during the onsite survey. The facility policy Fall Prevention and Management dated 4/8/25, directed staff to care plan appropriate interventions to prevent falls and communicate fall risks and interventions to prevent a fall before it occurred. The facility policy Call Light dated 7/29/24, identified a purpose to ensure residents always had a method for calling for assistance and to promptly answer resident's call lights. When a resident's call light was observed, staff were to go to the resident's room promptly and respond to the resident's request as soon as possible.

Based on observation, interview and document review, the facility failed to ensure timely toileting assistance for 1 of 1 resident (R16) reviewed for activities of daily living and was dependent on staff. Findings include: R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 had moderately impaired cognition. R16 was dependent on staff for all toileting needs and was always incontinent of bowel and bladder. R16's care plan with revision date 2/15/24, directed staff to check and change for total incontinence every two hours. Continuous observations were conducted on 4/23/24, from 2:00 p.m. through 5:05 p.m. the following was identified: -At 2:04 p.m. R16 was sitting in his wheelchair waiting for the activity program Bingo to begin. -At 2:30 p.m. R16 was attending the activity program. -At 3:19 p.m. R16 was wheeled from the activity room to the nurses station. No staff had approached R16 during his attendance at activities. -At 3:46 p.m. R16 remained sitting in his wheelchair at the nurses station. -At 4:15 p.m. R16 remained sitting in his wheelchair at the nurses station. -A 4:35 p.m. R16 remained sitting in his wheelchair at the nurses station. -At 5:00 p.m. R16 remained sitting in his wheelchair at the nurses station. No staff had approached him since his return from activities. -At 5:05 p.m. trained medication assistant (TMA)-A approached R16 and wheeled R16 to the dining room without offering assist with toileting. TMA-A stated R16 needed to be checked and changed for toileting every two hours. If R16 had not been assisted with toileting prior to activities, that would be a problem. When the residents returned from activities it was shift change, ambulating residents and answering call lights, so checking R16 might have gotten missed. The morning shift would have recorded when they last check and changed R16. TMA-A stated the documentation identified R16 was last been checked and changed for incontinence care at 1:53 p.m. R16 had been due to be toileted at 3:00 p.m. which was not documented as completed. -At 5:10 p.m. TMA-A approached R16 in the dining room and offered to assist him with toileting. R16 agreed and was assisted back to his room to provide incontinence care. TMA-A and nursing assistant (NA)-A assisted R16 into bed using a mechanical lift. TMA-A assisted R16 to turn on his side and removed a soiled incontinence product that had visible urine present in the brief. Red crease marks were visible on the back of R16 thighs from his chair straps. R16 was assisted with peri-care and a new incontinence product was applied. R16 was assisted back to his wheelchair and to the dining room for supper. When interviewed on 4/24/24, at 2:25 p.m. registered nurse (RN)-A stated R16 was care planned for check and change every two hours and it would be a problem if he went longer than two hours. It was scheduled on the aides plan of care to do so every two hours. The toileting schedule in the electronic medical record would change color if it was past due, so it would alert staff to the task. It was important to check and change residents as per their care plan to prevent skin breakdown and R16 had very fragile skin. During interview on 4/24/24, at 4:00 p.m. the director of nursing (DON) stated it was her expectation the nursing assistant would follow the residents plan of care for toileting needs and if they were having difficulty meeting that expectation they should reach out to the charge nurses or administrative staff for help. The facility policy Activities of Daily Living dated 12/4/23, identified any resident who was unable to carry out activities of daily living would receive necessary services to maintain good nutrition, grooming, personal and oral hygiene. Toileting included assistance on and off toilet, use of bedpan, urinal or commode; cleansing after elimination; changing any protective pads; and adjusting clothing after toileting.

Based on observation, interview and document review, the facility failed to provide timely meal assistance to promote a dignified dining experience for 3 of 4 residents (R13, R21) observed who required staff assistance. Findings include: R13's significant change Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment and needed extensive assistance from staff to eat. R13's undated, face sheet included diagnoses of hemiplegia (paralysis of one side of the body), weakness, dementia, and a contracture of the right hand. R13's care plan dated 12/28/22, identified R13 had an activities of daily living (ADL) deficit and directed staff to set up the meal, R13 needed assistance of one, and directed staff to encourage R13 to participate with eating with cueing. R21's quarterly MDS dated [DATE], specified R21 had severe cognitive impairment and needed limited assistance from staff to eat. R21's undated, face sheet included diagnoses of dementia, Parkinson's, and tremors. R21's care plan, dated 3/8/23, directed staff to set up meals, use a lipped plate, two-handled cup with lid, built up utensils and assist with feeding as needed R21 and R13 were observed during a continuous observation on 3/15/23, from 8:17 a.m. to 8:33 a.m. during the breakfast meal. - At 8:17 a.m., NA-E delivered a meal to R21, which included oatmeal, pancakes and ham that was cut up into bite sized pieces . NA-E left the area to assist other residents. At 8:21 a.m., R21 was feeding himself. R21's right arm was shaking as R21 was attempting to feed himself oatmeal using his spoon. When R21 was bringing his spoon to his mouth the oatmeal fell on to his clothing protector and lap. R21 was able to get a minimal amount of oatmeal into their mouth to eat. At 8:24 a.m., R21 attempted to take another spoon full of oatmeal and brought it to his mouth. R21's hand was shaking and R21 dropped oatmeal onto their clothing protector. R21 continued in the same manner while feeding himself, staff were in the area and made no attempts to assist the resident. At 8:33 a.m., 16 minutes later, NA-E approached R21, sat next to the resident, and assisted him to finish his meal. - At 8:18 a.m., NA-D delivered R13 a meal which included juice, oatmeal, pancakes and ham which were cut up into bite size pieces. NA-D left the area to assist other residents. At 8:21 a.m. R13 was feeding himself, his right arm was shaking as he was attempting to feed himself a pancake using his fork. As R13 was bringing his fork to his mouth the pancake fell on to his clothing protector and lap. R13 was able to get a minimal amount of pancake to eat. At 8:24 a.m. R13 attempted to gather a spoon full of oatmeal and brought it to his mouth. R13's hand was shaking and R13 dropped the oatmeal onto his clothing protector. R13 continued in the same manner while feeding himself, staff were in the area and made no attempts to assist. At 8:33 a.m., 15 minutes later, NA-D approached R13, sat next to the resident, and assisted him to finish his meal. During an interview on 3/16/23, at 8:14 a.m., staff coordinator stated staff should always serve residents who could feed themselves first. Residents who required assistance should be served their meals last so staff could assist them. During an interview on 3/16/23, at 8:33 a.m. the director of nursing stated one staff member was assigned to two residents when assisting with meals and should be sitting by the resident within five minutes of the meal being served, otherwise residents could be embarrassed. A policy on meal preparation and service was requested, none was provided.

Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed to reduce the risk for the spread of herpes simplex virus for 1 of 1 resident (R10) identified with a communicable disease. Findings include: R10's undated, face sheet identified R10 had a diagnosis of herpes simplex virus, an infection that causes painful blisters or ulcers in the perineum area and was contagious when the vesicles are open. R10's pressure ulcer Care Area Assessment (CAA), dated 10/31/22, identified R10 was at risk for skin alteration and integrity and continued with a chronic red groin (Herpes Simplex) with much better control since admission. R10's undated order summary included an order for Valtrex (medication used to suppress herpes virus) 500 milligrams (mg) tablet by mouth daily for herpes simplex virus, with a start date of 9/16/22. R10's undated, care plan did not identify R10's history of herpes simplex including goals and intervention to direct staff on infection control precautions required during an active infections. During an interview on 3/15/23, at 2:45 p.m. the director of nursing stated R10 was on a prophylaxis medication of Valtrex for comfort and to reduce flare-ups of a herpes outbreak. R10's history of herpes simplex was not of on the care plan and should have been.

Based on interview and document review, the facility failed to report an allegation of mental abuse to the State Agency (SA), within two hours, for 1 of 3 residents (R1) who were reviewed for abuse, when resident reported intimidating and threatening behavior from a staff member to facility staff. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility report to the SA dated 1/25/22, at 1:30 p.m. indicated R1 reported, staff grabbed the wheelchair and slammed it up and down. Yelled at her to get up and she was jerked to get up. R1's son reported the concerns to the director of nursing (DON) in the morning of 1/25/22. DON interviewed R1 who reported staff got huffy and slammed the wheelchair up and down stating you gotta get out of bed and you gotta get up. R1 also reported staff threw the pillow. Review of facility document titled Suggestion or Concern dated 1/25/22, indicated the report to the DON as follows, she [R1] had to go to the BR [bathroom] grabbed the chair and slammed it up and down. Yelled at her, you need to get up. She was jerked to get up. Further review of document indicated on 1/25/22, at 9:00 a.m. R1 reported to the DON staff slammed the wheelchair up and down and threw pillow over and said you gotta get up she slammed it on the floor. Review of social worker (SW)'s interview with R1 following the allegation indicated on 1/25/22, R1 reported R1 is afraid of the perpetrator coming back to hurt her and it reminded me of people saying abuse in nursing homes. On 2/2/22, at 10:13 a.m. R1 indicated she felt safe at the facility however there was one incident with staff that occurred. R1 stated, I don't know her name. She came in and she looked angry when she came in. She was rough with me. I have to have help with my legs to get in and out of the chair and she didn't want to help me. She just jerked my legs all over. I said to her I am going to turn you in and from then on, she was just nice as can be and careful with me and I don't deserve to be treated like that. On 2/22/22, at 12:26 p.m. nursing assistant (NA)-A indicated she was provided training on abuse and reporting which included mental abuse. Further when asked what the timeframe for reporting abuse to the SA NA-A stated, I want to say 24 hours but the sooner the better. On 2/2/22, at 12:42 p.m. licensed practical nurse (LPN)-A indicated she was provided training on abuse and reporting, which included mental abuse. Further when asked what the timeframe for reporting abuse to the SA LPN-A stated, within 24 hours. On 2/22/21, at 12:56 p.m. NA-B indicated she was provided training on abuse and reporting, which included mental abuse. Further when asked what the timeframe for reporting abuse to the SA NA-B stated, I honestly don't know off the top of my head. On 2/2/22, at 1:13 p.m. NA-C NA-B indicated she was provided training on abuse and reporting, which included mental abuse. Further when asked what the timeframe for reporting abuse to the SA NA-C stated, within 24 hours however, she would report abuse as soon as you see it happening. On 2/2/22, at 1:38 p.m. DON indicated she was made aware of R1's allegation of abuse by FM-A on 1/25/22, at approximately 9:00 a.m. Further, DON indicated after she was made aware she spoke with the SW and came up with a plan. I go and get the resident's side of the story talked with the SW again and called the administrator and that takes a little time and then we pulled the trigger and submitted it. DON indicated the report was submitted to the SA on 1/25/22, at 1:30 p.m. and confirmed it was not within the two hours' time frame but that is if it involves harm that is my understanding. I take that as physical harm I could be misinterpreting it. In addition, when asked what the facility's policy was for reporting abuse allegations DON stated, if there is substantial harm its within 2 hours, otherwise we do have up to 24 hours when it's reported to us, but we try to do it immediately. On 2/2/22, at 1:55 p.m. administrator indicated the facility's policy was to report abuse allegations to the SA within two hours. Further, administrator stated, we did not think it was an alleged abuse until the second interview when SW interviewed R1, then we immediately turned it in. Administrator indicated she was informed by DON on 1/25/22, R1 was very depressed and she never said she felt abuse, so with the gray area let's have [SW] go back in and reapproach her and have her ask the same questions to see if its an alleged abuse. We thought maybe it was just reminding the staff to give TLC and slower with the resident. So once [SW] went in there and asked the same questions and this is what she said, and I said yeah let's turn it in and keep going with the investigation. On 2/2/22, at 2:07 p.m. when asked what the facility policy for reporting abuse allegations to the SA was SW stated, as soon as we determine if it is alleged abuse and we needed time to gather information from her [R1] but as soon as possible. I think its within two hours. Review of facility policy titled Abuse Definitions-Rehab/Skilled and Therapy/Rehab revised 12/20/21, defined mental abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Review of facility policy titled Abuse and Neglect-Rehab/Skilled, Therapy and Rehab revised 12/28/21, indicated if there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported not later than 24 hours after the allegation is made.

Based on observation and interview, the facility failed to maintain the walls, ceiling, floor, and floor mat in the ice machine alcove in good repair and/or a clean and sanitary condition within the resident dining room for 13 of 13 residents (R2, R7, R8, R13, R14, R15, R18, R21, R22, R23, R24, R25, R26) who dined regularly in the dining room. Findings include: On 5/10/21, at 5:56 p.m. the ice machine alcove in the dining room was observed. A large piece of wallpaper was removed and the sheet rock was missing from the kitchen-side of the space exposing the pipes and supply lines which were [NAME] out from the opening. Another smaller piece of sheet rock was missing from the same wall closer to the ceiling. The upper corner of the wall near the ceiling was visibly soiled with thick dust and dirt. A ceiling tile and light fixture had visible water damage. The black rubber matt covering the floor contained small holes approximately 1/2 inch (in) by 2 in's in parallel rows from end to end. The matt was visibly soiled, and when lifted a grid of black dirt remaining on the floor where the dirt had collected in the holes of the matt and around the edges at the base of the walls. During an interview on 5/12/21, at 2:54 p.m. nutrition services supervisor (NSS) stated the ice machine area was on a maintenance schedule. There was a plan to fix the area but due to COVID-19 the facility could not have people come into the building. Further, the floor in the ice alcove was the responsibility of housekeeping. During interview on 5/13/21, at 12:40 p.m. maintenance supervisor (MS) stated the area where the ice machine was stored had a leaky water supply pipe behind a cabinet approximately one year ago. The damaged cabinet was removed along with a portion of sheet rock. MS measured the opening and identified it was approximately 53 in. from the floor to the top of the hole . was 16 in. wide at its widest point at the bottom, and 2.5 in. wide toward the top of the opening. There was a capital budget request submitted to the corporate office to reconstruct the area to include a sink and felt it would be dealt with at that time, but all progress was halted with the COVID-19. Further since it had been about a about a year, the construction project would likely not happen any time soon so they probably needed to patch, paint, and re-install the cabinet. During interview on 5/13/21, at 12:54 p.m. environmental services supervisor (EVS)-A stated the ice machine alcove was cleaned by dietary staff, but every once in a while housekeeping would do a deep clean. There was no written schedule for this area, but it was cleaned approximately one month ago. Further, it was due for a deep clean and stated, I think that is really gross, actually. During interview on 5/13/21, at 5:49 p.m. the administrator stated there was a remodeling project scheduled before COVID-19 that had gone by the wayside and agreed the ice machine area was not good. A policy regarding facility maintenance was requested but not provided.

Based on observation, interview and document review, the facility failed to provide assistance with activities of daily living (ADL) for 2 of 2 residents (R21, R7) who were dependent upon staff for assistance. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment. R21 was always incontinent of bowel and bladder, and was fully dependent on staff for toileting and personal hygiene. R21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's urinary incontinence and indwelling catheter Care Area Assessment (CAA) dated 10/28/20, identified R21 had no functional bladder control. R21 was no longer able to sit up, required total physical assistance to manage incontinence, total mechanical lift to transfer, and was an assist of one to two staff to manage clothing, hygiene and incontinent products. R21 was no longer able to make their needs known. R21's care plan dated 1/14/21, directed staff to check and change the resident's incontinence brief every two hours. R21's current undated Kardex provided 5/13/21, instructed staff to check and change the resident's incontinence brief every two hours. During continuous observations on 5/12/21, R21 was dressed and seated upright in her wheelchair in the doorway of her room from 7:07 a.m. until 8:11 a.m. when an unidentified staff person wheeled R21 to the dining room and set her at a table for breakfast. -At 8:47 a.m. R21 was wheeled back to their room by an unidentified staff following breakfast where she remained seated in her wheelchair. -At 9:14 a.m. nursing assistant (NA)-D entered R21's room and reclined R21's wheelchair to approximately 20 degrees; however, did not check her brief. -At 9:38 a.m. NA-D peered into R21's room and then continued walking down the hall, without checking to see if incontinence care needed to be completed. -At 9:50 a.m. R21 remained reclined in her wheelchair. During interview on 5/12/21, at 10:05 a.m. NA-D stated R21 got up a little before 7:00 a.m. and staff would be repositioning the resident soon. NA-D identified she looked at the care plan daily and stated R21 needed to be checked and changed every two or three hours as she was always incontinent. On 5/12/21, at 10:17 a.m. NA-D and NA-A used a mechanical lift to transfer R21 from her wheelchair to her bed. NA-D checked R21's brief [3 hours and 10 minutes after the previous check] which was soiled with stool and a small amount of urine. The NA's provided peri care and placed a new incontinence brief. No redness was observed to R21's buttocks. During interview on 5/13/21, at 1:07 p.m. NA-A and NA-E stated the Kardex identified R21 should be checked and changed every two hours. During interview on 5/13/21, at 3:10 p.m. registered nurse (RN)-A stated R21 should be checked and changed every two to three hours. Upon review of the care plan, RN-A clarified the care plan instructed staff to check and change every two hours and did not direct staff to go up to three hours. During interview on 5/13/21, at 5:15 p.m. the director of nursing (DON) stated R21 should be checked, changed, and repositioned at a minimum of every two hours, and three hours was an unacceptable length of time to go without being checked. The policy Activities of Daily Living - Rehab/Skills revised 12/28/21, directed staff to provide appropriate treatment to maintain the residents activities of daily living including cleaning after elimination and the changing of protective pads. R7's quarterly MDS dated [DATE], indicated R7 had severe cognitive impairment with no behavioral issues related to refusal of cares. R7 required extensive assistance for personal hygiene/grooming. R7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's care plan dated 1/27/20, identified R7 preferred to be shaved daily during evening cares. During observation on 5/10/21, at 5:09 p.m. R7 had rough stubble and was not clean shaven. During observation on 5/12/21, at 7:20 a.m. R7 had rough stubble and was not clean shaven. During observation on 5/12/21, at 9:55 a.m. R7 had rough stubble and was not clean shaven. During observation on 5/13/21, at 9:30 a.m. R7 had rough stubble and was not clean shaven. During interview on 5/13/21, at 9:33 a.m. R7 stated he liked to be clean shaven and preferred to be shaved daily. He did not like having stubble on his face. During interview on 5/13/21, at 9:35 a.m. (NA)-A stated R7 should be shaved daily and it was on his care plan. Further R7 had not been shaved since 5/10/21. R7's progress notes from 1/1/21, through 5/10/21, did not identify R7 had refused any offered to shave. During interview on 5/13/21, at 9:36 a.m. trained medication assistant (TMA)-A identified R7's care plan indicated R7 liked to be shaved daily and did not know the last time R7 was shaved. TMA-A stated they did not document resident refusals. During an interview on 5/13/21, at 4:12 p.m. DON stated R7 had facial hair and had not been shaved. Further, there were no refusals of shaving documented. The DON expected R7's care plan to be followed and for R7 to be clean shaven. If a resident refused it should be documented. The facility policy Activities of Daily Living (ADL) dated 12/28/20, indicated ADL's are those necessary tasks conducted in the normal course of a resident's daily life and identified shaving as daily hygiene/grooming.

Based on observation, interview, and record review, the facility failed to provide timely repositioning assistance for 1 of 1 residents (R21) who was at risk for pressure ulcer. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment. R21 was totally dependent on staff and required assistance with transferring and bed mobility. R21 was at risk for pressure ulcers, and was on a turning/repositioning program as an intervention. The MDS did not identify R21 had any current pressure ulcers. R21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's Positioning Assessment and Evaluation dated 4/12/21, directed staff to reposition R21 every two hours. R21's care plan dated 1/14/21, identified R21 was at risk for pressure ulcer development and directed staff to reposition R21 every two hours. During continuous observations on 5/12/21, R21 was dressed and seated upright in her wheelchair in the doorway of her room from 7:07 a.m. until 8:11 a.m. when an unidentified staff person wheeled R21 to the dining room and set her at a table for breakfast. - At 8:47 a.m. R21 was wheeled back to her room by unidentified staff following breakfast where she remained seated in her wheelchair. - At 9:14 a.m. nursing assistant (NA)-D entered R21's room and reclined R21's wheelchair to approximately 20 degrees; However, was not offloaded to reduce pressure to her buttocks. - At 9:38 a.m. NA-D peered into R21's room and then continued walking down the hall. - At 9:50 a.m. R21 remained reclined in her wheelchair. During an interview on 5/12/21, at 10:05 a.m. NA-D stated R21 got up a little before 7:00 a.m. and staff would be repositioning the resident soon. NA-D stated R21 needed to be repositioned every two or three hours. NA-D defined repositioning as laying down, as R21 was unable to stand, and stated she was not aware of any recent pressure ulcers for R21. On 5/12/21, at 10:13 a.m. NA-A and NA-D were present in R21's room where R21 was repositioned from her wheelchair to her bed using a mechanical lift [3 hours and 6 minutes after the previous repositioning]. NA-D checked and changed R21's brief and protective barrier cream was applied. R21's buttocks was intact without any redness or pressure ulcers. During interview on 5/13/21, at 1:07 p.m. NA-A and NA-E stated the Kardex outlined each resident's needs including repositioning and how frequently to check and change a resident's incontinence brief. R21's Kardex dated 5/13/21, instructed staff to notify the nurse of any new skin issues, provide a pressure relieving mattress and wheelchair cushion, and apply topical barrier cream to buttocks to prevent skin conditions; however, the Kardex lacked any instruction to reposition R21. During interview on 5/13/21, at 3:10 p.m. registered nurse (RN)-A stated R21 should be repositioned every two to three hours. Upon review of the care plan, RN-A clarified the care plan instructed staff to reposition every two hours and did not direct staff to reposition every two to three hours. On 5/13/21, at 3:18 p.m. licensed practical nurse (LPN)-A reviewed R21's care plan and stated R21 should be repositioned every two hours. Further, the repositioning instruction in the care plan was not linked to the Kardex, therefore it would not appear on the Kardex for the nursing assistants to follow. LPN-A was unsure how to make the edit to ensure the direction showed on the Kardex. During interview on 5/13/21, at 5:15 p.m. the director of nursing (DON) stated R21 should be repositioned at a minimum of every two hours, but more often if there were skin issues. Further, three hours was an unacceptable length of time to go without being repositioned for R21. The facility Skin Assessment Pressure Ulcer Prevention and Documentation Requirements - Rehab/Skilled policy reviewed 4/21/21, directed staff to reposition residents who were unable to reposition themselves as often as directed by the care plan.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was performed to prevent cross contamination for 3 of 4 residents (R26, R2, R21) observed during personal cares. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had severe cognitive impairment. R26 required extensive assistance with all activities of daily living (ADL's). R26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation of [NAME] cares on 5/12/21, at 7:39 a.m. nursing assistant (NA)-C entered R26's room to assist her with getting up and ready. NA-C sanitized her hands and donned a clean pair of gloves. NA-C removed R26's blanket and assisted R26 to sit on the edge of the bed. R26's bed was saturated with urine. R26 was assisted to the bathroom where NA-C removed her urine saturated brief and assisted R26 onto toilet. NA-C assisted R21 with puting on her foot wear and assisted her to get her pants on and got a new brief ready for the resident. NA-C did not remove her gloves or perform hand hygiene after removing the saturated brief. With the same dirty gloves NA-C started preparing a clean wash basin. NA-C then removed the dirty gloves; however, did not wash or sanitizer her hands and then put on clean gloves using dirty hands. NA-C then started to assist R26 to wash her face and upper body. NA-C then assisted her with dressing her upper. NA-C assisted R26 to stand and NA-C removed her dirty gloves. NA-C did not wash or sanitize her hand and then put clean gloves on her using dirty hands. NA-C washed and dried R26's groin and buttocks, applied a barrier cream on R26's bottom then pulled up the brief and her pants. NA-C assisted R26 to the wheel chair. NA-C then removed the dirty gloves; however did not wash or sanitize hands and put clean gloves on using dirty hands and assisted R26 to brush her teeth, wash up around her eyes and comb her hair. After R26 went for breakfast, NA-C stripped the bed, gathered linens and brought them to the dirty utility room. NA-C then removed her gloves and washed her hands with soap and water. During interview on 5/12/21, at 8:18 a.m. NA-C stated she should of either washed or sanitized her hand between glove changes, especially when going from dirty to clean to prevent the spreading urine or feces to other areas. NA-C stated she did not wash or sanitizer her hands between glove changes when caring for R26. During interview on 5/13/21, at 4:12 p.m. the director of nursing (DON) stated she would have expected staff to wash or sanitize their hands when changing gloves, especially when going from dirty to clean to prevent transfer of body fluids, and prevent the spread of infections. R2's quarterly MDS dated [DATE], identified R2 had severe cognitive impairment. R2 was frequently incontinent of bowel and bladder and required staff assistance to use the toilet. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/21, at 7:50 a.m. NA-D assisted R2 with morning cares in the bathroom while R2 was seated on the toilet. NA-D put on clean gloves, assisted R2 to a standing position, and cleansed R2's perineal area of urine and stool. NA-D removed the soiled gloves, walked over to the sink area to retrieve clean gloves, and then put on clean gloves without performing hand hygiene. NA-D proceeded to apply ointment to the perineal area and continued to use the same gloves to put on incontinence brief and to assist R2 with putting on shirt and pants. No hand sanitizer was present in the bathroom. R21's quarterly MDS dated [DATE], identified R21 had severe cognitive impairment. R21 was always incontinent of bowel and bladder, and fully dependent on staff for toileting/perineal hygiene. The MDS identifed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/21, at 10:17 a.m. NA-D checked R21's brief, removed her gloves, used a disposable washcloth to wash her hands and then put on clean gloves. NA-D stated R21's brief was soiled with stool and a small amount of urine. NA-D removed the soiled brief out from under R21, removed her gloves, used a disposable washcloth to clean her hands, donned clean gloves, then proceeded to clean R21 of urine and stool. NA-D wiped R21's perineal area with a disposable washcloth from front to back, folded it and used the same wipe again from front to back, and folded the wipe and used it a third time, also front to back. NA-D then discarded the disposable washcloth. Using dirty gloves, NA-D held the outside of an unopened tube of perineal barrier ointment, removed the cover, and applied the ointment to R21's perineal area. NA-D removed the soiled gloves and adjusted R21's blankets without performing hand hygiene. The tube of ointment was not disinfected after contact with NA-D's soiled gloves and was placed on the side table. During interview on 5/12/21, at 10:30 a.m. NA-D stated she used a disposable washcloth in a pinch, to perform hand hygiene, as she did not want to leave the resident's side when changing the resident's brief. NA-D stated she should put on a clean glove, remove the brief, dispose of gloves, wash hands, and put on clean gloves before placing the clean brief. On 5/13/21, at 5:15 p.m. DON stated staff were expected to sanitize or wash their hands when going in and out of each room, and to wear gloves when providing hands-on cares, including when removing a resident's brief. If gloves were visibly soiled then the staff should remove the gloves, perform hand hygiene, let their hands dry, and put on clean gloves before proceeding. The DON clarified, if the resident could be cleaned up by wiping any fecal matter off using the brief and a disposable washcloth and the gloves were not visibly soiled, she did not expect staff to perform hand hygiene in between glove changes. She stated the need to change gloves depended on the size of the mess, and she would expect good sanitation at the end of cares. Further, when using ointment, staff were to clean the resident, put on clean gloves before applying ointment and change gloves again after application. Staff would have to leave the resident to go into the bathroom to wash their hands between glove changes, as they did not have hand sanitizer in the rooms. The DON confirmed the policy directed staff perform hand hygiene between glove changes, but stated the facility was not set up that way, and expressed concern the presence of dispensers in each room might be a safety concern with residents. The facility policy Hand Hygiene and Handwashing - Rehab/Skilled, Senior Living revised 4/6/21, directed staff to wash hands with soap and water or utilize hand sanitizer after removing gloves. The facility policy Putting On/Taking Off Personal Protective Equipment (Donning/Removing)- Rehab/Skilled, Senior Living, Child Daycare Services, Therapy revised 11/17/20, requires staff to Always wash hands between gloving.

Based on interview and document review, the facility failed to implement care planned interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell from a shower chair resulting in lacerations to her forehead, lip and knee. In addition, the facility failed to thoroughly assess for the root and identify a pattern of falls and failed to implement interventions for 1 of 3 residents (R3) reviewed for falls. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was severely cognitively impaired, required extensive assistance from two staff for bed mobility, transfers and toileting and total assistance from one staff for bathing. The MDS indicated R1 had no falls since the previous assessment. R1's Falls Care Area Assessment (CAA) dated 11/7/19, indicated she had difficulty maintaining sitting balance and had impaired balance during transfers. The CAA further identified poor insight and no safety awareness and R1 remained at risk for falling. R1's Care Plan dated 5/12/20, indicated a self care deficit and directed staff to provide whirlpool baths due to fall risk. The care plan was updated 7/21/20, to include, could have showers with safety belt. The care plan was revised on 7/23/20, to include staff to provide bathing assistance and indicated tub or bed bath for safety. The care plan further identified a risk for falls related to a history of putting herself on the floor to look for things, impaired mobility and impaired cognition and directed the use of a tilt in space wheel chair, Dycem in recliner, a wheel chair and a low bed. A nursing assistant (NA) care guide (Kardex) dated 7/19/20, indicated R1 required assistance from one staff for bathing and she could receive a shower with the safety belt on the shower chair for safety. On 7/23/20, at 9:56 a.m. R1 was observed seated in a tilt in space wheelchair in her room. R1's face was noted to have red/purple bruising around her eyes and forehead extending into her hairline. A cut was also noted on her upper lip. A facility incident report dated 7/20/20, indicated R1 was receiving a shower when she fell from the shower chair. NA-A called for help and writer entered the shower room to find R1 on the floor. R1 was lying on the floor on her right side with blood coming from her forehead, top lip and right knee. R1 complained of her head hurting. A facility Progress Note dated 7/20/20, indicated R1 fell out of the shower chair at 5:10 p.m. She was found to have a laceration on her forehead, laceration on right knee and a bruise and laceration on her upper lip. R1 was transferred to the hospital. Progress Note dated 7/21/20, indicated the interdisciplinary team (IDT) met to review R1's fall. While in the shower chair, staff turned away and R1 fell forward from the shower chair. R1 was care planned to have a seat belt on while in the chair and staff had not put the belt on. A facility document titled Investigation Interview dated 7/20/20, indicated NA-B stated the brakes and the PVC pipe on the shower chair were loose. NA-C's Investigation Interview dated 7/20/20, indicated she did not know how to use the shower chair and indicated she had not been trained on who needed a safety belt while in the chair. NA-A further stated the brakes on the shower chair did not work very well. NA-D's Investigation Interview dated 7/20/20, indicated she had not received training regarding the use of seat belts on the shower chair. Licensed practical nurse (LPN)-A's Investigation Interview indicated she was not aware R1 required the use of a seat belt when seated in the shower chair. During interview on 7/24/20, at 9:51 a.m. the maintenance director (MD) was observed in the facility shower room inspecting the shower chairs. The MD stated prior to R1's fall in the tub room, no regular inspections of the shower chairs had been completed and stated they were only inspected if someone reported an issue. The MD stated since R1's fall, routine safety inspections of the bathing equipment had been integrated into the buildings maintenance management system. Upon inspection of the shower chairs, the maintenance director removed one of three shower chairs from the tub room and stated the chair had loose PVC pipes and no safety seatbelt. At 10:15 a.m. the director of nursing (DON) stated R1 had always been a fall risk and had sustained multiple falls in the past. The DON stated R1 had a previous fall out of the shower chair which was when the seat belt in the shower chair was initiated. The DON stated while investigating R1's recent fall, it was determined staff were not aware of the need to use the seat belts when a resident was seated in the shower chairs. At that time, the DON said the facility had directed staff not to use the shower chairs, provided education on the the policies and procedures and initiated a return demonstration training to be completed before the staff could use a shower chair again. The DON stated staff that had not completed the return demonstration could only use the whirlpool. She stated NA-C received training prior to returning to work following the incident. During interview on 7/24/20, at 11:02 a.m. NA-C stated she was not aware R1 needed a lap (seat) belt while in the shower chair. NA-A stated during training, she was only trained on using the whirlpool and had not received training on the use of the shower chairs. NA-C said at the start of the shift staff only got a list of who was scheduled to receive a bath and what type of bath they were to receive. When asked about the use of the Kardex, NA-C stated, I actually don't know where the Kardex is. NA-C stated prior to returning to work she was required to review the policies and procedures related to bathing and had not been allowed to give showers until the new shower chairs were obtained. R3's admission MDS dated [DATE], indicated R3's [DIAGNOSES REDACTED]. The MDS also indicated R3 had short and long term memory impairment, impaired decision making, and displayed no [MEDICAL CONDITION], physical, verbal or other behavior symptoms, rejection of care or wandering and required limited assistance with all mobility and extensive assistance with toileting. R3's Cognitive CAA dated 6/02/20, indicated R3 had memory impairment and dementia which affected day to day tasks and created a fall risk due to R3 self transferring and forgetting his limitations. R3's Urinary Incontinence and Indwelling Catheter CAA dated 6/02/20, indicated R3 was incontinent of bladder daily and was inconsistent with recognizing his own toileting needs, even when wet. R3's Care Plan dated 5/21/20, with revision date of 6/21/20, indicated a high risk for falls related to impaired mobility, weakness and history of falls. The Care Plan indicated R3 self transferred, had no idea of his limitations, did not use his call light and would often refuse assistance with cares. The care plan indicated due to the self transfers, R3 had numerous falls, but indicated further physical interventions were felt to be too restrictive and could cause more harm than good. The care plan directed staff to continue to make attempts to keep R3 safe and reduce falls. Staff were directed to remind R3 not to bend over to pick up dropped items, encourage to participate in activities that promoted exercise and ensure R3 was wearing proper foot wear and gripper socks when in bed. The care plan further directed staff to place pancake button on R3's bed, non-skid strips on floor in front of the toilet and to monitor R3 hourly. Review of R3's clinical record revealed the following: -Incident report dated 6/9/20, at 10:41 p.m. R3 was found lying on the bathroom floor with his pants down. R3 stated he must have fallen. No injury. Intervention: gripper socks on at all times and non-skid strips to R3's bathroom floor. -Incident report dated 6/13/20, at 2:00 a.m. R3 was anxious and trying to get out of bed, but refused staff assistance. Staff accompanied R3 to walk in the hall. R3 was ambulated back to bed and while staff was straightening his bed, R3 lost his balance and fell backwards. R3 was wearing gripper socks and had a gait belt on. No injuries. Interventions: pancake button placed on bed to alert staff of any attempts R3 made to get out of bed and staff to monitor R3 hourly. -Incident report dated 6/19/20, at 7:30 p.m. R3 was found lying on the floor in his room. R3 had gripper socks on and his call light and pancake light had alerted. R3 stated he was going to the bathroom. No injuries. No interventions were identified. The Care Plan was updated for R3 to remain free from injury of falls. R3 was mobile, impulsive and independent minded. Physical therapy was at max baseline, other material interventions felt to be invasive and would cause more distress than good. -Incident report dated 7/17/20, at 2:50 p.m. R3 was found lying on the bathroom floor. R3 stated he was trying to get to the restroom and lost his balance. No injuries. No interventions identified. R3's clinical record lacked comprehensive assessments and identified interventions to address the falls which occurred on 6/19/20 and 7/17/20. On 7/23/20, at 11:22 a.m. RN-A was observed to enter R3's room following his request to go to the bathroom. RN-A was unable to locate a gait belt in the room and so exited the room to find one. R3 stated she will be gone a half hour or more, they always say a couple of seconds but it ends up to be a long time, and when you have to go to the bathroom, you just can't wait that long. RN-A returned and started to assist R3 to the bathroom and with hand hygiene. -At 11:58 a.m. a dietary aide (DA)-A was observed to enter R3's room and was overheard to offer to take him into the dining room for his noon meal. R3 replied he had to go to the bathroom first. DA-A left the room without reply. -At 12:01 p.m. NA-A knocked on R3's door and looked into the room and then left. -At 12:02 p.m. R3 was observed to have transferred himself onto the toilet in his bathroom. NA-A was requested to assist R3. NA-A entered the room and after washing his hands and gloving, assisted R3 with toileting and hand hygiene. -At 12:05 p.m. DA-A confirmed R3 had requested to go to the bathroom and verified he had not informed nursing staff of R3's request. On 7/24/20, at 9:36 a.m. R3 was observed wheeling himself back to his room following breakfast in the dining room. -At 9:41 R3 was observed to have self transferred himself to the toilet in his bathroom. RN-B was asked to assist R3 in the bathroom. RN-B confirmed R3 was not safe to transfer alone and called for an aide to assist R3 but was informed the aides were all occupied assisting other residents. RN-B entered R3's bathroom to assist him with completing his toileting however, R3 stated he would need more time. RN-B handed R3 his bathroom pull cord and instructed R3 to ring for assistance when he was finished. RN-B then left the room. -At 9:46 a.m. NA-A entered R3's room and after washing his hands and applying gloves, assisted R3 to complete toileting and hand hygiene. NA-A stated the staff tried to check on R3 as frequently as they could, but the call lights were exceptionally busy that morning. NA-A stated, We are doing the best we can. NA-A stated he thought R3 was on two hour checks but that he would have to check R3's Kardex and plan of care to be sure. NA-A checked R3's Kardex and stated R3 was to be toileted every two hours and was on hourly monitoring. NA-A stated the aides had to document each check they performed on the Kardex to record they were doing them. -At 9:50 a.m. NA-B stated she would look on the Kardex to see what each resident needed and how they were to transfer. She stated she could not think of anyone on a specific toileting program and that they pretty much toileted every resident every two hours. -At 10:00 a.m. RN-B stated they add an intervention after each fall and if that did not work they would add another one and another one and so on. RN-B stated the interventions were chosen based on how the resident fell , such as if someone rolled out of bed, they would add a fall mat. RN-B stated a fall mat would not work with R3. After reviewing all of R3's falls since admission, RN-B confirmed all but one fall involved toileting and stated she did feel a toileting schedule may be an appropriate intervention for R3. -At 10:50 a.m. the DON stated R3 had a history of [REDACTED]. The DON stated he was just a frequent faller, had received therapy, but continued to transfer independently, did not use the call light appropriately and did not ask for assistance. The DON stated R3 was on an every two hour toileting schedule however, they had not looked at his toileting needs that closely. The DON confirmed a more specific toileting schedule tailored to R3's needs, may prevent some falls. In addition, the DON confirmed that the dietary staff should have notified nursing of R3's request and had been educated on what to do in the future. -At 1:29 p.m. the DON confirmed that while a bowel and bladder assessment had been completed on 6/3/20, following admission, another assessment was not initiated in order to identify a potential relationship between R3's toileting needs and falls. The facility Fall Prevention and Management policy, dated 6/24/20, identified five purposes which included: to promote resident well-being by developing and implementing a fall prevention and management program and to identify risk factors and implement interventions before a fall occurred. The policy defined root cause analysis as a method for identifying the causes of the problem so that the best solutions could be identified and put into place. The policy directed staff to review admission documentation for fall risk factors and to care plan the appropriate interventions, including personalizing all areas.

Based on interview and document review, the facility failed to obtain and monitor weights in order to identify significant weight gain and the signs and symptoms of [MEDICAL CONDITION] for 1 of 3 (R1) residents reviewed. This failure resulted in actual harm due to the failure to identify R1's significant weight gain, bilateral [MEDICAL CONDITION], and chronic [MEDICAL CONDITION] and notify the physician resulting in R1's admission to the hospital and required mechanical breathing support. Although noncompliance was present at the time of the events, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance for R1. Findings include: R1's Face Sheet dated 8/9/19, indicated R1 was admitted from the hospital with [DIAGNOSES REDACTED]. R1's admission orders [REDACTED] -oxygen therapy: 2.0 liters/minute -[MEDICATION NAME] (diuretic) 40 milligrams (mg) two tablets twice daily -low sodium diet and do not drink more than 8 glasses (64 ounces) of fluid per day. -weigh patient daily. Call physician if weight increases 5 pounds or more in 1 week or 2 pounds overnight, more swelling in feet, ankles, legs or abdomen, if short of breath or have more trouble breathing, and if has chest pain or feels lightheaded or dizzy. R1's care plan initiated 8/11/19, indicated the following: -R1 was at risk for alteration in cardiac and respiratory status and fluid retention related to [MEDICAL CONDITION] [MEDICAL CONDITION], and end stage [MEDICAL CONDITIONS]. The staff were directed to monitor for side effects including changes in weight, [MEDICAL CONDITION], and shortness of breath, -required a 1920 milliliter daily fluid restriction and needed to be monitored daily. -received diuretic therapy related to heart failure and localized [MEDICAL CONDITION] and directed the staff to monitor status. -oxygen therapy related to acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. Keep physician informed of changes. Review of R1's clinical record revealed the following: -9/21/19: 291.0 pounds (lb.) -9/23/19- 308.0 +17 lbs. weight gain. However, no documented evidence of physician notification. -9/24/19- 297.4 lb. -9/27/19: 301.0 +3.5 lb. weight gain with no documented evidence of physician notification -9/28/19-305.2 +4.0 lb. weight gain with no documented evidence of physician notification. -9/29/19-302.4 lb. -9/30/19-305.0 +2.6 pound weight gain with no documented of physician notification -10/13/19-307.9 lb. -10/14/19-305.8 lb. -10/15/19 298.0 lb. -10/16/19 299.4 lb. -10/18/19: 299.4 lb. -10/19/19: 310.4 +11 lbs weight gain with no documented evidence of physician notification. -10/20/19- weight not obtained. R1's clinical record lacked consistent evidence of daily weight monitoring and the reporting of gains to the physician, as ordered. R1's Avera eCare Service note dated 10/20/19, at 2:46 p.m. indicated R1 was noted to be lethargic (state of tiredness, weariness, fatigue, or lack of energy) confused, and his right hand was shaky. Avera telemed was contacted to evaluate the symptoms. Order for blood work and a urinalysis was given due to the altered mental status and hypoxemia. No transfer required and directed to treat R1 at the facility. However, during this evaluation, the facility failed to inform Avera telemed of R1's overnight, significant weight gain. R1's progress notes also lacked any information related to the overnight weigh gain. R1's Progress Note (PN) dated 10/21/19, indicated R1 continued to show signs of confusion and lethargy. R1's weight was 313.2. Avera telemed was notified as well as the nurse practitioner (NP) who directed R1 be evaluated in the emergency department. R1 was subsequently admitted to the Intensive Care Unit (ICU) for medication treatment, monitoring, and [MEDICAL CONDITION] (mechanical ventilation) breathing support. A facility Incident report dated 10/21/19, indicated R1 was admitted to the local hospital for [MEDICAL CONDITION], acute [MEDICAL CONDITION] with [MEDICAL CONDITION] and hypercapnia. R1 was admitted to the ICU unit for [MEDICAL CONDITION] use and monitoring. The 10/21/19, Emergency Department(ED) provider note indicated over the past two days, R1 was noted to have generalized weakness, a cough, increased confusion, and orthopnea (shortness of breath or difficult breathing when lying down), and bilateral dependent [MEDICAL CONDITION] was noted. R1 was administered [MEDICATION NAME] 80 mg intravenously, and was started in [MEDICAL CONDITION] breathing support and admitted to the ICU for the [DIAGNOSES REDACTED]. On 12/18/19, at 2:00 p.m. licensed practical nurse (LPN)-B confirmed R1 was to be weighed daily and his weights monitored for weight gain with gains reported to the physician, as ordered. LPN-B verified R1's weights had not been obtained daily nor monitored for gains and stated it was a facility breakdown in monitoring weights. On 12/19/19, at 10:00 a.m. registered nurse (RN)-A confirmed R1's weights were to be monitored daily and changes were to be reported to his physician/Avera telemed, as ordered, due to R1's history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, RN-A verified R1's weights had not been obtained daily nor monitored. In addition, RN-A confirmed although R1 had been evaluated by Avera telemed related to clinical changes, the Avera telemed provider had not been made aware of R1's overnight, significant weight gain. When asked why, RN-A stated it was a facility systemic breakdown. On 12/19/19, at 1:30 p.m. the DON stated on 10/21/19, when it had been reported to her that R1 was not feeling well, she reviewed his status. The DON stated upon her review, she had identified that R1 had had a 13.8 pound weight gain from 10/18/19, to 10/19/19, and had not been reweighed on 10/20/19, and this significant weight gain had been reported to the Avera telemed provider when R1 was evaluated on 10/20/19, and should have been. The DON stated after her review of R1's condition, she had initiated a change of condition and contacted the facility NP as well as R1's cardiac practitioner and received the directive to transfer R1 to the emergency department. The DON stated as a result of her review findings, she conducted an investigation which included other facility residents who required weight monitoring, and identified obtaining and monitoring resident weights as ordered in order to identify significant changes including the identification of the signs and symptoms of [MEDICAL CONDITION] exacerbation was a problem at the facility and had immediately implemented corrective actions. The DON confirmed the nursing staff failed to weigh, monitor and identify R1's significant weight gain as well as the signs and symptoms of [MEDICAL CONDITION] and report to the physician, as ordered, which resulted in R1's admission to the hospital's intensive care unit with [MEDICAL CONDITION] breathing support. The facility's Weight and Height policy revised 10/17, directed staff to report changes in a resident's clinical condition (significant weight change) immediately to physician. The past non-compliance that began on 10/19/19, was verified during the 12/17-12/19/19, onsite visit and reviewed to be corrected by 10/24/19. Verification of corrective action was confirmed by interviews with a variety of nursing and dietary staff, observations and document review was also conducted. Training and education was completed by 10/24/19, and ongoing audits conducted verified interventions had been implemented. Nursing staff were educated to the facility policy and revisions were made to include the on-going monitoring of resident weights in order to prevent future incidents. The facility incorporated the action plan into the facility wide quality assurance program. The action plan implemented included: -Ensuring all residents had weights completed as directed and the physician had been notified, if needed. The Floor nurses were assigned to obtain, monitor, review, and follow up on all resident weights. -The identification of all potentially affected residents and reviewed all obtained weights as well as documentation. -Nurse Managers and Dietary manager to review weights and document progress notes weekly. Notify MD if weight gain or loss of 5% or greater or per MD orders. -Education related to the notification of the physician of weight gain or loss as per residents orders. -Continued Quality Assurance-weight audits implemented to ensure enhanced system compliance. Weekly weight audits and daily weight audits, director of nursing responsible for follow up. The DON continues to monitor all weights. -Staff education was provided.

Based on observation, interview and document review, the facility failed to provide provide assistance in a dignified manner for 1 of 1 resident (R282) observed to have requested assistance to the bathroom and staff repeatedly turned off her call light without returning to provide assitance. Findings include: R282's admission Minimal Data Set ((MDS) dated [DATE], indicated R282 had [DIAGNOSES REDACTED]. The MDS indicated R282 had short term memory impairment and required extensive assist of two staff for all activities of daily living (ADL)'s. The MDS also indicated R282 was frequently incontinent of bladder. R282's Urinary CAA dated 4/23/19, revealed R282 had bladder incontinence with some control present, urinary urgency and required assistance with toileting. R282's Care Plan revised on 4/18/19, indicated R282 required assistance of two with all ADL's and directed staff to assist R282 with toileting every three hours with the assistance of two staff. The undated Bedside Kardex Report printed on 4/24/19, directed the staff to assist R282 with toileting every three hours. During continuous observation on 4/23/19, from 9:24 a.m. to 10:53 a.m. the following observations were noted: -At 9:24 a.m. R282's call light illuminated in the hallway. -At 9:27 a.m. nursing assistant (NA)-G entered resident's room, turned off the call-light, stated to resident just give me one minute and left the room. -At 9:31 a.m. the activity director (AD) entered R282's room and spoke with resident briefly from the doorway and left the room. The AD did not offer assistance. -At 9:35 a.m. R282 stated I put my light on. She (NA-G) came in and I told her I had to go to the bathroom. She turned off my light and told me she would be right back. She hasn't come back yet. -At 9:37 a.m. RN-A entered R282's room to perform a dressing change. R282 informed RN-A that she needed to use the restroom. RN-A stated it would be a few minutes. RN-A left room and informed NA-A R282 needed assistance. NA-A was then observed to answer another residents call light. R282 remained seated in her recliner, in her room until 10:48 a.m. without having received assitance. -At 10:48 a.m. when asked, NA-A stated NA-G had left for the day. NA-A stated she was unaware R282 had requested to use the restroom. -At 10:49 a.m. NA-A entered R282's room and asked R282 if she needed assistance. R282 stated she would like to go to the bathroom. NA-A informed R282 that she would need to wait five or ten minutes until she could find another NA to assist R282 to transfer. NA-A left room and requested assistance to assist R282 to the bathroom. -At 10:53 a.m. NA-A and NA-B entered R282's room and assisted R282 to the bathroom. A total time of 1 hour and 29 minutes after R282 had initially turned on her call light and requested assitance to toilet. On 4 /23/19, at 11:27 a.m. the director of nursing (DON) stated it was not acceptable for the staff to turn off a call light, not to address the resident needs, and then leave the facility. The DON stated she expected the staff to assist with the resident needs in a timely fashion On 4/25/19 at 8:38 a.m. NA-C stated she answered call lights as soon as possible. NA-C stated she would immediately page for help if the resident required two persons assist. NA-C stated it was not her practice to turn off a call light and then go search for additional staff to assist the residents. NA-C explained the facility had a walkie-talkies that were to be utilized to communicate between the staff members to ask for assistance. -At 8:51 a.m. NA-A stated she answered call lights as soon as possible. NA-A stated a typical wait time for assistance was five to ten minutes. NA-A stated she would ask nurse for assistance if another NA was not immediately available. NA-A confirmed a wait time of one half hour or longer would be unacceptable. The Call Light Procedure dated 9/12, directed staff to promptly answer resident's call lights and to respond to residents request as soon as possible. The Care Plan policy revised on 11/16, indicated residents were to receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. The care plan was to emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. The Resident Dignity Policy and Procedure revised on 2/17, directed staff to refrain from practices demeaning to residents such as refusing to comply with a resident's request for toileting assistance.

Based on observation, interview and document review, the facility failed to provide assistance with cares during the night shift for 1 of 1 resident (R282) who was at risk for falls and was found on the floor for an undetermined amount of time. Findings include: R282's admission Minimal Data Set ((MDS) dated [DATE], indicated R282 had [DIAGNOSES REDACTED]. The MDS indicated R282 had short term memory impairment and required extensive assist of two staff for all activities of daily living (ADL)'s. The MDS also indicated R282 was frequently incontinent of bladder. R282's Pressure Ulcer Care Area Assessment Summary (CAA) dated 4/23/19, indicated R282 was at risk for pressure ulcer development and required a regular schedule for turning when in bed (the CAA did not identify the turning schedule). R282's Urinary CAA dated 4/23/19, revealed R282 had bladder incontinence with some control present, urinary urgency and required assistance with toileting. The CAA did not identify the a toileting plan. R282's Fall CAA dated 4/23/19, identified R282 at risk for falls and indicated an increased risk due to need for assist with ADL's, mobility, maintaining balance, cognitive impairment and incontinence. The CAA did not include fall prevention measures. R282's Care Plan revised on 4/18/19, indicated R282 required assistance of two with all ADL's and specifically, assist of two to turn and reposition when in bed. The care plan directed staff to assist R282 with toileting and repositioning every three hours with the assistance of two staff. The Care Plan also identified R282 at risk for falls and directed the staff to ensure R282 wore gripper socks at bedtime. The undated Bedside Kardex Report printed on 4/24/19, directed the staff to turn R282 from side to side with assist of two staff for bed mobility and to assist R282 with toileting every three hours. R282's Progress Notes revealed the following information: On 4/19/19 at 1:50 p.m. an incident note indicated staff entered resident's room at 8:30 a.m. to get R282 up for the day and found her lying on the floor. It was noted at that time R282's back was quite cold, indicating R282 had been lying on the floor for an undetermined amount of time. R282 stated she did not remember how long she had been on the floor. The charge nurse (unidentified nurse) questioned night staff regarding when R282 had last been checked and was informed R282 had not been checked on by staff all night. On 4/23/19, at 10:55 a.m. nursing assistant (NA)-B stated she occasionally worked the night shift and verified R282 was to be assisted every two to three hours during the night. NA-B stated all residents were to be assisted or observed every two to three hours during the night. On 4/23/19, at 2:47 p.m. A telephone interview with NA-E was attempted and was unsuccessful. On 4/24/19 at 5:58 a.m. register nurse (RN)-B stated during the night shift, she and a NA did resident rounds at midnight, 2:00 a.m. and 4:00 a.m. and they would lay eyes on everyone. RN-B stated she had done rounds on 4/18/19, at midnight and had flushed R282's [DEVICE] at that time. RN-B provided incontinence cares and repositioned R282 with the assistance of NA-E. RN-B stated NA-E had completed the 2:00 a.m. and 4:00 a.m. rounds on her own. RN-B verified she had not observed R282 after midnight on 4/19/19. -At 11:12 a.m. the director of nursing (DON) stated she had completed an investigation regarding R282's fall on 4/19/19. The DON confirmed R282 had not been observed between 12:52 a.m. and 8:30 a.m. when R282 was found on the floor. The DON stated the night staff were expected to complete rounds on all residents every two to three hours. The Don verified the night staff on 4/19/19, had not provided care or supervision to R282 for the seven hours and 38 minutes between 12:52 a.m. and 8:30 a.m. when R282 was found on the floor. The Abuse and Neglect Policy and Procedure revised on 10/18, indicated the resident has the right to be free from abuse and neglect. It directed the facility to ensure it had an effective system to prevent mistreatment, neglect, exploitation and abuse of residents.

Based on observation, interview and document review, the facility failed to monitor fluid restrictions for 1 of 1 resident (R20) reviewed for [MEDICAL TREATMENT]. Findings include: R20's quarterly Minimum Data set ((MDS) dated [DATE], indicated R20 was alert and orientated and was independent with eating. R20's Transfer/Discharge Report (face sheet) dated 9/14/18, indicated R20 had [DIAGNOSES REDACTED]. R20's Care Plan dated 9/15/18, indicated R20 was on a fluid restriction as ordered by health care provider: 2000 cubic centimeters (cc) as follows: -540 cc between meals and with medications (day shift 300 cc; evening shift 300 cc; night shift 240 cc. Fluids allowed at meals -1160 cc per day. -See charge nurse before giving any fluids between meals. -Document all fluids provided. R20's Order Summary Report (physician's orders [REDACTED]. R20's Dietician assessment dated [DATE], completed by the registered dietician (RD) indicated R20 was on 1500 ml fluid restriction and 960 cc of fluids given at meals. The RD indicated R20 drank 240 ml or less fluids at meals which was within the identified fluid restriction. R20 had been educated on fluid restriction and diet restrictions in the past and has agreed to the follow the prescribed dietary, however, R20 usually ate and drank what she wanted. The RD directed the staff to continue to monitor R20 and encourage her to be complaint with the prescribed diet. Review of R20's clinical record lacked evidence of a system to monitor R20's fluid intake. On 4/24/19 at 8:20 a.m. R20's room was observed to have three beverage mugs and an empty can of soda on the over bed table. Nursing assistant (NA)-A verified the beverages on the R20's overbed table and stated R20 was not on a fluid restriction. -At 8:26 a.m. registered nurse (RN)-A looked at R20's electronic medication record and stated R20 was not on a fluid restriction. When asked to check the diet order, RN-A verified R20 was to be on a 2000 ml fluid restriction, and nursing was not monitoring her intake. -At 8:28 a.m. RD stated she was aware of R20's fluid restriction and dietary was monitoring her intakes with meals. The RD stated she had educated R20 about her diet and restriction and there were times R20 choose for go over the amount of fluids or types of foods to eat per her choice. -At 8:36 a.m. R20 stated she was aware of her fluid restriction and that the facility monitored her intake and had communicated this information with the [MEDICAL TREATMENT] center. -At 8:44 a.m. the director of nursing (DON) stated she was aware of R20's fluid restriction and verified the care plan identified the fluid restriction and also directed the staff were to monitor R20's fluid intake, which had not been done as directed by the care plan and should have been. -At 10:46 a.m. a telephone interview was conducted with the an RN from CentraCare [MEDICAL TREATMENT], Brainerd. The [MEDICAL TREATMENT] RN stated R20 had not had any concerns with fluid overload or abnormal laboratory levels at the [MEDICAL TREATMENT] center, yet she would expect the nursing home to be assisting R20 to ensure compliance with fluid restrictions. Review of Intake and Output procedure revised 10/17, directed the staff to measure and record a residents fluid intake when ordered by the medical provider. The procedure directed staff to measure and record all fluid intake at meals and in-between meals.

Based on observation, interview and document review, the facility failed to evaluate, monitor and/or ensure justification was identified for 1 of 1 resident (R19) who received [MEDICATION NAME] (antipsychotic). Findings include: R19's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R19 had significant cognitive impairment and did not display behaviors. The MDS indicated R19's [DIAGNOSES REDACTED].) R19's Change in Condition Evaluation dated 4/9/19, indicated R19 had experienced significant changes due to [MEDICAL CONDITION] resulting in a decrease in physical and cognitive function. R19's Psychosocial Wellbeing Care Area Assessment (CAA) dated 4/18/19, indicated R19 was having [MEDICAL CONDITION] and depression. R19's [MEDICAL CONDITION] Medication CAA dated 4/18/19, indicated R19 had experienced a decline in physical and cognitive function. R19 had been started on hospice service and was ordered [MEDICATION NAME] (antipsychotic medication) 0.25 milligrams (mg) for hallucinations and both [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 5.0 mg twice a day for anxiety. R19's current physician's orders [REDACTED]. -[MEDICATION NAME] 0.25 mg every 4 hours as needed for hallucination. -[MEDICATION NAME] 0.5 mg every 4 hours as needed for anxiety -[MEDICATION NAME] 5.0 mg twice a day for anxiety. R19's Care Plan indicated R19 had a [DIAGNOSES REDACTED]. The care plan identified R19's target behaviors as: worrying which interfered with R19's ability to enjoy activities and not wanting to attend meals/activities. The care plan directed the staff to take R19 to activities, provide one to one visits, offer to take R19 for a walk or ride in the wheelchair, provide musical events or take R19 outside. On 4/22/19, at 2:30 p.m. R19 was observed visiting with an unidentified staff member in her room. R19 stated I am going to bite your hand. -At 2:50 p.m. R19 was observed wheeling herself up and down the hallway repeatedly yelling where are you (name of unknown person) The direct care staff were observed to respond to R19's requests by informing her the person she was looking for would be right back, however, without success of calming R19. On 4/23/19, at 8:28 a.m. R19 was observed quietly seated in a reclined wheelchair (Broda chair) next to the nurses station with her eyes closed. -At 8:34 a.m. registered nurse (RN)-A was observed to administer medications to R19. RN-A stated R19 only accepted her morning dose of [MEDICATION NAME] and spit out the rest of her medication. R19 was intermittently observed to remain quietly reclined in the Broda chair, at the nurse's station until 10:04 a.m. at which time she had begun to yell out for help. RN-A responded to R19 by talking to her. On 4/24/19, at 6:06 a.m. until 7:15 a.m. R19 was observed soundly sleeping in the reclined Broda chair, at the nurses station. R19's Electronic Medication Administration Record [REDACTED]. R19's Progress notes from 4/12/19 - 4/24/19, indicated R19 had been admitted to Hospice care on 4/12/19. R19 progress notes indicated R19 displayed behaviors such as yelling out, throwing items, accusing staff of plotting against her, wheeling up and down the hallways and being disruptive to others. However, the documentation did not identify the specific behavior R19 displayed or the nonpharmacological interventions attempted prior to the administrator of the antipsychotic. In addition, the documentation did not identify R19's response to the medication. R19's Consultant Pharmacy review dated, 4/24/19, indicated the pharmacist had questioned the use of [MEDICATION NAME] for a [DIAGNOSES REDACTED]. On 4/25/19,. at 9:48 a.m. the director of nursing (DON) reviewed R19's clinical record and confirmed R19 had received several doses of [MEDICATION NAME], however, the clinical record did not identify that R19 was hallucinating/include justification of its use. The DON confirmed the staff were to document R19's hallucinations prior to the administration of the medication. The Unnecessary Medications Policy revised 7/17, indicated each resident's drug regimen was to be must be free from unnecessary drugs. An unnecessary drug was defined as any drug when used without adequate indications for its use.

Based on observation, interview and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 8 percent with 2 errors out of 25 opportunities for error involving 1 of 4 residents (R282) who were observed during the medication pass. Findings include: Review of R282's medical record indicated a [DIAGNOSES REDACTED]. R282's current physician's orders [REDACTED]. A second order indicated R282 was to receive [MEDICATION NAME] (medication used to treat and prevent stomach and intestinal ulcers) 30 milligrams daily on an empty stomach. On 4/24/19, at 9:30 a.m. registered nurse (RN)-A was observed preparing R282's morning medications. A total of 10 medications were prepared which included liquid Floconazole and [MEDICATION NAME] tablet. RN-A poured the Fluconazole into a 30 ml calibrated medication cup. The liquid medication was observed slightly below the 5 ml calibration line. RN-A proceeded to administer the prepared medications via the gastrostomy tube. -At 9:40 a.m. RN-A confirmed she had eye balled the Fluconazole dose and stated the method of measurement was not accurate and she should have been measured the medication with a dosing syringe. -At 11:27 a.m. the director of nursing (DON) verified 2.5 ml liquid medication could not be accurately measured with a 30 ml calibrated medication cup and should have been measured with a dosing syringe. In addition, the Fluconazole and the [MEDICATION NAME] medications were to be administered in accordance to the physician orders. -At 1:55 p.m. RN-A confirmed R282 received her morning medication after she had eaten breakfast and did not receive [MEDICATION NAME] on an empty stomach, as ordered by the physician. On 4/24/19, 9:58 a.m. the consulting pharmacist stated [MEDICATION NAME] was to be given on an empty stomach in order for it to be most effective and R282's medications were to be administered in accordance to the physician orders. Review of the Medication Administration Policy and Procedure with revision date 10/17, indicated medications were to be scheduled to maximize the effectiveness of the medication. In addition, the medications were to be administered to the residents according to the six rights which includes the right dosage. The policy did not address a procedure to measure liquid medications.

Based on observation, interview and document review, the facility failed to complete hand hygiene during personal cares for 1 of 4 residents (R16) observed to receive to receive personal cares, the facility failed to ensure personal protective equipment (PPE) was appropriately utilized by the housekeeping staff for 1 of 1 resident (R27) observed in contact precautions. The facility also failed to ensure appropriate linen handling for 1 of 1 residents (R27) observed in contact precaution. The facility failed to ensure the infection control surveillance was completed in real time. Lastly, the facility failed to develop and implement a program to reduce the risk of a Legionella (a bacterium) in the facility water system to prevent cases and outbreaks of Legionnaires' disease (a serious type of pneumonia). This had the potential to affect all 30 residents who resided in the facility. Findings include: Hand Hygiene R16's admission Minimum Data Set ((MDS) dated [DATE], identified R16 with severe cognitive impairments and [DIAGNOSES REDACTED]. R16's care plan dated 1/11/18, directed the staff to provide assistance with all activities of daily living. On 3/13/18, at 7:36 p.m. nursing assistant (NA)-A and NA-E entered R16's room to assist with bedtime (HS) cares. R16 was observed to be resting in bed fully dressed. NA-A donned gloves removed R16's pants. NA-E also donned gloves as he/she opened R16's incontinence brief. NA-E utilized a wash cloth and soap and water as he/she washed R16's perineal area. NA-E then used the same cloth to wash R16's hips. The two NA's rolled R16 onto her side as NA-E finished washing R16's anal area and buttocks. R16 was observed to be incontinent of urine. NA-E and NA-A removed their gloves as they assisted R16 to reposition in bed, remove R16's shirt and placed a fresh pajama top on R16. NA-E pulled up the covers and completed room order. Upon exiting the room, NA-E gathered the laundry, garbage and turned off the light. At no time were the NA's observed to wash their hands or utilize hand sanitizer during the cares or before leaving the room. - At 7:48 p.m. NA-E confirmed hand hygiene had not been completed during the cares. NA-E stated she would be washing her hands in the soiled utility room. On 3/14/18, at 1:45 p.m. registered nurse (RN)-A stated staff was to perform hand hygiene as necessary during personal cares. The Hand Washing and Glove Use Policy dated 2/13, and revised on 12/17, directed the staff to complete hand hygiene before and after using gloves and and after direct resident contact. Contact Precautions R27's admission Minimum Data Set ((MDS) dated [DATE], indicated R27 displayed mild cognitive impairments and had [DIAGNOSES REDACTED]. R27's Progress Note dated 3/13/18, at 4:18 p.m. indicated R27 was on [MEDICAL CONDITIONS] contact isolation precautions. On 3/13/18, at 12:11 p.m. housekeeping staff member (HSKP)-A was observed outside of R27's room with a housekeeping cart. HSKP-A was observed to don personal protective equipment (PPE) consisting of a gown, gloves and mask. Once the PPE was applied, HSKP-A gathered a cleaning cloth from the cart and spayed the rag with cleaner. HSKP-A then entered R27's room. - At 12:15 p.m. HSKP-A exited R27's room while wearing the PPE, placed the cloth into a collection bag and removed a small bucket containing the toilet bowel brush and toilet bowl cleaner. HSKP-A then carried the items into R27's room. - At 12:17 p.m. HSKP-A returned to the cleaning cart wearing the PPE and replaced the bucket of toilet bowl cleaner into the cart. HSKP-A then entered a soiled utility room and returned carrying red bags along with clear plastic bags. - At 12:19 p.m. HSKP-A exited R27's room carrying a large red bag encased in a clear plastic bag. HSKP-A continued to be donned in the PPE as she placed the large bag on the end of the cleaning cart and gathered a dust mop and returned to R27's room. - At 12:21 p.m. HSKP-A exited R27's room wearing the PPE, replaced the mop and walked into the soiled utility room. Upon exiting the soiled utility room, HSKP-A was observed to have removed the PPE while in the utility room. HSKP-A was then observed to utilize hand sanitizer in the hallway. - At 12:26 p.m. HSKP-A stated she was to wear PPE while cleaning R27's room due to contact precautions. HSKP-A stated she had been trained on how to utilize PPE, but was not aware PPE was not to be worn outside of the potentially infection room. Additionally, she stated she was done cleaning rooms for the day so toilet bowl cleaner and mop were not used in any other rooms. The Contact Precaution policy dated 6/2016, revised on 1/2017, directed the staff to ensure PPE had been removed prior to leaving the resident room. On 3/15/18, at 1:00 p.m. RN-C stated all PPE was to be removed prior to exiting the resident room contaminated with C- Diff. Linen Handling On 3/12/18, at 11:00 a.m. R27's room was observed to be equipped with two tall (approximately 3 foot by one foot) red containers near the room door. The containers were observed to have lids on them, however, the lids were propped open and overflowing. The first red bin contained garbage, the second contained soiled laundry. On 3/14/18, at 7:30 a.m. R27's room was not observed to have red bins for laundry or garbage by the door. - At 7:35 a.m. NA-D and licensed practical nurse (LPN)-A were observed to assist R27 with morning cares. NA-D utilized three wash cloths as she assisted R27 to wash his face, arms, and back. After each use, NA-D placed the soiled washcloths onto the floor next to R27's bed. NA-D then assisted R27 with perineal cares. NA-D again placed the washcloth and towels onto the floor. - At 7:46 a.m. NA-D picked the soiled laundry off of the floor and carried it into R27's bathroom. NA-D then picked up a partially filled red bag of laundry off of the bathroom floor and placed the soiled laundry in the bag. NA-D then returned the bag to the floor. - At 7:48 a.m. NA-D confirmed the red bag on the floor of the bathroom contained R27's soiled laundry. NA-D stated there had been a laundry container in R27's room, however, she did not know why it had been removed. A linen handling policy was requested and none was provided. On 3/15/18, at 1:15 p.m. RN-C stated soiled laundry was to be placed in a laundry bag. The laundry bags were not to be placed on the resident's floor. Surveillance System On 3/15/18, at 12:50 p.m. RN-C/infection control preventionist stated the facility surveillance system included tracking and trending of all bacterial and [MEDICAL CONDITION] infections. RN-C stated the charge nurse was responsible for filling out the infection control logs as concerns were identified. RN-C stated she reviewed the infection control logs 1-2 times per week. Review of the 3/18, Monthly Report of Resident Infection in Center, did not include R27's [MEDICAL CONDITION] infection or the implementation of contact isolation precautions. - At 3:00 p.m. RN-C confirmed R27's [MEDICAL CONDITION] infection had been identified on 3/8/18, and had not been added to the infection control log. The Surveillance policy dated as revised on 10/17, directed the staff to identify, track and prevent nosocomial infections. The policy directed the staff to include data collection to ensure corrective actions could be completed. The staff were to implement process and outcome surveillance. Legionella Review On 3/15/18, at 1:40 p.m. the environmental services director (ESD) verified he was responsible for the implementation of facility policies pertaining to water born illness. The ESD stated National Campus had recently developed policies for Legionella , however, he had not implemented the policies. Review of the Legionnaires' Disease and Water Management Program dated 8/17, directed the facility to conduct a facility assessment to identify areas in the facility in which the building connected to the municipal water supply, how the water was distributed, how cold water was heated and then distributed, how waste water was discarded, where pools, hot tubs, cooling towers and water heaters or boilers were located. In addition the facility was to describe how the water system (using a flow diagram) was distributed within the facility, identity area where Legionella could grow and spread, control measures and corrective action along with the applications of the control measures. - At 1:50 p.m. the ESD stated in addition to the policy, National Campus had recently sent information from a TELS cooperation which directed the individual campus how to test and monitor the water system. The ESD stated he had ordered a water testing kit, however, it had not arrived at the facility. The ESD confirmed the facility had all the tools to completed a water assessment and testing, but the they had not been completed.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R31, R17, R21) received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The Center for Disease Control and Prevention identified Adults [AGE] years of age or older who have not previously received PCV13 and who have previously received one or more doses of PPSV23 (pneumococcal [MEDICATION NAME] vaccine 23) should receive a dose of PCV13. The dose of PCV13 should be administered at least one year after the most recent PPSV23 dose. R31 was an [AGE] year old female admitted to the facility on [DATE]. Review of the undated Minnesota Immunization Report indicated R31 had received a Pneumococcal [MEDICATION NAME] (PCV13) immunization. However, R31 had not received the pneumococcal PPSV23 immunization. R31's undated clinical immunization report lacked documentation as to why R31 had not received the PPSV23. R17 was an [AGE] year old male admitted to the facility on [DATE]. Review of R17's undated Minnesota Immunization Report indicated R17 had received a PPSV23 immunization on 1/3/11. However R17 had not received a PCV13 immunization. R17's undated clinical immunization report lacked documentation as to why R17 had not received a PCV13 immunization. R27 was a [AGE] year old male admitted to the facility on [DATE]. Review of R27's undated Minnesota Immunization Report indicated R27 had received a PPSV23 immunization on 11/11/99, however, R27 had not received a PCV13 immunization. R27's undated clinical immunization report lacked documentation as to why R27 had not received a PCV13 immunization. On 3/15/18, at 9:35 a.m. registered nurse (RN)-A stated the health information specialist and the charge nurses were responsible for checking the immunization records and following up to make sure the immunizations were discussed with the resident's primary physicians. RN-A confirmed the aforementioned residents were lacking pneumococcal immunizations. - At 1:00 p.m. the infection control preventionist/ RN-C stated all resident immunizations were to be reviewed upon admission and addressed with the primary physician as needed. The Immunization for Residents policy revised on 11/16, directed the staff to review the influenza and pneumococcal vaccinations upon admission with the resident and/or representative. The policy directed both PCV13 and PPSV23 immunizations to be administered to all adults aged 65 and order for the prevention of pneumococcal disease in accordance to the CDC guidelines.

Based on observation, interview and document review, the facility failed to provide assistance with activities of daily living in accordance with the care plan for 1 of 4 residents (R16) who was dependent upon staff for all activities of daily living. Findings include: R16's admission Minimum Data Set ((MDS) dated [DATE], identified R16 with severe cognitive impairments and [DIAGNOSES REDACTED]. The Activities of Daily Living Care Area Assessment (CAA) did not trigger at the time of the admission MDS. The Urinary Incontinence Care Area Assessment (CAA) dated 10/26/17, indicated R16 was totally incontinent of bowel and bladder and required assistance to check and change an incontinence brief. R16 required total assistance with all activities of daily living. The Bladder assessment dated [DATE], indicated R16 was incontinent of bowel and bladder and identified the staff was to assist with check and change every two hours. R16's care plan dated 1/11/18, directed the staff to provide the following care: - Bathing, assist of one. - Oral Cares: Assist of one with mouth cares. - Personal hygiene: requires assist of one with personal hygiene - Toilet use: Extensive assist of two to check and change. On 3/13/18, at 7:36 p.m. nursing assistant (NA)-A and NA-E entered R16's room to assist with bedtime (HS) cares. R16 was observed to be resting in bed fully dressed. NA-A removed R16's pants. as NA-E opened R16's incontinent brief and performed perineal cares for R16. The NA's rolled R16 onto her side and completed perineal cares and applied a fresh incontinence brief. The NA's then dressed R16 in a fresh pajama top and covered her with the blankets. R16 was observed to yell out during the cares. NA-E explained to R16 on three occasions that as soon as the cares were done she would be allowed to rest. NA-E stated we are all done now, you have a good night as she covered R16 with a blanket and turned out the lights. The NA's were not observed to assist R16 with washing her hands, face, upper body or provide oral cares. - At 7:48 p.m. NA-E confirmed R16 had received bedtime (HS) cares and the next time the staff would assist her with cares would be during last rounds at the end of the shift. NA-E confirmed R16 had not received oral cares and had not been given the opportunity to wash her face, hands or upper body. - At 7:50 p.m. NA-A confirmed R16 had been dressed in her pajamas and had not received assistance with oral cares or washing her upper body. NA-A stated he/she would return to R16 and complete HS cares. On 3/14/18, during continuous observations from 7:07 a.m. to 10:50 a.m. R16 was not observed to receive assistance with incontinence cares. At 7:07 a.m. R16 was observed seated in a reclining geri chair in the hallway by the nurses station. At 7:14 a.m. R16 was wheeled to the dining room and served breakfast. R16 remained in the dining room until 9:30 a.m. at which time she was wheeled into the activity room/ Cedar lounge area. - At 10:46 a.m. NA-D stated she did not know when the last time R16 had been assisted with incontinence cares. - At 10:50 a.m. NA-C stated she had assisted R16 out of bed at 6:30 a.m. and had not assisted her with incontinence cares since that time. - At 10:52 a.m. NA-C and NA-D wheeled R16 from the Cedar lounge to her room and transferred R16 from the chair to the bed via a full body mechanical lift. Once in bed, NA-C and NA-D changed R16's incontinence brief. R16 was observed to be incontinent of urine. - At 11:05 a.m. NA-C confirmed R16 had not received incontinence cares between 6:30 a.m. and 10:50 a.m. a total of 4 hours and 20 minutes. - At 1:45 p.m. registered nurse (RN)-A stated bedtime cares were to include washing the residents face, hands, and upper body along with oral cares. RN-A stated R16 was to be assisted with incontinence cares every two hours. RN-A confirmed R16 had not received cares in accordance with her care plan. On 3/15/18, at 1:15 p.m. the director of nurses stated R16 was to receive cares in accordance to the care plan. The Oral Hygiene policy dated 9/2012 and revised on 10/2017, directed the staff to provide oral cares. The Bathing policy dated 9/2012, and revised on 10/2017, directed the staff to bathe the residents upper and lower body. The Toileting Program policy dated 9/2017, and revised on 2/2016, directed the staff to provide assistance with check and change every two hours. A policy related to care plans was requested and none was provided.