Every finding on record at Good Shepherd Lutheran Home

Based on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was displayed for residents, visitors, and staff to review. This had the potential to affect all residents currently residing in the facility, as well as all staff and visitors. Findings include: On 7/8/26 at 8:47 a.m., it was observed that RBOR poster was displayed in a locked glass case in a small common area near the entrance and was dated 1/16. On 7/8/26 at 12:02 p.m., director of Social Services confirmed the poster was outdated and a new one needed to be ordered. A facility policy was requested but none provided.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 2 of 6 resident reviewed for bedrails. Findings include: R55's comprehensive minimum data set (MDS) dated [DATE] indicated R55 was cognitively intact and had the following diagnoses: atrial fibrillation, high blood pressure and arthritis. Section P of the MDS which covers restraints and alarms indicated R55 did not use bedrails. During observation and interview on 7/6/26 at 10:24 a.m., R55's bed was noted to have quarter bed rails attached to the top portion of the right and left side of the bed. R55 stated they had been there since her admission. R55's medical record was reviewed and did not indicate the use of bedrails. R16's quarterly MDS assessment dated [DATE] indicated R16 was cognitively intact and had the following diagnoses: coronary artery disease, heart failure, and high blood pressure. Section P of the MDS which covers restraints and alarms indicated R16 did not use bedrails. During observation and interview on 7/6/26 at 2:13 p.m., R16's bed was noted to have quarter bed rails attached to the top portion of the right and left side of the bed. R15 stated he did not use them for positioning. R16's medical record was reviewed and did not indicate the use of bedrails. During interview on 7/9/26 at 4:51 p.m., director of nursing (DON) stated she expected the MDS assessment to be accurately completed and to include all necessary information pertaining to the resident's current health conditions. DON stated it was important to have the assessments be accurate as it drives the resident plan of care and ensures the resident received appropriate care. DON went on to state the MDS assessments also drive reimbursement and if incorrect the facility would not receive proper reimbursement. A policy was requested but not provided.

Based on observation and interview, the facility failed to promote independence for 1 of 1 resident (R 72) reviewed for self determination.Findings include: R72's face sheet printed 7/9/26, indicated admission date of 4/10/25, and had diagnoses of Cerebral Infarction affecting left side, type 2 Diabetes, and difficulty in walking. R72's care plan printed 7/9/26, indicated at risk for falls, resident needs a safe environment with even floors free from clutter, when in bed place blue mats on each side of the bed.During observation and interview on 7/7/26 at 5:02 p.m. R72 was sitting in wheelchair with a blue mattress on the floor opposite side of the bed and blocking access to the refrigerator. R72 stated he was not able to access his pop or yogurt that was in the refrigerator. During observation on 7/8/26 at 4:48 p.m. R72 was sitting in his wheelchair. There were 2 blue mats on the floor opposite side of bed and blocking access to the refrigerator. on 7/9/26 at 8:09 a.m. nursing assistant (NA)-A stated resident needed assistance with activities of daily living (ADLs) and keeping his room picked up and organized. NA-A stated R72 required mats when in bed and staff were expected to move them when he was out of bed. NA-A stated R72 would not be able to safely access the refrigerator when the mats were left on the floor. The mats should be placed out of the way. On 7/9/26 at 8:15 a.m. LPN-C stated R72 was able to self-propel himself enough to retrieve items from the refrigerator. The mats should not be left on the floor when R72 was out of bed. On 7/9/26 at 8:41 a.m. ADON stated she expected mats to be removed from the floor and placed out of way when residents were not in their beds. It was an issue if a resident was not able to access their refrigerator when capable of doing so. Policy was requested but none provided.

Based on record review, and interview, the facility failed to update the provider of a weight change per physician order for 1 of 5 residents (R8) reviewed for unnecessary medications.Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 was mildly cognitively impaired, was admitted on [DATE], and had the following diagnoses: coronary artery disease, heart failure (HF) (hearts failure to pump blood efficiently and can cause weight fluctuation), hypertension (HTN) (high blood pressure), and dementia.R8's clinical physician orders dated 7-9-26, indicated the following order:daily weight- every day shift (REPORT CHANGE OF 3LBS OVERNIGHT). Start date 4-9-26R8's weights and vitals dated 7-9-26, indicated the following weight fluctuations:On 5-29-26 weight-153.5lbsOn 5-30-26 weight-149.5lbs, which showed a change of 4lbs.On 6-3-26 weight-148.5lbsOn 6-4-26 weight-153.5, which showed a change of 5lbs.R8's medical record lacked any evidence that the provider was ever updated per the provider order.On 7-9-26 at 12:08p.m. via email, the director of nursing confirmed the provider was never updated of the weight changes.On 7-9-26 at 4:51p.m., the director of nursing stated their expectation was the provider should have been updated on these weight changes per the physician order and stated the importance of preventing decline in regards to the residents HF, and in order start treatment as soon as possible if ordered by the provider.A policy for provider notification was requested and none was provided.

Based on observation, interview and document review, the facility failed to ensure resident receive adequate supervision and assistance for 1 of 1 resident (R5) when transferred with and EZ stand lift.Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated cognitive deficit and dependent for toileting, Diagnoses included: Alzheimer's disease, dementia, fracture, and repeated falls. R5's care plan printed 7/8/26, indicated moderate risk for falls related to weakness. Toileting: EZ stand w/2A [with 2 assist]. Does not ambulate at this time. During observation on 7/6/26 at 1:49 p.m., nursing assistant (NA)-D entered R5's room with EZ stand. NA-D placed harness, safety belt and loops appropriately. NA-D asked R5 if she was awake and proceeded to raise the arms. R5 stood at approximately 135 degrees, never coming to a full stand. NA-D grabbed the back of R5's pants during transfer to toilet. R5 was allowed some privacy, but remaining by door of bathroom. Staff re-entered bathroom to assist resident with cares. Safety belts were placed, R5 was raised using the lift, however, never came to a full stand. Staff transferred R5 to bed. During observation on 7/8/26 at 10:47 a.m. NA-B and NA-C entered R5's room with the EZ stand, sanitized hands and donned gloves. Staff placed harness, safety straps and loops appropriately. Placed R5's hands appropriately to hang on. NA-C encouraged R5 to stand and to feel the pressure on [R5's] feet. R5 stood at approximately 135 degrees, never coming to a full stand. R5 was allowed privacy, but staff remained by the bathroom door. Staff re-entered, raised R5 and encouraged her to stand. However, R5 never came to a full stand, raising to approximately 135 degrees. R5 was placed in wheelchair. During interview on 7/8/26 at 10:59 a.m., NA-B stated the resident's Kardex hung in the closet for reference on how to care for each resident. NA-B stated R5 did not stand up straight. She felt it was a safe transfer because there were 2 staff assisting with the transfer. During interview on 7/8/26 at 11:05 a.m. RN Case Manager (RN)-A stated she expected a resident stood straight up when transferred with the EZ stand. The staff encouraged resident to stand-up. Staff were expected to sit residents back down and try again if they did not. Further, she expected staff to notify her when a resident was no longer doing so. RN-A was unaware of any concerns related to R5 transferring safely when using the EZ stand. Facility policy was requested but none provided.

Based on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives prior to use of bed rails for 2 of 6 residents (R55, R16 ) reviewed for bed rails. Findings include:R55's comprehensive minimum data set (MDS) dated [DATE] indicated R55 was cognitively intact and had the following diagnoses: atrial fibrillation, high blood pressure and arthritis. Section P of the MDS which covers restraints and alarms indicated R55 did not use bedrails. During observation and interview on 7/6/26 at 10:24 a.m., R55's bed was noted to have half-length bed rails attached to the top portion of the right and left side of the bed. R55 stated they had been there since her admission, and she did not routinely use them. R55's medical record was reviewed and lacked an assessment, or consent and education for the use of bedrails. R16's quarterly MDS assessment dated [DATE] indicated R16 was cognitively intact and had the following diagnoses: coronary artery disease, heart failure, and high blood pressure. Section P of the MDS which covers restraints and alarms indicated R16 did not use bedrails. During observation and interview on 7/6/26 at 2:13 p.m., R16's bed was noted to have quarter bed rails attached to the top portion of the right and left side of the bed. R15 stated he did not use them and could not recall how long they had been on his bed.R16's medical record was reviewed and lacked an assessment, consent and education for the use of bedrails.During interview on 07/09/2026 at 4:51 p.m., Director of Nursing (DON) stated a resident who used bedrails required an assessment for appropriateness, a physician's order, consent and education provided to the resident or their representative. Further, bedrails needed to be compatible with the bed and installed by maintenance staff. DON confirmed R55 and R16 had not had a bedrail assessment prior to the installation of bedrails. DON stated she expected nursing staff to complete a bedrail assessment prior to initiating bedrails. It was important to ensure the bedrails did not restrain the residents in any way, and to ensure residents safety.A policy titled Side-Rail Use with a last review date of 2/2026 indicated the purpose of bedrails was to promote resident independence at the highest possible level for turning, repositioning and mobility in bed while ensuring resident safety and compliance with regulatory standards. The policy stated bedrails were only used when clinically indicated to support resident mobility, positioning and comfort and never as a restraint, and are based on individual assessments.

Based on observation, record review, and interviews, the facility failed to transcribe orders according to standards of practice for medication management for 1 of 5 (R150) residents reviewed for unnecessary medications.Findings include:R150's undated faceheet indicated they were admitted on [DATE], and had the following diagnoses: restlessness and agitation, pain, palliative care, and a frontotemporal neurocognitive disorder. R150's clinical physician orders dated 7-9-26, indicated the following order: Ativan 0.5mg solutabs- Give 0.25mg by mouth every 4 hrs as needed for restlessnessR150's corresponding narcotic book page associated with the Ativan order, showed the following: Ativan 5mg three times a day (TID) q4hr PRNR150's bubble pack card for Ativan listed the following: Lorazepam (Ativan) 0.25mg solutab-dissolve 1 tablet (0.25mg) by mouth three times a day AND dissolve 1 tablet by mouth every 4 hours as needed. The pharmacy card did not include a sticker or any other connotation which would have indicated the different tablet strength which was listed in the EMAR and not on the card.The undated index page for the above listed narcotic book listed the following: R150-Lorazepam 0.25mg- entered on 7-1-26.On 7/9/26 at 1:40p.m. during an observation of medication storage in a medication cart, the narcotic drawer contained a card for R150's Ativan 0.25milligrams (MG) by mouth (PO). Page 111 of the corresponding narcotic book listed Ativan 5mg every (q) 4 hours (HR) as needed (PRN). The electronic medication administration record (EMAR) listed 0.5MG solutabs-give 0.25mg PO q4hr PRN. The licensed practical nurse (LPN)-B confirmed all the transcribed locations for the same order did not match and should have. On 7/9/26 at 1:50p.m., LPN-B stated the facility process for receiving and transcribing new narcotics was for the nurse or trained medical aide (TMA) to receive them and verify they have the correct medication, enter it in the narcotic book and verify with two nurses. Furthermore, when they completed a narcotic count, one staff would have the narcotic book, and one staff would have the medication cards. LPN-B stated they go by the index, the staff with the book would refer to the page listed on the medication card, and the person with the medication card would count the number of tablets and ensure they matched.On 7/9/26 at 2:50 p.m., the pharmacist (PHARM) confirmed all three areas regarding the above listed order, narcotic book, and the card should all match, and if there was a change in dose or tablet strength, the card should have had a sticker or another connotation to denote the change, however, it did not. The PHARM stated their expectation was for staff to be comparing the name/strength/dose of the medication during narcotic counts and during medication administration, and the importance of completing those checks to reduce the likelihood of medication errors.On 7/9/26 at 4:51p.m., the director of nursing (DON) stated their expectation was staff entered orders received from the pharmacy, two nurses counted the medications and ensured they were correct and matched. Then write the correct directions for use in the narcotic book and were to be given a number from the index. Additionally, the DON stated they expect the staff members compared all areas listed above during narcotic count and medication administration, to ensure the resident received the correct medication, therapeutic dose, and to prevent diversion of medications.A policy for medication transcription was requested, however none was provided.

Based on observation and interview, the facility failed to ensure medications were labeled with an opened-on date as well as an expiration date for 1 of 4 medication carts (500 wing cart) reviewed for medication storage and labeling.Findings include:On [DATE] at 1:50 p.m., during review of the 500 wing medication cart with licensed practical nurse (LPN-A) the following was observed: 1 Lantus insulin pen with no expiration date noted.A box containing 2 bottles of Systane eye drops: bottle 1 indicated an open date of [DATE], but lacked an expiration date. Bottle 2 lacked both an opened on and expiration date. LPN-A stated when new medications were delivered the nurse who received the medications was to place an opened-on/Expired sticker on the medication and when the medication was first used that date, as well as the expiration date was written on the sticker. LPN-A opened medication cart to demonstrate the process, however, could not find any of the stickers needed for proper labeling. LPN-A stated without the opened-on or expiration date staff wouldn't know how long a medication was opened and whether or not it was safe to use. Further, LPN-A stated eyedrops expired in 28 days after opening, and the eyedrops dated [DATE] were past expiration. During interview on [DATE] at 4:51 p.m., Director of Nursing (DON) stated she expected when staff checked in medications from pharmacy, they should place an opened-on and expires-on sticker to medications such as eye drops, insulin, nasal sprays, and inhalers. DON stated it was important to have this information on the medications to make sure the medication was safe to use and given appropriately, and still within its therapeutic level to prevent infections and to prevent a resident from receiving a non-therapeutic dose. A policy related to medication labeling and storage was requested but not provided.

Based on observation, interview and record review the facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 2 of 2 residents (R2, R69) reviewed for medication administration.Findings include:R69's comprehensive MDS assessment dated [DATE] indicated R69 was cognitively intact and had the following diagnoses: atrial fibrillation, high blood pressure and renal insufficiency.R69's self-administration of medication inquiry form signed by R69 on 4/15/26 indicated R69 did not want to self-administer medications either independently or after set-up by facility staff.During observation and interview on 7/6/26 at 11:04 a.m., a bottle of Nystatin powder with a pharmacy label containing R69's name was observed on the dresser.R69's orders reviewed on 7/8/26 lacked an order for self-administration of medication.R2's quarterly minimum data set (MDS) assessment dated [DATE], indicated R2 was cognitively intact and had the following diagnoses: heart failure, high blood pressure, end stage renal disease (ESRD) and diabetes.R2's self-administration of medication inquiry form signed by R2 on 8/28/25 indicated R2 did not want to self-administer medications either independently or after set-up by facility staff.During observation and interview on 7/6/26 at 3:32 p.m., a bottle of antifungal powder with a pharmacy label containing R2's name was observed on the bedside table in R2's room.R2's orders reviewed 7/8/26 lacked an order for self-administration of medication.During interview on 07/09/2026 at 7:28 a.m., licensed practical nurse (LPN-A) stated medications could be left at the bedside only if they have the doctors order to leave them and they have been assessed as safe to self-administer.During interview on 7/9/26 at 4:51 p.m., Director of Nursing (DON) confirmed R69 and R2 did not have a SAM assessment and stated her expectation for SAM was residents were assessed and had a physician's order before a SAM was put in place or medications be left at bedside. DON went on to state it was important for residents to be assessed to ensure the 5 rights of medication administration were being followed, important for staff to know what medications the resident is taking and to prevent another resident gaining access to medications.A policy for self-administration of medications was requested but not provided.

Based on record review and interviews, the facility failed to ensure all required data were included on the nurse staffing information posted daily. This had the potential to affect all 114 residents residing in the facility and their visitors who may wish to view the information. Findings include: On 4/14/25 at 1:21 p.m., the posted nurse staffing information dated 4/14/25, was observed in a clear, plastic cover on the visitor sign-in table. However, the nurse staffing information lacked the total number and the actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Additionally, the nurse staffing information lacked the resident census. On 4/15/25 at 2:12 p.m., the posted nurse staffing information dated 4/15/25, lacked the total number, and the actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Additionally, the posting lacked resident census. On 4/16/25 at 7:18 a.m., the posted nurse staffing information dated 4/16/25, lacked the total number and the actual hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Additionally, the posting lacked resident census. On 4/17/25 at 7:58 a.m., the posted nurse staffing information lacked the total number, and the actual hours worked, by categories of licensed and unlicensed nursing staff directly responsible for resident care per shift, and resident census. Additionally, the posted nurse staffing information was dated 4/16/25. On 4/17/25 at 10:10 a.m., the director of nursing (DON) stated she was unaware the information on the nurse staffing information postings lacked required information. The DON stated the nurse staffing post was expected to be updated and posted with correct information and was important so that residents and visitors knew who was in the facility providing care. On 4/16/25 at 8:56 a.m., DON verified the facility did not have a nurse staffing information policy.

Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding drug storage. This had the potential to affect all 114 residents residing in the facility. Findings include: Review of the facility CASPER Report dated 3/17/25, indicated the facility was cited F761 for drug storage on the survey exited 5/2/24. See F761: Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 7 medication carts. The facility's QAPI meeting minutes dated 3/13/25, lacked ongoing data related to the above repeat citation. On 4/17/25 at 10:45 a.m., the quality assurance registered nurse (RN)-B acknowledged the importance of continued monitoring of prior Performance Improvement Projects (PIPS). RN-B stated formal auditing and then more periodic auditing, chart review, and observational audits, were completed to ensure improvements were sustained. The facility's Quality Assurance and Performance Improvement Program policy, revised 4/15/24, indicated the facility monitors the effectiveness of its performance improvement activities to ensure improvements are sustained.

Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. In addition, the facility failed to maintain the ice machines in a sanitary manner to prevent potential food-borne illness. This deficient practice had the potential to affect all 116 residents who received food, beverages, and ice from the refrigerators, kitchen and ice machine. Findings include: On 4/14/25 at 10:44 a.m., during the kitchen tour with the dietary supervisor (DS), the following concerns were identified: Produce cooler: -1/4 container of yogurt without notation of an open date. -3/4 container tartar sauce without notation of an open date. -1/4 container mayonnaise without notation of an open date or an expiration date, and a foul odor when container was opened. Stand up freezer: -1/4 bag of sausage without notation of an open date or expiration date. -3/4 bag of pepperoni without notation of an open date or expiration date. -1/2 container of pork Salisbury steak without notation of an open date or expiration date. Stand up cooler: -1/4 container of yogurt without notation of an open date. -two bowls of yogurt without notation of an open date. -1/4 whip topping no open date or expiration date -1/4 container yogurt -2 bowls of yogurt without notation of an open date. Resident fridge on Ace unit: -bowl of chicken noodle soup without notation of a date. Resident fridge on Sunny Lake unit: -one bowl of potato soup without notation of a date. -two blueberry muffins dated 3/31/25. - one bowl of chicken rice soup dated 4/3/25. Resident fridge on Milacs Lake unit: -One piece of fish in a Styrofoam container without notation of a date. Ice Machines: During an observation on 4/14/25 at 11:00 a.m., the ice machine located outside of the kitchen had a large white flaky substance approximately one half to one inch thick on the ice machine cover and the drip tray. In addition, the drip tray had a large orange buildup around the edge of the tray. During an observation on 4/14/25 at 11:15 a.m., the ice machine located on the Ace unit had a large white flaky substance approximately one half to one inch thick on the ice machine cover. During an interview on 4/14/25 at 11:30 a.m., (DS) verified the above findings during the kitchen tour. DS stated his expectation was that all food should have been dated when opened and placed in fridge or freezer and thrown away after seven days of being opened or prior to the expiration date. During an interview on 4/14//25 at 6:39 p.m., dietary manager (DM) stated her expectation was that all food items would have been dated once opened and thrown away after the shelf life or the expiration date to prevent a food borne illness. DM stated maintenance cleans the ice machine quarterly and her expectation was that there was no build up on the ice machines. During an interview on 4/15/25 at 1:45 p.m. maintenance director (MD) verified the buildup on the ice machines. MD stated his expectation was that the ice machines would not have any build up on them Review of a facility policy titled maintenance: Scale Removal dated 12/2014, identified scale removal was performed on all ice machines at least twice yearly, every three months or as necessary to maintain a sanitary unit. Review of a facility policy titled Food Handling Standards and Procedures dated 2024, identified all food needs to be dated once opened and discarded within seven days or prior to the expiration dates.

Based on observation, interview and document review, the facility failed to ensure proper personal protective equipment (PPE) was used when providing cares for 1 of 1 residents (R80) reviewed for enhanced barrier precautions (EBP). Findings include: R80's admission Minimum Data Set, dated dated dated [DATE], included R80 had moderate cognitive impairment. R80 had diagnosis of COVID-19, depression, and metabolic encephalopathy (a condition causing altered metal status). R80's undated care plan, included R80 was on EBP due to a pressure ulcer on buttocks. Care plan included to wear a gown and gloves when providing high contact cares. On 4/15/25 at 9:21 a.m., licensed practical nurse (LPN)-B was observed in R80's room cutting her toenails. LPN-B was not wearing a gown and was leaning on foot of bed. During interview on 4/15/25 at 9:25 a.m., LPN-B confirmed R80 was on EBP for a pressure ulcer. LPN-B confirmed she had received education on EBP and should be wearing PPE whenever providing close contact cares. LPN-B confirmed she should have been wearing a gown. On 4/15/25 at 9:48 a.m., physical therapy assistant (PTA)-F was observed assisting R80 with walking in her room and transferring to her bed. PTA-F was observed assisting R80 adjust the covers on her bed to cover R80's lower body. During interview on 4/15/25 at 9:51 a.m., PTA-F stated she had received training on EBP and R80 was on EBP. PTA-F stated PPE should have been worn whenever assisting with personal cares, such as dressing or toileting. During interview on 4/16/25 at 8:22 a.m., clinical manager (CM)-A confirmed R80 was on EBP and staff should wear PPE whenever providing close contact cares, such as transferring, toileting and repositioning. CM-A confirmed staff should have been wearing a gown and gloves while clipping toenails, assisting with physical therapy, and adjusting covers on the bed. During interview on 4/16/25 at 12:59 p.m., infection control prevention nurse (IP)-G stated all staff are trained on EBP and the facility follows center for disease (CDC) guideline for precautions. IP-G confirmed gown and gloves should have been worn when clipping toenails and providing therapy assistance. IP-G confirmed all departments including therapy was trained on EBP. During interview on 4/16/25 at 1:16 p.m., director of nursing (DON) stated PPE should be worn any time a staff person is completing hands on care for a resident on EBP. The DON stated this was important to protect all residents and staff. Facility infection control and prevention manual dated October 2024, included EBP involved gown and glove use during high-contact resident care activities.

Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 4 residents (R12) with a current pressure ulcer and at risk for further development of pressure ulcers. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition and diagnosis which included arthritis, anxiety disorder and paraplegia (paralysis of the legs and lower body). Identified R12 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting R12's annual Care Area Assessment (CAA) dated 8/2/24, identified R12 was a at risk for skin breakdown and had a pressure ulcer to her left gluteal fold. Identified R12 required extensive assistance to reposition in bed and wheelchair. she required a regular turning schedule. R12's care plan revised 10/4/24, identified R12 had a chronic wound to her right gluteal fold. Care plan directed staff to reposition R12 every two hours when in bed. R12's weekly wound assessment dated [DATE], identified R13 had a chronic pressure ulcer to her right gluteal fold which measured 3 centimeters (CM) in length and 2.2 cm in width. Identified pressure ulcer was a stage 3 (a deep, open wound that penetrates through the dermis and into the subcutaneous tissue, exposing fat but not bone, muscle, or tendon) and required a foam dressing. R12's current physician orders dated 4/14/25, identified wound to right sacrum -cleanse wound with wound cleanser and pat dry. Apply skin prep around the wound and allow to dry then place Santyl to the wound base and cover with adhesive foam dressing daily and as needed. During an interview on 4/14/25 at 1:26 p.m., R 12 stated she had a sore on her bottom and required staff assistance to turn and reposition off of her bottom. During a continuous observation on 4/15/25 at 1:41 p.m., nursing assistant (NA)-A and NA-B exited R12's room with a hoyer lift. NA-A sanitized the hoyer lift and placed the lift at the end of the hallway. -1:42 p.m., R12 was lying in bed on her back. -2:00 p.m., R12 remained lying in bed on her back. -2:20 p.m., R12 remained lying in bed on her back. -2:48 p.m., R12 remained lying in bed on her back. -3:17 p.m., R12 remained lying in bed on her back. -3:47 p.m. R12 remained lying in bed on her back. -4:10 p.m., R12 remained lying in bed on her back. -4:35 p.m., R12 remained lying on her back and surveyor requested NA-C to reposition R12 after R12 remained lying in bed on her back and not repositioned for almost 3 hours. During an observation on 4/15/25 at 4:38 p.m., NA-C, NA-D, and registered nurse (RN)-A sanitized hands, put a gown and gloves on and entered R12's room, changed R12's incontinent product, wound bandage, and repositioned R12. During an interview on 4/15/25 at 4:48 p.m., NA-C stated R12 required staff assistance to reposition and was to be repositioned every two hours because she has a pressure ulcer. NA-C stated according to the day shift's documentation the the last time R12 had been repositioned was around 1:45 p.m. NA-C stated R12 should have been repositioned around 3:45 p.m. During an interview on 4/15/25 at 4:53 p.m., RN-A verified R12 had a pressure ulcer and required staff assistance to reposition. RN-A stated R12 was at continued risk of developing further skin breakdown and should have been repositioned every two hours while in bed. RNA stated her expectation was that R12's care plan would have been followed to help prevent any further skin breakdown. During an interview on 4/16//25 at 1:08 p.m., director of nursing (DON) verified R2 required staff assistance to reposition. DON stated R2 had a pressure ulcer on her right gluteal fold and was at risk for further skin breakdown. DON stated her expectation was that R12's care plan for repositioning would have been followed. A repositioning policy was requested and was not received. .

Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 3 resident s (R5) who were observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnosis which included arthritis, hypertension (elevated blood pressure ) and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). Further, R5 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. R5's care plan dated 3/4/24, identified R5 had an activity of daily living (ADL) self-care performance deficit related to activity intolerance. R5's care plan interventions included dependence on staff for bathing, dressing, and personal hygiene. Directed staff to administer medications as ordered. Review of R5's electronic health record (EHR) revealed a self-administration of medication (SAM) assessment dated [DATE], and identified R5 did not wish to self- administer medications. R5's Order Summary Report dated 2/18/25, directed staff to administer Albuterol Sulfate inhalation nebulizer 2.5 MG/3 ML via nebulizer twice daily for chronic cough. Further, it directed staff to administer Budesonide inhalation suspension 0/5 MG/2 ML via nebulizer twice daily for chronic cough. R5's Order Summary Report lacked an order to self administer medication. During a continuous observation on 4/15/25 at 9:33 a.m., R5 was seated in her wheelchair in her room and trained medication aide (TMA)-A entered R5's room with a vial containing albuterol nebulizer solution. (TMA)-A poured the solution into a nebulizer mask, placed the mask on R5's face, and told R5 she would return in 10 minutes to place the second nebulizer. TMA-tuned on the nebulizer machine, left R5's room, and returned to medication cart in the hallway which was not within visual sight of R5's room. At 9:43 a.m., TMA-A entered R5's room and the nebulizer mask was lying on R5's bedside table. TMA-A picked up the nebulizer mask and rinsed it out with water in R5's bathroom. TMA-A placed the budesonide nebulizer solution in the nebulizer mask. TMA-A placed the nebulizer mask on R5's face and told R5 she would return in 10 minutes to remove the nebulizer mask. TMA-returned to her medication cart in the hallway not within visual sight of R5's room. At 9:50 TMA-A entered R5's room and the nebulizer mask was lying on R5's bedside table with solution still coming from the mask. TMA-A picked up the nebulizer mask, turned the nebulizer machine off and placed the nebulizer mask on the nebulizer machine. During an interview on 4/15/25 at 10:05 a.m., TMA-A verified she had placed the nebulizer treatment on R5 and exited the room. TMA-A stated she was unsure if a SAM assessment had been completed for R5. TMA-A stated she was unsure what the process was for a resident that did not have an order to self-administer medications. During an interview on 4/15/25 at 10:10 a.m., registered nurse (RN)-A confirmed R5's SAM dated 3/4/24, identified R5 had not wished to self-administer medications. RN-A stated her expectation was nursing staff would have stayed in the room with R5 while she received the nebulizer treatments to ensure R5 received the nebulizer treatments appropriately. During an interview on 4/16/25 at 1:05 p.m., director of nursing (DON) verified R5 was not safe to self-administer medications. DON stated if a resident had not been assessed to safely self-administer medication or have a physician order to self administer medications staff were expected to remain with the resident the entire nebulizer treatment. Review of a facility policy titled Medication Administration revised 6/2024, identified medications ordered by the physician would be set up and administered within the established guidelines. Identified the resident must take the medications when the nurse/TMA is present unless the resident has completed Medication Self-Administration Assessment and noted to be safe.

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration of an inhalation medication for 1 of 3 residents (R5) observed for medication administration. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnosis which included arthritis, hypertension (elevated blood pressure ) and and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). Indicated R5 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. R5's care plan dated 3/4/24, identified R5 had an activity of daily living (ADL) self-care performance deficit related to activity intolerance. R5's care plan interventions included dependence on staff for bathing, dressing, and personal hygiene. Directed staff to administer medications as ordered. R5's Order Summary Report dated 2/18/25, directed staff to administer Budesonide inhalation suspension 0/5 MG/2 ML via nebulizer twice daily for chronic cough. Identified to rinse mouth with water and spit after use, if unable to rinse and spit mouth should be swabbed. During an observation on 4/15/25 at 9:43 a.m., trained medication aide (TMA)-A entered R5's room and the nebulizer mask was lying on R5's bedside table. TMA-A picked up the nebulizer mask and rinsed it out with water in R5's bathroom. TMA-A placed the budesonide nebulizer solution in the nebulizer mask. TMA-A placed the nebulizer mask on R5's face and told R5 she would return in 10 minutes to remove the nebulizer mask. TMA-returned to her medication cart in the hallway not within visual sight of R5's room. At 9:50 TMA-A entered R5's room and the nebulizer mask was lying on R5's bedside table. TMA-A picked up the nebulizer mask, turned the nebulizer machine off and placed the nebulizer mask on the nebulizer. R5 was not observed to rinse her mouth out and TMA-A had not instructed R5 to rinse mouth out as ordered after taking the Budenoside nebulizer. During an interview on 4/15/25 at 10:05 a.m., TMA-A confirmed she had not instructed R5 to rinse her mouth after receiving the Budesonide nebulizer. TMA-A stated she had not seen the order instructions to rinse mouth after use. TMA-A stated it was not her usual process to instruct R5 to rinse her mouth after the Budesonide nebulizer. During an interview on 4/15/25 at 10:10 a.m. registered nurse (RN)-A verified R5 had an order to rinse and spit after the Budesonide nebulizer. RN-A indicated it was important to rinse the mouth after a steroid nebulizer was received to prevent any infections. During an interview on 4/15/25 at 10:39 a.m., pharmacy consultant (PC)-A stated it was important to rinse the mouth after receiving Budesonide nebulizer because it was a steroid. PC-A indicated it could cause thrush, a fungal infection inside the mouth. PC-A stated it was her expectation nursing staff would instruct the resident to rinse their mouth after each use. During an interview on 4/16/25 at 1:05 p.m. director of nursing (DON( confirmed R5's Budesonide nebulizer physician orders included instructions to rinse mouth after use. DON stated it was important for residents to rinse their mouth after use to prevent infections in the mouth. DON stated her expectation was nursing staff to instruct R5 to rinse mouth after receiving the Budesonide nebulizer. R5's Budesonide nebulizer box instructions indicated Budesonide was indicated for chronic respiratory conditions. Indicated Patients should rinse the mouth after inhalation of budesonide inhalation suspension to prevent fungal infections. Review of a facility policy titled Medication Administration revised 6/2024, identified medications ordered by the physician will be set up and administered within the established guidelines and given according to physician orders.

Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 7 medication carts. Findings include: On 4/15/25 at 9:12 a.m., medication cart on locked memory care unit was observed to be unlocked. Medication cart was in a common area. Medication cart remained unlocked while staff walked past unlocked medication cart. On 4/15/25 at 2:44 p.m., medication cart on 100 wing of the facility was observed being unlocked. At 2:46 p.m., staff walked past medication cart to pass water. Cart remained unlocked. At 2:48 p.m., staff walked past cart with housekeeping cart. Cart remained unlocked. At 2:49 p.m., registered nurse (RN)-B was observed coming out of spa room and walking down hall away from medication cart. Medication cart remained unlocked. At 2:50 p.m., RN-B re-entered locked spa room. Cart remained unlocked. AT 2:53 p.m., RN-B walked from spa to nurse's office out of direct eyesite of medication cart. Cart remained unlocked. At 2:54 p.m., staff passed medication cart while pushing a resient in a wheelchair. Cart remained unlocked. At 2:55 p.m., licensed practical nurse (LPN)-A walked past medication cart. Cart remained unlocked. At 2:57 p.m., RN-B locked the cart. During interview on 4/15/25 at 2:57 p.m., RN-B confirmed the medication cart was unlocked for an unknown amount of time. RN-B confirmed she did not have the medication cart direct eyesight during that time. During interview on 4/16/25 at 2:39 p.m., director of nursing (DON) stated she expected medication carts to be locked any time the nurse is away and out of eye site of them for any amount of time. DON stated this was important to make sure no one had access to items in the cart they should not have access to. The DON confirmed this was especially important in on the dementia until where residents had memory impairments. The DON confirmed the do complete regular audits to ensure medication carts were locked. A policy was requested, but none provided.

Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 3 of 3 residents (R 5, R16, and R13) who resided on the North shore unit, reviewed for food. This deficient practice had the potential to affect all 21 residents residing on this unit. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], indicated R5 had intact cognition ad was able to feed herself after staff set up her tray. R16's significant change MDS dated [DATE], indicated R16 had intact cognition and could feed herself after staff set up her tray. R13's admission MDS dated [DATE], indicated R13 had intact cognition and could feed himself after staff set up his tray. During an interview on 4/14/25 at 2:00 p.m. R5 stated the food was not always hot by the time they were served on this unit. During an interview on 4/14/25 at 3:56 p.m., R16 stated the food was not always served very hot especially the meat and potatoes. During an interview on 4/14/25 at 4:09 p.m. R13 stated the food was usually only lukewarm. During an observation on 4/14/25 at 6:24 p.m., food was being dished up onto plates and placed on a plate warmer from the steam table in the main kitchen. The plates were placed on trays and put into a cart. As the last plate was being placed into the cart a test tray was requested and placed into the cart. The meal consisted of a hamburger patty, a chicken patty, baby potatoes, and cauliflower. -at 6:24 the cart was wheeled to the north shore unit. -at 6:36 p.m. as the last tray was being passed dietary aide (DA)-A tested the food temperatures and the temps were as follows: -Hamburger was 121 degrees Fahrenheit (F). -chicken was 118 degrees Fahrenheit (F). - baby potatoes were 131 degrees Fahrenheit (F). -cauliflower was 120 degrees Fahrenheit (F). Surveyor tasted the food from the tray: the hamburger and chicken were cold, the baby potatoes, and cauliflower were lukewarm. Dietary aide (DA-A) confirmed the hamburger and chicken were cold and the remaining items were barely warm. During an interview on 4/14/25 at 6:48 p.m. DA-A stated she was unsure of what the food temperatures should be but would find out. During an interview on 4/14/25 at 6:55 p.m., R13 stated his chicken was only lukewarm as always. During an interview on 4/14/25 at 7:00 p.m., R16 stated her chicken was cold tonight but she ate it because she was hungry. During an interview on 4/14/25 at 7:04 p.m., dietary manager stated her expectation was that food holding temps should be at least 140 degrees Fahrenheit (F). Review of a facility policy titled Food Service and Delivery undated, identified, hot food was to be held at 140 degrees Fahrenheit (F). or higher.

Based on interview and document review the facility failed to maintain records of a thorough investigation for 4 of 4 residents (R29, R318, R319, R50) related to facility reported events. Findings include: On 8/30/23 at 11:42 a.m., the facility submitted an incident report to Minnesota Department of Health (MDH) regarding possible allegations of financial exploitation for R29. R29 had reported her tablet had been missing, and after searching felt someone had taken it. Report indicated that Sauk Rapids police department (PD) had been notified, and no alleged perpetrator (AP) had been identified. On 9/6/23 at 4:32 a.m., the facility submitted a five day incident report to MDH with an overall summary of the event and their investigation summary. The investigation summary noted R29 history of losing tablet in the past, but not being able to find this time, resulting in a report filing. Tablet remains missing with no identified AP's at this time. Facility will continue to investigate. Report indicated R29 most recent BIMS of 15, interviewing of staff, and resident conducted. On 5/2/24 all documents were requested for R29 incident reported on 8/30/23. On section C of the provided documents titled, VA investigative format, labeled Interviews of staff on current shift, indicated see attached information. However, evidence of interviews conducted was not provided. On 5/9/23 at 10:03 p.m., the facility submitted an incident report to Minnesota Department of Health (MDH) regarding possible allegations of Neglect of R318. R318 had been found on the floor, call light had not been activated and skin tear noted. Immediate intervention of 15-minute checks, toileting, and anticipating of needs. X-Ray obtained following R318 increased right hip pain. On 5/15/23 at 5:04 p.m., the facility submitted a five day incident report to Minnesota Department of Health (MDH) regarding possible neglect of R318. R318 had fallen on 5/9/23 with skin tear noted and no other complaints of pain. MD ordered X-ray later revealed right hip fracture resulting in hospitalization , report to MDH and internal investigation conducted finding through interviews care plan had been followed and no evidence of neglect or abuse had been found. On 5/2/24 all documents were requested for R318's incidents reported on 5/22/23. On section C of the provided documents titled, VA investigative format, labeled Interviews of staff on current shift, indicated see attached information. However, evidence of interviews conducted was not provided. On 3/22/23 at 10:11 a.m., the facility submitted an incident report to the Minnesota Department of Health (MDH) regarding possible injury of unknown origin. R319 was found to have a dislocated right shoulder after reporting complaints of pain and having an x-ray on 3/21/23. On 3/28/23 at 4:21 p.m., the facility submitted a five-day incident report to MDH with an overall summary of the event and investigation summary. The investigation summary noted R319's had a fall documented on 3/18/23 with no injuries noted at the time. Resident was noted to have had a previous right shoulder dislocation on 2/23/23 and significant degeneration to the area. According to the report, R319 denied anyone harming her. The five-day incident report indicated 4 staff interviews had been conducted. On 4/30/24 the internal investigation regarding R319's incident was requested. Facility provided a VA Investigative Format Initial Determining Investigation packet dated 3/22/23. Which included a short summary of the event and a copy of the initial MDH report and the five-day report and a copy of the x-ray results. On section C of this document labeled Interviews of staff on current shift, indicated see attached information. However, evidence of the interviews conducted was not provided. On 5/22/23 at 11:19 a.m., the facility submitted an incident report to the Minnesota Department of Health (MDH) regarding possible allegations of neglect. R50 was found outside the facility, had fallen and obtained a head laceration (cut) and was sent to the emergency department (ED) for care. On 5/26/23 at 3:06 p.m., the facility submitted a five day incident report to MDH with an overall summary of the event and investigation summary. The investigation summary noted R50's mobility and cognition status and interventions in place prior the event on 5/22/23. At approximately 5 a.m. on 5/22/23, staff saw R50 through the window, R50 had fallen in the parking lot and was on the ground. Staff noted injuries to R50's knees, elbows, and a laceration over right eye. R50 was sent to the hospital. Upon return to the facility on [DATE], R50 was moved to the locked unit and had sustained additional injuries of a rib fracture, small subdural hematoma (bleeding in the brain), and wrist fracture. The five day incident report also discussed 10 staff interview had been conducted. On 4/30/24 internal investigation regarding R50's incident on 5/22/23 was requested. Facility provided a VA Investigative Format Initial Determining Investigation packet dated 5/22/23. Which included a short summary of the event, names of staff contacted with in the facility, and a copy of the initial MDH report and the five day report. On section C of this document labeled Interviews of staff on current shift, indicated see attached information. However, evidence of the interviews conducted was not provided. On 5/1/24 at 08:41 a.m., the assistant director of nursing (O)-D and the director of nursing (DON) stated they typically do not keep the information other than what was provided and will use the information gathered during their investigation to write up a summary which was then included in the 5 day report to MDH. On 5/2/24 at 11:52 a.m., the assistant director of nursing (O)-D and the DON stated after conducting an investigation they entered the information gathered into the vulnerable adult reporting website, then place the summarized information into their binder of investigations. However, it was not their practice to keep the evidence of the investigation and/or interviews conducted. The Good [NAME] Community's Abuse Prevention Plan last revised 7/22, indicated incidents are to be reported, documented and investigated internally using the Good [NAME] Incident reporting policy and procedure. 49035 49657

Based on observation, interview and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 2 of 2 residents (R48, R108) reviewed for dialysis. Findings include: During observation on 04/29/24 at 2:20 p.m., R48 was in bed with long sleeve sweater covering both arms. R48 was able to adjust sweater sleeve with assistance from family member to show clean, dry and intact dressing she received at dialysis center earlier that day. R48 stated the staff would remove the dressing but was unsure a what time they typically removed the dressing. R48's admission record dated 5/2/24, included diagnosis of end stage renal disease (ESDR), chronic kidney disease [NAME] 4 (severe), fluid overload, type 2 diabetes, and dependence on renal dialysis. R48's order summary report dated 5/2/24, included an order for a 1500 milliliter (mL) fluid restriction, dialyvite oral tablet one time a day for ESDR, and lidocaine-prilocaine external cream 2.5-2.5% to affected area topically one time a day every Monday, Wednesday and Friday before dialysis. R48's orders failed to include daily monitoring of dialysis graft, removal of dressing after dialysis appointments and post-dialysis assessment requirements. R48's undated care plan printed 4/30/24, included enhanced barrier precautions due to Hemodialysis catheter. R48's care plan included the need for dialysis related to renal failure. Approaches included to not take blood pressure or blood draws from the arm with graft (a type of access for dialysis). Care plan included to encourage R48 to go to scheduled dialysis appointments on Monday, Wednesday and Friday. Care plan included to monitor/document/report signs of infection at the access site PRN (as needed), signs and symptoms of renal insufficiency PRN, and to monitor for signs and symptoms of bleeding PRN. R48's care plan failed to include scheduled monitoring of the resident post dialysis, where R48 received dialysis, and which arm had the graft. R108's admission record dated 5/2/24, included diagnosis of ESRD, type 2 diabetes, and dependence on renal dialysis. R108's order summary report dated 5/2/24, included 1500 mL fluid restriction and full set of vitals every evening shift. Order summary report failed to include orders for monitoring pre or post dialysis. R108's undated care plan printed 4/20/24, included a problem of needing dialysis related to chronic kidney disease. Approaches included to not take blood pressure or draw labs on the arm with a graft. However, R108 did not have a graft for dialysis. Staff were to have encouraged resident to attend scheduled dialysis appointments. Staff were to monitor/document/report signs and symptoms of infection to the access site as needed and to monitor/document/report signs and symptoms of renal insufficiency as needed. The care plan failed to include scheduled monitoring post dialysis the dates, location and contact information of the dialysis center. During interview on 5/1/24 at 9:10 a.m., unlicensed staff (NA)-C stated she had not received any training specifically on how to care for a resident who received dialysis. During interview on 5/1/24 at 7:29 a.m., licensed practical nurse (LPN)-B stated she would look at a resident's orders to see if anything specific needed to be done, such as monitoring or assessments. LPN-B stated there was not anything specific she did for her dialysis residents when they returned. During interview on 5/1/24 at 8:45 a.m., registered nurse case manager (RN)-B stated the staff would have had to look at the calendar in the electronic charting system to see when residents had appointments, such as dialysis. RN-B stated she was unsure if unlicensed staff had access to the calendar. RN-B stated staff did not typically document on the dialysis graft or do an assessment when they returned from dialysis. RN-B stated there was no specific time frame or orders for monitoring the dressing on the dialysis access site or orders of when it could be removed. RN-B stated the staff should have used nursing judgement to determine when the dressing could have been removed. RN-B confirmed there was not a current orders for R48 for monitoring of her dialysis graft. During interview on 5/1/24 at 11:05 a.m., dialysis center RN stated there are not standard orders the dialysis center sends for monitoring of a resident who received dialysis for return to the facility. Dialysis center RN stated the bandage on the access site needed to remain in place for a minimum of 4 hours after dialysis. She stated it was best practice to monitor the dialysis graft site for a thrill (a specific feeling over the dialysis graft) and a bruit (a whooshing sound heard with a stethoscope over the dialysis graft site) daily. During interview on 5/1/24 at 10:27 a.m., director of nursing (DON) stated a resident's care plan should have indicated if they received dialysis. She stated the staff should look at the calendar for details on where and when dialysis appointments are scheduled. DON confirmed the location and contact information for dialysis would not included on the a resident's care plans. DON stated she would have expected staff to look it up if they needed the number for the dialysis center. DON stated there was not a specific length of time to keep a dialysis bandage on after the resident returned from dialysis. She stated the staff would monitor for bleeding and if there was no active bleeding, the dressing could have been removed. She stated if any monitoring had been done on a resident, she would have expected the medical record to reflect it in an assessment or progress note. The DON stated there was not any specific standard monitoring when a resident returned from dialysis unless ordered by the provider. DON stated if any specific training was needed, the facility would have provided it to staff. Undated facility policy titled Good [NAME] Lutheran Home Dialysis procedure, failed to include monitoring of residents, training to be provided to staff caring for residents receiving dialysis, or instructions on care plan requirements. Current facility contract with dialysis center requested and not provided.

Based on interview and document review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident (R1) who required such emergency care, in accordance with resident wishes and physician orders for full code status of CPR. This deficient practice resulted in an immediate jeopardy (IJ) situation when R1 was found not breathing and had no pulse. Timely CPR was not initiated, and R1 died . The immediate jeopardy began on [DATE], at 2:43 a.m. when R1 was noted to have no respirations or a pulse and CPR was not initiated to R1 for 25 minutes. However, once the facility identified the lack of providing immediate CPR, they implemented a corrective action to prevent recurrence by reviewing policies and procedures, re-educating the staff involved and other licensed staff to ensure they understood the proper procedure for identifying a resident's code status, where the emergency equipment was located and how to call a code blue (a procedure for notifying other staff a resident required CPR). On [DATE], at 1:23 p.m. the administrator, director of nursing (DON) and assistant director of nursing (ADON) were notified of the IJ situation. The facility implemented corrective action prior to the onsite investigation, therefore the IJ was removed on [DATE], when the majority of the staff had been re-educated. In addition, the facility completed audits of staff knowledge of the CPR status of residents. The deficiency is being issued at past noncompliance. Findings include: R1's admission record identified R1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. R1's care plan initiated on [DATE], indicated R1 required assistance of one to two with most activities of daily living (ADL's) which included bed mobility, transfers, toileting, bathing, grooming and dressing. The care plan lacked advance directives or R1's code status. Review of R1's Healthcare Directive Decision Form signed on [DATE], identified R1 was a full code in which CPR would be started and the ambulance would be called for transport to the hospital. Review of R1's standing physician orders undated, revealed R1 was a full code. Review of R1's progress notes dated [DATE], to [DATE], revealed the following: -[DATE], 3:05 a.m. staff walked by room at 2:40 a.m. and noticed R1 was not breathing. Nurse listened for a heartbeat, checked for pulse and did a sternal rub (applying a painful stimulus to the center of the chest with knuckles to someone who is not responding) and determined the time of death to be 2:43 a.m. The nurse made phone calls to three different family members, contacted the nurse practitioner (NP), the case manager (CM) and the ADON. The note indicated the nurse was waiting for one of the family to return the call. -[DATE], 3:49 a.m. the nurse went to get the chart after speaking with the ADON and noticed R1 was a full code on her healthcare directive form, ran to R1's room, began CPR on R1 and directed nursing assistant (NA) to call 911. The note identified CPR was administered by the nurse until police and paramedics arrived on the scene and took over administering CPR. - [DATE], 4:15 a.m. paramedics were unable to revive R1. On [DATE], at 2:52 p.m. during a telephone interview police officer (PO) who responded to the scene on [DATE], stated the facility waited almost 30 minutes to call 911 for assistance after R1 had no pulse or respirations. PO indicated he had a concern with the timely notification to EMS for proper administration of CPR. PO stated he had informed the facility administration of his concerns and had filed a report. During interview on [DATE], at 2:07 p.m. licensed practical nurse (LPN)-A stated she was working on [DATE], day shift from 6:00 a.m. to 2:30 p.m. and indicated LPN-B was working the night shift on [DATE]. LPN-A stated LPN-B informed her R1 had been found unresponsive at quarter to three in the morning on [DATE], and stated she did not know R1 was a full code. LPN-B informed LPN-A she had thought R1 was a do not resuscitate (DNR) status due to R1's age and did not realize until she looked in R1's medical record (MR) that she was a full code. LPN-A stated the code status of all residents was located in the front of their MR and staff were expected to look there if a resident had been found unresponsive to determine what their wishes were. LPN-A stated if a resident was a full code, staff were expected to administer CPR immediately, bring the equipment needed, call 911 and announce a code blue overhead so other nurses can respond and assist as needed. On [DATE], at 2:32 p.m. LPN-B stated she had been working the night shift on [DATE], from 10:00 p.m. to 6:30 a.m. LPN-B stated she had checked R1's blood pressure, pulse, respirations and oxygen levels at 12:30 a.m. and the results were within R1's normal limits. LPN-B stated sometime after that R1 called out for a bus a few times and then fell asleep. At around 2:43 a.m. NA-A called for LPN-B to assess R1 and R1 had no pulse or respirations and her skin was yellow and cold. LPN-B performed a sternal rub which elicited no response from R1 and determined R1 had expired. LPN-B confirmed CPR had not been initiated at that time. LPN-B stated she had experienced one other resident death in the facility who was a DNR and she began the death notification process based on that experience. LPN-B stated she had assumed R1 had been a DNR status due to her advanced age. LPN-B stated she had made telephone calls to the NP to release the body to the funeral home, family, case manager (CM) on call and the ADON to answer questions she had. LPN-B stated she had started to review R1's MR when she noted that R1's healthcare directive indicated R1 was a full code status. LPN-B stated she was not certain of the amount of time that had lapsed since R1 was noted to have expired, however, estimated around 17 minutes had elapsed from the time R1 had been found with no pulse and respirations and the discovery of her full code status. LPN-B stated she dropped R1's MR, ran to her room and began administering CPR. LPN-B stated she asked NA-A to call 911. LPN-B stated she thought seven minutes or so had gone by when PO arrived at the scene and took over administering CPR. LPN-B stated the EMS staff arrived a few minutes after the PO. LPN-B stated R1 was pronounced dead after PO and EMS staff administered CPR unsuccessfully. LPN-B stated she had not received training on the code blue status, where to find the healthcare directives of residents or where emergency equipment was located during her new employee orientation. LPN-B stated she could not remember the education identified on her orientation checklist that she had signed on [DATE], which indicated she had received training in the code blue process, where to find emergency equipment and where to find the code status. LPN-B stated she was aware CPR should begin immediately upon finding a resident who was a full code with no pulse and respirations and confirmed CPR was not administered immediately for R1 after finding her unresponsive. LPN-B stated she had current certification in providing CPR. During interview on [DATE], at 2:59 p.m. registered nurse case manager (CM)-A stated she was responsible for providing education to new employees on her unit regarding the code blue process, the place to find the resident's healthcare directive and where to find the emergency equipment. CM-A stated all licensed staff received the education. CM-A stated she went over paperwork with all new residents admitted and went over the advance directives with each resident. CM-A stated the forms were then placed in the front of the MR for staff to refer to. CM-A stated R1's healthcare directive was completed and signed by R1 on [DATE], which indicated R1 was a full code and placed in the front of her MR . CM-A stated staff were expected to look in the front of the MR if a resident was found unresponsive to determine what their healthcare directive was. CM-A stated if the resident was a full code, staff were expected to administer CPR immediately, call 911, bring emergency equipment and announce a code blue overhead. CM-A stated licensed staff were certified in CPR and were expected to be the staff to perform CPR, however, could delegate other tasks to the NA such as calling 911 and retrieving the emergency equipment. CM-A stated she had been aware of the [DATE], death of R1 and lack of providing timely CPR. CM-A stated the documentation showed LPN-B contacted the coroner and ADON and later realized R1 was a full code and then started administering CPR. CM-A stated on [DATE], the facility began to audit staff knowledge of code blue status, healthcare directive location and where emergency equipment was located and provided education to staff as a result of the [DATE], incident. During interview on [DATE], at 3:21 p.m. NA-A stated she had worked the night shift on [DATE], from 10:00 p.m. to 6:15 a.m NA-A stated around 1:30 a.m. R1 had called out for the bus a couple of times and then appeared to fall asleep. NA-A stated around 2:30 a.m. or so she checked on R1 and noticed her chest was not rising. NA-A entered R1's room, turned the overhead light on, noted her skin was yellow and she was not breathing. NA-A notified LPN-B. LPN-B entered R1's room, performed a sternal rub three or four times, took R1's hand, checked for a pulse, opened R1's eyelids and informed NA-A R1 had expired. NA-A confirmed CPR had not been started on R1 at the time. NA-A stated LPN-B left R1's room and made several phone calls. NA-A stated LPN-B provided NA-A with the portable phone to answer in case R1's family called back as LPN-B expected to be tied up with other phone calls and returned to the nurses office. NA-A stated she was not aware how much time had elapsed from the time they found R1 unresponsive to the time LPN-B came running out of the nurses office and stated R1 was a full code. NA-A stated LPN-B ran to R1's room, began CPR and instructed NA-A to call 911. NA-A called 911 and returned to R1's room where LPN-B continued to administer CPR. PO arrived at the scene and took over administering CPR. NA-A stated it was two or three minutes later when EMS staff arrived and assisted with providing CPR. NA-A stated healthcare directives were located in the front of the MR and verified she did not know what R1's healthcare wishes were at the time. On [DATE], at 3:43 p.m. ADON stated she received a telephone call from LPN-B on [DATE], at 2:50 a.m. and notified her of a resident death. LPN-B stated the resident who had expired was in her 90's and did not inform ADON the name of the resident. ADON answered LPN-B's questions and the call ended. Around a half an hour later, ADON stated she received another telephone call from LPN-B who stated PO and EMS had arrived and were performing CPR on R1. LPN-B stated after she had called ADON she made other phone calls and noted in R1's MR she was a full code. LPN-B stated she dropped the MR, ran to R1's room, began CPR and asked NA-A to call 911. LPN-B stated it had been six to seven minutes before CPR was started on R1 after she had been found with no pulse and respirations and ADON confirmed it was closer to 25 minutes after reviewing the documentation and timing of the phone calls to herself and EMS. ADON confirmed CPR had not been administered timely to R1 and stated it was expected CPR be administered immediately when a resident who was a full code was found without a pulse or respirations. ADON stated the facility process was to keep all residents' healthcare directives in the front of their MR's and stated staff were expected to refer to the MR when a resident was found without a pulse or respirations to determine if a resident was a full code or not. ADON stated staff were trained in new employee orientation regarding CPR status, how to call a code blue and where emergency equipment was located by the CM's of each unit. ADON stated all licensed staff were certified in CPR. ADON stated the facility had initiated staff training on where to find the healthcare directives, where the emergency equipment was located and how to call a code blue beginning on [DATE] as a result of the [DATE], incident. On [DATE], at 4:08 p.m. DON stated she had received a telephone call from ADON on [DATE], in the early morning sometime. ADON informed DON she had received two telephone calls during the night from LPN-B and stated R1 had been found without a pulse or respirations by NA-A. LPN-B started CPR once she had determined R1 was a full code. ADON informed her at the time five minutes had lapsed between the time R1 had been found unresponsive and CPR had been administered. DON stated the PO contacted her on [DATE], to inform her CPR had not been administered for a longer period of time and EMS had not been called for close to 30 minutes. After that conversation, DON and ADON reviewed the timing of the phone calls, documentation and determined it had been closer to 25 minutes before CPR was initiated on R1 after being found without a pulse or respirations. DON confirmed CPR had not been initiated on R1 for 25 minutes after being found expired. DON stated it was expected staff begin CPR immediately after being found without a pulse or respirations and determining their code status. DON stated a report to the State Agency (SA) was completed on [DATE], and a full investigation into the incident began. The DON, ADON and CM's began educating staff regarding the location of residents' healthcare directives in the MR, the location of emergency equipment and the process for calling a code blue. DON stated they had not encountered a nurse who was not aware of the code blue process, where the healthcare directives were located and where the emergency equipment was located. On [DATE], at 8:05 a.m. medical doctor (MD) stated R1 had only been in the facility for a few days and he had not seen or examined R1 prior to her death on [DATE]. MD stated he would have expected facility staff would have administered CPR on R1 immediately after she had been found without a pulse or respirations. The American Heart Association current guidelines dated 2015, identified: The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period, the rescuer should start CPR beginning with chest compressions. Ideally, the healthcare provider performs a pulse check at the same time as the check for no breathing or only gasping to minimize delay in detection of [MEDICAL CONDITION] and initiation of CPR. Begin chest compression as quickly as possible after recognition of [MEDICAL CONDITION]. Review of the facility policy titled Code Blue- [MEDICAL CONDITION] undated identified if staff found a resident in [MEDICAL CONDITION], staff would find their code status in the front page of their MR. The policy identified if a resident with a full code status was found in [MEDICAL CONDITION], staff were to initiate CPR, call code blue over the phone system and call 911. The policy indicated Ambu bags (a device used for mouth to mouth ventilation) and cardiac boards ( used to lay residents on when performing CPR) were located at the nurses stations of each unit. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed [DATE], when the majority of the staff had been re-educated on CPR practices. In addition, the facility implemented a systemic plan which included the following actions: -the staff involved were placed on leave pending the investigation results. - re-educated licensed staff on where to find the resident's healthcare directives, the code blue process, and where emergency equipment used during CPR was stored. The education was provided during one to one sessions prior to the employee's next shift by the CM's, ADON and DON. -re-educated non-licensed staff on where to find the resident's healthcare directive and where the emergency equipment used during CPR was stored. The education was provided during one to one sessions prior to the employee's next shift by the CM's, ADON and DON. - completed audits of staff knowledge of where to find the residents' health care directive, the code blue process, and where emergency equipment used during CPR was stored.

Based on interview and document review the facilty failed to ensure they had a system to assess, monitor and identify urinary and bowel charestics and amounts for 1 of 1 resident (R2) who had bladder distension, serious urinary infection, and possible bowel obstruction that required hospitalization . The immediate jeopardy (IJ) began on [DATE], when R2's indwelling catheter was not monitored, with a distended abdomen, pain and was transferred to the hospital and diagnosed with [REDACTED]. R2 returned to the facility, continued to deteriorate and had no bowel movements for six days, developed a temperature, increased heart rate, low oxygen levels, became agitated and was yelling out. He was transferred to the hospital on [DATE] for a change in condition and died . The administrator and director of nursing were notified of the IJ on [DATE] at 11:17 a.m. The IJ was removed on [DATE], at 3:03 p.m. when the facility developed and implemented bowel and bladder management protocols, procedures and educated staff. Non-compliance remained at the lower scope and severity of G, isolated, actual harm that is not immediate jeopardy. Findings include: R2's [DATE], admission Minimum Data Set (MDS) identified R2 had severe cognitive impairment. R2 had verbal behaviors directed towards others that put R2 at risk for physical illness or injury, interfered with care, and interfered with participation in activities and social interactions. R2 required extensive assistance of all activities of daily living and had an indwelling catheter, and was occasionally incontinent of bowel. There was no constipation present. R2's active [DIAGNOSES REDACTED]. R2 received as needed, PRN, pain medication and had moderate pain. R2's hospital discharge note [DATE], included [DIAGNOSES REDACTED]. R2's discharge records did not include when R2's last had a bowel movement at the hosptial. R2's [DATE], admission nurse note stated R2 admitted to the facilty with arm fracture and pneumonia. R2's bowel sounds were active in all four quadrants. He was alert and oriented to himself and denied pain. R2 had an indwelling urinary catheter, was incontinent of bowel, and wore incontinent briefs. There was no mention of when R2 last had a BM (bowel movement). R2's [DATE], admission medication included [MED] and [MED] daily, both used for [MEDICAL CONDITION] and [MEDICATION NAME] 25 mg (narcotic opioid medication) every 6 hours for pain. R2's care plan, undated, identified R2 had self-care performance deficits and required assistance of 2 staff for activities of daily living, had an indwelling catheter for an enlarged prostate. Staff were to provide catheter cares every shift, monitor for signs of discomfort due to catheter, and symptoms of UTI. The care plan did not identify that R2 was at risk for constipation, even though R2 was on opioid medications ([MEDICATION NAME] and [MEDICATION NAME]) and [MED] that had side effects of constipation. R2's had physican standing orders for constipation and could use [MEDICATION NAME] or [MEDICATION NAME] (bulk-forming laxative for constipation). The facility bowel protocol medications included [MEDICATION NAME] 5 mg tablet orally every day as needed (PRN); [MEDICATION NAME] 10 milligram (mg) suppository daily PRN; [MEDICATION NAME] suppository every day PRN; tap water enema every day PRN (,[DATE] milliliters (ml)); and fleets enema daily PRN. Review of R2's bowel record identified on [DATE] to [DATE], no bowel movement (BM), on [DATE] R2 had a large formed BM, on [DATE], and on [DATE], no BMs. R2's December, 2019 medication administration records (MAR)s identified between [DATE], and [DATE], R2 received [MEDICATION NAME] 25 mg PRN (as needed) four times. No bowel protocols were initiated between [DATE], and [DATE] when R2 had no bowel movement from [DATE] to [DATE], and no BM on [DATE] to [DATE]. R2's [DATE], MAR indicated [REDACTED]. There was no indication the facility bowel program was followed. The MAR indicated [REDACTED]. R2 also received [MEDICATION NAME] 5 mg two times daily, from [DATE] to [DATE]. R2 [MEDICATION NAME] 5 mg was increased to three times daily and received it from [DATE] to [DATE]. In addition R2 used additional [MEDICATION NAME] 5 mg on [DATE], [DATE], [DATE], and [DATE]. Review of the facility notes identified the following: R2's [DATE], initial intake by nurse practitioner (NP)-A stated R2 was admitted to the facility following a left arm fracture. He had [MEDICAL CONDITION] at the hospital, and an indwelling urinary catheter was placed. He also had dementia and agitation with behaviors. The note did not address R2's medications or history of constipation. R2's nutritional assessment dated [DATE], identified R2 consumed a mechanical soft diet with sporadic intakes between ,[DATE]% of meals and received a nutritional supplement. The note identified R2 had no gastrointestinal complications, and had not required any bowel medications. A nursing note on [DATE], at 7:17 a.m. identified R2's catheter was intact, with darker straw colored cloudy urine. On [DATE], a fax was sent to R2's provider to address his agitation coming from pain. The fax requested to schedule R2's PRN [MEDICATION NAME]. Nurse practitioner (NP)-A responded to discontinue [MEDICATION NAME] and schedule [MEDICATION NAME] 5 mg twice daily and every four hours PRN. A nursing note on [DATE], at 3:46 a.m. identified R2's catheter was intact with dark, cloudy odorous urine with no signs of discomfort. A nursing note on [DATE], at 4:12 a.m., identified R2s urine was very dark yellow and cloudy and R2 was restless. Even though R2's urine was cloudy, dark, odorous, and R2 had discomfort and restlessness, identifying possible infection. The facility did not contact the physician regarding these urinary changes. Also, there was no additional documentation about R2's urinary characteristics. R2's urinary output was 1,150 ml. A provider visit note, [DATE], identified R2's was evaluated for follow-up of multiple medical problems. Medications were reviewed by physician (P)-A. P-A decreased R2's [MEDICATION NAME], and [MED] and increased [MEDICATION NAME] to 5 mg from two times daily to three times daily and 1 tab every 2 hours PRN for breakthrough pain. The provider note identified R2 had chronic constipation, but required no medication management. There was no mention of R2's urinary changes. The nursing notes identified on [DATE], R2 was calling out throughout the afternoon. Interventions were implemented, but noted unsuccessful. R2 held staff's hand and pulled her hand to his groin area. The writer pulled her hand away and reminded R2 this action was inappropriate. There was no documentation to support R2's physician had been notified. Review of R2's bladder record from [DATE] to [DATE], identified there was no bladder output documented from [DATE] to [DATE]. On [DATE], R2 had no urine output recorded. there was no documentation to show staff had alerted R2's physician. Nurse Practioner (NP)-A noted on [DATE], at 12:30 p.m. identified she was contacted about R2's bowel status. R2 had a distended abdomen but had bowel sounds present. Bowel obstruction was not present due to presence of bowel sounds, and R2 had no additional symptoms. NP-A ordered [MEDICATION NAME] 17 grams to be given daily. R2's family members were updated regarding R2's bowel status. RN-A identified R2 had increased behaviors, and noticed he had not had a bowel movement for seven days. R2 was given prune juice and MOM PRN on [DATE] during the evening shift per bowel protocol. If R2 had no BM results by 1:30 p.m., the floor nurse was directed to administer an enema, and if no BM occurred by 3:00 p.m., NP-A was to be notified. There was no documentation to support nurses had followed orders or contact the physician when interventions were not successful. R's hosptial note on [DATE], identified R2 was sent to the emergency department (ED) with altered level of consciousness. R2 was usually alert and feisty, but now was fatigued and less active. R2 had not had a bowel movement in eight days, and was given an enema and [MEDICATION NAME] without relief. R2 had a urinary catheter in place that was not draining. R2's temperature was 99.2, pulse 105, blood pressure (B/P) ,[DATE], respirations 27, and oxygen saturation (SPO2) 95 percent (%). R2's had a bedside ultrasound showing a distended bladder extending into his diaphragm. His abdomen was very tender. R2's bladder was emptied and three liters (3,000 milliliter) of urine was drained from his bladder, normal bladder volume before emptying, 400 ml or less. R2 received an intravenous (IV) dose of antibiotic and discharged with an order for [REDACTED]. The provider note on [DATE], identified they visited R2 following a phone review with an unidentified family's concerns about R2's health. R2 had issues with constipation on [DATE], and was started on [MEDICATION NAME]. R2 had a change in condition later in the day, and was sent to the hospital where he was found to have a UTI. R2's medications and recent medication changes were reviewed. [MEDICATION NAME] was ordered daily for constipation, and was not implemented because the facility had a bowel monitoring program. There was no mention of R2 having 3,000 ml of urine emptied from their bladder from a clogged catheter, but staff were directed to monitor urine output from the catheter two times daily. The nursing note on [DATE], at 6:05 p.m. R2 was given PRN MOM to promote a BM. At 7:46 p.m., R2 was very sleepy, and was given scheduled [MEDICATION NAME] for constipation. The results of R2's bowel movements were documented as unknown. There was no additional assessment or evaluation of R2's abdominal status to determine if R2 had signs of constipation, or if R2's had BM after administraiton of R2's bowel medication. Nursing note on [DATE], identified R2 had a change in condition his respiration rate was 30, normal ,[DATE], and his oxygen saturation was [AGE]% on room air, normal ,[DATE]%. R2's temperature was 100.5, and was sent to the ED and was admitted to the hospital. A nursing note on [DATE] identified the hospital contacted the facilty to notified them R2 had passed away [DATE], at 10:24 p.m. as a result of [MEDICAL CONDITION]. R2's, hosptial Discharge Summary dated, [DATE] identified [DIAGNOSES REDACTED]. Interview on [DATE] at 1:19 p.m., with family member (FM)-A identified R2 was admitted to the facility for rehabilitation. While in the hospital, R2 had an indwelling catheter placed and was discharged to the facility. On [DATE], RN-B reviewed R2's medical record, and advised FM-A staff noticed R2 had no bowel movements for about a week but R2 was given prune juice and medication to move his bowels and was told a bowel protocol was initiated. FM-A visited R2 on [DATE]. That same day, FM-A noticed R2 was lethargic and slumped over in his wheelchair. His was difficult to arouse and his abdomen was distended and hard. Staff gave R2 an enema because he had no had a BM and he had obvious discomfort. Family present heard him screaming outside the room when R2 was administered the enema. On [DATE], at 11:30 p.m., the facility called FM-A identifying R2 was [MEDICAL CONDITION] (high heart rate), temperature and increased respirations. The nurse expressed concerns [MEDICAL CONDITION] (infection in the blood), and wanted approval to transport R2 to the hospital. At the hospital, R2 had a clogged urinary catheter and had no previous urine output. The hospital drained three liters (L) of urine from his bladder. R2 was found to have a UTI (bladder infection) and was given antibiotics and discharged back to the nursing home. FM-A talked with the facility about their concerns about not checking on R2 and were not meeting the family's care expectations. R2 was only back in the nursing home for a few days, when his condition declined. R2 had problems breathing on [DATE], and was found to have a temperature and transported back to the hospital. While en route, the paramedics provided respiratory assistance. While in the hospital, R2 was unable to breath on his own and required a respirator. Family elected to discontinue breathing assistance and R2 died at the hospital later that day. FM-A stated the facility should have monitored R2 bowel status prior to his his transport to the hospital on [DATE]. The lack of inadequate monitoring of R2's bowel movement and urination made R2's last week of life unpleasant. The facility told her they would look into the issue. An interview on [DATE], at 3:43 p.m. with the nurse manager (RN)-B identified she expected staff to document BMs and urine output in the the electronic medical record when residents had a BM, and amount of urine drained from catheters. RN-B expected to appropriatetly monitor and document changes in bowel and bladder. Charge nurses are to ask hospitals when residents return from the facility about their bowel movements. RN-B was not sure if R2's bowel regime was reviewed by staff or if the physician was aware R2 had not had consistent BMs prior to prescribing narcotic pain medication when the physician rounded on [DATE]. RN-B confirmed on [DATE], R2 had no urine output, and no documentation regarding R2s urine characteristics. RN-B spoke with FM-A and advised R2 had no BM since [DATE], and informed family staff would implement standing orders for bowel protocol. RN-B contacted the NP-A on the [DATE], regarding R2's lack of BMs. NP-A ordered [MED] (bm stimulant) in the morning. NP-A was notified of R2 having no results, and subsequently ordered a suppository. If there was no BM by 1:30 p.m. staff were to give an enema. If there were no results from the enema, staff were to notify NP-A at 3:00 p.m. The enema produced no BM. there was no documentation to identify staff had notified NP-A of the lack of BM. Continued interview with RN-B identified R2 had a distended abdomen, and had bowel sounds present on [DATE]. RN-B indicated nurses track bowl movements in the medical record to identify the resident had no BM. RN-B stated the MAR indicated [REDACTED]. RN-B confirmed R2 had no BM protocols initiated prior to [DATE]. The charge nurses were expected to run bowel and bladder reports every shift and implement bowel protocols when needed. RN-B verified there was no documentation for actions taken in R2's MAR indicated [REDACTED]. RN-B identified it was atypical for providers not to order bowel medications for residents taking opioids or medications with constipation as a side effect. RN-B was unsure whether staff had attempted to contact the providers to clarify if bowel medications were necessary or not. RN-B identified R2's family was upset he was not sent to the ED sooner, because R2's condition was not improving. An interview on [DATE] at 9:10 a.m. with the staff development nurse, RN-D stated she was responsible for staff training. The facility used the On Track program to train NAs. The facility completed skills fairs for nurses and NAs every 3 months. Recently training was completed about documentation for bowel monitoring in January, 2020. Not all nurses had received the training. Two of the nurses have continued to work, and had not yet completed training because they work nights, and just have not gotten the training done yet. RN-D had no plan to get all staff trained. An interview on [DATE], at 10:22 a.m. the director of nursing (DON), stated the facility followed guidelines for admission MDS and entry MDS and complete complete assessments accordingly. The MDS was used to create the care plan developed for the residents. Case managers were responsible to document resident care functions in the electronic medical records, and musing assistants (NA)'s view resident care plans from Kardex. The case managers were expected to process resident information watching 24 hours so the NAs know what to do. NA's view the care need from electronic documentation system and Kardex. Pool staff communicate to the facility staff and do chart in the electronic system to ensure information was documented. Case managers are responsible to make sure staff were doing what policies and procedures dictate. NAs were responsible to complete tasks and report concerns to the charge nurses. The charge nurse was to ensure NAs completed their tasks, and the case managers were responsible to oversee the entire process to ensure tasks were completed. There was no specific process in place to monitor the overall process of documentation. The DON expected nurses to monitor resident abnormalities for bowel and bladder and notify provider when if necessary and follow orders. Nurses were expected to document observations, effectiveness in interventions, and to report concerns needing follow-up to the oncoming shift. She expected documentation for follow-up from next shift until concerns were resolved. The facility's October, 2001, Bowel Management procedure indicated to assess bowel status in terms of medications, fluid intake, food intake, exercise and regularity of routine, and identify factors involved with present bowel status. The assessment was to be documented in the Bowel and Bladder assessment form. If staff determined a resident may have a problem with decreased bowel motility due to use of medications that decrease motility such as [MEDICATION NAME], [MEDICAL CONDITION], sedatives, hypnotics, and diuretics, and other medications. The bowel protocol for the facility is to (1) on the 2nd day of no bowel movement (BM), the morning shift was to offer prune juice; (2) if no results,, the evening shift was to offer milk of magnesia (MOM); (3) if no results, the night shift was to give a Bisocodyl suppository; (4) if no results from the suppository, follow-up with a Fleets enema on the next shift. The nurse managers were responsible to complete bowel and bladder assessments on admission, with significant changes annual reviews, and as appropriate. The purpose of a bowel management program was to ensure dignity through continence of bowel and bladder unless incontinence was unavoidable. Nursing assistants (NA)s were responsible to documented bowel habits on daily nursing care. The immediate jeopardy was removed on [DATE], at 3:03 p.m., when it could be verified staff had been re-educated on reporting of abnormal symptoms, the facility had updated policies and procedures, and implemented measures to alert staff for abnormalities. Staff were interviewed, observations of implementation of the new alerts were made and a verification of the policies and procedures was completed.

Based on interview and document review, the facility failed to ensure safe transfer techniques of securing a sling to a mechanical lift were implemented for 1 of 3 (R1) residents reviewed for falls. During the transfer, R1 fell and sustained a head laceration and a right intertrochanteric (hip) fracture.Findins include:R1's medical record was reviewed, and included a [DIAGNOSES REDACTED]. R1's care plan dated 2/28/2013, directed two staff to use a x-small divided leg sling with a full mechanical lift for all transfers. Staff used a mechanical lift for R1's transfers related to R1's anxiety when transferred with only staff assistance.An internal investigation report revealed that on 8/22/2013 at 4:00 p.m., nursing assistant (NA)-A and nursing assistant (NA)-B were transferring R1 using a mechanical lift, when one of the four sling loops became unhooked from the mechanical lift. R1 slipped out of the sling and fell to the floor.An incident report initiated on 8/22/2013 revealed that after the fall, registered nurse (RN)-C assessed R1 for injury. R1 had normal range of motion (ROM) to both arms and legs. R1 did not have pain when moving R1's arms and legs. R1 had a laceration on the back of R1's head. Licensed practical nurse (LPN)-D cleansed R1's head laceration, applied ice, and administered pain medication. The documentation lacked a description of the laceration. R1's progress notes between 8/22/2013 and 8/23/2013 were reviewed. On 8/23/2013 at 3:10 a.m. documentation revealed that R1 was "Crying, screaming and shaking with cares." LPN-K administered "oxy" (Oxycodone) for pain. At 5.23 a.m. documentation indicated that the Oxycodone was "somewhat effective," and that R1 continue to say "ow, ow" with cares. Documentation lacked the location of R1's pain. Certified Nurse Practitioner (CNP)-J was notified of R1's increased pain on 8/23/2013 at 12:39 p.m.. An x-ray of R1's right hip was completed on the evening of 8/23/2013 (exact time unknown.) A 9/11/2013 care conference summary indicated that R1 fell on [DATE] resulting in a right hip fracture. RN-C was interviewed on 9/18/2013 at 1:35 p.m.. RN-C stated that at the time of the fall, it was the facility's policy for two staff to perform all mechanical lifts. RN-C stated that once all four loop straps were connected to the lift, staff were expected to re-check that the loop straps were secure on the lift. RN-C stated it was common practice for one staff to attach two of the loop straps to the mechanical lift, while the other staff attached the remaining two loop straps. Once all four loop straps were attached to the lift, each staff was expected to re-check the loops that they personally attached to the lift, to ensure that the loop straps were securely attached to the lift prior to lifting a resident. RN-C stated that when she entered R1's room after the fall, three of the four loop straps were still connected to the mechanical lift and one of the shoulder straps was not connected. RN-C stated NA-A and NA-B believed that the sling loops were secure on the lift prior to lifting R1. RN-C was not aware if NA-A or NA-B re-checked that the slings loop straps were securely attached to the lift prior to lifting R1. RN-C confirmed that R1 suffered a 1 cm head laceration from the fall. RN-C stated after the fall R1's did not have hip pain with ROM. RN-C was informed of R1's complaints of right hip pain when she arrived to work at approximately 8:00 a.m. on 8/23/2013.NA-A was interviewed on 9/18/2013 at 3:46 p.m. NA-A stated NA-A and NA-B entered R1's room to transfer R1 from R1's bed to R1's wheelchair using the mechanical lift. NA-A stated that he secured the slings two leg loop straps to the mechanical lift, while NA-B attached the two shoulder loop straps. NA-A stated that NA-A re-checked the two loops straps that he attached to the lift. NA-A did not re-check the two loops that NA-B attached to the lift. NA-A stated that he lifted R1 up of the bed, and when NA-A began to move the lift away from the bed, R1 slid out of the sling head first, and fell to the floor. R1 hit her head on the mechanical lift during the fall and landed on her right side. NA-A stated R1 fell "very fast." NA-A stated one of R1's shoulder loops straps that NA-B was responsible to secure to the lift was not attached to the lift after the fall. NA-A provided cares for R1 the remainder of the evening. NA-A stated that R1 continued with her normal behavior of saying "help me, help me." NA-A stated that he believed that R1 was in pain, but could not describe the location of R1's pain. NA-B was interviewed on 10/4/2013 at 1:50 p.m. NA-B confirmed that she assisted NA-A transfer R1, and confirmed that NA-A attached the leg sling loops to the lift and that she attached the two shoulder loop straps to the lift. NA-B stated that NA-B believed that the loops were attached securely before NA-A began to lift R1 from the bed. NA-B stated that she did not re-check any of the four loop straps prior to NA-A lifting R1. NA-B was unable to say why she did not re-check the loop straps. LPN-D was interviewed on 10/3/2013 at 11:07 a.m. LPN-D stated R1 had head pain after the fall, and administered Oxycodone and Tylenol due to R1's pain. LPN-D stated that NA-A and NA-B did not report any changes in R1's condition, and the only pain that she recalls R1 having that evening was head pain. Licensed practical nurse (LPN)-K was interviewed on 10/3/2013 at 2:58 p.m. LPN- K confirmed that at 3:10 a.m. on 8/23/2013 R1 began crying, screaming, and shaking when LPN-K and nursing assistant (NA)-L turned R1 during cares. LPN-K stated that R1's hip was swollen, but could not recall whether it was the right or left hip. LPN-K stated that she administered Oxycodone to R1, due to R1's hip pain.The facility's policy titled "Mechanical Lift Transfer" updated 4/11 revealed under "Procedure: Follow manufacturer's instructions for the specific lift (attached)." Under Attachment the policy referred to "Skill 38 from Nursing Assistant Curriculum." The facility's procedure Titled "Skill: 38" Mechanical lift" directed under #7 to "Attach sling to lift according to manufacturer's directions." A second procedure titled "Lift Orientation on Hire"(undated) directs under #5 to "Recheck all 4 hoops a second time before lifting a resident."The lift manufacturer was contacted on 9/19/2013 and requested manufacturer instructions for the facility's mechanical lift used during R1's transfer. Additional information titled "MECHANICAL FULL BODY LIFTS GENERAL PROCEDURE GUIDE" was obtained from the manufacturer, which was not provided from the facility. Under step#13 the guide indicated to "Tell assistant to guide resident as you begin to lift them from the bed using "up" button on hand control or up button at handle grips. Once there is slight tension on the straps check to make sure all four loops are still on the hooks befor(sic) lifting."The facility's staff development coordinator, registered nurse (RN-E) was interviewed on 10/3/2013 at 10:04 a.m. RN-E stated that she educates all staff to recheck all four loop straps prior to lifting a resident with a mechanical lift. RN-E stated that she was unaware of the manufacturer's recommendations to re-check the loop straps after there is slight tension on the straps, and that staff are not trained on this.

Based on observation, interview, and record review the facility failed to provide appropriate care and services to prevent a decline in range of motion (ROM) for 1 of 1 residents (R57) with a decline in range of motion, resulting in actual harm and for 2 of 2 residents (R141, R52) who had a limitation in their range of motion. Findings include: Resident 57 (R57) had a decline in ROM to her left hand/ fingers and bilateral shoulders related to the facility's failure to assess, monitor, and implement a ROM program to prevent further decline. This resulted in contractures of her left hand and decreased in ROM to her bilateral shoulders caused a change in functional mobility (dressing and assistance with eating), which resulted in actual harm. R57 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as rarely/ never understood, severely impaired cognitive skills for daily decision making, short and long term memory problems, an extensive assist with all activities of daily living, and did not having any upper or lower extremity contractures. Resident R57 was observed on 8-15-11 at 2:00 p.m laying in bed with palm protectors on her bilateral hands. R57 fingers were curled around the palm protectors. R57's arms were up against her side and her hands were laying across her stomach. On 8-18-11 at 9:00 a.m. R57 was observed in the dining room sitting in her wheelchair with palm protectors on both hands receiving assistance with breakfast. Her arms were tight against the sides of her body with her hands laying on her lap. She did not attempt at any time to feed herself or move her arms or hands from 9:00- 9:15 a.m. during the observation time. R57's current care plan dated 7-11-11 identified the resident as having a right hand contracture and instructed the staff to remove splint twice daily and wash and dry hand and replace splint. The care plan did not identify a left hand contracture, and there were no limitations in ROM to her shoulders. The care plan also did not address a ROM program, or a left hand splint. The facilities "General Nurses Observation" identified R57 ROM on a quarterly basis to her bilateral upper and lower extremities. The following was noted: On 5-6-10 no contractures, no [MEDICAL CONDITION] (paralysis on one side of the body), and limitation in ROM in one of her hands but did not identify which hand. On 8-8-10 ROM limitation in the right upper hand, and no [MEDICAL CONDITION] On 11-1-10 right upper extremity contractures, ROM impairment on one side, and right sided [MEDICAL CONDITION]. On 1-25-11 right upper extremity contractures, ROM impairment on one side of the upper extremity, and had no [MEDICAL CONDITION]. On 4-15-11 right upper extremity contractures, no impairment of ROM in upper extremity with no [MEDICAL CONDITION]. On 7-11-11 right upper extremity contractures, no impairment of ROM in the upper extremity and no [MEDICAL CONDITION] Review of the OT notes for R57 on 3-11-09 indicated the resident was fitted for right hand splint...rehab nursing for bilateral upper extremity ROM. An OT "Plan of treatment" dated 6-5-09 indicated ROM "bilateral shoulder limitations; flex contracture right hand." The OT discharge date d 6-29-09 indicated "...fitted with a palm protector to right hand and nursing instructed...restorative nursing continue with ROM to bilateral upper extremities with gently stretch to digits." The notes from OT did not reflect any measurements of R57 shoulder limitations or hand contracture. Review of the OT notes indicated the last time R57 was seen by OT was on 6-29-09. Review of the facility progress notes on 11-1-10 indicated resident "has full ROM to all extremities except her right hand which she has a contracture. She has PROM performed to extremity and also wears a brace to prevent further contraction of the hand..." A Progress note dated 4-15-11 indicated resident "will bring cup up to mouth if put in hand." A 7-11-11 progress note indicated that resident had an extensive assist of 1 for eating but did not identify if R57 could hold onto a cup at this time. During interview on 8-18-11 at 7:55 a.m. Nursing assistant (NA) B stated R57 does not move her shoulders anymore when they get her dressed in the morning. It often takes two nursing assistants to dress her now because "we need to help her lift her arms." During interview on 8-18-11 at 9:15 a.m. with NA-C she stated she thinks R57 can move her arms but they have to lift them up for her when they put her shirt on in the morning. During interview on 8-18-11 at 9:20 a.m. with NA-D she stated R57's shoulders seem more "stuck" then they were before. She stated R57 will move her arms from the shoulders down but its seems like her elbows are always up against her side. NA-D was unsure when R57 got the splint on her left hand. She stated R57 no longer holds her cup and they "totally feed her (R57)." She stated it takes two of them to dress her now because she is so "stiff." During interview on 8-18-11 at 9:30 a.m. Rehab aide (RA) C stated they do not do any ROM with R57 and could not remember how long it had been but stated it's been "forever." During interview on 8-18-11 at 9:32 a.m. RA-D stated they stopped doing ROM on R57 "years ago" but could not remember why they stopped. During interview on 8-18-11 at 10:15 a.m. Registered Nurse (RN) A stated she was unsure why R57 had a left hand splint on and was unable to provide any documentation regarding when or why it was in place. She also indicated that she knows R57 had not received any ROM in the last year. RN-A stated, "There have been so many changes with the care managers in the last year unfortunately it is difficult to keep up." During interview on 8-18-11 at 1:05 p.m. with Occupational Therapist (OT)- B she stated normally they only do hand measurements of contractures if they are expecting an improvement in the contractures. She also stated OT would only be called back in to re-assess a resident if there was a "severe functional decline" because they can't just be called in to "see if someone has had a decline; there needs to be a reason." OT-B was unsure where or when the left hand splint came from for R57 but stated she would check her notes. OT-B stated she was unable to do an assessment on R57 to see if there was a decline because she did not have a physician order [REDACTED]. On 8-18-11 at 1:35 p.m. RN-A was observed doing a ROM assessment on R57. She stated she does quarterly ROM assessments on R57 and had not seen a decline. She took R57's splint off her left hand and asked the resident to straighten her hand. After RN-A did some gentle massage R57 moved her fingers slightly but her knuckles still remained bent and she was unable to straighten her hand completely. RN-A then assisted R57 in having her reach over with her left hand to touch her right shoulder; during this movement R57's elbow remained at her side not moving her shoulder. R57 was only able to move her arm from her elbow down and not her shoulder. RN-A indicated this is how she does her quarterly ROM assessment. She agreed R57's shoulders were not moving during this ROM exercise. RN-A stated R57's shoulder ROM may have gotten "minimally" worse but it is hard to tell because you have to "catch her (R57) on the right day" as she does have some stiffness. RN-A stated she thought R57 was wearing the left hand splint because the resident used to grab at things and clench her fist. OT-B entered R57's room on 8-18-11 at 1:37 p.m. while RN-A was doing the ROM assessment. She stated there was no way to tell from her 2009 documentation if R57's shoulders got worse because she did not measure or document if the ROM was active or passive and stated "should I be measuring?" OT-B stated there was no documentation of why R57 was wearing a left hand splint and could not provide any documentation that R57 had ever received any ROM program. OT-B stated all of the documentation from therapy in 2009 had been shredded. OT-B stated R57's looks like she currently had some flexion contraction of her left hand (by her knuckles). She also stated the splint on the left hand could be considered a restraint. It would be good for R57 to be grabbing and holding things with her left hand because it would provide some ROM for that hand when she did this behavior. OT-B stated there was a breakdown in communication between OT and nursing. Although R57 left hand and bilateral shoulders were becoming tighter, the facility did not assess, monitor or implement a ROM program to prevent further decline in ROM. The failure of these actions resulted in actual harm with a decline in ROM to her left hand and bilateral shoulders for R57. The decline in ROM, caused a change in functional mobility (dressing and assistance with eating) for R57, which resulted in actual harm. Resident 141 (R141) had a change in ROM to bilateral hands and fingers related to the facility's failure to assess, monitor, and implement a ROM program to prevent potential decline. R141 had [DIAGNOSES REDACTED].(shoulder, elbow, wrist, or hand). R141's prior Quarterly MDS, dated [DATE], identified no impairment in functional limitation in ROM of the upper extremities. On 8-16-11, R141 was observed at approximately 2:30 p.m. laying in bed wearing palm protectors on both hands. Her hands were laying on her chest curled up around the palm protectors. On 8-17-11, at approximately 12:15 p.m., R141 was observed being assisted with lunch. Both R141 hands were curled up and her left hand/ arm was supported by an arm board attached to the wheelchair arm rest. Her right hand was laying curled up on her lap. R141 did not attempt at any time to use her hands during the meal observation. Review of the "Care conference summary" dated 5-5-11 indicated: "Noting discomfort in right hands; ? (question) Occupation Therapy (OT) screening for right hand... gel topical to bilateral hands." This care conference was attended by the residents daughter, Registered Nurse (RN)- B, another nurse (unknown), and the rehab supervisor. There was no indication that R141 was referred to OT, no topical gel ([MEDICATION NAME] gel) was implemented or that R141 ROM exercise program was in place or was implemented. A "Care conference summary" dated 7-25-11 indicated: "Advance dementia and resident cannot communicate needs... Daughter concerned about tightening fingers. Will see about OT to evaluate..." This care conference was attended by a facility social worker, the residents daughter, and RN-B. An "OT evaluation for splints to hands" was ordered by a Nurse Practitioner on 7-27-11. A "Functional Maintenance Program" note which was signed on 7-29-11 by OT-B indicated: "Resident was fitted with palm protectors. Please have resident wear them whenever she is in bed during the day and at night. Can be off when up in wheelchair... Goal: Reduce risk of further contracture and skin breakdown." The OT discharge summary dated 8-3-11 indicated "Resident seen for 3 treatment visits including evaluation. Resident was fitted with palm protector splints and tolerated them well. Resident should continue with maintenance exercise program for ROM to bilateral upper extremities to help reduce risk for further contracture." The discharge summary did not address the frequency of the maintenance "ROM to bilateral upper extremities" program. The "Geriatric services of Minnesota Progress note" written by the nurse practitioner dated 8-2-11 indicated resident "was seen recently by OT for hand contractures...bilateral hand contractures, unable to straighten fingers..." R141's care plan updated 8-3-11 identified "I have a history of [MEDICAL CONDITION] residual [MEDICAL CONDITION] and am at risk for contractures. I will wear palm protectors when in bed during day and night." Although R141 was identified as developing contractures by the Nurse Practitioner on 8-2-11 and on 8-3-11 by the OT, this was not identified in the care plan nor was a ROM program implemented even though OT has identified "...ROM to bilateral upper extremities..." but did not identify a frequency of ROM. The most recent "General Nurses observation" dated 7-19-11 identified R141 was observed performing upper left and right ROM and no contractures were identified. During interview on 8-16-11 at 2:10 p.m. RN-B stated the facility calls a ROM program a resident exercise program. If a resident was participating in a resident exercise program it would be identified in their care plan. She stated the documentation of any resident exercise program was kept in the rehabilitation area by the rehab aides. During interview on 8-17-11 at 11:10 a.m. Rehab Aide (RA) C stated R141 used to do ROM but she kept refusing so "we just took her off any ROM program." She could not remember the exact time frame of when she did ROM on R141 but thought it was "along time ago, around a year?" During interview on 8-17-11 at 11:15 a.m. Occupational Therapist (OT)-B stated she evaluated R141 for hand contractures and fitted her with palm protectors at the end of July 2011. She stated R141 had always been on a ROM program and she was unable to do any ROM without staff assistance. She stated the rehab nurses do ROM on R141 when she is in bed and she did not make any changes to R141's current resident exercise program. OT-B was unsure what the current ROM program was but said the documentation was in the rehab aide book in the OT/PT department. The facility rehabilitation book was reviewed in rehab department on 8-17-11 at 11:20 a.m. with RA-D. RA-D stated she had "been here over [AGE] years and don't remember ever doing ROM" on R141. She was unable to find any documentation of the past or current ROM program for R141. During another interview on 8-17-11 at 11:25 p.m., OT-B stated she did not realize that R141 was not getting any ROM program and did not realize she had not been getting any ROM for over a year. She stated she did not evaluate the prior ROM program and "will make sure she gets on some kind of ROM program." OT-B stated R141 should be on a ROM program for comfort and to prevent further contractures. During interview on 8-17-11 at 12:10 p.m., Unit Manager RN-B stated she noticed the increase in R141 hand contractures when doing her assessment several month ago but did not refer this concern to OT. She stated there was no documentation of OT seeing R141 in May 2011 when the concern with R141 hands were identified. However, she stated sometimes OT will just "peek their head in the residents room" to see if they have anymore recommendations for nursing; OT does not always document if they see the resident. Unit Manager RN-B stated R141 had been getting ROM ongoing but was unsure exactly what kind of exercises they were providing. During interview on 8-17-11 at 1:40 p.m. R141's daughter stated she noticed her mothers fingers were more "curled up" several months ago. She had heard that can be painful "so I wanted to make sure they worked with her." She indicated that when she comes to visit her mother she will do some hand stretches with her and had noticed her hands getting gradually worse in the last several months. She stated she had never seen the facility perform ROM on R141 but "I assume they are doing some exercises with her hands." During interview on 8-18-11 at 3:00 p.m. the Assistant Director Of Nursing (ADON) stated she spoke with Unit Manager RN-B and there was a "breakdown in communication" between Unit Manger RN-B and OT regarding ROM with R141. The ADON verified R141 was not on a ROM program in the past or present to decrease R141 hand contractures. Neither Unit Manger RN-B nor OT-B were aware that R141 was not on a ROM exercise program and should have been. Although the facility identified bilateral hand contractures at the end of July 2011, the only intervention that was implemented were hand splint. A ROM program was not developed to improve ROM. Resident 52 (R52) had limitations in range of motion of their right upper/lower extremities which required a functional maintenance program. The program was not implemeted as directed by Occupational Therapy. R52 [DIAGNOSES REDACTED]. R52's annual Minimum Data Set ((MDS) dated [DATE] included she was oriented to year, month and day, did not reject cares, required extensive assistance with dressing/mobility and no functional limitations in range of motion. However, a Care Area Assessment for functional status/rehabilitation potential dated 8/12/11 identified R52 had contractures. R52 was seen by Physical Therapy (PT) in September of 2009; a communication memo from PT for the resident exercise program dated 9/17/09 included "Please provide res (resident) with right LE (lower extremity) AAROM (active assist range of motion) and right UE (upper extremity) PROM (passive range of motion) every day." R52 had a Occupational Therapy (OT) plan of treatment dated 5/20/10 that indicated "right hand/fingers flexion contractures" and OT would be working with her on a splint wearing program to increase range of motion and decrease pain to right hand. An "OT discharge letter" dated 6/18/10 included "caregivers instructed on splint program...set up on maintenance program for ROM." A communication memo from OT dated 6/9/10 indicated "resume PROM program for right UE (upper extremity)." Another communication memo dated 5/29/10 included "a right hand splint to wear at night and during naps during the day splint should be removed when up in w/c (wheel chair)." R52's care plan dated 3/16/09 included "I have had a stroke and am not able to move myself sufficiently to relieve pressure." An approach included "I wear a R (right) hand splint while I am sleeping." The care plan did not identify any contractures or an exercise maintenance program as directed by OT. R52's "Good Shepherd Lutheran Home Resident Exercise Program" monthly sheets from September 2010 through January 2011 identified R52 received only "ROM active UE/LE" The records failed to include any passive ROM for the right upper extremity as directed by OT on 6-9-10. Further, it indicated that R52 only received the AROM program 98 out of the 153 days the rest were zeros. The February 2011 "Good Shepherd Lutheran Home Resident Exercise Program" sheets for R52 included "Active Left U/E ROM" as well as "Passive Right lower extremity exercises." The Active exercises were performed 15 out of 28 days and the Passive exercises for lower extremities only once out of the 28 days the rest were zeros. The March 2011 "Good Shepherd Lutheran Home Resident Exercise Program" sheets for R52 included only Active ROM U/E L/E" and showed R52 performed the exercises 17 out of 31 days the rest were zeros. The April 2011 "Good Shepherd Lutheran Home Resident Exercise Program" sheets for R52 included only Active ROM U/E L/E" and showed R52 performed the exercises 15 out of 30 days the rest were zeros. The May 2011 "Good Shepherd Lutheran Home Resident Exercise Program" sheets for R52 included "Active U/E L/E ROM" as well as "Passive U/E L/E." The Active exercises were performed 29 out of 31 days and the Passive exercises were all marked with a zero. The June and July 2011 "Good Shepherd Lutheran Home Resident Exercise Program" sheets for R52 included only "Passive U/E L/E" and showed R52 only participated 34 out of 60 days the rest were zeros. The August 2011 to date (8-15-11) "Good Shepherd Lutheran Home Resident Exercise Program" sheets for R52 included only "Passive U/E L/E" and showed R52 participated 13 out of 15 days, the rest were zeros. On 8/17/11 at 7:20 a.m. Restorative Nurse Aide (NA)-D was interviewed and stated she performs range of motion on R52's shoulder and lower extremity; she only performs PROM, and no AAROM. On 8/18/11 at 9:28 a.m. Restorative Nurse Aide (NA)-C was interviewed and stated she only performs passive range of motion on R52's right upper extremity. R52 usually refuses the lower right active range of motion so she will perform passive ROM on her right leg. After reviewing the "Good Shepherd Lutheran Home Resident Exercise Program" monthly sheets with NA-C and the variable ROM program from active to passive each month. NA-C stated "looks like we messed up, it is always suppose to be documented under both the passive and active ROM, we must follow who ever starts the sheets in our documentation." She stated the zeros meant either R52 refused to participate or there was no rehab aide that day. On 8/16/11 the Unit Manager Registered Nurse (RN)-A was interviewed in the afternoon and stated R52 wears a hand splint at night and was not on any exercise program. On 8/18/11 at 9:38 a.m. NA-D was interviewed again and stated she performs PROM on both R52's upper right extremity and both legs. On 8/18/11 at 12:00 p.m. Certified Occupational Therapy Assistant (COTA)-F was interviewed and after reviewing the exercise programs documentation, she was unable to determine what exercises R52 had been performing. On 8/18/11 at 9:45 a.m. the facilities Assistant Director of Nursing (ADON) was interviewed and stated "there has been a break in the system when we switched to households." The Unit Manager's are now responsible for evaluating the resident exercise program. Previously this had been completed by one nurse overseeing the program, but they were no longer doing this. An evaluation of R52's exercise program was requested but the ADON was unable to find any evaluation of the program. The ADON further stated the facility did not have a policy/procedure for the exercise program. During observation on 8/18/11 at 1:10 p.m. RN-A performed a range of motion assessment on R52. RN-A performed Active ROM of left arm and fingers identifying ROM within normal limitations. RN-A then attempted to perform PROM to right arm and hand, R52 stated it hurt when RN-A tried to straighten R52's fingers. R52 took her left hand and straightened her right fingers but was unable to straighten them all the way out. RN-A then performed PROM to R52's right elbow. Right elbow was adducted (straight out) within normal limits, but the abduction (bending elbow with hand towards shoulder) was slightly limited. She was only able to lift R52 right arm up to shoulder level. R52 was able to wiggle her right ankle, but had no other active movement in her leg. Further range of motion of her lower extremities was not completed because R52 refused. RN-A and Occupation Therapist (OT)-B were interviewed together on 8/18/11 at 2:50 p.m. R52's range of motion was compared to a documented ROM assessment that had been completed by OT on 5/28/10. The assessment completed by RN-A on 8/18/11 showed no functional decline since the OT evaluation 5/28/10. Even though the facility had identified R52 had limitations of range of motion of right upper and lower extremities and required a functional maintenance program. The facility failed to perform the program as directed by OT since September of 2010. Further, the facility failed to evaluate any alternative measures to be implemented because of R52 refusals or why there "no rehab aid some days."