Every finding on record at Grand Village

Based on interview and document review the facility failed to ongoing assessment of respiratory status for 1 of 3 residents (R1) who experienced a change in respiratory status. In addition, facility staff administered medications to R1 while he displayed symptoms of respiratory distress resulting R1 requiring medications to be suctioned out of the back of his throat.Findings include: R1's face sheet printed 5/15/26, indicated he was admitted to the facility 11/12/25. Diagnoses included Traumatic subdural hemorrhage, hydrocephalus, and dysphagia. R1's 5-day Minimum Data Set (MDS) 12/22/25, identified severe cognitive impairment. MDS indicated R1 required substantial/maximal assistance to eat, displayed coughing/choking during meals and complaints of difficulty or pain when swallowing. R1's care plan dated 2/18/26, identified a self-care deficit and indicated he required assistance from staff to eat. The care plan identified altered communication and problem with nutrition related to neurological symptoms. Staff were directed to monitor/report as needed any symptoms of dysphagia (difficulty swallowing): pocketing, choking, drooling, holding food in mouth, several attempts at swallowing, refusal to eat or appearance of being concerned during meals. R1's Progress Notes indicated the following: 4/2/26, 10:09 p.m., R1 did not eat supper this shift. R1 wanted to go to bed. R1 seemed weaker and did not hold his head up in his wheelchair. Medications were crushed and given by syringe. R1 seemed to have a harder time swallowing. 4/4/26, 4:51 a.m., R1 had increased respirations of 22-24 breaths per minute (bpm). R1's oxygen saturation was at 90% on room air. R1 had a slight gurgle when breathing and was unable to cough to clear it. Head of bed elevated to help with respirations. Staff continue to monitor. 4/4/26, Writer was notified by cart nurse, R1 had respirations of 44 and oxygen saturation level of 73 percent. Oxygen was initiated. Pulse was 135. Blood pressure 120/83 and temperature was 97.2 degrees Fahrenheit. Instructed cart nurse to call the family to see if they would like him to be seen in the ED [emergency department] as R1 was unable to make his own decision at this time. R1 had clear lung sounds but audible gurgles upon inhalation and exhalation. R1 was not at baseline and was not responding to questions at this time. Family did call cart nurse back and wanted him sent in. 911 called at 8:35 a.m., and nurse to nurse given with hospital registered nurse (RN). 4/4/26, R1 was sent to the emergency department (ED) via North ambulance due to increased respiratory rate of 44 bpm, Oxygen saturation was 71% on room air. R1 was placed on oxygen, family member was updated and requested R1 be seen in ED, R1 was sternum breathing and gurgling with breathing. 4/4/26, 6:26 p.m., Received update from hospital RN. Per RN, R1 was admitted to hospice for aspiration pneumonia. R1's Vitals Report (date) indicated: Respirations 4/4/26- 44bpm Pulse 4/1/26- 71 4/4/26- 135 Oxygen saturation 4/1/26- 95% room air 4/4/26- 71% room air R1's April Medication Administration Record indicated R1 received oral medications on 4/4/26, despite audible gurgling. Medications were administered at 6:00 a.m., and during morning medication pass. Review of R1's April 2026, TAR lacked evidence of monitoring of R1's respiratory status. R1's record lacked evidence of ongoing respiratory assessment and/or vital signs between 4/2/26 and 4/4/26. R1's hospital ED provider Note dated 4/4/26, indicated R1 presented for concern related to shortness of breath. Oxygen saturation was in the 70's for emergency medical services. On quick exam there were pills stuck in the back of his throat. Suspected aspiration pneumonia which had been ongoing. Increased work of breathing and aspiration events in recent days. During interview on 5/12/26 at 1:21 p.m., family member (FM)-A said when R1 went to the emergency department, the doctor had reported to them R1 had aspirated. FM-A stated she was told by facility staff, R1 was having trouble breathing at approximately 2:00 a.m., and was not called until 8:30 a.m. FM-A was concerned R1 may have been struggling for many hours. During interview on 5/13/26 at 8:44 a.m., medical doctor (MD)-A stated while reviewing R1's chart it was noted he had pills stuck in the back of his throat when he first got to the emergency department. MD-A stated the risk associated with aspirating pills included pneumonia and could lead to respiratory arrest. During interview on 5/13/26 at 9:44 a.m., licensed practical nurse (LPN)-A said she remembered the note written on 4/2/26, and said if there had been a change of condition she would have notified the RN supervisor but did not remember who that would have been. During interview on 5/13/26 at 10:00 a.m., RN-B stated she had been working the overnight shift on 4/4/26, when R1 had increased respirations. RN-B remembered R1's head of bed was raised to help with breathing. RN-B stated the floor nurses were supposed to monitor R1 and let her know if any changes occurred. RN-B expected vital signs and oxygen saturation were checked, especially with concerns related to respirations. During interview on 5/13/26 at 1:11 p.m., NP-A stated she had not been notified of R1' s condition between 4/2/26 and 4/4/26. Staff could have notified someone sooner and medications could have been held. If concerns occurred over the weekend, an on-call provider would have sent R1 to the hospital. During interview on 5/13/26 at 1:25 p.m., RN-C stated before R1 was sent to the ED, his oxygen saturation declined and was being monitored. RN-C was told R1 was placed on monitoring that included temperature, lung sounds, oxygen saturation, and secretions. The monitoring documentation should have been in the treatment administration record (TAR). RN-C recalled, a couple hours later, R1 declined and was admitted to the hospital. RN-C stated if R1 was having difficulty she should have been notified so she could have updated the provider but said she had not been aware. During interview on 5/13/26 at 2:09 p.m., the director of nursing (DON) stated during the middle of the night on 4/4/26, R1's oxygen saturation levels dropped, and respirations increased. The nurses on duty questioned if R1 should be evaluated in the ED. DON stated within a few hours R1 declined further so the physician was updated and R1 was sent to the ED for eval. During interview on 5/14/26 at 8:35 a.m., RN-B acknowledged she had administered medication to R1 at 6:00 a.m. on 4/4/26. RN-B stated she would have given the medication crushed in applesauce or dissolved in water if R1 was having difficulty swallowing. RN-B stated she had not considered holding his medications due to R1's status because she had been told he did that sometimes, referring to the gurgling sound. During interview on 5/14/26 at 10:10 a.m., LPN-B acknowledged she had administered medication to R1 on 4/4/26 during morning medication pass. LPN-B stated when she received report from the previous shift, the nurse reported R1 had been breathing weird. LPN-B stated when staff got R1 up for breakfast he was breathing with his mouth open which was weird. LPN-B stated R1 was not at his baseline, but she administered his pills in pudding. LPN-B recalled, R1 held the medications in his mouth. LPN-B said had not noticed R1's breathing until after she gave the medications. During interview on 5/14/26 at 3:29 p.m., DON stated when R1 displayed a change of condition, a respiratory assessment should have been completed including respirations, lung sounds, and a full set of vital signs. DON stated staff should have let a manager know if R1 was having difficulty swallowing. A policy related to change of condition was requested but not received.

Based on observation, interview and document review, the facility failed ensure beard coverings were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect 68 out of 68 residents that received food out of the kitchen or kitchenette. Findings included: During initial kitchen tour on 5/19/25 at 11:19 a.m., cook-A was observed in the kitchen not wearing a beard covering. Cook-A stated he had just finished making lunch. On 5/20/25 at 8:27 a.m., cook-B was observed in a unit kitchenette serving food to residents without a beard net. Cook-B's facial hair went from below the ears to the top of the neck and under the chin, and was approximately 1.5 inches long and shaggy in areas. Cook-B stood over an open loaf of bread with one slice of bread on the countertop and putting a plate of food into the microwave. After several seconds cook-B removed the plate of food from the microwave, walked to the counter and handed the plate to another staff member who brought the plate to a resident. Cook-B stated his facial hair was long and needed to be trimmed. Cook-B stated beard coverings should be worn prior to the start of work although had not put on a beard covering because he was uncertain where to locate them. Cook-B stated the potential risks of not covering facial hair was that hair could fall into the food. On 5/20/25 09:02 a.m., dietary manager (DM) stated staff were instructed to always wear hair/beard coverings, including when prepping, cooking, serving foods, and anytime they are working with food. DM stated she was aware cook-B was not wearing a beard covering and stated she just hadn't had time to tell him to put one on. DM stated the potential risks of staff not wearing a hair/beard covering was hair could fall into the residents food and cause bacteria to grow. The Employee Sanitary Practices policy revised 7/19, identified staff were to wear hair restraints to prevent hair from contacting exposed food, including a beard net, when an employee had a beard. According to section 2-402.11 of the FDA Food code: A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. This is crucial to prevent cross-contamination. Staphylococcus aureus is an example of a common pathogen that is found on skin and hair. If enough of the bacteria is ingested, it could cause illness. Common symptoms of this illness include vomiting, nausea, and stomach cramps.

Based on interview and document review the facility failed to notify the physician when a weight gain of greater than 3 pounds (lbs) in 48 hours or a weight gain of greater than 5 lbs in a week was identified for 1 of 1 (R124) residents reviewed for edema. Findings include: R124's undated admission Record identified R124 was [AGE] years old and was admitted on [DATE]. R124 had diagnoses that included acute respiratory failure with hypoxia (low oxygen levels), hypertensive heart disease, and congestive heart failure (CHF). R124's care plan dated 5/15/25, identified R124 had an altered respiratory status and staff were directed to observe for signs of increased edema (swelling) /increased weight related to fluid retention. Document and report to medical provider as necessary R124's physician orders dated 5/15/25, directed staff to obtain daily weights: Update nurse practitioner (NP) for weight gain of 3 pounds (lbs) or greater in 48 hours or 5 lbs in a week. R124's Weights and Vitals Summary dated 5/21/25, identified the following: - On 5/17/25 at 7:51 a.m., R124 weighed 318.8 lbs. - On 5/18/25 at 11:01 a.m., R124 weighed 325.2 lbs. However, the summary failed to identify a weight increase of increase 6.7 lbs. - On 5/19/25 at 9:03 a.m., R124 weighed 326.0 lbs. However, the summary failed to identify a weight increase of 0.8 lbs in 24 hours or increase of 7.2 lbs in 48 hours. - On 5/20/25 at 3:40 p.m., R124 weighed 331.4 lbs. However, the summary failed to identify a weight increase of 5.4 lbs in 24 hours or but total increase 12.6 lbs in 72 hours. R124's nursing progress note dated 5/20/25 at 4:56 p.m., identified staff spoke with R124 regarding his pain. R124 had a hospital follow up in house with the nurse practitioner (NP) that morning. R124 had no pain then and did not need any pain medication so R124 did not ask for it from the NP when the NP was here. Now R124 was asking for morphine or codeine for leg pain from leg swelling from his water weight. R124 had 2+ edema (2+ edema is a moderate pitting edema. It is characterized by indentation that subsides rapidly. Edema is graded on a scale of 1 to 4, with 2+ being a moderate level of edema and is characterized by 3-4 millimeter (mm) of depression, rebounding in 15 seconds or less.) to his lower legs. R124 had his legs slightly elevated in bed and was refusing to move to have his legs elevated my more. R124 would not allow lower part the bed elevated either. No new orders have been received from the NP at this time from hospital follow up visit. Due to R124 having new onset of new pain, R124 would need to be evaluated in the emergency room (ER); however, R124 refused to go into the ER. R124's medical lacked evidence the provider was contacted prior to 5/20/25. During an observation on 5/20/25 at 8:29 a.m., R124 was up and dressed for the day. R124 sat in his wheelchair at the dining room table eating breakfast. R124 was wearing oxygen via a nasal cannula. R124's face, hands and legs were swollen. During an interview on 5/20/25 at 3:47 p.m., registered nurse (RN)-D reviewed R124's weights and stated R124 did have a significant weight gain because R124 had gained greater than 3 lbs in 48 hours. RN-D reviewed R124's medical record and stated she did not see where staff notified R124's NP of R124's weight gain. During an interview on 5/20/25 at 4:17 p.m., RN-B stated R124's NP had been notified of R124 earlier in the day, but RN-B hadn't had time to document it yet. However, staff should have notified the provider on 5/18/25 of R124's weight gain or the staff may have waited until 5/19/25 due to the weekend but RN-B wasn't notified until 5/20/25. During interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to follow the physician orders and should have notified R124's provider on 5/18/25 when R124's weight increase was identified. During an interview on 5/21/25 at 2:00 p.m., the administrator stated staff were expected to follow physician orders to ensure residents received the care they deserved. During a phone interview on 5/22/25 at 12:35 p.m., NP-A stated she evaluated R124 on 5/20/25 and was told R124 gained 5.2 lbs over the course of 5 days. NP-A contacted R124's cardiologist for guidance and R124 was evaluated by cardiology. NP-A was unaware of R124's physician order to contact the provider if a weight gain of 3 lbs in 48 hours and would have expected nursing to contact a provider on 5/18/25 to obtain care sooner. The facility policy Edema Scale and assessment dated 5/2013, identified It is the policy of this facility to provide standardized assessment of lower leg edema and associated issues. Document any untoward results and as necessary by degree of problem, notify the Health Care Provider. The facility policy Change of Condition/Notification revised 3/25, identified Attending physician/NP, or physician on-call, is to be immediately contacted (not by voicemail) of residents change in condition/health status based on a comprehensive assessment. I. Facility must immediately inform the resident, consult with the physician, and notify representative when there is: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention. B. A significant change in the resident's physical, mental, or psychosocial status. C. A need to alter treatment significantly - due to adverse consequences or new form of treatment. D. A decision to transfer or discharge the resident from the facility.

Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) or a clinical justification of a psychotropic medications was documented for 1 of 5 residents (R42) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified R42 had moderate cognitive impairment. R42 had verbal behaviors directed toward others and behaviors not direct toward others 1 to 3 days a week. R42's diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs to periods of deep lows) and anxiety. R42 received an antipsychotic medication and an antidepressant medication. The MDS identified the last gradual dose reduction (GDR) of medications was done 2/23/21, and a GDR was not documented as clinically contraindicated. R42's most recent Physician Order Report dated 5/21/25, identified haloperidol (typical antipsychotic medication) to be given twice a day related to bipolar disorder and was dated 11/22/23. R42 also received Zoloft (an antidepressant medication) given one time a day for depression related to bipolar disorder and was dated 11/29/22. R42's monthly pharmacy reviews were reviewed from 6/2024 to 5/2025, with no irregularities identified with antipsychotic medications or antidepressant medications. R42's medical record was reviewed and lacked evidence a GDR had been attempted or identified a medical justification for continued use and R42 was on the lowest effective dose, within the past calendar year for the haloperidol. During an interview on 5/21/25 at 1:13 p.m., registered nurse (RN)-H, nurse manager, stated the resident's medications were reviewed on a regular basis and discussed with nursing and pharmacy consultant (CP). RN-H stated they did not look for when a GDR was due but waited for the CP to make a recommendation for a GDR. During a telephone interview on 5/21/25 at 2:00 p.m., the CP stated GDRs on psychotropic medications were done twice a year for new medications and yearly for established medications. The CP identified the last GDR attempt was done 2/2024. During an interview on 5/21/25 at 2:37 p.m., the director of nursing (DON) stated it was the expectation nursing staff would work with pharmacy to ensure psychotropic medication GDRs were addressed for the health of the residents. The facility's Psychopharmacological Drug Use policy dated 5/2025, the resident drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in an excessive dose, for an excessive duration, or without adequate indications for use.

Based on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 1 of 3 residents (R24) reviewed for injectable diabetes medications. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diabetes (a disorder characterized high blood sugar levels due to either insufficient insulin production or the body's inability to effectively use insulin). The MDS identified R24 received an insulin injection and was receiving hypoglycemic medication (used to lower blood sugar levels). R24's Medication Administration Record (MAR) for the month of February 2025, identified R24 received Trulicity (a medication which increased insulin release, reduced glucagon secretion; however is not insulin) for diabetes. The February 2025, MAR did not identify R24 had received any insulin during the month. During an interview on 5/21/25 at 1:45 p.m., registered nurse (RN)-B stated the MDS was coded incorrectly and should not have identified R24 had received insulin. R24 had only received Trulicity during the assessment period and not insulin. During an interview on 5/21/25 at 2:47 p.m., the director of nursing (DON) would expect the MDS to be completed correctly and stated Trulicity was not insulin. The facility's Resident Assessment policy dated December 2013, identified staff needed to utilize information found in Point Click Care (an electronic health record) to complete sections required on the MDS.

Based on observation, interview and document review, the facility failed to implement interventions for edema for 1 of 1 resident (R124) reviewed for edema. Findings include: R124's undated admission Record identified R124 was [AGE] years old and was admitted on [DATE]. R124 had diagnoses that included acute respiratory failure with hypoxia (low oxygen levels), hypertensive heart disease, and congestive heart failure (CHF). R124's care plan dated 5/15/25, identified R124 had an altered respiratory status and staff were directed to observe for signs of increased edema (swelling) /increased weight related to fluid retention. Document and report to medical provider as necessary R124's physician orders dated 5/15/25, directed to obtain daily weights: Update nurse practitioner (NP) for weight gain of 3 pounds (lbs) or greater in 48 hours or 5 lbs in a week. R124's Weights and Vitals Summary dated 5/21/25, identified the following: - On 5/17/25 at 7:51 a.m., R124 weighed 318.8 lbs. - On 5/18/25 at 11:01 a.m., R124 weighed 325.2 lbs. However, the summary failed to identify a weight increase of increase 6.7 lbs. - On 5/19/25 at 9:03 a.m., R124 weighed 326.0 lbs. However, the summary failed to identify a weight increase of 0.8 lbs in 24 hours or increase of 7.2 lbs in 48 hours. - On 5/20/25 at 3:40 p.m., R124 weighed 331.4 lbs. However, the summary failed to identify a weight increase of 5.4 lbs in 24 hours or but total increase 12.6 lbs in 72 hours. R124's nursing progress note dated 5/20/25 at 4:56 p.m., identified staff spoke with resident regarding his pain. R124 had a hospital follow up in house with the nurse practitioner (NP) that morning. R124 had no pain then and did not need any pain medication so R124 did not ask for it from the NP when the NP was here. Now R124 was asking for morphine or codeine for leg pain from leg swelling from his water weight. R124 had 2+ edema (2+ edema is a moderate pitting edema. It is characterized by indentation that subsides rapidly. Edema is graded on a scale of 1 to 4, with 2+ being a moderate level of edema and is characterized by 3-4 millimeter (mm) of depression, rebounding in 15 seconds or less.) to his lower legs. R124 had his legs slightly elevated in bed and was refusing to move to have his legs elevated my more. R124 would not allow lower part the bed elevated either. No new orders have been received from the NP at this time from Hospital follow up visit. Due to R124 having new onset of new pain, R124 would need to be evaluated in the emergency room (ER). R124 refused to go into the ER. R124's medical lacked evidence if a nursing assessment was conducted and new interventions implemented. Further there was no evidence the provider was contacted prior to 5/20/25 During an observation on 5/20/25 at 8:29 a.m., R124 was up and dressed for the day. R124 sat in his wheelchair at the dining room table eating breakfast. R124 was wearing oxygen via a nasal cannula. R124's face, hands and legs were swollen. During an interview on 5/20/25 at 3:47 p.m., registered nurse (RN)-D reviewed R124's weights and stated R124 did have a significant weight gain because R124 had gained greater than 3 lbs in 48 hours. RN-D reviewed R124's medical record and stated she did not see where R124's weight gain or edema had been addressed. During an interview on 5/20/25 at 4:17 p.m., RN-B stated R124's NP had been notified of R124 earlier in the day but RN-B hadn't had time to document it yet. However, RN-B was not notified of R124's weight gain until 5/20/25. During interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to monitor daily weights and ensure the appropriate actions were taken when a significant weight increase was identified. During an interview on 5/21/25 at 2:00 p.m., the administrator stated staff were expected to monitor daily weights and take appropriate action when a significant weight gain was identified. During a phone interview on 5/22/25 at 12:35 p.m., NP-A stated she evaluated R124 on 5/20/25 and was told R124 gained 5.2 lbs over the course of 5 days. NP-A contacted R124's cardiologist for guidance and R124 was evaluated by cardiology. NP-A was unaware of R124's physician order to contact the provider if a weight gain of 3 lbs in 48 hours and would have expected nursing to contact a provider on 5/18/25 to obtain care sooner. The facility policy Edema Scale and assessment dated 5/2013, identified It is the policy of this facility to provide standardized assessment of lower leg edema and associated issues. Document any untoward results and as necessary by degree of problem, notify the Health Care Provider.

Based on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified the need for a gradual dose reduction (GDR) or medical justification of use for 1 of 5 residents (R42) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment with verbal behaviors directed toward others and behaviors not direct toward others 1 to 3 days a week. R42's diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs to periods of deep lows) and anxiety. R42 received an antipsychotic medication and an antidepressant medication. The MDS identified the last gradual dose reduction (GDR) of medications was done 2/23/21, and a GDR was not documented as clinically contraindicated. R42's most recent Physician Order Report dated undated, identified haloperidol (typical antipsychotic medication) to be given twice a day related to bipolar disorder and was dated 11/22/23. R42 also received Zoloft (an antidepressant medication) given one time a day for depression related to bipolar disorder and was dated 11/29/22. R42's monthly pharmacy reviews were reviewed from 6/2024 to 5/2025, with no irregularities identified with antipsychotic medications or antidepressant medications. R42's medical record was reviewed and lacked evidence a GDR had been attempted or identified a medical justification for continued use within the past calendar year for antipsychotic or antidepressant medications. During an interview on 5/21/25 at 1:13 p.m., registered nurse (RN)-H stated the consulting pharmacist (CP) reviewed the residents' medication lists and identified if any residents were due to a GDR, and that is how she was flagged if a resident was due for one. RN-H stated R42's medical record lacked any evidence a GDR had be attempted or a clinical justification for continued use. During a telephone interview on 5/21/25 at 2:00 p.m., the CP stated a resident's medication lists were reviewed monthly and medications were monitored, this included reviewing psychotropic medications (drugs that affect mental processes and behavior, often used to treat mental health conditions like anxiety, depression, and psychosis) for adverse reactions, monitor GDR or clinical contraindication for medication reduction. GDR's are to be attempted yearly. The CP stated the last documented GDR was from 2/2024, and a GDR or clinical contraindication should of be documented and was not. During an interview on 5/21/25 at 2:37 p.m., the director of nursing (DON) she would expect GDR's to be attempted or documented contraindication to be done yearly. The facility's Psychopharmacological Drug Use policy dated 5/2025, identified the CP would review resident medication records on a monthly basis for documentation/justification for the drug use and will recommend dosage reductions or modifications as appropriate.

Based on interview and document review, the facility failed to ensure conflicting notes and orders transmission based precautions were clarified to ensure an accurate medical record was maintained for 1 of 1 resident (R127) whose medical record was found to lack admission notes. Findings include: R127's entry Minimum Data Set (MDS) dated [DATE], identified R127 was [AGE] years old and was admitted to the facility on [DATE]. R127's Diagnosis Report dated 5/21/25, identified R127 had diagnoses that included enterocolitis due to Clostridium difficile (C. diff, or costridioides difficile, is a bacterium that can cause severe diarrhea and colitis (inflammation of the colon). It is often associated with antibiotic use, which can disrupt the normal gut flora, allowing C. diff to proliferate. Symptoms of a C. diff infection can range from mild diarrhea to severe, life-threatening conditions. Treatment typically involves specific antibiotics to target the infection.) R127's History and Physical dated 5/7/25, identified R127 had been diagnosed with C. diff, completed a 10-day course of oral vancomycin (an antibiotic used to treat C. diff) and R127's diarrhea had resolved. R127's admission Screening dated 5/9/25, was a handwritten paper form that identified R127 had C. diff 4/22. R127's Nursing Home Visit progress note dated 5/12/25, identified R127's C. diff was resolved. R127's nursing progress notes dated 5/9/25 through 5/21/25, failed to identify an admission note or a nurse-to-nurse communication (nurse-to-nurse communication refers to the exchange of information, opinions, and ideas between nurses, either face-to-face, through written reports, or electronically) regarding R127's hospital discharging condition. During an interview on 5/20/25 10:33 a.m., RN-B stated the admission nurse completed R127's admission screening. The admission nurse completed the nurse-to-nurse communication and entered an admission note. During an interview on 5/20/25 at 10:40 a.m., RN-F stated the hospital usually sent a referral packet for any potential resident: history and physical, notes, etc. RN-F reviewed everything from medications to therapy notes to ensure the facility could meet the resident's needs. If the resident was accepted, that information was loaded into the electronic medical record. R127's C. diff diagnoses was on 4/22/25 and RN-F entered that on R127's screening form. R127's C. diff may have been resolved but that was the cue for the admission nurse to talk to the hospital nurse regarding R127's stool. That information should be entered into an admission note, however, RN-F was unable to find an admission note in R127's medical record. During an interview on 5/20/25 at 11:13 a.m., RN-C stated he did R127's admission, however, could not recall a nurse-to-nurse communication about R127 because he completed 3 admissions that day. RN-E did not enter an admission note because all that information was on the admission nurse's screening form. RN-C may have hand written notes of the conversation on that paper form, however, that form was sent to the shred box for destruction. Yea, I guess if I don't enter a note and don't scan that form, it's not documented. RN-C stated days were rapid fire and staff got through what we needed to get done to get people settled. It was staff's responsibility to be aware of what residents needed. The IP nurse did send out a list every morning in an email and RN-C thought the cart nurses did get that email but who had time to read their emails. Really, staff just did what they had to do to get through it. During an interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to either enter an admission note or scan handwritten notes in the medical record to ensure the resident's medical record was complete and to document what condition the resident was in on admission. During an interview on 5/21/25 at 2:04 p.m., the administrator stated staff were expected to ensure a resident has a complete medical record to ensure the resident receives the quality of care they deserve. The facility policy Documentation Standards Policy dated 10/24, identified the following: a. All documentation must reflect the resident's condition, care provided, and any status changes. b. Documentation must be completed at the time of care or as soon as possible after care is provided.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was completed during personal cares for 1 of 3 residents (R121) whose cares were observed. Findings include: R121's 5-day Minimum Data Set (MDS) dated [DATE], identified R121 required set up to touching assistance for most care areas including toileting. R121's care plan revised 5/19/25, identified R121 required assist of one staff for toileting, dressing and grooming. During an observation on 5/20/25 at 3:02 p.m., nursing assistant (NA)-A assisted R121 to the bathroom for toileting. NA-A failed to use hand sanitizer and put on a pair of gloves R121 stood up from the toilet and NA-A stated R121 had a medium bowel movement (BM) and used a disposable wipe to clean feces from R121's buttocks. NA-A with the contaminated gloves assisted R121 to sit down on the toilet. NA-A then assisted R121 to put on a clean pull-up brief and pajama pants without completing hand hygiene or changing gloves.NA-A flushed the toilet, continued to wear the same soiled gloves and assisted R121 back to his bed. NA-A hung R121's gait belt on R121's door and picked up R121's urinal off his overbed table and dumped it in the toilet. NA-A gave R121 the call light and removed her soiled gloves. During an interview on 5/20/25 at 3:19 p.m., NA-A stated she was always told you wear the same gloves from the start of a care until the care was finished. During an interview on 5/20/25 at 3:22 p.m., licensed practical nurse (LPN)-A stated staff were expected to change gloves after wiping BM because you don't want to cross contaminate anything with feces. During an interview on 5/20/25 at 3:27 p.m., registered nurse (RN)-A stated staff were expected to remove their soiled gloves after doing BM cares, before touching clean items to prevent cross contamination of clean items. During an interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to immediately removed gloves soiled with feces and to put on clean gloves before completing cares to prevent cross contamination of clean items. During an interview on 5/21/25 at 2:00 p.m., the administrator stated staff were expected to change gloves whenever going from dirty to clean to prevent transferring feces or bacteria on the resident's clothing. The facility policy Hand Hygiene revised 4/24, identified staff were expected to change gloves during patient care if the hand would move from a contaminated body site (e.g., perineal area) to a clean body site. Staff were directed to perform hand hygiene when removing gloves and before putting on a new pair of gloves.

Based on observation, interview and document review the facility failed to perform an assessment delaying care for 1 of 3 residents (R1) reviewed for a change of condition. R1 had right arm/hand weakness on 3/23/25, was not assessed, and was sent to the hospital on 3/24/25 diagnosed with a stroke. Findings include: R1's Admission Record indicated an initial admitted [DATE]. Diagnosis included multiple sclerosis (MS), paraplegia and a diagnosis added 3/24/25, of cerebral infarction (also known as an ischemic stroke which occurs when the blood supply to part of the brain is blocked or reduced. Symptoms include Trouble speaking and understanding what others are saying. A person having a stroke may be confused, slur words or may not be able to understand speech. Numbness, weakness or paralysis in the face, arm, or leg. This often affects just one side of the body. The person can try to raise both arms over the head. If one arm begins to fall, it may be a sign of a stroke). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. The MDS indicated R1 had upper extremity impairment on one side, lower extremity impairments on both sides and required substantial/maximal assistance for toileting hygiene, showering and upper body dressing. R1's care plan dated 1/23/25, identified a self-care deficit related to activity intolerance, fatigue, impaired balance, MS, and paraplegia. The care plan was updated 3/26/25, to include acute stroke affecting right side. The care plan directed staff to provide assistance of two staff for bed mobility and toilet use. If R1 did not wish to get out of bed at night, offer use of bed pan and approach/attempt to check and change every four hours. R1's Progress Note dated 3/24/25 indicated writer was summoned to assess R1 at 7:20 a.m. for upper right sided weakness. Upon assessment R1 was unable to squeeze or lift right upper extremity. Extremity appeared limp. R1 requested to be sent to the ED for evaluation. Progress Note dated 3/24/25 at 3:40 p.m., indicated ED nurse called to update facility R1 was admitted to the hospital for an acute infarction. R1's hospital History and Physical (H and P) dated 3/24/25, indicated she presented to the emergency departement (ED) on 3/24/25, due to a reported history of right arm weakness and that her arm was posturing straight beginning on 3/23/25, at around 3:00 p.m. R1 was right handed and informed staff she could not move her arm at all. R1 was admitted for further evaluation and monitoring and diagnosed with acute cerebrovascular accident (CVA) with right arm weakness. Found to have frontal/parietal embolic appearing CVA's. Neurology evaluated and recommended continuing Apixaban (an anticoagulant medication used to treat and prevent blood clots and to prevent stroke). Progress Note dated 3/26/25, indicated maintenance was notified that R1 would need controls on her wheelchair switched to the left side. R1 was unable to lift her right arm. During observation and interview on 4/10/25 at 1:07 p.m., R1 was seated in a power wheelchair in her room with family member (FM)-A. FM-A stated R1 lucked out, she was totally gone with her right arm. The nursing assistants (NA)'s kept reporting it and the nurse never came in. FM-A said starting the morning of 3/23/25, R1 was up and about and had to eat with her left hand which was unusual. R1 spoke with NA-A during the day and later it was getting worse and was reported to NA-B and another aide at 4:30 p.m. FM-A said the next incident occurred at 9:45 p.m. when R1 spilled everything on her bedside table. NA-B and another staff cleaned up the spill, asked R1 a lot of questions and reported concern to the nurse. FM-A stated he had turned in a grievance form because no one had come in to assess R1 the whole day, then at 6:10 a.m. the next day (3/24/25), NA-D came in to get R1 ready for the day, looked at R1 and went out to report to the nurse. The NA's had to power R1 out to the dining room because R1's arm was hanging, and she could not use the control on her chair. FM-A said he called the building charge nurse who came to the unit and said she thought R1 had a stroke. At 1:26 p.m. R1 said on 3/23/24, her arm had started tingling, then went to numbness. R1 said she could not really use it as far as picking something up and her motor skills were gone. A Formal Grievance/Concern dated 3/29/25, written by FM-A on behalf of R1 indicated the following: -3/23/25 at 10:30 a.m. R1 told NA's of right-hand numbness, had to use left hand. -3/23/25 at 4:30 p.m., R1 reported right arm was very weak to the NA's. -3/23/25 at 9:45 p.m., R1 spilled everything on her bedside table and her right arm and hand were numb. NA-B reported. -3/24/25 at 6:10 a.m. R1's right hand and arm were unusable. NA-D reported to licensed practical nurse (LPN)-A. R1 was assisted to dress and staff powered the chair to the dining room. FM-A called the charge nurse at 7:30 a.m. All this time, no nurse had checked on R1. An untitled, undated facility documented indicated FM-A reported R1 had been having trouble with her right arm since 3/23/25 at 10:30 a.m., nurses were made aware several times and did nothing. NA-A was interviewed and denied any complaints from R1 during day shift on 3/23/25. NA-B was interviewed and said R1 had no complaints until just before 10:00 p.m., when her light was on because she had spilled her water. NA-B stated R1 reported being weak and he reported it to the nurses. LPN-B was interviewed and denied any concerns until NA's reported at the end of the PM shift that R1 spilled her water because she had been weak. LPN-B did not take it as a concern, just a resident who was tired and spilled her water. The overnight nurse, LPN-C stated no concerns were brought to her during her shift until the morning when the NA reported to the oncoming nurse R1 was having a problem with her right arm. LPN-A was interviewed and said on 3/24/25, NA-D came to her and reported R1 was unable to move her right arm. LPN-A called the charge nurse and left a message as she believed assessing for a stroke was outside her scope. During interview on 4/10/25 at 2:03 p.m., NA-B stated he went in to check on R1 just before 10:00 p.m. on 3/23/25. R1 had dropped her cup, and she was kind of out of it. NA-B said not tired but groggy and her fingers were stuck in the mug, and she could not feel them. NA-B asked R1 if that had ever happened before, and she said no. NA-B said he had been working with NA-E and they had reported everything to LPN-B who made a comment how strange it was but did not do anything or go see R1. During interview on 4/10/25 at 3:27 p.m., NA-D said at shift change on 3/23 she noticed R1 could not grip and thought it was weird. NA-D told both the P.M. shift, LPN-B, and overnight nurse LPN-C that R1 had dropped her water and was having trouble grabbing stuff with her hand which was unusual for her. NA-D said R1 sometimes dropped things but could grip with her hand and that night she could not. NA-D remembered NA-B being there and both talking about it to the nurses. During interview on 4/10/25 at 3:37 p.m., the administrator said she and the director of nursing (DON) had spoken to FM-A who had reported everything as it had been written on the grievance form. The administrator said she had not spoken to R1 about the reported events. The administrator stated the expectation would have been that the nurses would have gone in and assessed R1. During interview on 4/10/25 at 3:53 p.m. the DON stated she heard through the rumor mill that FM-A had been having concerns for a day. The DON said she asked some staff and NA-B reported just before 10:00 p.m., that R1 said she was weak, and it was reported to the nurses. The DON said LPN-B reported the NA's had told her R1 was weak during shift report. NA-D reported the next morning R1 could not move her right arm and reported it to LPN-A. LPN-A told the DON she could not assess for a stroke, so she called the charge nurse who was doing a training with staff. The DON stated the overnight nurse should have assessed R1 and LPN-A could have gone in and assessed R1 instead of waiting for the charge nurse. During interview on 4/11/25 at 8:41 a.m., NA-D said on 3/24/25, she walked into R1's room and asked how she was doing. R1 said I don't know and said I can't move my right arm. NA-D said when she looked, she could tell something was different and asked R1 if she had reported it. R1 said the previous night she told the NA's, but no one had come to see her. NA-D reported the concern to LPN-A and LPN-C who said it was the first time she had heard of it. NA-D stated she went to complete cares for R1 and FM-A which took approximately 45 minutes. During that time, no nurses came to assess R1. NA-D had to drive R1's wheelchair to the dining room because she could not operate the controls. NA-D said R1 had been in the dining room for a half hour to an hour before the charge nurse came to assess R1. During interview on 4/11/25 at 8:49 a.m., the nurse practitioner (NP) stated R1 had already been taking Apixaban due to a blood clot. The NP said it was hard to know for sure but if R1 had gone in earlier the ED may have tried tPA (Tissue plasminogen activator, a drug given through a vein to help break up a blood clot so that blood flow can return to normal. It is used for the emergency treatment of ischemic stroke, which occurs when a blood clot interrupts blood flow to a region of the brain) which was used if they could catch the symptoms within three hours. The NP said staff should have contacted the nurse manager, assessed R1 and sent her in right away. During interview on 4/11/25 at 10:33 a.m. registered nurse (RN)-A stated she had been the charge nurse on 3/24/25. RN-A said she arrived at the facility at 6:00 a.m. to complete training with the night shift. RN-A got a phone call around 7:20 a.m. from FM-A who was concerned about R1's right arm and that she could not move it. R1 was in the dining room when RN-A assessed her and R1's right arm was completely limp, there was nothing there, she could not move it or squeeze. RN-A said there was no record of LPN-A attempting to contact her. R3's Admission Record indicated an initial admitted [DATE]. Diagnosis included heart failure, contusion of left thigh and left artificial knee joint. R3's 5-day MDS dated [DATE], identified intact cognition. R3's care plan dated 3/23/25, identified a self-care deficit related to activity intolerance, fatigue, impaired balance, and infected traumatic left thigh hematoma. The care plan identified altered skin integrity and directed staff to observe for signs and symptoms of infection and report to physician. A Formal Grievance/Concern dated 4/1/25, indicated during care conference, R3 voiced concern that the previous day, 3/31/25, he asked multiple times to go to the ED to have his leg looked at but no one did anything until 10:00 p.m. The timeline completed by LPN-D indicated: -At 9:00 a.m., R3 asked to LPN's to look at his leg. -At 11:00 a.m., RN-B back in office and was told about R3's leg and that he may want to be seen. -At 1:00 - 2:00 p.m., RN-B went to look at R3. -At 5:30 p.m. R3 started to complain of pain in his leg. R3's Progress Notes dated 3/31/25, indicated: -At 12:19 p.m., staff wrote R3's left upper leg was swollen and warm to touch. -At 8:50 p.m., staff wrote incision had healed over but area under thigh had swollen dramatically. R3 agreed to go to the ED. Previous nurse gave pain medication but R3 was still very concerned about the swelling. -At 11:33 p.m., staff wrote R3 had increased swelling to left upper thigh, no drainage from area. R3 requested to go to the ED for evaluation. During interview on 4/11/25 at 8:49 a.m., the nurse practitioner stated no one had reported to her that R3 had requested to go to the ED. During interview on 4/11/25 at 9:47 a.m., RN-C stated she had taken the grievance but had not been at the facility on 3/31/25. RN-B was present and said LPN-D had talked to her about R3 and she went and looked at his leg. R3's leg was swollen about the size of a football, and he said it had not been draining. RN-B said she told R3 she would let the NP know, and said R3 replied I suppose she will want me to go in. She said she asked the NP if there was anything she needed to do before she left, and the NP said no. RN-B said she left early that day and said she had not documented an assessment of R3's leg. During interview on 4/11/25 at 11:51 a.m., the DON stated she thought R3 had been thinking in his mind that he wanted to be seen but did not say it to anyone. Job Description Licensed Practical Nurse dated March 2017 indicated essential job responsibilities that included assists registered nurse with completion of assessments, documentation, and data collection within scope of practice and acting timely on findings. Facility policy Change of Condition/Notification dated March 2025, indicated a change in condition may include but not limited to: Injury, abnormal lab values, acute symptoms, change in vital signs and other conditions as deemed necessary.

Based on interview and document review, the facility failed to provide the opportunity for an admission care conference for 1 of 3 residents (R49) reviewed for care planning. Findings include: R49's admission Minimum Data Set (MDS) assessment dated [DATE], identified R49 was cognitively intact. Diagnoses included renal insufficiency, diabetes, and arthritis. Review of R49's electronic medical record (EMR) lacked documentation of a care conference since admission to the facility. During an interview on 8/26/24 at 7:09 p.m. R49 stated he had not been invited to, or attended any care conference to discuss the plan of care (POC) since admission to the facility on [DATE]. During an interview on 8/28/24 at 2:29 p.m. registered nurse (RN)-B stated the facility would rarely have an admission care conference. They would build the care plan and just let the resident review it after completion. Staff usually never met with the resident until closer to discharge, to discuss the discharge planning. Turn around times on the rehab unit did not allow to meet with each resident at admission to discuss the POC with them. During an interview on 8/29/24 at 10:28 a.m., the social services designee (SSD) stated care conferences would be scheduled by her and social services, nursing, therapies, and other departments would attend them with the resident and family members. The SSD reviewed R49's EMR and confirmed there was no documentation related to a care conference. The SSD also confirmed R49 had not had a care conference since admission. During an interview on 8/29/24 at 10:49 a.m., the director of nursing stated an expectation that all care conferences would be done within 7-12 days of admission, as stated in the policy and the resident admission handbook. Facility Welcome to Grand Village resident handbook last revised 4/11/24 indicated 7-12 days after admission an interdisciplinary team (IDT) meeting called a resident care conference would be held to discuss the residents care at the facility. The meeting would include several staff at the facility, the resident, and the resident family. Facility policy Individualized Care Plan last revised 6/24, indicated the IDT would meet with the resident and family related to the POC. The policy lacked documentation of when the care conference should take place.

Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R2) reviewed and observed for self-administration of medications. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. During observation on 8/27/24 at 10:46 a.m., R2 was sitting in her recliner with the nebulizer mask on her face. Nebulizer cup contained a clear solution and nebulizer machine was running with no staff present in room. Nurse walked from the medication cart into R2's room, stated to R2 that the treatment was all done and shut the nebulizer machine off. Nurse washed nebulizer mask and cup and left it to air dry. During record review on 8/26/24, the self-administration of medications assessment that was completed on 7/11/24, identified R2 required frequent prompting, cues and reminders, and was not safe to self-administer own medications. Assessment also indicated that R2 did not wish to self-administer any medications. During interview on 8/29/24 at 8:34 a.m., licensed nursing staff (LPN)-A stated there were no residents on this unit that were able to self-administer medications. LPN-A stated if a resident was able to self-administer medications, it would be displayed in the resident's banner in the electronic health record (EHR). LPN-A confirmed that R2 did not have an order to self-administer medications which included nebulizer treatments. LPN-A stated an assessment would need to be completed before a resident was able to self-administer medications. LPN-A stated the assessment was important to ensure that the mask was properly place on resident's face and that the resident was able to keep mask on during treatment as nebulizer could be running with the resident not receiving any solution making the treatment ineffective. During interview on 8/29/24 at 10:17 a.m., registered nurse (RN)-C stated an assessment would need to be completed by the RN prior to a resident being able to self-administer medications. RN-C confirmed R2 did not have an order for self-administration of medications. RN-C stated it was important to complete the assessment to ensure that the resident was cognitively able to use the nebulizer without monitoring and to ensure the resident could remove nebulizer mask from face if resident was experiencing adverse side effects such an increased heart rate with palpitations during nebulizer treatment. During interview on 8/29/24 at 10:38 a.m., director of nursing (DON) stated self-administration of medications assessments are completed by the nurse manager or the MDS nurse. DON stated assessments are completed at time of admission, annually, or with a significant change in status. DON confirmed that nebulizer treatments, when nurse leaves the room, needed to be assessed and a self-administer order would need to be obtained from the provider. It was important for the resident to be assessed for self-administration of medications to ensure that the resident was safe to be left alone with the nebulizer treatment running. The facility Self-Administration of Medications policy, dated 4/23, identified a self-administration of medications assessment would be completed for any resident requesting to administer any medication without the direct supervision of a nurse. Residents who have nebulizer treatments may only self-administer if assessed for self-administration of nebulizer assessment and a physician order is received to self-administer.

Based on observation, interview, and document review, the facility failed to ensure proper wheelchair equipment was used to prevent potential complications for 1 of 1 resident (R55). Findings include: R55's significant change Minimum Data Set (MDS) dated [DATE], identified R55 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R55's diagnoses included progressive neurological conditions, degenerative disease of nervous system, non-Alzheimer's Dementia, and unspecified abnormalities of gait and mobility. During observation on 8/26/24 at 1:28 p.m., R55 left the unit with staff to go to activities. Staff assisted R55 with propelling down hallway in his wheelchair that did not have foot pedals. R55 was experiencing difficulty with holding his feet up while staff pushed wheelchair. R55's feet dropped on floor and bounces. R55's foot pedals were laying on top of dresser in room. During observation on 8/29/24 at 9:13 a.m., R55 left the unit with staff to go down to therapy. Staff assisted R55 with propelling down hallway in his wheelchair that did not have foot pedals. R55 was experiencing difficulty with holding his feet up while staff pushed wheelchair. R55's feet dropped on floor and bounced. R55's foot pedals were laying on top of dresser in room. During record review on 8/28/24, R55's care plan indicated staff were to ensure bilateral foot pedals were on wheelchair when assisting resident to and from destinations due to limited physical mobility related to weakness. During interview on 8/29/24 at 8:36 a.m., licensed practical nurse (LPN)-A stated if R55 was going a long distance or off unit, staff assisted R55 with propelling wheelchair down hallway. LPN-A stated R55 does not have foot pedals for his wheelchair. During interview on 8/29/24 at 8:40 a.m., nursing assistant (NA)-A stated if R55 was going off unit, staff assisted R55 with propelling wheelchair down hallway. NA-A stated R55 does not use foot pedals on his wheelchair. During interview on 8/29/24 at 10:11 a.m., registered nurse manager (RN)-A confirmed R55 was to have foot pedals on his wheelchair when been propelled for longer distances. RN-A stated it was important for foot pedals to be used on wheelchair, so the resident does not fall forward out of wheelchair and/or sustain injuries. During interview on 8/29/24 at 10:31 a.m., director of nursing (DON) stated nursing evaluated whether or not foot pedals needed to be used for the resident and if foot pedals were needed it would be added to the care plan. DON stated that if a resident was not able to hold their legs up that foot pedals should be used. DON stated it was important for foot pedals to be used per care plan to ensure resident safety. A wheelchair/foot pedal policy was requested but was not provided.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning to minimize the development of pressure ulcer risk for 1 of 2 residents (R50) reviewed for wound care. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], identified R50 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R50's diagnoses included hypertension, renal failure, non-Alzheimer's dementia, anxiety disorder and other symptoms and signs involving the musculoskeletal system. MDS also identified that R50 was at risk for developing pressure ulcers/injuries and is on turning and repositioning program. R50's care plan undated, identified R50 had altered skin integrity related to fragile skin due to closed lumbar fracture and was at risk for the development of pressure ulcers. R50's care plan directed staff to reposition R50 every two hours while in bed and/or wheelchair. During continuous observations on 8/27/24 from 1:12 p.m. to 3:37 p.m. R50 was lying on his back in his bed. At 1:12 p.m., R50 was observed to be lying on his back in bed. At 2:30 p.m., R50 remained in same position in bed. At 2:54 p.m., nurse went into R50's room and obtained vitals but did not reposition R50 and R50 remained in same position in bed. At 3:01 p.m., staff brought in new water pitcher into room and did not reposition R50. At 3:32 p.m., R50 remained in same position in bed. At 3:37 p.m., staff went into R50's room and assisted R50 with repositioning. During interview on 8/27/24 at 3:29 p.m., nursing assistant (NA)-B stated R50 was unable to reposition himself in his bed and needs staff to assist with repositioning. NA-B stated R50 was to receive assistance with repositioning every two hours. During interview on 8/27/24 at 3:40 p.m., licensed practical nurse (LPN)-B stated R50 was to receive assistance with repositioning every two hours when in bed or wheelchair. LPN-B stated R50 was not able to reposition himself in his bed. During interview on 8/29/24 at 8:36 a.m., LPN-A stated R50 had a wound on his spine that was not open at this time. LPN-A stated R50 had a protective bandage, placed along his spine, due to him having thin skin. LPN-A stated R50 was to receive assistance with repositioning every two hours as it was important to ensure that R50's skin on back/spine does not break down. During interview on 8/29/24 at 8:40 a.m., registered nurse clinical manger (RN)-A stated R50 currently does not have any open wounds as the pressure ulcers that he had has resolved. RN-A stated R50 had a preventive protective dressing that was placed on his spine for a bulge that staff has been monitoring closely. RN-A stated R50's skin was very thin and the bulge on his spine was protruding with the area being blanchable. RN-A stated R50 was to receive assistance with repositioning every two hours as it was important due to R50's skin being so vulnerable and his history of pressure ulcers. During interview on 8/29/24 at 10:35 a.m., the director of nursing (DON) stated the staff were to provide assistance with repositioning in accordance with the care plan. DON stated repositioning a resident was important to prevent skin breakdown. The facility Positioning the Resident policy dated 6/24, indicated that it was the policy of the facility that staff reposition identified residents to relieve pressure, prevent skin breakdown, pain, and promote proper body alignment. The facility Individualized Care Plan policy dated 6/24, indicated the facility would develop a comprehensive care plan using the comprehensive assessments, will individualize the plan of care to accurately reflect resident's functional capacity and medical, nursing, psychosocial, activity and other identified needs.

Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to facility policy and failed to ensure nebulizer tubing/cannister was cleaned and allowed to air dry after each use for 1 of 1 resident (R38) reviewed for oxygen therapy. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], identified R38 was cognitively intact and had continuous oxygen therapy since admission to the facility. R38's provider order dated 8/13/24, identified oxygen at 2 liters/minute by nasal cannula (NC) continuously and budesonide inhalation suspension 0.5 milligrams/2 milliters inhaled via nebulizer two times a day. R38's care plan dated 8/7/24, identified R38 needed continuous oxygen therapy and to administer oxygen and respiratory medications as per orders. The care plan lacked documentation when to change oxygen tubing and when/how to clean nebulizer tubing/cannister. R38's treatment administration record for 8/24 indicated oxygen tubing and nasal cannula had been changed on 8/11/24, 8/18/24, and 8/25/24. On 8/26/24 at 3:09 p.m., R38 was observed wearing continuous oxygen via NC. The date on the green extension tubing and the NC was 8/18/24. A nebulizer canister and tubing was observed sitting on the bedside table and was also dated 8/18/24. The cannister was noted to be closed and had visible liquid in the cannister along with condensation along the inner walls of the cannister. During interview on 8/26/24 at 3:09 p.m., R38 stated the staff very rarely change the oxygen tubing the way they were supposed to. The staff will never clean out the nebulizer cannister after my treatment. They start out the day by bringing me the vials of nebulizer liquid for all treatments that day and R38 would set up and self-administer the nebulizer treatments when scheduled. The staff never came back to clean the nebulizer cannisters after each use. On 8/27/24 at 1:29 p.m., all the oxygen tubing in R38's room was observed to be dated 8/18/24 along with the nebulizer tubing and cannister. The nebulizer cannister was again noted to have liquid and condensation built up inside the cannister. During interview on 8/27/24 at 1:34 p.m., licensed practical nurse (LPN)-A stated all oxygen tubing and nebulizer tubing/cannisters would be changed every 7 days based on when the resident was admitted . Documentation of the change would be done in the TAR and the tubing would be labeled with tape and the current date on the tape. LPN-A stated nebulizer cannisters needed to be cleaned after each use and allowed to air dry before the next treatment was given. Cleaning should occur immediately after the medication in the nebulizer was administered. LPN-A entered R38's room and confirmed the date on all oxygen tubing was 8/18/24. Based on that date the tubing should have been changed on 8/25/24. LPN-A also confirmed the nebulizer had not been cleaned out since the last treatment that day which had been at 8:00 a.m. During interview on 8/29/24 at 10:38 a.m. registered nurse (RN)-A stated all oxygen tubing and nebulizer tubing/canisters should be changed every 7 days, on Sunday evening shft. RN-A stated nebulizer cannisters should be cleaned immediately after each use to prevent bacteria growth that can occur in left over moisture in the cannister. During interview on 8/29/24 at 10:48 a.m. the director of nursing (DON) stated an expectation all staff would follow the facility policy related to oxygen tubing changes and nebulizer cleaning schedules. Facility policy Nebulizer Treatment last revised 12/23, identified after each use the nebulizer would have all excess fluid removed from the nebulizer and placed on a paper towel to air dry completely. Nebulizer pieces would be changed weekly, which included tubing. A facility policy for oxygen tubing changes was requested but not provided.

Based on interview and document review, the facility failed to assure the use of PRN (as needed) psychotropic medications (a drug which affects mood/behavior) were limited to 14 days, or had a physician specified, time limited order and failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 1 of 1 residents (R4) reviewed for hospice. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R4's diagnoses included non-Alzheimer's dementia, anxiety disorder, nutritional deficiency, and chronic pain. R4's physician orders included orders for lorazepam 0.5 milligram (mg) every four hours as needed. This order was initiated on 3/8/24 and was open-ended. Orders also included risperidone (antipsychotic) 0.25 mg by mouth two times daily for obsessive itching/picking related to generalized anxiety disorder. R4's medical record was reviewed and lacked any evidence orthostatic blood pressures had been obtained for R4. During interview on 8/28/24 at 1:43 p.m , registered nurse case manager (RN)-A stated for psychotropic medications monitoring needed to be completed for behaviors. RN-A confirmed that R4's lorazepam was ordered on 3/8/24 and has no end date. RN-A stated R4 did not have any behaviors and probably does not need the lorazepam order at this time. RN-A stated antipsychotic medications are monitored for adverse effects and orthostatic blood pressures are obtained monthly. RN-A confirmed R4 has not had orthostatic blood pressures obtained. DON stated orthostatic blood pressures are important as antipsychotic medications can cause dizziness and cause blood pressure to drop, which could lead them to fall. During interview on 8/29/24 at 10:26 a.m., director of nursing (DON) stated target behaviors and adverse effects are monitored for PRN psychotropic medications. DON stated PRN psychotropics need to be evaluated every 14 days with the provider to ensure medication was still needed with the rationale of why it is needed. It was important to re-evaluate to ensure that resident was not receiving the medication that was not needed and are on the lowest dose possible. During interview on 8/29/24 at 11:40 a.m., consultant pharmacist (CP) stated Lorazepam was to be re-evaluated after 14 days. Provider was expected to document rationale and specify duration of medication. CP stated it was important to re-evaluate medication to make sure the resident was benefiting from it and to ensure the resident was not having any adverse effects from the medication. CP stated any resident on an antipsychotic medication should have orthostatic blood pressures obtained monthly. Pharmacist stated orthostatic blood pressures consist of obtaining a blood pressure when resident is lying, sitting, and then standing within the same timeframe. Pharmacist stated orthostatic blood pressures were important to monitor due to postural hypotension being one of the major side effects, especially in an older person, and would put the resident at a higher risk for falls when taking these medications. The facility Psychopharmacologic Drug Use policy, dated 7/8/2024, identified residents are free from the use of any psychotropic medication for purposes of discipline or convenience and from mediations not required to treat medical symptoms. Psychopharmacologic drugs include antianxiety agents, antidepressants, sedatives, hypnotics, antipsychotics, and other drugs that affect behavior. As needed (PRN) orders must include an indication for use. PRN orders for psychotropic drugs are limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The attending physician or prescribing practitioner directly examines the resident's current condition and progress to determine if the PRN antipsychotic medication is still needed. The facility Blood Pressure - Orthostatic policy, dated 1/2022, identified orthostatic blood pressures are to be obtained to assess effectiveness of medication, assess potential side effects of medications and to assess risk for falls.

Based on interview and document review the facility failed to ensure 1 of 3 residents (R1) reviewed for medication errors received physician ordered medications. In addition, the facility failed to notify the physician of the missed medications. Findings include: R1's Admission Record indicated she admitted to the facility on [DATE]. Diagnosis included atrial fibrillation, chronic kidney disease and hypertension. R1's care plan dated 7/9/24, identified an alteration in health status and directed staff administer medications per physicians order. R1's Order Summary Report printed 7/31/24, identified the following order dated 7/9/24: Slow Magnesium/Calcium oral tablet delayed release 70-117 milligram, give two tablets one time a day for hypomagnesemia. R1's Medication Administration Record for July 2024, indicated she received the medicaion on 7/10/24, 7/15/24 and 7/29/24. All other days staff indicated she did not receive the medication. R1's Hospitalist Discharge Summary dated 7/28/24, indicated she admitted to the hospital on 7/24/24 and discharged on [DATE]. Discharge diagnosis included atrial fibrillation with ventricular response. The discharge summary indicated during R1's hospital stay she required ongoing magnesium replacement. During interview on 7/31/24 at 10:33 a.m., licensed practical nurse (LPN)-A stated if a medication was not available they could either call the pharmacy or fill out a reorder form and send via fax. LPN-A stated usually she just notified the charge nurse. During interview on 7/31/24 at 10:10 p.m., registered nurse (RN)-A, nurse manager, stated when a medication was not available the nurses were supposed to notify her so she could call the pharmacy. RN-A stated she had not been aware R1's magnesium had never been delivered to the facility. During interview on 7/31/24 at 11:59 p.m., nurse practioner (NP)-A stated she had written the order for the Slow Magnesium because when she last saw R1, her magnesium levels were low which could cause an electrolyte imbalance. NP-A stated the facility had not notified her that R1 never received the prescribed medication. During interview on 7/31/24 at 1:01 p.m. pharmacy technician (PT)-A stated the pharmacy had never delivered R1's magnesium to the facility. PT-A stated the medication was back ordered from their supplier. PT-A stated typically the pharmacy would have either called or sent a fax to the facility to let them know when a medication could not be delivered. During interview on 7/31/24 at 2:05 p.m. the director of nursing (DON) stated she had not been aware R1 had never received her prescribed magnesium and said staff should have notified the physician. Facility Medication Error Management Policy dated 3/31/23, identified medication errors to include medication not available for administration. The policy indicated all medication errors must be reported immediately to the nursing supervisor and DON. The policy further indicated the residents physician or NP must be notified.

Based on observation, interview and document review, failed to implement timely transmission-based precautions (TBP) and testing according to the Centers for Disease Control (CDC) for 1 of 1 residents (R10) who were displaying COVID-19 symptoms; and the facility failed to conduct COVID-19 outbreak testing was conducted according to CDC guidance for 4 of 4 residents (R21, R26, R21, R41) who were exposed to COVID-19 and 1 of 1 staff ( NA-D) who worked without participating in outbreak testing; and failed to ensure surveillance tracking of infections was completed for 6 of 6 residents (R118, R1, R14, R49, R15, R45) who displayed signs and symptoms of potential infection. This had the potential to affect all residents and staff. In addition, the facility failed to ensure catheter care was done to prevent transmission of organisms for 1 of 1 residents (R121). Findings include: COVID: The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 5/8/23, identified when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. - A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. - The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. - Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. - In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction ' s public authority recommends these and additional precautions. - If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. - If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. The CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 updated 9/23/22, identified HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays. When testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. For HCP who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. R10's annual Minimum Data Set, dated dated dated [DATE], identified no cognitive impairment and diagnoses included atrial fibrillation, hypertension, renal insufficiency, and diabetes. The Easy Reporting testing log dated 9/26/23, identified R10 tested positive for COVID-19 on 9/20/23, and 9/21/23. R10's nursing progress notes identified the following: - 9/21/23 at 3:12 a.m., R10 put on his call light and complained of not feeling well. R10 sounded congested/nasal congestion. R10's temperature was 97.5 degrees Fahrenheit (F). No coughing noted. R10 stated he felt achy all over and requested to be COVID tested which was negative. The note lacked to identify if R10 was placed in transmission-based precautions. - 9/21/23 at 5:16 p.m., staff approached R10 at approximately 4:00 p.m. in the commons area to complete an informed consent for use of escitalopram. R10 had a congested cough, moderate amounts of bright green mucous at the edge of his nose, and face was flush. R10 stated he was feeling under the weather and that it was worsening throughout the day. R10 was chilled. R10's skin was warm and clammy to touch. R10 was rapid tested earlier and was negative. R10 was retested which was positive. R10 was assisted to his room, updated on status, and R10 would like to take an antiviral if he was eligible. Director of nursing (DON), medical director, administrator, and infection control nurse were updated. An isolation cart was placed outside R10's room and immediate contract tracing was completed with shift staff on at that time and residents who R10 had contact with greater than 15 minutes of high-risk exposure. These residents were scheduled for Covid testing on days 1, 3, and 5. - 9/22/23 at 1:33 a.m., R10 was admitted to the hospital due to COVID-19. - 9/22/23 at 1:47 a.m., late entry for 9/21/23: unidentified trained medication assistant (TMA) reported to writer R10 was not doing well and wanted to go to the ER. The TMA stated R10's oxygen saturations were 77% on 2 liters per minute (lpm) per nasal cannula (nc). R10 had yellow mucus from his nose, lung sounds were adventitious (abnormal lung sounds heard over the lungs and airways) bilaterally. Called the provider on call and received order to send R10 to ER for evaluation and treatment. R10's blood pressure was 139/29, pulse 99, temperature 103.2 degrees F, and oxygen saturations were 77% on 2 lpm via nc. R10 was transported to the hospital via ambulance at 6:55 p.m. R21's significant change MDS dated [DATE], identified R21 had no cognitive impairment and diagnoses included atrial fibrillation, heart failure, hypertension, renal insufficiency, and diabetes. The Easy Reporting testing log dated 9/26/23, identified R21 tested negative for COVID-19 on 9/21/23, 9/22/23 and 9/23/23. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R21's COVID-19 testing was initiated by RN-C during contact tracing from R10's positive COVID-19 test. R21 should have been tested on day 1, day 3 and day 5. R21 tested on day 0, day 1 and day 3. This did not meet the facility's testing plan. R26's significant change MDS dated [DATE], identified R26 had a severe cognitive impairment and diagnoses included Alzheimer's disease, renal insufficiency, and hypertension. The Easy Reporting testing log dated 9/26/23, identified R26 tested negative for COVID-19 on 9/22/23 and 9/24/23. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R26's COVID-19 testing was initiated by RN-C during contact tracing from R10's positive COVID-19 test. R26 should have been tested on day 1, day 3 and day 5. R21 tested on day 1 and day 3, but the log did not identify R26 was tested on day 5. This did not meet the facility's testing plan. R27's quarterly MDS dated [DATE], identified R27 had severe cognitive impairment and diagnoses included Alzheimer's disease, hypertension, renal insufficiency, and diabetes. The Easy Reporting testing log dated 9/26/23, identified R27 tested negative for COVID-19 on 9/22/23 and 9/24/23. During an interview on 9/27/23 at 9:20 a.m., RN-B stated R27's COVID-19 testing was also initiated because of her exposure to R10. R10 should have completed testing according to the facility's testing plan. R41's quarterly MDS dated [DATE], identified R41 had a severe cognitive impairment and diagnoses included Alzheimer's disease. The Easy Reporting testing log dated 9/26/23, identified R41 tested negative for COVID-19 on 9/22/23 and 9/24/23. During an interview on 9/27/23 at 9:25 a.m., RN-B stated R41 was also exposed to R10. R10 should have completed testing according to the facility's testing plan. R41 tested the morning of 9/27/23, due to exhibiting possible symptoms of COVID-19. NA-D's Sample Risk Assessment for Healthcare Workers Potentially Exposed to COVID-19 in Minnesota dated 9/21/23, identified NA-D was within 6 ft of a person with confirmed COVID-19 for greater than 15 minutes without personal protective equipment (PPE). NA-D was determined to be high-risk due to NA-D had prolonged close contact with R10 and was not wearing a surgical mask or respirator. The Easy Reporting testing log dated 9/26/23, identified NA-D tested negative on 9/22/23 and 9/24/23. The log did not identify if NA-D tested for COVID-19 on 9/26/23. During an interview on 9/27/23 at 7:16 a.m., NA-B stated staff really didn't have to do anything with R10. R10 did his own cares, staff picked up his trash and his dirty clothes. That was about it. The day R10 became ill, R10 was in the dining room, the common area, he was all over. No one was wearing PPE. The next day, NA-B tested and threw the test away. It was negative. NA-B did not know if the facility had to track any testing results. NA-B did not write it down anywhere. During an interview on 9/27/23 at 7:48 a.m., LPN-B was observed unmasked and stated she worked the day R10 became sick. R10 was saying he had a little tickle but did not have a fever. Later that day, he became sick. LPN-B didn't think anything of it. R10 was independent with supervision to make sure he's clean and his bathroom was clean. R10 was about and about. He ate at the corner table in the common area. His tablemate, most of the time, ate his meals in his room. LPN-B could not say if R10 ate alone that day. All staff tested for COVID-19, the results were written down on the sign in sheet and staff with close contact masked for 10 days. Staff would know if they had close contact because you knew what you've done with the resident every day. For LPN-B, close contact meant if you had to assist the resident to eat or if you had to help with daily cares. LPN-B passed medications to R10 but R10 thought he was the boss, so you don't like to hang around. It really depended on how much care a resident required. Staff tested that day, you can't lie, staff reported to the nurse manager and RN-B. RN-B took care of all that for staff. During an interview on 9/27/23 at 8:00 a.m., NA-F was observed unmasked and stated she worked until 5:00 p.m. the day R10 became ill. R10 was sitting in his recliner in the common area like he always did, and he sounded horrible. Coughing, congested. NA-F told the nurse but could not remember who the nurse was. R10 was tested after NA-F left for the day and was sent to the hospital. The next day, NA-F had to test. Staff collected their own swab in the nurses' station and the nurse put the swab in the card. The nurse took care of it after that. Afterwards, NA-F was instructed to wear a mask for 10 days. NA-F stated 9/27/23, was day 6. NA-F was off and when she came to the facility that morning the sign in sheet did not say she needed to mask or not. So, NA-F did not need to. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she was responsible for the facility's infection control program for a little less than three months. If a resident was feeling ill, the cart nurse should update the nurse manager and, if there were any concerns, the nurse manager would let RN-B know. RN-B was also available during off hours by phone and email. There was always a RN on-call, and they should call her for guidance as well. RN-B was informed of R10's positive COVID-19 test on Monday, 9/25/23, because she was on vacation. R10 wasn't feeling good, the nurse manager tested him that morning and R10 was negative. Then, the nurse went to get a consent form that afternoon, R10 was clammy and didn't feel good. R10 was tested again, and it was positive. Test results are entered in the assessment tab in R10's electronic health record (EHR) and the result automatically populated on the Easy Reporting testing log. In R10's progress notes, it showed R10 was tested at 3:12 a.m. on 9/21/23, but nursing did not enter the test in the assessment. R10 complained of nasal congestion and achy all over. On rounding notes, it just said R10 wasn't feeling well, and no monitoring was initiated. Ideally, monitoring should have been implemented in R10's EHR. Because R10's COVID-19 antigen test was negative and there was no known exposure, R10 was not placed in transmission-based precautions prior to his COVID-19 antigen test was positive. RN-B did not know the CDC guidance regarding using antigen tests for residents or staff that were symptomatic for COVID-19. The facility policy one test confirmed a resident was negative. RN- B stated it would make sense to place R10 in transmission-based precautions because he was symptomatic. Symptoms could mean he was contagious to other staff and residents. RN-C and the director of nursing (DON) did contact tracing the day R10 tested positive. For residents, they determine who was exposed for greater than 15 minutes in 24 hours. Staff did not observe every resident at all times because it just was not possible. RN-C and the DON filled out the contract tracing sheets and found only two staff that needed to test: NA-D and NA-E. RN-B was unaware of any other staff that needed testing. Staff were to notify RN-B when a test was completed for tracking of the information. When RN-B was in the facility and was notified of a staff's exposure, RN-B would put in a note prior to the shift to make sure the staff tested . The result was entered into Easy Reporting. RN-B stated there are antigen tests on the units, so the nurses have them for residents. Staff used them though and didn't communicate that. If RN-B did not know of a test, she was unable to document it and track it properly. RN-B has spoken to the DON about that because, according to the contact tracing forms, only NA-D was supposed to test for COVID-19. During an interivew on 9/27/23 at 10:25 a.m., RN-C stated when a resident exhibited signs or symptoms of COVID-19, nursing assessed them depending on the symptoms and the resident's medical history. It really didn't matter what symptoms, a COVID-19 antigen test was done because it either rule it out or clarified the problem. R10 was tested at approximately 3:00 a.m. on 9/21/23, with an antigen test with a negative result. That's what was reported off to day shift. R10 was not placed into transmission-based precautions but was greater than 6 feet away from residents and staff. Contact tracing was done. There were four residents and two staff that needed to be tested . Initially two staff tested right away because they had direct contact, but with further evaluation no one had more than 15 minutes with R10. R10 usually sat by himself and talks to others but sits so most are more than 6 feet away from him. Basically, we're told if a resident is acting abnormal to test. The nurse practitioner always asked if we tested a resident when we call her. RN-C was unaware of CDC guidance for use of antigen tests with symptomatic residents and stated, in her experience, one COVID-19 antigen test with a negative result ruled out COVID-19. Typically, nursing looked for a persistent cough, fever, burning in the chest, loss of taste or smell. During an interview on 9/27/23 at 10:45 a.m., the DON stated the unit nurse managers were responsible for infection control on their unit, implementing transmission-based precautions and tracking/trending of infections during the month. Staff should update the nurse manager or charge nurse with symptoms so they can be assessed and tested . All testing should be documented. I know we were doing it wrong. During an interview on 9/27/23 at 12:53 p.m., the DON stated the staff figured out where problems began. Prior to June, the facility was using a quantative real-time PCR or q test which only required one test. After June, the staff began using the antigen tests and did not realize they needed to change the testing process. The facility policy COVID-19 Community Testing Plan dated 8/6/21, identified the purpose of the policy was to identify COVID-19 positive residents and staff through viral testing; testing was a priority to help inform clinical care and infection prevention and control practices in the facility's setting. A negative RT-PCR test only indicated that an individual did not have detectable virus material present at the time of testing, and repeat testing might be needed. Widespread community transmission as well as movement of staff and residents in and out of a facility result in continuous introduction. Testing complimented existing infection control interventions but did not replace good infection control. However, the policy did not address the use of antigen tests. The facility policy COVID-19 policy undated, identified residents and team members with suspected/confirmed COVID-19 or exposures would be quarantined/isolated based on the most up-to-date CDC guidance. Residents and team members with symptoms of COVID-19 would be tested unless an alternate diagnosis was provided by a healthcare provider with the appropriate scope of practice. Admission testing, outbreak testing, and exposure-related testing of residents and team members would be based on the most up-to-date CDC guidelines. Residents would be placed under enhanced respiratory precautions until symptoms could be ruled-out as COVID (via testing or alternate diagnosis). However, the policy did not address the use of antigen tests. Surveillance R118's Admission Record dated 9/27/23, identified R118 was admitted to the facility on [DATE]. R118 had diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. R118's progress notes identified the following: - 9/8/23 at 4:35 p.m., R118 admitted to the facility with a primary diagnosis of left femur fracture and UTI. Resident is alert and oriented to person, place, and time, pleasant and cooperative upon assessment. Faint crackles in lower lobes. Resident reports a dry cough. COVID test was negative. Does report having issues with dizziness and vertigo. Educated R118 to change positions slowly and not to get up without staff present until cleared by therapy to do so. Educated on the use of the call light and was able to verbalize understanding of its use. No further questions or concerns at this time. - 9/10/23 at 3:32 p.m., identified R118 complained of nausea and general gastrointestinal distress. R118 had her morning medication sitting on bedside table and stated, I'm just not going to take them with me being nauseated, I was going to earlier but decided not to as won't keep them down. Resident sat at bedside, alert and orientated, complained of nausea, pneumand was given Maalox. R118's COVID test negative. R118 just could not give specific symptoms of not feeling right; just nauseated. R118 had large normal bowel movement, denied shortness of breath or respiratory distress, chest pain or discomfort. Vital signs were within normal range for R118's baseline. Staff encouraged resident to be up and see if that helped. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she was unaware of R118's cough or symptoms. R1's significant change MDS dated [DATE], identified R1 had a moderate cognitive impairment and diagnoses that included dementia, pneumonia, and respiratory failure. R1's progress note dated 9/10/23 at 5:53 a.m., identified R1 was awake this shift since 01 :30 and was irritable. R1 had a non-productive cough since 1 :30 a.m. which was unaided by an Albuterol nebulizer but responded somewhat to Tussin cough syrup. COVID swab administered at 3:30 a.m. and was negative. R1's progress note dated 9/10/23 at 5:44 a.m., identified at 1:00 R1 started having an infrequent nonproductive cough. At 3:00 a.m., R1's cough had increased in frequency but remained non-productive. Vitals were within normal limits. R1's lung sounds were wheezy on left and mildly congested on right in all lobes. R1 was given an Albuterol nebulizer treatment and was somewhat effective. Cough decreased in frequency and respirations came down to 20. At 3:28 a.m., Tussin cough syrup was offered and accepted for cough (medication was effective). At 3:30 a.m., COVID swab administered with negative results. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R1 had repetitive aspiration pneumonia. R1 was not added to the Monthly Infection log. R14 annual MDS dated [DATE], identified R14 had a severe cognitivie impairment and had diagnoses that included Alzheimer's disease. R14's progress note dated 9/10/23 at 5:52 a.m., identified at 3 :30 a.m. a COVID swab was administered to R14 with negative results. R14 had a frequent, non-productive cough from 03:30 - 05:00 with a temperature of 97.5 degrees F. R14's EHR failed to identify further documentation related to R14's cough. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R14 did not have a repeat test. RN-B read the progress note and was aware of R14's symptoms but did not add R14 to the Monthly Infection log. R49's admission MDS dated [DATE], identified R49 had no cognitive impairment and had diagnoses that included atrial fibrillation, hypertension, and diabetes. R49's progress notes identified the following: - 9/17/23 at 8:19 p.m., R49 was out of the facility, returned with upper wheeze vocal sounds with breathing. Only happened when breathing through his nose. Denied any allergies. COVID test was done, lungs assessed, clear throughout. Denied shortness of breath. Denied wanting to go to ER. fell asleep during the assessment. Noted short periods of apnea, and then R49 coughed and took a deep breath. -9/17/23 at 11:09 p.m., identified R49 was of the facility for a birthday party. R49 came back very fatigued and went straight to bed. He did not get up for supper so R10's insulin was held and continued to monitor his blood sugar. Later, R49 was complaining of a cough and phlegm in his throat. His lungs were clear. Blood pressure was 111/73, oxygen saturations were 93%, pulse was 77, temperature 98 degrees F and respirations 14. R49 continued to state that he was not feeling well, he thought this may be because of taking the suboxone. This was his third dose, but R49 stated his symptoms started shortly after. Nursing continued to check in on the R49 multiple times throughout the remainder of the shift. R49 was having longer periods of apnea and staff reminded him to breathe. R49 was still refusing to go into the ER. During an interview on 9/27/23 at 9:06 a.m., RN-B stated the charge nurse stated in her note R49 said it was a side effect of his meds, but R49 had signs of COVID-19. RN-B was unaware of R49's symptoms. R15's significant change MDS dated [DATE], identified R15 had no cognitive impairment and had diagnoses that included atrial fibrillation, renal insufficiency, and cancer. R15's progress notes identified the following: - 9/17/23 at 8:27 a.m., identified the nursing assistant summoned nursing to R15's room and stated she thought R15 was sick. R15 was lying in bed with blankets and all clothes stripped away, a flushed complexion, and covered in yellow vomit. R15 stated I feel like horseshit. R15's rapid COVID test was negative. R15 was taking chemotherapy. Charge nurse was updated. - 9/17/23 at 11:00 a.m., identified staff stopped and spoke with R15. R15 reported he was not feeling well all over. Rapid COVID test was negative. R15 was in bed resting. - 9/17/23 at 1:27 p.m., identified R15 was in bed since 9:30 a.m., stating I feel sick. Supervisor updated. During an interview on 9/27/23 at 9:06 a.m., RN-B stated, yes, R15 was showing signs and symptoms of COVID-19. RN-B was unaware of his symptoms. R45's significant change MDS dated [DATE], identified R45 had a mild cognitive impairment and had diagnoses that included hypertension, pneumonia, and diabetes. R45's progress note dated 9/23/23 at 4:25 p.m., identified R45 told staff she had been sneezing and coughing and had a burning throat. A COVID-19 test was administered and was negative. R45's EHR lacked to identify further information regarding R45's symptoms. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she was unaware of R45's symptoms but R45 had previously been positive for COVID-19 less than 30 days prior. The facility Monthly Infection log dated September 2023, identified room number, resident name, site, criteria met, date of admit, date of symptoms, signs/symptoms, antibiotic treatment, antibiotics entered in antibiotic tracker, 72-hour hold completed in antibiotic tracker and resolved date. The log identified five UTI, one sepsis, one right ankle repair and one cellulitis. The log lacked to identify any infection not requiring antibiotic treatment, including R10's COVID-19 infection; and R118, R1, R14, R49 or R15 potential infection symptoms. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she would need to speak with the DON because she was unsure what was requested when asked for the surveillance logs. RN-B provided a large green binder and stated the facility conducted infection prevention rounds weekly. A map of the facility was color coded by infection type to determine if there were any common factors such as room location. The log identified any resident who required antibiotic treatment for an infection. RN-B reviewed nursing progress notes daily and ensured monitoring was entered into the resident's EHR. On the units, nursing also had a log where they entered information, but this was also for residents treated with an antibiotic. RN-B reviewed the unit logs at the end of the month and entered them onto the log in the binder. Because R118, R1, R14, R49 or R15 were not prescribed an antibiotic, they would not be entered into the log for trending and/or tracking. During an interview on 9/27/23 at 10:45 a.m., the DON stated RN-B was in the infection prevention role for approximately three months. In the beginning, the DON was pretty involved, but RN-B seemed to catch on quickly. General surveillance logs should be reviewed by the nurse managers consistently and then given to RN-B at the end of the month to review them. The nurse managers were responsible for infection prevention on their units, were responsible to implement transmission-based precautions, and tracking and/or trending of infections during the month. The nursing staff should update the nurse managers with any signs/symptoms of infection and enter the information on the log. During an interview on 9/27/23 at 12:54 p.m., RN-B stated she was aware of the missing months of Monthly Infection Control Reporting Logs from the units and the Lodge unit never completed them. [NAME] verified there are months missing from the Monthly Infection Control Reporting Log and The Lodge unit never completed them. They should have and the unit managers were educated about that. The facility policy Surveillance for Infections revised September 2017, identified the Infection Preventionist would conduct ongoing surveillance for healthcare acquired infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Infections that will be included in routine surveillance include those with: a. Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection; c. Clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C. diff); and d. Pathogens associated with serious outbreaks. (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza). In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted; for example, focused surveillance data may be gathered for residents with a high-risk for infection or those with a recent hospital stay. Catheter Care: R121's admission MDS dated [DATE], identified R121 had no cognitive impairment and R121 used an indwelling urinary catheter. R121's Order Summary Report dated 9/26/23, identified the following: 1. Staff were to provide education regarding catheter care every shift. 2. Change foley catheter as needed based on clinical indications such as infection, obstruction or when the system is compromised. During an observation on 9/26/23 at 10:23 a.m., LPN-C emptied R121's catheter leg bag. LPN-C applied gloves and obtained R121's graduate from his bathroom. LPN-C placed the graduate on the floor under the R121's catheter leg bag port, opened the port and drained the bag. LPN-C cleaned the catheter bag port with an alcohol swab and closed the port. LPN-C then poured the urine into the toilet and rinsed the graduate with water. During an interview on 9/26/23 at 10:32 a.m., LPN-C stated you needed to make sure to wipe the port with alcohol before opening the catheter bag port. Normally, she would have placed a barrier between the graduate and the floor. She just didn't today. LPN-C believed she cleaned the port before opening. During an interview on 9/27/23 at 1:05 p.m., RN-D stated she expected staff to follow the facility's procedure for catheter care by placing a barrier between the graduate and the floor and cleaning the port before and after opening. During an interview on 9/27/23 at 1:14 p.m., the DON stated she expected staff to perform catheter care per procedure by placing a barrier between the floor and the graduate as well as cleaning the port prior to opening to prevent the spread of possible bacteria. The facility's catheter care policy was requested but not received.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R5, R26, R19, R58, R61) reviewed for immunizations. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 admitted to the facility on [DATE], was [AGE] years old, at had diagnoses including hypertension, atrial fibrillation, and history of pancreatic cancer. The facility Immunization Report dated 9/27/23, identified R5 received the pneumococcal polysaccharide vaccine (PPSV23) on 12/2/08 and the pneumococcal conjugate vaccine (PCV13) on 10/30/15. R5's electronic health record did not include evidence R5 or R5's representative received education regarding pneumococcal vaccine booster and there was no indication R5 was offered the pneumococcal vaccine per CDC guidance. R26's quarterly MDS dated [DATE], identified R26 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses including hypertension and stage 3 chronic kidney disease. The facility Immunization Report dated 9/27/23, identified R5 received the PPSV23 on 11/3/05, and the PCV13 on 6/9/16. R26's electronic health record did not include evidence R26 or R26's representative received education regarding pneumococcal vaccine booster and there was no indication R26 was offered the pneumococcal vaccine per CDC guidance. R19's quarterly MDS dated [DATE], identified R19 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses including diabetes mellitus type 2 and hypertension. The facility Immunization Report dated 9/27/23, identified R19 received the PPSV23 on 9/22/10. R19's electronic health record did not include evidence R19 or R19's representative received education regarding pneumococcal vaccine booster and there was no indication R19 was offered the pneumococcal vaccine per CDC guidance. R58's significant change MDS dated [DATE], identified R58 was readmitted to the facility on [DATE], was [AGE] years old and had diagnoses including coronary artery disease, hypertension, and ischemic cardiomyopathy. The facility Immunization Report dated 9/27/23, identified R58 received the PPSV23 on 10/2/09, and the PCV13 on 2/1/16. R58's electronic health record did not include evidence R58 or R58's representative received education regarding pneumococcal vaccine booster and there was no indication R58 was offered the pneumococcal vaccine per CDC guidance. R61's admission MDS dated [DATE], identified R61 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses including coronary artery disease, hypertension, and rheumatoid arthritis. The facility Immunization Report dated 9/27/23, identified R61 received the PPSV23 on 1/4/12, and the PCV13 on 5/2/17. R61's electronic health record did not include evidence R61 or R61's representative received education regarding pneumococcal vaccine booster and there was no indication R61 was offered the pneumococcal vaccine per CDC guidance. During interview on 9/27/23 at 2:30 p.m., the director of nursing (DON) stated upon admission the nursing staff review the residents medical record as well as the Minnesota Immunization Information Connection (MIIC) database for immunizations and enter the data into the facility immunization assessment. The assessment would identify what immunizations the resident was due for, then staff would offer the immunizations to the resident and/or family representative. The DON was aware the guidance for pneumococcal vaccines had recently changed, and their assessment was updated accordingly. During interview on 9/27/23 at 2:47 p.m., registered nurse (RN)-A, stated they were looking at pneumococcal vaccines with new admission, quarterly, and significant change assessments. The electronic assessment was recently updated but was not updated according to the newest CDC guidance. When there was a new admission, the staff would assess the residents needs and then offer the pneumococcal vaccine, if indicated. They did not have a plan in place to offer or administer pneumococcal vaccinations for current residents. The facility Pneumococcal Vaccine policy version 2.2 (H5MAPL0650), identified upon admission, residents would be assessed for eligibility to receive pneumococcal vaccines and when indicated, would be offered on of the pneumococcal vaccines within thirty days of admission unless medically contraindicated. Before receiving a pneumococcal vaccine, the resident or legal representative would receive education regarding the benefits and potential side effects of the pneumococcal vaccine according to the current vaccine information statements. Provisions of such education would be documented in the resident's medical record. The policy did not address the updated CDC guidance. The facility copy of the currently used Pneumococcal Vaccine Information Sheet was requested but not received.

Based on observation, interview and document review, the facility failed to honor resident's right for privacy for 1 of 1 resident (R10) reviewed for resident privacy. Findings included: R10's annual Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment and a diagnosis of COVID-19. R10's progress note dated 9/25/23 at 4:42 p.m., identified R10 returned following a hospitalization for acute respiratory failure due to COVID-19 and was to remain in isolation until 9/28/23, at 11:59 p.m. During an observation on 9/25/23 at 5:17 p.m., a visitor and seven other residents were in the dining room. The visitor asked if R10 would be coming to the dining room to join for the meal. Nursing assistant (NA)-E stated residents had to maintain a 6 foot distance between each other because R10 was positive for COVID-19. Other residents began asking NA-E questions about how long they had to do that, etc. NA-E wasn't up-to-date with COVID requirements, but NA-E thought it was 10 days. NA-E told the residents they needed to stay 6 feet apart at least for a few more days. During an interview on 9/25/23 at 5:34 p.m., NA-E stated the residents already knew R10 had COVID-19 because R10 told them, but, no, we're not supposed to tell people that. During an interview on 9/25/23 at 6:67 p.m., R10 stated he valued his privacy and did not want the other residents in the facility to know he was hospitalized with COVID-19; and didn't want the other resident spreading rumors around about him. During an interview on 9/27/23 at 9:19 a.m., NA-A stated you never discuss a resident's health status or illnesses with other residents. During an interview on 9/27/23 at 1:25 p.m., the director of nursing (DON) stated staff should not talk with residents about the health status or illness of another resident. It was an expected right for R10 to have privacy. The facility's Health Insurance Portability and Accountability Act (HIPAA) Privacy Policy and Procedure dated 9/2016, identified the facility was responsible for ensuring the employees were trained to adhere to HIPAA privacy policy and procedures.

Based on interview and document review, the facility failed to provide adequate supervision when staff did not appropriately respond to a sounding exit door alarm for 1 of 3 residents (R1) identified at risk for elopement, who was able to exit the building, despite WanderGuard alarming, resulting in R1 being outside the facility without staff knowledge. This resulted in an immediate jeopardy (IJ). The immediate jeopardy began on 4/16/23, at approximately 3:00 a.m. when R1 was found outside the facility banging on the entrance door near the unit he resided on. The IJ was identified on 4/28/23, and the administrator was notified of the IJ on 4/28/23, at 5:45 p.m. The immediate jeopardy was removed on 4/19/23, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's Admission Record indicated admitted [DATE], with diagnosis that included: vascular dementia, epilepsy, muscle weakness and a history of falls. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he did not display wandering behaviors during the assessment period. The MDS indicated R1 required extensive assistance from two staff to transfer and indicated he required extensive assistance for locomotion off the unit. R1's care plan updated 4/19/23, identified a risk for elopement related to impaired safety awareness and diagnosis of severe cognitive impairment related to a traumatic brain injury. Additionally, the care plan indicated areas of vulnerability to include: mobility limitation, poor orientation to time, person and place, memory loss and a history of falls. R1's facility Progress Notes dated April 2023 identified the following: -4/9/23, at 2:19 p.m. R1 was described as pleasant, anxious and exit seeking. -4/9/23, at 9:50 p.m. R1 repeatedly wanted to know when the bus was coming and left his coat on all shift. -4/10/23, 9:51 p.m. R1 exited his room asking staff to grab his coat. R1 stated he had a friend coming to pick him up to take him to work. Staff attempted to re-orient R1 to time and that he did not need to go to work but R1 persisted that he needed his coat and propelled himself around the unit. -4/12/23, 7:07 a.m. R1 had no behaviors on shift but had his coat on and was waiting for the bus to come. -4/13/23, 9:00 p.m. R1 was exit seeking and wandering. -4/14/23, 4:00 a.m. R1 was confused and restless, would put his coat on, self transfer into wheelchair and come to the nurse's station stating he was ready to go. -4/15/23, 10:33 p.m. R1 had been wandering and kept thinking someone was coming to get him to take him to the VFW. R1 slept on the couch in the day area and refused to go to bed. -4/16/23, 4:38 a.m. Writer had been alerted by another nurse that R1 had been brought in from outside after he was found banging on the side door of the Woods community. PN indicated, R1 stated a car had pulled up then took off as he attempted to get in. R1 stated he had been heading to work. R1 was asked if had had fallen and he stated he and his wheelchair had tipped forward which was why the knees of his pants were muddy. -4/16/23, 5:02 a.m. Writer was notified R1 was found outside the doors of the unit at 3:00 a.m. with mud on both pant legs. R1 had a history of wandering and a history of falls. 15 minute checks were initiated. An undated, untitled document indicated interviews were conducted with staff who worked on 4/15/23, who indicated there had been nothing out of the ordinary about R1's day, demeanor or behavior. Nursing assistant (NA)-A and NA-B stated R1 came out of his room after supper wearing his jacket and stated he was waiting for the guys to pick me up for work. NA-A stated it was common for R1 to wear his coat and said R1 had been making comments for several weeks about waiting to be picked up for work. NA-B stated R1 used to say that sometimes but had been making that statement every shift for several weeks. Both NAs denied any exit seeking by R1 that shift and said he was asleep on the couch at the end of the shift at 10:30 p.m. NA-C stated he was working when R1 eloped from the facility and said he had assisted R1 to bed around midnight. NA-C stated he had last seen R1 during a routine safety check between 1:45 a.m. and 2:00 a.m. Licensed practical nurse (LPN)-A stated between 2:45 a.m. and 3:00 a.m. on 4/16/23, she was going to assist a NA with cares and heard the main entrance door alarm sounding. LPN-A said she went to the front door and did not see anyone so she turned the alarm off and went back to the unit to assist the NA. LPN-A stated after she exited the resident's room, another resident was standing in the hallway saying she could hear someone. LPN-A said she went into the resident's room but said she could not hear anything and left the room. LPN-A said the resident began yelling and when asked why she was yelling stated, in case they can hear me. As LPN-A left the room she could hear someone and indicated it sounded like it was coming from down the hall. A NA went to look and at that time LPN-A saw R1 sitting outside the door. When R1 saw LPN-A he began banging on the door and yelling help me. R1 told LPN-A a car pulled up and then left without him. LPN-A stated she had not seen any vehicles when the alarm sounded or when she found R1 outside. LPN-A said R1 was wearing his winter coat, shoes and a baseball cap. R1 was noted to have mud on his knees but denied falling and stated his wheel chair had tipped forward but he caught himself. The temperature outside was 37 degrees Fahrenheit and R1 had been outside for approximately 10 - 15 minutes. During interview on 4/28/23, at 2:29 p.m. R1 was laying in bed in his room. R1 said he used to work for his cousins on the farm bailing hay and was up at 4:00 in the morning. R1 said he had been at the facility for [AGE] years or more. When asked about going outside on the night of the 16th, R1 said he had to go outside in his wheel chair. R1 said, If I get to places, I know how to get around and stuff. If I had to do it again I would probably do it. On 4/28/23, at 2:43 p.m. NA-D stated the reason R1 moved to his current unit two years ago was because of attempts to leave the facility and said back then he had found R1 outside and R1 thought he was meeting a police officer. NA-D stated he was aware R1 had gotten outside again on the 16th and said education and elopement drills had been done after the incident. On 4/28/23, at 3:16 p.m. the administrator stated when LPN-A was interviewed she said she had looked outside and did not see anyone so she silenced the alarm The administrator stated LPN-A had not followed the procedure for a missing resident. The administrator said elopement training had been conducted on 4/6/23, following the closure of the secured unit and said that LPN-A had reviewed the policy and procedure at that time and was re-educated following the incident on 4/16/23. On 4/28/22, at 4:22 p.m. LPN-B stated if an alarm sounded she would go outside and check to see if anyone was there. LPN-B stated she would then call and alert all of the units, check rooms and locations and notify a supervisor. On 4/28/23, at 4:23 p.m. NA-E and dining assistant (DA)-A stated they had received education following the incident on 4/16/23, and said if an alarm sounded indicating a resident had gotten outside they would alert everyone and do a head count. Facility document titled, Missing Resident, Elopement and Wandering Residents dated 4/6/23, indicated if a door alarms and you respond but do not see a resident who would have caused the alarm, initiate a missing resident drill to confirm the whereabouts of each resident. Facility policy Emergency Procedure-Missing Resident dated August 2018, indicated resident elopement resulting in a missing resident was considered a facility emergency. The policy identified the missing resident procedure and directed staff to: Announce missing resident with room number, note the time missing, report to the nursing station to see if signed out and conduct a thorough search for the resident. The past noncompliance immediate jeopardy began on 4/16/23. The immediate jeopardy was removed, and the deficient practice corrected by 4/19/23, after the facility implemented a systemic plan that included the following actions: - R1 was immediately placed on 15 minute checks. - Elopement training on 4/16/23, to include review of the policy and procedure and the implementation of wander books (books that contained a picture of all residents assessed at risk for elopement). - Elopement drills performed each shift then daily on 4/17/23 - 4/20/23. - Interdisciplinary team met on 4/19/23, to review and updated care plan interventions to include: increased 1:1 visits, sitting in common area after dinner to increase socialization and improve sleep schedule and removing items from room that act as visual cues for exit seeking behaviors such as work boots and fishing pole. A sign was also placed in R1's room that said congratulations on your retirement. Other interventions included a medication review and referral to neurology.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R2) with sexual behaviors, was comprehensively assessed and interventions implemented to mitigate risk to others and prevent subsequent sexual abuse of 1 of 1 resident (R1) reviewed whom was dependent on staff for their care. These findings resulted in an immediate jeopardy (IJ) situation for R1 when she was sexually abused by R2 while at the nursing home. The IJ began on 10/1/21, when the facility failed to implement appropriate interventions to protect a resident (R1) from sexual abuse after they became aware R2 was exhibiting inappropriate sexual behaviors toward staff, residents and R1. This lack of action contributed to R2 subsequently entering R1's room and sexually assaulting her as well as a witnessed and video recorded assault which occurred in the facility dining room. The administrator and the director of nursing (DON) were notified of the IJ for R1 on 10/12/21, at 4:35 p.m. The IJ was removed on 10/13/21, at 3:03 p.m. when the facility successfully implemented a removal plan. Findings include: A submitted state agency (SA) incident report, dated 10/1/21, identified a facility's reported allegation of sexual abuse involving R1 and R2. The report outlined the facility had received a report from a resident (R4) who witnessed unwanted touching between R1 and R2 of a sexual nature. The report outlined the police were contacted and an investigation was underway. R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact. On 10/11/21, at 1:56 p.m. during an interview, R4 stated he witnessed R2 groping R1's leg, groin and breasts in the dining room on 10/1/21. R4 indicated R1 had not said anything however he could tell from the look on her face that it was shocking to her. R4 stated the incident had made him angry and he reported it immediately to the charge nurse. R1 R1's quarterly MDS dated [DATE], identified R1 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 had no behavioral concerns and required extensive assistance with all ADLs. On 10/11/21, at 2:11 p.m. during a joint interview with R1 and family member (FM)-A, R1 stated R2 had groped her on four separate occasions. R1 indicated she was unable to recall if she had reported all incidents to staff however had reported a couple of the past incidents. R1 stated R2 entered her room when she was seated in her recliner, pulled up her pants leg and stroked her calf. He progressed higher up with his hand to stroke her inner thigh and then her groin area. R1 demonstrated where R2 had stroked her. R1 indicated this had occurred three or four times in her room, prior to the dining room incident on 10/1/21. R1 stated on 10/1/21, while she had been seated in the dining area, R2 wheeled up to her, stroked her inner thigh and progressed to her groin area. R1 indicated R2 then reached up and grabbed her right breast in a squeezing manner. R1 again demonstrated where R2 had touched her. R1 denied feeling frightened of R1 however stated she did not want R2 to make sexual advances towards her. R2 R2's quarterly Minimum Data Set MDS, dated [DATE], indicated R2 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R2 demonstrated no hallucinations, delusions or rejection of care behaviors, and required extensive assistance with activities of daily living (ADLs). The MDS indicated R2 was unable to ambulate, used a wheelchair for mobility, required supervision for mobility on the unit and limited assistance with mobility off of the unit. R2's care plan, dated 8/19/21, identified R2 was hard of hearing, however was able to communicate his needs and understand others when his hearing aides were worn. The care plan indicated R2 required assistance of one staff with bathing, dressing, grooming, transfers and bed mobility. The care plan identified R2 was independent in using his manual wheelchair, however required assistance propelling long distances. On 9/16/21, an additional focus problem was added to R2's care plan and identified R2 had exhibited sexually inappropriate behavior with female staff and residents. The care plan outlined an intervention to administer medications as ordered, however, no behavior medications had been ordered. The care plan identified additional interventions which included: staff were to assist R2 to develop more appropriate methods of coping/interacting with female residents and staff, intervene as necessary to protect the rights and safety of others, remove R2 from the situation and take to a different location when needed to minimize disruptive behavior by offering tasks to divert his attention. The care plan indicated R2 required assistance of two staff with all cares. R2's care plan lacked instruction for staff to supervise R2 to ensure safety for female residents or to limit R2's access to vulnerable female residents, which included R1. Review of R2's progress notes from 9/5/21, to 10/4/21, identified the following: -On 9/5/21, R2 wandered around the unit and entered other resident rooms. R2 had stated he had been trying to learn where other residents lived. R2 indicated he had seen them in the dining room but did not know where they lived. R2 had no documented behaviors of wandering prior to 9/5/21. -On 10/1/21, R2 was observed by another resident (R4) in the dining area, inappropriately touching a female resident's upper thigh and breast. R2 voluntarily agreed to stay in his room the rest of the weekend. He agreed to just go out in the courtyard near his room and to the dining area for meals. He was reminded to keep his hands to himself. -On 10/4/21, R2's primary care provider had been contacted and an order was received to obtain a mental health evaluation and treatment. R2's progress notes lacked documentation of the 9/6/21 incident with facility staff and did not include documentation of any incidents when R2's care plan was modified on 9/16/21 to address sexually inappropriate behaviors. On 10/12/21, during a joint interview, at 8:53 a.m. with occupational therapist (OT)-A and rehabilitative aide (RA)-C, OT-A stated she had heard R2 had demonstrated inappropriate sexual advances towards her co-worker, OT-B, who no longer worked at the facility. OT-A indicated it was strange the behaviors had not been documented however she was aware OT-B had reported R2's behavior to the unit manager (UM). RA-C stated she had experienced an unwanted sexual encounter with R2 as well. She had been alone in the therapy room on 9/6/21, when R2 entered the room and wheeled his wheelchair up to where she was seated. R2 commented to RA-C he noticed she had dyed her hair. R2 proceeded to grab RA-C in the crease of her groin with a stroking motion and asked if her downstairs matched as well. RA-C indicated she had been frightened of what R2 might do next and she felt trapped. R2 wheeled away after a short time to see his therapist. RA-C stated she had reported it immediately to UM-B. RA-C indicated since the incident occurred, she did what she could to avoid being near R2. On 10/12/21, at 11:42 a.m. during an interview,UM-B confirmed RA-C had verbally reported R2 had demonstrated inappropriate sexual behavior toward her, which consisted of sexual language and touching. UM-B stated she implemented behavior monitoring of R2 for seven days after the incident to see if there was a pattern and notified UM-A, R2's UM, on her return from vacation leave. UM-B stated she had not documented the incident in R2's medical record (MR). Additionally, UM-B stated she was aware of the behavioral incident with OT-B, and verified the incident had not been documented either. UM-B indicated the incidents should have been documented in R2's MR and was unsure why they had not been recorded. On 10/12/21, at 11:52 a.m. UM-A stated she was aware it had been reported R2 had displayed inappropriate sexual behavior towards facility staff. UM-A indicated OT-B informed her R2 had grabbed her around the waist, pressed her into his body and rubbed her thigh while they were talking. OT-B stated to UM-A, R2 gave her the creeps. Additionally,UM-A had been notified of the inappropriate sexual encounter R2 had demonstrated with RA-C. After being informed of the incidents, UM-A added the problem to R2's care plan on 9/16/21, as well as the intervention of having two staff assist with all R2's cares. UM-A indicated R2 was alert and oriented and had not exhibited wandering behaviors. UM-A confirmed R2's inappropriate sexual behavior incidents had not been documented in R2's MR and indicated she expected such incidents to be documented. UM-A stated she had communicated R2's incidents on the facility communication log and instructed staff to have two staff assist with his care. Additionally, UM-A indicated after R2's inappropriate sexual behaviors towards R1, the physician had ordered a psychiatric evaluation for R2. UM-A confirmed the facility had not implemented supervision for R2. The interdisciplinary team (IDT) had met and discussed options and they had talked to R2 again. R2 had denied doing anything sexually inappropriate and continued to state he had just tapped R1's leg and patted her shoulder in an attempt to encourage her. UM-A stated the facility had educated R2 on maintaining others personal space. R2 had verbalized understanding and a psychiatric appointment was in the process of being scheduled. The IDT team decided the interventions were appropriate and R2 did not require supervision. Review of the facility staff communication logs from 9/1/21, through 10/12/21 identified on 9/16/21, a note was made which instructed staff to have two staff present to assist with R2's cares. Review of the facility nurses communication logs from 9/1/21 through 10/12/21 identified on 10/1/21, an entry was made which instructed staff R2 would be confined to his room over the weekend and staff were expected to remind R2 to keep his hands to himself. The logs lacked documentation of any other interventions for protection of other residents which included supervision of R2. On 10/11/21, at 4:34 p.m. during an interview, nursing assistant (NA)-A stated she had assisted R2 with cares and was not aware he had inappropriate behaviors. NA-A stated she had observed him visiting with other residents in the dining area and was not aware of any specific interventions in place for R2 to manage his behavior. On 10/11/21, at 4:42 p.m. during an interview, NA-B indicated he had not been aware of R2's inappropriate behaviors until he was informed about the resident to resident incident a week ago. NA-B stated he had never been instructed on any behavior interventions for R1. Nursing Assistant daily unit report sheets for September 2021 were reviewed. The report sheets identified assistance needed, voiding, and behaviors for each resident. The sheets indicated R2 received a weekly bath and had hearing aides. The nursing assistant daily unit report sheets lacked identification and interventions related to R2's sexual behaviors or protection of other residents. On 10/12/21, at 9:47 a.m. during an interview, R2 stated he had been talking with R1 when someone reported he had been flirting with her. R2 indicated he had stopped to talk with R1 in the dining room and he reached over and squished her leg. R2 stated he had been watching R1 and noticed she never seemed to have any visitors. R2 indicated he might have visited R1 in her room once however was not sure as it had been a while ago. R2 stated he had been pissed off when the facility had brought in a cop to investigate the incident however indicated the incident had since been resolved. R2 indicated he might have been at fault because when he had spoke with R1, he had touched her legs and stuff. R2 stated the facility staff had informed him if he entered another resident's room he was to leave the door open. R2 indicated the facility had stated he was not to visit R1 in her room anymore. R1 R1's care plan dated 9/23/21, identified R1 required extensive assist of one staff with ADLs. The care plan indicated R1 was able to communicate her needs and understood others, however, her speech was quiet and soft. The care plan identified R1 as a vulnerable adult related to limited mobility and sensory impairment. R1's care plan identified the following interventions: staff were to observe and provide a safe environment, if staff observed or suspected abuse, staff were to remove resident from aggressor and relocate her to a safe location, notify immediate supervisor and complete an incident report. The care plan identified R1 received an anti depressant medication and had target behaviors of tearfulness, isolation, agitation and poor self-outlook. Review of R1's progress notes from 9/5/21, to 10/6/21, identified the following: -9/5/21, LPN-A noted R1 had another resident in her room. -9/19/21, LPN-A noted R1 had visits from another resident. -10/1/21, R1 was reported to have been inappropriately touched by a male resident in the dining room. The incident was witnessed by another resident. Investigation had been started and the police were contacted. The male resident had agreed to voluntarily stay in his room over the weekend. On 10/11/21, at 4:42 p.m. during an interview, nursing assistant (NA)-A stated he had seen R2 patting other resident's knees. NA-A indicated he had observed R2 in R1's room a couple of times a week in the past three to four weeks. NA-A stated he had been informed by the day shift a few weeks ago, R1's spouse did not want R2 visiting R1. Since then, NA-A stated he re-directed R2 to leave R1's room when he noticed him in there. On 10/11/21, at 5:41 p.m. licensed practical nurse (LPN)-A stated she was aware R2 wandered on the unit and entered R1's room. LPN-A indicated the behavior had started in early September when R2 was observed to be roaming the halls and going in and out of resident rooms. LPN-A stated when she asked R2 what he was doing, R2 said he was trying to figure out where the other residents who ate meals with him in the dining room lived. LPN-A indicated about a week later she had found R2 in R1's room. LPN-A stated the room had been dark and R2 had his hand resting on R1's knee. LPN-A indicated she had redirected R2 out of R1's room and reported the incident to the unit manager. LPN-A stated she was not sure what interventions had been put in place after the incident. LPN-A confirmed R2 was the resident who was observed to be in R1's room in 9/5/21, and 9/19/21. On 10/12/21, at 10:14 a.m. R1 was wheeled into the dining room by staff for her breakfast meal. R2 exited his room via his wheelchair independently into the dining room and stopped six to eight feet away from R1. Staff offered R2 a cup of coffee and did not redirect him from the area. R1 was observed to glance up and watch R2 several times as she was eating. Nursing staff left the dining room. The dietary aide was in the kitchenette, loaded the breakfast trays onto a cart and left the area. R1 and R2 remained in the dining room area alone, for several minutes. No other staff or residents were present. On 10/12/21, at 12:45 p.m. during a joint interview with director of nursing (DON) and the administrator, the administrator stated they believed R2 had understood the seriousness of his actions and R2 stated he would not do it again. The administrator indicated when the facility had spoke with R2 in the past regarding his inappropriate sexual behaviors, they did not believe it had hit home, however they believed when the police officer arrived and spoke to R2, he had the understanding the incident was very serious and his behaviors were inappropriate. The administrator had offered R1 and R2 a change of rooms and both had declined. The DON indicated she had discussed one to one supervision with R2 and he adamantly refused the intervention. DON stated R2 had indicated he preferred to stay in his room for the weekend after the incident instead. The DON indicated after the weekend of the incident, R2 was free to resume his normal activity and R2 received no additional supervision other than what was provided to all residents residing on the unit. DON confirmed R2 was able to go to the therapy department several hallways away and his movements throughout the building had not been restricted without supervision. DON and administrator offered no other interventions the facility had put in place to ensure safety and protection for R1 and other vulnerable female residents. The administrator indicated the 10/1/21, incident had been recorded as the dining room area was video monitored, however felt the recording was inconclusive. On 10/12/21, at 4:00 p.m. the video recording was reviewed with the surveyor, administrator and DON, which revealed the following: On 10/1/21, around 12:00 p.m. R1 was observed to be seated at her dining room table with her back to the camera. R2 became visible in the camera and wheeled past R1. R2 wheeled himself to the nurses room and was just visible on the upper right hand side of camera, facing the nurses room with his back towards the camera. R2 then turned and wheeled back into the dining area and wheeled his wheel chair next to R1's wheel chair. R2 lifted his hand and placed it inside R1's wheel chair, into her lap. R2's hand was not visible on camera, however remained in the vicinity of R1's lap area for several minutes and his arm was observed to move in a back and forth stroking motion. Another wheel chair became visible on the upper right hand side of the camera's view. R2 looked behind him, toward the other wheel chair, turned back to R1 and after several seconds longer of continued stroking motions, patted R1's thigh and removed his hand from her lap area. R2 started to wheel away from R1, stopped, again backed his wheel chair next to R1's chair and reached out with his hand and grasped an area of R1's upper torso for several seconds. R2 removed his hand from R1's upper torso and wheeled away from her and exited from view of the camera. The administrator stated the video had not confirmed unwanted sexual contact, as R2's hand placement was not able to be determined. The facility's Grand Village & Ecumen's Abuse Prevention Plan For Minnesota Skilled Nursing Facilities, dated 2/5/20, identified all residents residing in the facility would be protected from abuse, neglect, misappropriation of property, exploitation, maltreatment and mistreatment. The policy defined sexual abuse as non consensual sexual contact of any type with a resident. Sexual contact may include the intentional touching of a resident's intimate parts, including the touching of the clothing covering the immediate area of the intimate parts. Protection of residents during an investigation of maltreatment outlined all residents would be protected from harm during an investigation. The facility would prevent further potential abuse or mistreatment and ensure the resident's psychosocial well-being as related to to the incident under investigation,while the investigation was in progress. Individual abuse prevention plans would be developed and implemented for all residents, including specific measures to be taken to minimize the risk of abuse for each individual. The IJ which began on 10/12/21, was removed on 10/13/21, when the facility successfully implemented a removal plan which included: comprehensively reassessing R1's psychosocial status, constant supervision for R2 to ensure the safety of all female residents residing in the facility, physician appointment for R2 for evaluation of potential acute condition changes, psychiatric appointment scheduled for R2, reassessing other female residents identified at risk to ensure no other residents were affected by R2's behaviors and education of facility staff on the facility's abuse prevention policy. On 10/13/21, from 1:00 p.m. to 3:00 p.m. interviews with direct care staff and management verified training on abuse and the newly implemented interventions were in place with R2, along with reporting resident behaviors. Observations of R2's one to one supervision were also completed. The facility reassessed all female residents residing in the facility to identify any other potential residents affected.

Based on observation, interview and document review, the facility failed to ensure staff implemented appropriate infection control practices to prevent and control the transmission of [CONDITION(S)] (C-Diff, a highly infectious spore forming bacterium) when caring for 1 of 1 resident (R98) diagnosed with C-Diff. The facility's lack of infection control precautions resulted in an Immediate Jeopardy (IJ) with the potential for serious harm, injury or death for the other 12 residents residing on the Spruce unit. In addition the facility failed to implement appropriate infection control practices for 1 of 1 resident (R299) who was presumed to have the bacterium, and failed to perform appropriate hand hygiene and/or catheter care for 3 of 7 residents (R299, R200, R54) observed during personal care. Lastly, the facility failed to ensure wound care was not performed with expired normal saline solution for 1 of 1 resident (R51) who was observed to receive wound care. The Immediate Jeopardy (IJ) began on [DATE], when staff were observed providing cares for R98 who was on contact precautions related to the C-Diff infection without implementing appropriate infection control techniques. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:50 p.m. The IJ was removed on [DATE], at 4:39 p.m. however, non-compliance remained at the lower scope and severity of E, pattern, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: R98's significant change Minimum Data Set (MDS) dated [DATE], indicated R98 had severe cognitive impairment, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R98 required extensive assistance with all activities of daily living (ADL) and was always incontinent of bowel and bladder. R98's Urinary Incontinence Care Area Assessment (CAA) dated [DATE], indicated R98 was always incontinent of bowel and bladder, and required staff assistance to check and change incontinence products every two hours. In addition, R98 was diagnosed with acute C-diff on [DATE], and was treated with [MEDICATION(S)] (antibiotic medication) for one week. R98 was noted to have had 23 bowel movements during the reference period, and the staff were to monitor the number of bowel movements. R98 was to remain on contact transmission based precautions until the C-Diff resolved. R98's Progress Notes (PN) revealed the following: -[DATE], at 5:04 a.m. R98 had a large loose [MEDICATION(S)] stool. -[DATE], at 551 a.m. R98 had two flemmy, loose gelatinous stools .one stool had about ,d+[DATE] 1 cm (centimeter) long red streaks. -[DATE], at 9:45 a.m. R98 had a loose stool prior to breakfast that was yellowish brown and slimy. -[DATE], at 1:04 p.m. R98 was unresponsive, loose stools were evaluated and family member were offered to have R98 evaluated at the emergency room . Family declined evaluation and requested a Hospice consult. -[DATE], at 3:57 p.m. R98 evaluated at the emergency room (ER) per family request. -[DATE], at 8:57 p.m. R98 returned to the facility. R98 did have a bowel moment while in the ER and received orders to monitor bowel moments. -[DATE], at 5:25 a.m. R98 had [MEDICATION(S)] stools during the night shift. -[DATE], at 9:24 p.m. R98 had blood in stools. -[DATE], at 1:31 p.m. R98 had three loose yellow stools. -[DATE], at 10:28 p.m. R98 had two loose stools (no further description). -[DATE], at 5:46 a.m. R98 had three loose stools during the night shift that were of mucous like texture. -[DATE], at 12:16 p.m. the facility obtained an order to obtain a stool culture for C-diff. The facility implemented contact precautions. -[DATE], at 4:29 p.m. R98 was diagnosed with C-diff and started on medication. R98's laboratory results collected on [DATE], revealed R98 was positive for the C-Diff infection. R98's Care Plan initiated [DATE], and revised on [DATE], indicated R98 had diarrhea related to C-Diff infection. R98 was always incontinent of bowel and bladder and directed the staff to check and change incontinent brief every two hours and as needed. R98 was rarely/sometimes aware of the urge to urinate/defecate and directed two staff to utilize the EX-Lift for transfers. The plan also directed the staff to monitor for signs and symptoms of dehydration and infection, to monitor R98's frequency of bowel movements every shift, and to provide peri cares after each incontinent episode. The plan did not direct the staff to ensure contact precautions were maintained. R98's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 5:55 p.m. R98 was observed in the dining room, seated in a wheelchair. Licensed practical nurse (LPN)-D assisted R98 with his liquids as he waited for the evening meal to be served. -At 6:12 p.m. LPN-D wheeled R98 out of the dining room and into his room. -At 6:29 p.m. LPN-D stated R98 had been wheeled out of the dining room because he had a loose stool and was on contact precautions due to C-Diff. Nursing assistant (NA-A) donned a face mask, gown, and gloves and entered R98's room. On [DATE], at 8:20 a.m. NA-F and NA-D stated they were going to transfer R98 from bed into a wheelchair for breakfast. The NA's were observed to don face masks and gloves, and without gowns on, wheeled a full body mechanical lift into R98's room. The NA's proceeded to transfer R98 from the bed and into the wheelchair via the full body lift. Throughout the set-up and transfer, both NA's uniforms were observed to touch the sides of the bed, bedding and R98. Following the transfer, NA-D removed her mask and gloves, tossed them into the trash just inside of R98's room, and exited the room. However, NA-D did not wash her hands prior to leaving the room. Shortly thereafter, NA-F removed her mask and gloves, placed them in the same trash can, and wheeled R98 into the dining room. NA-F did not wash her hands prior to leaving R98's room. -At 8:29 a.m. when asked, NA-D stated she had washed her hands in the Spruce unit's nurses' station sink which was across the unit from R98's room. NA-F confirmed she had not washed her hands after leaving R98's room. -At 8:32 a.m. NA-F was observed to enter the Spruce kitchenette and washed her hands as dietary aide (DA)-A was at the steam table preparing resident breakfast meals. When done washing her hands, NA-F was not observed to disinfect the sink area. -At 8:33 a.m. NA-F confirmed she had washed her hands in the kitchenette while DA-A was preparing meals. NA-F stated she could have washed her hands in an alternative sink instead of in the kitchenette while the meal was being served. NA-F also verified she had not attempted to disinfect the sink or report the potential infection control breach to other staff members. -At 9:17 a.m. DA-A prepared to remove the dirty dishes from the Spruce dining room. The State Agency (SA) informed DA-A of the potentially contaminated sink. DA-A was observed to clean the sink with a bleach based disinfectant. -At 9:28 a.m. NA-D and NA-E reported they were going to assist R98 back to bed. NA-D was observed to don a mask and gloves (no gown). NA-E donned a mask, gown, and gloves. NA-E stated she would be assisting R98 with incontinence cares so she was required to wear a gown. NA-D stated she would not be providing incontinence cares, therefore, she only had to wear a mask and gloves when in the room. -At 9:32 a.m. the NA's were observed to transfer R98 from the wheelchair to the bed via a full body mechanical lift. Once in bed, NA-E rolled R98 towards NA-D. NA-D's uniform came into contact with R98's clothing and bed while she held R98 on his side while NA-E checked R98's incontinent product. NA-E reported R98 had not been incontinent. The NA's positioned R98 onto his side and positioned R98's feet on pillows. NA-D's uniform touched R98's bedding while positioning R98 in bed. -At 9:36 a.m. NA-E offered to cover R98 with a blanket, and proceeded to cover R98 with a sheet, as he requested. NA-E held onto the bottom edge of a blanket, fanned it causing the blanket to lay flat over R98, folded it away from R98's face, and rested the bottom of the sheet on a foot cradle. NA-D was directly next to the bed while the blanket was shook/fanned in the air. NA-D removed her gloves and mask and washed her hands in R98's bathroom. NA-E removed the gown, gloves, and mask and washed hands in R98's room. -At 9:39 a.m. NA-D stated she did not have to wear a gown during cares because NA-F had completed R98's perineal cares. NA-D confirmed her uniform touched R98's clothing and bedding while assisting R98 to bed. -At 9:44 a.m. NA-E stated while providing care for R98, only one NA was required to wear full personal protective equipment (PPE/gown, gloves, mask) as only one NA would come into contact with R98's perineal area. -At 1:42 p.m. registered nurse (RN)-A confirmed C-Diff had the ability to survive on inanimate object for days, weeks, or months, and stated she would expect the staff to wear protective gowns, gloves and masks while providing care to a resident diagnosed with C-diff. In addition, the staff were to remove the PPE in the infected resident's room, and wash their hands in the resident's bathroom and not in the nurse's station or the unit's kitchenette, especially during meal service. -At 3:03 p.m. NA-N stated he had assisted R98 with bowel incontinent cares on [DATE], during the evening meal. NA-N stated R98 had had a loose bowel movement which leaked out of the incontinent product thereby not contained within the incontinent product. At 3:04 p.m. NA-N was observed to don gloves and a mask, enter R98's room carrying a blue, plastic non-disposable cup. NA-N picked up a non-disposable cup from R98's room, left the room, and entered the Spruce living care, and placed the cup on a three tier cart stationed in the main area of the unit. NA-N returned to R98's room, removed the gloves and mask, and without performing hand hygiene, exited the room and asked RN-A what to do with the non-disposable cup that was placed on the cart. RN-A directed NA-N to place the cup in a plastic bag, identify the cup as being from R98's room, and return it to the kitchen. -At 3:07 p.m. NA-N confirmed he had exited R98's room with PPE on and had not washed his hands prior to leaving the room. NA-N proceeded to R98's room and washed his hands, exited the room, began to clean the three tier cart and the outside of R98's cup with a bleach wipe, placed the cup in a plastic bag, and wheeled the cart/cup to the kitchen. R98's PN dated [DATE], at 3:15 p.m. indicated R98's C-Diff isolation precautions were removed due to R98 having been free of symptoms. R98's PN dated [DATE], at 9:00 p.m. indicated R98 had a large incontinent bowel movement. A subsequent PN at 9:05 p.m. indicated R98's physician ordered R98 to be tested for C-diff. A PN at 11:14 p.m. indicated R98 had a stool sample sent to the laboratory. R98's PN dated [DATE], at 9:29 a.m. indicated R98 had a large bowel movement that seeped from the incontinent brief and onto his pants and lift sling. R98 was to be kept in his room to avoid contact with others. R98's PN dated [DATE], at 10:08 a.m. indicated R98's laboratory results were positive for C-Diff therefore R98 was started on [MEDICATION(S)] (antibiotic) 125 milligrams by mouth four times per day for 14 days and contact precautions were re-started. The facility's undated, C-diff Protocol indicated infected clients should be placed in a private room if available or cohort if possible. Contact isolation precautions should be employed as follows: -use gloves when entering residents room for: direct care contact, environmental contact. -Use gowns if soiling likely: resident or environmental soiling. -Use dedicated equipment if possible: stethoscope, thermometer, transfer belt, and lift sling etc. All staff must be diligent about hand washing for both themselves and the infected resident. The C-Diff spores is spread through oral-fecal contact-this meant anything that unwashed hands touched could become contaminated. The spores can live on a surface for a month or more. Soap, water and friction are to be used for cleansing hands. Alcohol gel is not effective against the spore. When a resident was free from signs and symptoms for three days, the room infection control precautions could be removed. The facility's undated, [CONDITION(S)] policy indicated preventative measures would be taken to prevent the occurrence of C-Diff infections among residents and precautions would be taken while care for residents with C-Diff to prevent the transmission to others. C-Diff infections would be considered for a resident with an acute onset of diarrhea (three or more unformed stools within a 24 hour period) or abdominal pain. Residents considered at high risk of developing symptoms associated with C-Diff include those with previous gastrointestinal illness caused by C-Diff and antibiotic or anti-neoplastic therapy. Residents with diarrhea associated with C-Diff (resident who are colonized and symptomatic) will be placed on isolation precautions. Healthcare workers would wear gloves and gowns upon entering the room of a resident with C-Diff infection, and will remove gown and gloves prior to exiting the room. When caring for a resident with diarrhea of fecal incontinence caused by C-Diff the staff would maintain vigilant hand hygiene. Glove use and washing hands with soap and water upon exiting the room and strict hand hygiene in general was considered best practice. Enhanced infection control measures include reduced sharing of or dedicated medical equipment. The policy directed the staff to place residents with C-Diff in contact precaution and the staff providing cares to the resident to wear gowns and gloves. On [DATE], at 5:50 p.m. the administrator and director of nursing were informed of the immediate jeopardy based upon the lack of staff knowledge and implementation of contact precautions required to care for the residents in contact isolation for C-Diff. The facility's lack of implementation of contact precaution placed the other residents, staff and visitors at risk of contracting C-Diff. The IJ that began on [DATE], was removed on [DATE], at 4:39 p.m. when the facility had completed the following interventions. -The [CONDITION(S)] policy and procedure was reviewed and updated. -The Isolation Transmission Based Precautions policy and procedure was reviewed and updated. -The Isolation Notices of Transmission-Based Precautions was reviewed and updated. -The Handwashing/Hand Hygiene policy and procedure was reviewed and updated. -Staff members were provided verbal and written education regarding infection control. -The staff demonstrated appropriate donning and doffing of PPE. -The facility developed guides to direct staff as to when to use each EPA approved disinfecting wipes. R299's Order Summary Report [DATE], indicated R299's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R299's Medicare 5 day MDS dated [DATE], indicated R299 required extensive assist of two staff for bed mobility, transfers, dressing, and toileting. Extensive assist of on staff for hygiene, limited assist of one staff for locomotion, and was non-ambulatory. R299's Cognitive Loss/Dementia CAA dated [DATE], indicated R299 had severely impaired cognition. R299's Urinary Incontinent CAA dated [DATE], indicated R299 required assistance from two staff for transfers with mechanical standing lift, bed mobility, toileting and personal hygiene/grooming. One staff assist for dressing. He was non ambulatory. History of multiple falls prior to admission. Frequently incontinent of bowel and bladder with staff providing peri care with each incontinent episode. R299 was sometimes aware of the urge to urinate/defecate. Two staff to toilet R299 every two hours and as needed, and to not leave unattended in the bathroom. Has a history of frequent loose stools and was prescribed lomotil which had not been used during the MDS reference period. No additional bowel medications ordered. R299 had three bowel movements, two of which were incontinent. R299 was admitted with a non-removable surgical wound dressing to left hip. R299's care plan printed on [DATE], indicated R299 had altered elimination due to decreased mobility, weakness, medication use, and impaired cognition. Staff were directed to encourage fluid intake, provide good peri cares, maintain record of bowel movements, observe for signs and symptoms of infection, utilize incontinent briefs, and assist to toilet every two hours and as needed. Two staff to transfer to the bathroom with gait belt and front wheeled walker for stand, pivot transfers and to not leave R299 alone in the bathroom maintain within an arm's reach away from the resident when toileting due to confusion. The care plan also indicated R299 was at risk for falls and directed the staff to place a fall mat next to the bed. R299 was not ambulating with staff at this time. R299 had long term antibiotic use due to a history of a kidney transplant. Acute pain related to a history of falls with recent lumbar fracture, fractured hip repair. Staff directed to administer analgesics per physician orders, offer heat/ice, evaluate, monitor, and report changes in pain. R299's Telephone Orders form dated [DATE], included the following orders: -Test for C-Diff and if test negative, to use [MEDICATION(S)]-[MEDICATION(S)] 2.,d+[DATE].025 mg one tablet four times a day, as needed for diarrhea -Florastar 250 mg daily for chronic diarrhea. On [DATE], at 1:43 p.m. R299 was observed in the dining room, seated in a wheelchair. On [DATE], at 1:59 p.m. NA-V was observed to assist R299 to his room. R299 stated his legs were sore post physical therapy therefore NA-V assisted R299 to transfer to the bed via the mechanical standing lift. A fall mat was positioned on the floor, next to the bed. An infection control bin was not observed stationed in or near his room. On [DATE], at 7:10 a.m. during continuous observations from 7:10 a.m. until 9:13 a.m. the following was observed: -7:10 a.m. R299 was observed in his room, in bed. R299's roommate, R82 was seated at a table in the dining area. An infection control bin was stationed outside of their shared room door. Infection control signage was posted on the door which had a picture of large stop sign with the directive to please see nurse before entering patient's room. A second form read ATTENTION, turn over for information. When turned over, the back directed the following: -Gloves were indicated if touching infective materials stool -Gowns were to be worn if soiling was likely. -A private room was identified as not indicated. -hands must be washed after touching resident or potentially contaminated articles and before taking care of another resident. -Plastic bags were to be used when handling linens/garbage. -Staff were to assist with resident as needed to ensure resident followed good handwashing techniques after going to the bathroom. -Staff to wash hands with soap and water as alcohol gel is not effective. -Bleach disinfectant was to be used after each use of the toilet including the seat, grab bars, and sink which must be wiped down with bleach and paper toweling. -If a bedpan or commode was used, it must be wiped down after each use. -Housekeeping to use comet bleach on hard surfaces daily, such as toilet sink, grab bars, door handles, TV remove, bedside table, nightstand, and bed handrails. At this time, LPN-A stated R299 was under contact precautions due to being tested for C-Diff. A commode was not observed in R299's room or shared bathroom. -At 7:53 a.m. R299 remained in bed as NA-A donned a gown and gloves and pushed a mechanical standing lift into R299's room. NA-A stated R299 needed to use the bathroom. When asked if the State agency could observe the transfer, R299 declined and the surveyor exited the room. R82 remained in the dining room. -At 7:57 a.m. NA-A stepped out of the bathroom, confirmed R299 was assisted onto the toilet, and indicated R299 had been continent throughout the night. R299 remained in the bathroom. -At 8:01 a.m. LPN-A donned a gown and pair of gloves, and with wound dressing in hand, entered R299's room and went directly into the bathroom. Prior to entering the room, LPN-A stated R299 had a surgical wound which required dressing. -At 8:06 a.m. LPN-A exited the bathroom, doffed the gown and one pair of gloves. Upon removing the gloves, a purple pair of gloves were revealed on her hands. With the second pair of gloves on, LPN-A exited the room with the standing lift, positioned it up against the wall next to the infection control bin, walked across the unit, entered the nursing station, removed the gloves, and washed her hands. The standing lift was not disinfected prior to or after leaving R299's room. R82 remained in the dining area, eating breakfast. Shortly thereafter, R299 exited the bathroom seated in the wheelchair and was assisted out of the room and positioned at a dining table. R299's floor mat was noted to be upright and leaning against R299's dresser/closet area which was located on the wall near the end of R299's bed. The staff were not observed to clean or disinfect the bathroom following R299's use. -At 8:11 a.m. laundry/housekeeping (Lndry/Hskp)-A entered the unit pushing an uncovered, open faced, clean linen rack which half consisted of a bar with clean, resident clothing hanging and a column of small individual bins next to it which held clean, smaller clothing items. Lndry/Hskp-A stationed the rack next to the nurse's station. With gloved hands, Lndry/Hskp-A removed clothing on hangers from the rack, walked across the unit, and entered R229/R82's room without donning any other PPE or asked the nurse about the precautions prior to entering. Once in the room, [NAME]/Hskp-A picked up a corner of the floor mat, repositioned it to gain better access to the closet, and leaned it against herself stabilizing it as she walked the few steps to reach the closet. Lndry/Hskp-A opened the closet door, hung the clean clothing up, and removed unused hangers while the floor mat leaned against her person. Once the clothing had been hung, and with the same gloved hands, Lndry/Hskp-A repositioned the floor mat, walked over to R82's closet, opened the door, hung his clean clothing up, removed unused hangers, exited the room, walked across the unit, and placed the hangers onto the bottom of the clean, open linen rack. With the same gloved hands, Lndry/Hskp-A grabbed a clean, brown, blanket from the clean linen rack, held the blanket against her person with both hands, and asked the nurse if she knew who the blanket belonged to. With the blanket in her arms, Lndry/Hskp-A entered the nurse's station, obtained a key, and exited the nurse's station. At this time, the State agency intervened and asked to speak with her. Lndry/Hskp-A placed the blanket on top of the hangers on the bottom of the rack, removed her gloves, and utilized hand sanitizer. -At 8:20 a.m. Lndry/Hskp-A stated the key she had obtained was for the unit's locked, clean linen closet as she was going to put the blanket in there for community use. Lndry/Hskp-A stated she worked in both housekeeping and laundry and had not noticed the infection control bin outside of R299's room yesterday. When asked what the procedure was when entering a room with posted isolation precautions, Lndry/Hskp-A stated she would use a piece/corner of the resident's clean clothing to touch/open the closets/drawers in order to avoid touching anything with her hands. Lndry/Hskp-A stated the laundry staff were informed every morning of any resident with isolation precautions in place. However, this morning she had not been informed of R299 having been placed on precautions the night before therefore she had just applied a pair of gloves to make sure she wouldn't touch anything. When asked what type of isolation precautions R299 had in place, Lndry/Hskp-A stated she did not know, and generally did not know what type of bug a resident had so she would just apply gloves because it was the biggest thing to do and she would also not touch the resident. Lndry/Hskp-A verified she had entered the room with gloves on while holding clean clothing for both R82 and R299. Lndry/Hskp-A also verified while in the room, she had handled the floor mat, stabilized it against her person, touched both closet/door handle surfaces, and touched the clean clothing that was hanging in both residents' closets with the same gloved hands. When asked if she should have applied a gown prior to entering the room, Lndry/Hskp-A stated she did not know if she should have or not. Lndry/Hskp-A confirmed she did not remove her gloves or wash her hands after touching a potentially contaminated surface, between resident room areas, nor upon exiting the room. Lndry/Hskp-A also stated the hangers that were removed from the residents' room were placed on the clothing rack to be taken back to laundry so they could be cleaned with bleach due to having been removed from an room with isolation precautions. Lndry/Hskp-A verified she had held handled the clean blanket with her gloved hands and held against her person and agreed she had potentially contaminated the blanket. Lndry/Hskp-A stated she would return the blanket to laundry so it could be washed again. -At 8:44 a.m. R82 remained at the dining table. The mechanical standing lift remained positioned up against the wall. Both the lift and R299's bathroom remained untouched. -At 8:56 a.m. R299 was assisted out of the dining room and off the unit to the therapy department. -At 9:03 a.m. R82 wheeled himself back to his room and positioned himself next to his bed. -At 9:06 a.m. R82 wheeled himself into the shared bathroom, put himself onto the toilet, and shut the door. At this time, NA-B stated he did not know why R299 was on isolation precautions. -At 9:10 a.m. both NA-B and NA-A acknowledged R299 was in contact isolation precautions and stated they had not been informed of any extra precautions to take regarding R229's roommate, R82. Both also stated they had not been directed to clean/disinfect the bathroom or any resident equipment after R299 had used it. When asked about the standing lift, NA-A and NA-B stated the standing lift positioned against the wall was ready and available to be used for any resident. NA-A and NA-B stated there were two other residents on the unit who utilized the same standing lift. At 9:13 a.m. R82 remained in the bathroom. At 9:15 a.m. RN-A stated if a resident was suspected of having C-Diff, they were to be put on contact isolation precautions which involved placing an infection control bin outside of the room and stocked, isolation precaution signage taped to the room door, and if the resident shared a room, the staff would evaluate to see if the resident required a private room or if the roommate needed to be moved out. If the resident or roommate was not able to move, the staff were to try and not cross contaminate. RN-A stated R299 had recently returned from the hospital with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ordering physician had been contacted in order to obtain the script, however, the physician did not respond. Therefore, on [DATE], RN-A asked the rounding nurse practitioner (NP) to review the order, provide a script or to discontinue the order. The NP had asked if R299 had been having diarrhea and RN-A informed her that R299 had dumping syndrome (when food moves too quickly from your stomach which causes symptoms like cramps and diarrhea) and had been having chronic diarrhea for a couple months prior to hospitalization , and R299 had also received a multiple antibiotics while hospitalized . Due to the history of the diarrhea and recent antibiotic use (contributing factors for C-Diff), the NP requested R299 be tested in order to rule out C-Diff prior to providing a script for the lomotil. RN-A stated subsequently, R299 was placed on contact isolation precautions for presumed C-Diff as he was to be considered to have it [C-Diff] until the test results returned. RN-A stated the staff should be disinfecting any equipment used by R299 including the mechanical lift after each use. RN-A verified R299 and R82 shared a room including bathrooms and stated the bathroom was to be disinfected with bleach after R299 used it. RN-A verified the lift was used for other residents on the unit, and stated it should have been disinfected immediately after R299's use. RN-A stated if the State agency had not brought the potential infection control concern to the attention of the staff, the lift would have been used on other residents prior to it having been cleaned/disinfected. -At 9:35 a.m. LPN-A stated a stool sample was ordered at 7:00 p.m. on [DATE], which was when isolation precautions were started. LPN-A stated when there was a change to resident cares such as the implementation of isolation precautions, the nurses would share this information to the oncoming nurse during shift report, but she did not know if the NAs' had also discussed it during their separate shift report. -At 11:25 a.m. RN-A stated he had spoken with the NP and since R299 had not had a bowel movement in a 48 hour period, the C-Diff testing was discontinued and the staff were informed that the isolation precautions had been discontinued. -At 12:58 p.m. the DON stated when RN-A had spoken with the NP regarding R299, she was seeking a hard copy prescription for antidiarrheal medication due to R299 having had been on lomotil when hospitalized . The DON stated they were wondering if they should not have initiated isolation precautions because R299 had been asymptomatic, and the stool sample was just to rule out C-Diff. The DON stated R299 had not had any signs or symptoms of C-Diff, therefore isolation precautions should not have been put into place. The DON stated the nurse manager working on [DATE], thought isolation precautions were warranted because of R299's order for a stool sample testing. The DON stated the order should have been clarified upon receipt, rather than waiting until now to seek clarification. The DON stated when a resident was suspected to have C-Diff, nursing would go directly to social services so that another room could be found for that resident because residents should not cohort when they have infections requiring isolation. Additionally, the DON stated if a resident scored a seven on the bristel scale (tool used to classify the form of human feces into seven categories) it indicated the resident had had a liquid, watery stool. The DON stated R299 had more mushy, soft stools and not diarrhea consistency stools which was not an indicator of C-Diff. The DON stated she did not know when R299 had last had a bowel movement and if a resident had more than three diarrhea type stools in a 24 hour period, they would obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the test was positive for C-Diff, the isolation precautions would continue and if the test was negative, the precautions would be discontinued. When asked, the DON stated she was uncertain if the staff had been educated on the colonization (the detection of the organism in the absence of symptoms) of C-Diff. The DON agreed that if a resident did have C-Diff, the staff were expected to follow facility policy which included the implementation of isolation precautions. Hand Hygiene/Catheter Care R200 was observed on [DATE], at 3:05 p.m. being a [TRUNCATED]

Based on observation, interview and document review, the facility failed to implement interventions including comprehensive assessment, notification of the physician, and pressure redistribution devices, in order to promote healing and prevent further development of pressure ulcers for 1 of 3 (R146) residents reviewed for pressure ulcers. R146 experienced actual harm due to development of multiple stage II pressure ulcers (Partial thickness skin loss involving epidermis, dermis, or both.) Findings include: R146's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R146 had intact cognition, required extensive assist of two staff for bed mobility and transfers and was at risk for developing pressure ulcers. The MDS also indicated R146 had no pressure ulcers. A corresponding note related to the MDS dated [DATE], indicated R146 had an area that was prone to reopening and indicated staff would apply protective ointment to the area and alert nursing to any changes. R146's [DIAGNOSES REDACTED]. R146's care plan dated September 2014, indicated R146 was at high risk for pressure and moisture related breakdown and had a physical mobility deficit related to increased weakness and ongoing heart related issues. The care plan indicated R146's skin would be free from pressure or moisture related skin conditions. The care plan had no pressure ulcer prevention interventions nor pressure ulcer treatments identified. R146's weekly skin assessment form indicated R146 had a pressure ulcer on the right buttock midway between the coccyx and leg crease and the following measurements were documented: -7/18/14, ulcer measured 0.4 centimeter (cm) x 1.4 cm, open area. dressing applied, to be changed every three days. -8/13/14, ulcer measured 2.1 cm x 0.8 cm, dressing applied, change every day and as needed. Review of R146's Skin Ulcer Data Collection Forms revealed the following entries: -8/27/2014, a pressure ulcer, location not identified, No measurement was indicated. However, indicated the wound bed was [MEDICATION NAME] with macerated edges/surrounding skin. No odor. No further information was provided. -9/11/14, right buttock pressure ulcer measured 1.2 cm x 0.5 cm with an [MEDICATION NAME] / granulated wound bed, no pain, no odor. -10/2/2014, the right buttock ulcer measured 0.4 cm x 0.5 cm, the left buttock ulcer was identified and measured 0.4 cm x 0.5 cm., rolled edges, epithealized wound bed, no pain, no odor. -10/8/2014, the right buttock ulcer measured 0.2 cm x 0.3 cm, the left buttock ulcer measured 0.5 cm by 0.7 cm. The remainder of the form was blank with no further information / wound description provided. -10/14/14, the right buttock ulcer measured 1.0 cm x 1.0 cm, the left buttock ulcer measured 0.6 cm by 1.2 cm. with minimal bloody drainage and redness around the edges. A written entry on the same form dated 10/14/14, indicated some bloody drainage, ulcers were painful when cleaned and dressed. -10/21/2014, the right buttock ulcer measured 1.0 cm by 1.0 cm and an additional right buttock ulcer measured 0.5 cm by 0.5 cm. The left buttock ulcer measured 0.7 cm by 1 cm. with minimal bloody drainage, slough present, redness around edges, no odor and no pain. A written entry on the same form dated 10/21/14, indicated small open areas one on left and two on the right with small amount bleeding and yellow slough on right wound. -10/22/14, coccyx pressure ulcer on the right buttock measured 1.0 cm by 1.0 cm, the lower second pressure ulcer on the right buttock measured 0.6 cm by 1.2 cm, the pressure ulcer on the left buttock measured 0.5 cm by 0.5 cm. and an open area on the center of the coccyx area,by the tail bone measured 0.2 cm by 0.3 cm. The rest of the form was blank with no further information / description of the ulcers was indicated. On 10/29/14, RN-A completed a Skin Ulcer Data form for R146 and the following five stage two pressure ulcers were identified: ?upper left of coccyx measured 0.7 X 1.2 cm with a depth of 0.2 cm. The wound had minimal serous drainage with 50% slough and 50% granulation. The outer edges of the wound were red. No odor or pain was noted. The section which indicated if signs of progress toward healing and if not contact the physician was blank. ?upper right of coccyx ulcer measured 0.6 X 0.3 cm with a depth of 0.2 cm with minimal serous drainage, 50% slough and 50% granulation, redness around the edges, no odor and indicated R---had pain at the site. The section which indicated if signs of progress toward healing and if not contact the physician was blank. ?lower right of coccyx ulcer measured 1.5 X 1.0 cm with a depth of 0.2 cm. with minimal serous drainage, 50% slough, 40% granulation and 10% eschar (dead tissue), redness around the edges, pain at site and no odor. The section which indicated if signs of progress toward healing was present and if not contact the physician within 2-3 weeks was blank. ?lower left of coccyx ulcer measured 1.5 X 1.3 cm with a depth of 0.2 cm. with minimal serous drainage, 50% slough, 50% granulation, redness around edges, had pain at site and no odor present. ?center of the coccyx ulcer measured 0.5 cm X 0.3 cm with a depth of 0.1 cm with minimal serous drainage, 10% slough, 90% granulation and redness around the edges. There was no evidence that a comprehensive skin assessment had been completed following the development of the above pressure ulcers. On 10/28/2014, at 11:40 a.m. R146 was observed in the dining room, seated in her wheelchair. No pressuring distribution cushion was observed on the seat of the wheelchair. On 10/29/14, at 12:36 p.m. licensed practical nurse (LPN)-A stated when a resident developed an ulcer or any kind of open area, the nurse would initiate a skin ulcer data form, obtain measurements, obtain a pressure ulcer wound kit and would inform the registered nurse (RN) who was responsible for monitoring pressure ulcers. LPN-A stated wounds were measured weekly on Tuesdays and if it was determined the wound was not healing or worsening, the RN would make the call as to the next step in the treatment process. At this time, LPN-A was observed to complete R146's coccyx dressing change. LPN-A verified R146 had five stage two pressure ulcers on her coccyx area: two on the right buttock, one in the center of the coccyx and two on left buttock. When asked whether the RN had assessed R146's ulcers, LPN-A stated, "I don't know." When asked if R146 utilized a wheelchair pressure redistribution device, LPN-A stated, "I think she does." LPN-A proceeded to look around R146's room and stated, "I guess not." When asked if R146 would benefit from the use of a pressure relieving cushion in both the recliner and wheelchair, LPN-A replied, "Oh absolutely." LPN-A stated she was not aware if R146 had been assessed for the use of a pressure redistribution device. On 10/29/14, at 1:52 p.m. R146 was observed in her room, seated in the recliner. When asked if she had a cushion for the wheelchair seat, R146 stated, "no I don't." When asked if her bottom hurt while seated in the wheelchair or recliner, R146 stated, "yes it does hurt, it hurts all the time." When asked if she had been assessed by anyone for pressure redistribution devices for both the wheelchair or recliner, R146 stated, "No they have never done that." On 10/29/14 at 2:20 p.m., when asked whether R146 utilized a pressure redistribution device in the wheelchair, nursing assistant (NA)-A stated "I am not sure, I thought she had one." However, after looking, NA-A verified R146 did not currently have a cushion to help prevent pressure ulcers in her wheelchair. NA-A further stated, "I think it would probably help her." On 10/29/14 at 4:13 p.m., RN-A stated skin assessments had not been completed for R146 following the development of any of the five pressure ulcers R146 had developed. RN-A further stated, "I know that she had a cushion at one time, even though it is not on the care plan. I called her daughter, and the daughter stated she did have a cushion at one time but we're not sure when it disappeared." On 10/30/14 at 8:34 a.m., RN-A stated she had implemented a pressure redistribution device last night. However, at that time RN-A and the surveyor observed R146 to be seated in her wheelchair in the dining room without a pressure relieving device in the wheelchair. RN-A verified this observation. In addition, when asked, RN-A verified she had not notified R146's medical doctor about the development of the five pressure ulcers. RN-A stated R146 had been seen by the nurse practitioner, however during review of the record, there was no documentation to indicate whether the pressure ulcers were ever brought up or discussed during those visits: 10/10/14, 10/16/14 and 10/21/14. RN-A also verified she had not completed a comprehensive skin assessment when R146 had developed the five pressure ulcers, and stated she was unaware an assessment was supposed to be completed following the development of pressure ulcers. On 10/30/14, at 9:17 a.m. the director of nursing (DON) stated it was the facility's policy and protocol to complete a comprehensive skin assessment with the development of a pressure ulcer. The DON stated she was unaware the assessments had not been done when R146 developed the pressure ulcers. The DON also stated it was her expectation the RN would contact a resident's medical provider when an ulcer was not healing. The DON confirmed she would expect a wheelchair pressure redistribution device be implemented when a resident had a pressure ulcer. During the conversation, the DON verified the appropriate skin assessments and interventions were not completed/implemented for R146 and stated, "we can only go forward from here." The DON verified the facility's policy was not followed. The DON provided documentation of steps the facility had implemented on 10/30/14, which consisted of a request for Occupational and Physical therapy to evaluate and provide treatment related to the need for wheelchair and bed positioning interventions for pressure reduction, transfers and comfort measures. In addition, on 10/30/14, a notice was sent to R146's medical doctor which requested an evaluation of the worsening stage two ulcers, and a Braden Scale (pressure sore risk assessment) was completed. The resident's Braden score was identified as 13, which indicated R146 was at moderate risk for pressure ulcer development. The facility's policy titled, Skin Assessment and Care revised November 2013, included: "Each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care related to skin care; a resident who enters the facility without pressure ulcers does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing." The policy further included, "A registered nurse must complete a skin assessment if a new pressure ulcer develops. The assessment must include a review of the resident's tissue tolerance to pressure."

A. Based on observation, interview, and document review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible related to the application of hot packs by nursing assistants for 2 of 2 residents (R27, R159) in the sample who had experienced burns from the hot packs. This practice had the potential to affect all 110 residents residing in the facility. Facility staff had knowledge of the injuries sustained to R27 and R159 following hot pack applications by nursing assistants, but had not conducted adequate investigations to identify the systemic issue related to the lack of adequate supervision, training and facility policies and procedures for the application of hot packs by nursing assistants. Findings include: The immediate jeopardy began when the systemic issue related to the lack of adequate supervision, training and facility policies and procedures for the application of hot packs by nursing assistants was identified on 11/17/11. The facility's standing orders included the application of hot packs. The facility utilized nursing assistants to apply hot packs at their discretion to any of the residents residing in the facility. The administrator and the director of nursing (DON) were informed of the immediate jeopardy for R27 and the potential to affect all 110 residents residing in the facility at 7:27 p.m. on 11/17/11. The immediate jeopardy was removed at 12:05 p.m. on 11/21/11, which reduced the scope and severity to actual harm but no longer an immediate jeopardy. R27 had a hot pack applied to her right arm on 10/12/11, and was left unattended in the therapy department. The hot pack became too hot and resulted in pain and reddened skin tissue. R27's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R27 to have normal cognitive function. The Care Area Assessment (CAA) dated 10/14/11, indicated R27's PLS had progressed and had severely limited R27's ability to move any extremity or participate in cares. An incident report dated 10/12/11, indicated that at 3:05 p.m. on 10/12/11, a hot pack was applied to R27's right forearm. The resident was heard calling out in the physical therapy (PT) room and stated to the social worker (SW) that her arm was burning. The PT room was unoccupied by staff. The SW removed the hot pack from the resident's arm. Examination of the arm by nursing staff revealed an 8 cm x 10 cm area of reddish pink skin on the upper forearm. A cool compress was applied and R27 indicated the area felt better after approximately 10 minutes. The report also indicated staff re-education on the use of hot packs. R159 sustained harm related to the use of a hot pack applied to his right arm, which resulted in second degree burns on 8/19/11. R159 was discharged from the facility on 9/7/11. R159 had [DIAGNOSES REDACTED]. An ((MDS) dated [DATE], indicated R159 to have normal cognition and to be independent with decision making. An incident report dated 8/19/11, indicated during the night shift (no time listed), R159 requested a hot pack for right arm aching, and the skin was blistered when the microwavable pack was removed. The resident had stated that the hot pack became to warm, however, the report did not indicate at what point this occurred. A vulnerable adult (VA) internal investigation and reporting form dated 8/21/11, indicated that an interview with nursing assistant (NA-F) was conducted on 8/20/11. NA-F had reported the hot pack was heated in the microwave for 60 seconds on each side, wrapped in a towel and applied on the resident's arm. When the pack was removed 20 minutes later, blisters were noted on the resident's skin. The report's concluded no maltreatment occurred and the incident was not reported to the State agency. In addition, the report indicated all staff were educated on the use of hot/cold packs. An interview with the registered nurse (RN) was conducted by the facility on 8/21/11. The RN had stated the incident happened at the end of the RN's shift and the RN forgot to complete an incident report. The RN further indicated NA-F had stated the hot pack had been wrapped in a towel and must have slid out. NA-F was re-interviewed by the facility on 8/20/11, and NA-F indicated that heating the hot/cold pack in the microwave had been standard practice on the night shift. The interview also indicated disciplinary action was pending internal investigation. The hot pack (CorPak-a hot/cold pack by Core Products International) manufacturer's instructions undated, indicated: heat in the microwave for 30 seconds, and to continue heating at 10 second intervals until desired temperature is reached and to knead pack after each heating, and that overheating may cause injury. An interview with the DON conducted at 7:35 a.m. on 11/17/11, revealed the incident report for R159 did not indicate if the hot pack was heated according to the manufacturer instructions. In addition, the incident report did not indicate at what point R159 stated that the pack became too warm. The DON also indicated she was unaware if the nursing assistant had been trained to use hot packs. She stated nursing assistants use their own judgment regarding using blankets from the warmers which is safer or to heat a pack in the microwave. The DON further indicated that no other resident had sustained a burn from a hot pack. The DON further stated it was not possible to determine from the incident report if the instructions for heating were followed. The DON was unable to reach the NA involved to clarify the report. The DON further indicated the facility did not have a policy regarding the use of hot packs. She also indicated some followup work on the investigation could have been done differently including an interview with the resident involved. The DON stated the incident would be promptly reported to the State agency. Additional interviews with nursing assistants were conducted on 11/17/11, as follows: At 1:45 p.m. NA-H stated the microwave packs are heated for 30 seconds and if not warm enough, heated another 30 seconds. At 1:50 p.m. NA-J stated the packs were heated for 2 minutes and placed in a pillow case. At At 2:00 p.m. NA-G stated the packs are heated for 1 - 1 1/2 minutes and placed in a pillow case. At 2:35 p.m. NA-D stated the packs are only to be placed by licensed nurses. At 2:40 p.m. NA-I stated the packs were heated for 40 seconds, turned over and heated a another 40 seconds and placed in a pillow case. The DON was re-interviewed at 2:55 p.m. on 11/17/11, regarding the incident report for R27. The report did not indicate what type of hot pack was used, if it was heated in the microwave or was a hydroculator pack (kept in hot water). In addition, the DON stated the rehab nursing assistant (NA-R) did not use the best judgment leaving the resident unattended. The DON further indicated the application of hot/cold packs are part of the facility's standing orders and can be used on all residents by the NA's. In addition, these incidents should have been part of the facility's quality improvement, and that the incident would be promptly reported to the State agency. On 11/17/11, at 5:36 p.m. the DON indicated staff had attended a skills fair during the summer that would include some training related to hot packs. An undated slide under the heading of Skilled Nursing Services was provided and stated heat treatments, specifically ordered by the medical doctor as part of active treatment which requires observation by nurses to adequately evaluate patient progress (may be done in therapy). NA-R was interviewed at 9:27 a.m. on 11/18/11. NA-R stated a heated rice pack had been used for R27, which allowed it to be more form fitting, which was the resident's preference. NA-R stated the pack was heated for 2 minutes and shuffled around, and tested on her own forearm. NA-R further stated the instructions indicated to heat for 1-2 minutes. NA-R was unable to find any instructions. At that time, the pack used for R27 appeared to be a homemade bag with no manufacturer stamp or instructions. An interview with the DON was conducted at 10:07 a.m. on 11/18/11. The DON confirmed the above findings and indicated both incidents were to be promptly reported to the State agency. The DON also stated a policy regarding the use of microwavable hot packs was in development and that nursing assistants would no longer be allowed to apply the hot packs. The immediate jeopardy that began on 11/17/11, was removed on 11/21/11, at 12:05 p.m. when the facility developed policies and procedures for the use of hot packs (heat application therapy) and implemented a system that required heat applications to be administered by licensed nurses only. Staff received training in the new policies and procedures for all on-coming staff prior to beginning each shift. Survey staff completed observations and interviews of residents and facility staff on 11/20/11 and 11/21/11, to verify the plan of correction had been implemented. B. Based on observation, interview, and document review, the facility failed to ensure adequate supervision and interventions had been implemented to minimize accidents based on a comprehensive assessment for 1 of 1 resident (R147) reviewed with a history of possible life threatening behavior. Facility staff had knowledge of a report of R147's continued and possible life threatening behavior. The facility staff had not conducted an adequate investigation or reassessment of the reported behavior and care planned appropriate alternative interventions for safety. The immediate jeopardy began on 11/17/11, related to R147 not receiving appropriate investigation and assessment of documented high risk behavior on 11/2/11, which had the potential to be life threatening to R147. Additionally, the facility had not implemented effective interventions to prevent serious injury which placed R147 in imminent danger. The findings constituted an immediate jeopardy for R147. The administrator and the (DON) were informed of the immediate jeopardy at 7:27 p.m. on 11/17/11. The immediate jeopardy was removed on 11/21/11, at 12:05 p.m. which reduced the scope and severity to no actual harm with potential for more than minimal harm for R147. Findings include: R147 lacked adequate assessment and interventions to provide a safe environment when the resident was documented as observed to perform autoerotic asphyxiation (strangulation while masturbation.) R147's record indicated on 11/2/11, at 6:13 p.m. the resident was observed to perform autoerotic asphyxiation with a telephone cord. R147 had been educated in the past about the dangers of this action. No further follow up occurred following this documented report, such as investigation, safety risk assessment, a vulnerable adult assessment, social service interventions, or mental health referrals. This practice resulted in an immediate jeopardy for R147. R147 was diagnosed with [REDACTED].) The quarterly ((MDS) dated [DATE], indicated R147 exhibited no cognitive impairment and required staff assistance with mobility. The plan of care dated 8/22/11, identified R147 at risk for injury related to self harm and suffocation as evidenced by strangling self to increase sexual pleasure. However, the plan of care dated October 2011, lacked identification of the behavior and any planned interventions. On 11/17/11, at 7:08 a.m. R147 was observed to propell a wheelchair out to the breakfast meal. The resident was observed to eat breakfast independently and continue to self propell in the wheelchair. At 7:19 a.m. R147's room was observed to have a telephone with a cord attached on the bedside table. The 8/22/11, nursing notes indicated a report was received from a previous facility R147 had resided at related to R147's history of autoerotic asphyxiation. The note indicated staff spoke with the resident about risk factors related to autoerotic asphyxiation including a discussion of risks such as passing out or death. At this time, R147 denied this behavior. R147 was found not to be a suicide risk. The nursing notes indicated the plan of care was updated related to behavior and safety risk. The facility's document Rehab care: recommendations to caregivers dated 9/21/11, directed staff to monitor R147 every 1/2 hour to ensure oxygen was on the resident and to monitor self-transferring and fall risks. The facility "30 minute tracking" forms noted completed documentation of 1/2 checks, but multiple scheduled checks were found undocumented. The 11/2/11, nursing notes indicated R147 was observed to be "partaking self strangulation with the phone cord to enhance masturbation. Has been educated in the past about the dangers of this action." The record lacked any further follow up related to the incident including an assessment, interventions, or social service referrals related to the documented behavior. On 11/17/11, at 7:49 a.m. licensed practical nurse (LPN)-D stated another facility had notified them that R147 would perform autoerotic asphyxiation. The LPN was unaware of any reported observations or documentation of the resident exhibiting this behavior at the facility. LPN-D stated R147 was on safety checks every 1/2 hour. LPN-D verifed the safety checks had been initated on 9/21/11, and were not specific to the autoerotic asphyxiation behavior. LPN-D stated this behavior should be reported to nursing staff if observed. LPN-D stated R147 had declined physically and had been more tired so they had not seen these behaviors. On 11/17/11, at 8:32 a.m. nursing assistant (NA)-V stated she had heard about R147's history of autoerotic asphyxiation. NA-V stated she had not heard of R147 performing this behavior recently. NA-V stated she would report to the nurse immediately if a behavior occurred. On 11/17/11, at 8:38 a.m. NA-W stated he was unaware of any behavior such as autoerotic asphyxiation displayed by R147. NA-W stated he normally worked in R147's wing as a trained medication assistant (TMA). On 11/17/11, at 8:50 a.m. registered nurse (RN)-F stated R147 was struggling with some unmet needs and losses. RN-F stated they had offered psychiatric services, but R147 had refused. RN-F added clergy was involved. RN-F stated she was aware of the history of autoerotic asphyxiation. She stated she had a discussion with the resident about this reported behavior and the resident had denied it. Risks were discussed at this time. RN-F stated she thought that was on 8/22/11. RN-F was unaware of any further reports of this behavior. On 11/17/11, at 11:43 a.m. LPN-D stated the previous facility where the resident had resided had informed them about R147's history of autoerotic asphyxiation. LPN-D stated he understood the prior facility was happy to be getting out of that high risk situation (meaning the resident). LPN-D stated he was unaware of the incident on 11/2/11, and was only aware of what the previous facility had reported. LPN-D stated R147 could potentially use oxygen cords, a sheet, a phone cord, or shoe lace. LPN-D stated R147 could have enough time to perform this act inbetween the 1/2 hour checks. On 11/17/11, at 11:57 a.m. licensed social worker (LSW)-A stated she was aware of R147's reported history of autoerotic asphyxiation, but R147 had denied this. She stated she was unaware of the 11/2/11, incident and had not followed up with the resident related to the documented incident. She stated autoerotic asphyxiation would pose a safety risk. On 11/17/11, at 12:09 p.m. the director of nursing (DON) stated she was unaware of the incident on 11/2/11, but was aware of R149's reported history of autoerotic asphyxiation. She stated the resident had denied this behavior in the past. She stated staff should be reviewing the record and follow up on incidents of potential self harm. The DON stated an incident report and investigation should have been completed. The DON stated autoerotic asphyxiation could put anybody at risk for injury regardless of physical condition. On 11/17/11, at 12:29 p.m. RN-F stated she was unaware of the incident documented on 11/2/11. RN-F stated no one had followed up with the resident or staff to determine what had transpired related to the 11/2/11 incident. RN-F stated further investigation should be completed to determine if further interventions should be implemented and to assess if the resident was safe or was a suicide risk. RN-F stated no physician involvement had occurred since she was unaware of the 11/2/11, documentation and the resident had denied the behavior. On 11/17/11, at 2:27 p.m. LPN-C stated she had documented the nursing note after TMA-A had reported R147 was "doing that thing with the phone cord." LNP-C stated she entered the room and witnessed R147 hanging up the phone while the resident's pants were down. LPN-C inspected the resident for injury and did not see any. LPN-C stated he did not fill out an incident report because RN-E was aware of the incident. She stated no further interventions or assessments were completed or implemented. On 11/17/11, at 2:34 p.m. the DON stated the facility was investigating and would report the incident to the appropriate State agency as well as implement a quality improvement process related to this incident. The DON stated the administrator had been notified of the incident. On 11/17/11, at 2:51 p.m. TMA-A stated LPN-C had documented the incident (on 11/2/11) incorrectly and had misinterpreted what she meant when she had said R147 was "doing that thing with the phone cord." TMA-A stated R147 was participating in a different sexual act but not autoerotic asphyxiation. She stated she did not fill out an incident report or report the incident further but expected nursing would fill one out and have her sign it. On 11/17/11, at 3:00 p.m. RN-E stated she recalled TMA-A reported R147 was "doing that thing with the phone cord." She stated she had asked if R147 was safe and instructed LPN-C to check R147 for injury. RN-E stated she did not assess the resident because she wanted to promote "continuity of care" because LPN-C was R147's medication nurse. RN-E stated it was not described to her what R147 was doing but she just thought the resident was just talking on the phone. The RN did not provide further explanation of as to why safety would need to be assessed or monitoring of injury would need to be observed for a resident phone conversation. RN-E stated she was aware of R147's reported history of autoerotic asphyxiation at the resident's previous residence. On 11/17/11, at 3:13 p.m. LPN-C clarified TMA-A and RN-E had described "doing that thing with the phone cord" specifically as autoerotic asphyxiation.. LPN-C stated she had to ask what R147 was doing because she worked in other units around the facility and was not aware of the resident's reported history of autoerotic asphyxiation. LPN-C stated TMA-A and RN-E made it clear this was the behavior that was exhibited on 11/21/11, and that was why she had documented that way in the clinical record. On 11/21/11, at 10:00 a.m. the DON stated through one on one observations of the resident, additional behaviors that compromised R147's safety had been identified that required further assessment, observation and interventions On 11/18/11, the facility conducted a functional safety, behavior assessment and initiated an investigation related to the high risk behaviors R147 was reported to have displayed. The facility implemented one on one monitoring of the resident. Additionally, the LSW interviewed the resident and the nurse practitioner (NP) provided education to R147 on the risk related to strangulation of a body part. The facility updated the plan of care related to the safety needs of R147. Education on abuse prevention and incident reporting policies to all staff commenced at the beginning of each shift starting on 11/18/11, and was ongoing for each shift until all staff were reoriented, with the administrator and DON providing on-going monitoring to assure compliance. Survey staff completed observations and interviews of residents and facility staff on 11/20/11 and 11/21/11, to verify the plan of correction had been implemented. The DON and Administrator were notified on 11/21/11, at 12:05 p.m. the immediate jeopardy was removed as a result of these interventions. The facility's corrective action removed the immediate jeopardy, however, the facility remained out of compliance with no actual harm with potential for more than minimal harm for R147. C. Based on observation, interview, and document review, the facility failed to provide an environment free of accident hazards related to hot surfaces on steam tables in 3 of the 6 neighborhood kitchenettes (Woods, Rivers, Lakes) which had the potential to affect 48 of 110 residents who resided in the facility and failed to provide an environment that was free of accidental hazards related to adaptic equipment for 1 of 110 residents (R126) identified with loose grab bars on the toilet. Findings include: During a dietary kitchen tour on 11/18/11, that included 6 kitchenettes in the facility's neighborhoods, steam tables that were very hot to touch were noted on 3 of the 6 kitchenettes (Woods, Rivers, Lakes). At 10:40 a.m., the Woods kitchenette's steam table surface temperature (temp) was 147 degrees which was verified by the food service managers (FSM) thermometer. The steam table was in the off position and the area was unattended by staff. The Woods kitchenette was open to all residents. At 11:08 a.m., the steam table in the Rivers kitchenette was turned on and was 140 degrees which was verified by the FSM. At the same time a trained medication aid (TMA-A) stated that the area was never unattended by staff. The Rivers is a memory care unit and contained a half door without a latch that led into the kitchenette. The Lakes kitchenette's steam table temperature at 11:15 a.m. was 142 degrees, which was verified by the FSM. At this same time TMA-B stated the room may be unattended by staff for a few minutes at a time, but no residents had wandered into the kitchenette. At 11:18 a.m. the dietary aid (DA-A) preparing for lunch service stated that residents had approached the area but had not entered the kitchenette. The Lakes kitchenette was also a memory care unit and contained a half door with no latch. At 11:20 a.m. the FSM confirmed the steam tables could pose a risk to residents and he would implement safety measures as soon as possible. At 12:45 p.m. on 11/18/11, the Woods kitchenette was noted to be unattended after lunch service and 5 residents were seated in the dining area. The steam table temperature was 140 degrees and the area was unattended by staff. An interview with LPN-B was conducted at 12:55 p.m. LPN-B indicated that 2 of the 19 residents on the unit are cognitively impaired and use the kitchenette independently. R-119 usually set and cleared tables and filled water pitchers at each meal on a daily basis, but was not doing so at this time related to an injury. In addition, R-7 used the refrigerator and freezer without staff assistance. The director of nursing (DON) was interviewed at 3:20 p.m. on 11/18/11. The DON stated she was aware of the issue with the hot surfaces of the steam tables and indicated the FSM was implementing steps to ensure residents would not have access to the steam table areas. In addition, the DON verified the temperatures were hot enough to cause potential harm from burns. R126's toilet had loose and unsafe grab bars. R126's [DIAGNOSES REDACTED]. On 11/21/11, at 2:45 p.m. during the environmental tour conducted with the Director of Environmental Services (DES) concerns were identified with loose toilet grab bars for R126. R126 had bilateral grab bars on the toilet that could be moved side to side and up and down several inches with the left side grab bars looser than the right. The DES verified that these grab bars had more "play" than they should and that it appeared that there was a problem with the bolts. The DES indicated that R126 had been at the facility a long time and that the grab bars and bolts had probably just wore out. On 11//21/11, at 4:30 p.m. the DES stated that the maintenance department would start on the repairs for concerns identified during the environmental tour including R126's grab bars on the toilet.