Every finding on record at Gundersen Harmony Care Center

Based on observation, interview, and record review, the facility failed to comprehensively reassess, implement appropriate person-centered interventions and analyze falls to help prevent future falls and potential injury for 2 of 2 residents (R22, R7). In addition, the facility failed to assess for proper use of a heating pad for 1 of 1 residents (R28) reviewed for accidents. Findings include: R22's Minimum Data Set (MDS) assessment dated [DATE] indicated no cognitive impairment. R22's function status showed she requires a walker for mobility, substantial assistance for toileting, partial assistance for dressing, and is dependent on facility staff to put on or take off footwear. R22's bladder status showed occasional incontinence. R22's special treatments include oxygen therapy. R22's diagnosis included: chronic respiratory failure with hypoxia, urinary incontinence, cognitive loss/dementia, and heart failure. R22's care plan dated 2/18/25 indicated R22 had mild cognitive impairment and problems with memory/recall, has impaired balance, and risk for falls related to impaired mobility, oxygen use, and self-transferring. R22's care plan dated 7/25/24 indicated staff interventions include assure glasses are nearby, assure floor is free of objects, encourage resident to use hand grips and handrail, provide proper footwear, give verbal reminders not to ambulate or transfer without assistance, provide environment free of clutter, and give medications as ordered. R22's Fall even report dated 8/12/24 indicated R22 had an unwitnessed fall with no noted injury. R22 stated at the time she was getting up to move her blanket. Interventions at the time of fall included call light within reach, frequently used items within reach, and appropriate footwear. No new person-centered interventions updated after fall. R22's fall event report dated 8/14/24 indicated R22 had an unwitnessed fall requiring an emergency room visit and two staples for a head laceration. R22 stated at the time she was unsure of what she was trying to do when she fell . Interventions in place at time of fall included call light within reach, walker within reach, frequently used items within reach, and appropriate footwear. No new person-centered interventions updated after fall. R22's fall event report dated 2/25/25 indicated R22 had an unwitnessed fall with minor injuries. R22 stated at the time she was trying to use the restroom, and her feet got tangled in her oxygen tubing. Interventions in place at the time of fall included call light within reach, walker within reach, frequently used items within reach, and appropriate footwear. No new person-centered interventions updated after fall. R22's fall event report dated 3/10/25 indicated R22 had an unwitnessed fall with minor injuries, due to dizziness required a visit to the emergency room to rule out a head blead. Resident was sent back to facility with no injuries. Resident stated at the time she was getting up to use the restroom and her feet got entangled in her oxygen tubing. Interventions in place at the time of fall included call light within reach, walker within reach, frequently used items within reach, and appropriate footwear. Resident was reminded to use call light and ask for assistance. No new person-centered interventions updated after fall. During observation and interview on 4/7/25 at 4:30 p.m., R22 stated she had fallen a few times, she has gone to the emergency room a couple of times because she became dizzy after her falls. R22 stated her last two falls were because her oxygen tubing got caught in her feet and she lost balance. R22 stated she would like shorter oxygen tubing to help prevent another fall. R22 stated staff will tell her she has to use her call light more and ask for assistance. Oxygen tubing observed extending from resident feet towards oxygen concentrator with tubing coiled in behind oxygen concentrator. Resident had call light on side table, side table was positioned in front of resident. [NAME] was across the room below the television. During observation on 4/8/25 at 2:04 p.m., oxygen tubing was stretched out across room, beneath walker, extending towards resident with the remaining tubing coiled beneath concentrator. During interview on 4/9/25 at 9:03 a.m., nursing assistant (NA)-C stated R22 has a history of falling; most always due to getting her feet caught in her oxygen tubing. NA-C stated the interventions in place for R22 included call light within reach, walker within reach, frequently used items within reach, and appropriate footwear. NA-C stated she didn't think these interventions were enough because R22 kept falling for the same reason. During observation on 4/9/25 at 9:07 a.m., resident attempting to get up on her own, did not use call light. Staff walking with another resident asked resident if she would sit back down and they would be in to help her in a few minutes. Resident stated she wanted to get dressed now. Staff continued to assist another resident. Oxygen tubing was beneath resident feet, stretching towards oxygen tubing. During observation on 4/9/25 at 11:06 a.m., resident attempting to get up on her own, she did not use call light. Oxygen tubing was beneath walker extending towards oxygen concentrator. During interview on 4/9/25 at 1:40 p.m., DON and registered nurse (RN)-A stated the process after a fall happens is to make sure the resident is assessed and treated immediately, notify appropriate staff and family, follow up per provider orders. Post falls assessments are completed based on provider orders. Post fall evaluation is completed during next stand-up meeting and/or interdisciplinary meeting if falls are repeated. RN-A confirmed interventions in place at time of all falls was call light within reach, walker within reach, frequently used items within reach, and appropriate footwear. RN-A confirmed only verbal reminders to ask for assistance were used to prevent future falls. DON and RN-A confirmed the current care plan does not reflect additional interventions to prevent future falls. DON and RN-A confirmed the resident does need an updated care plan to address her falls. 49893 R7 R7's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R7 was severely cognitively impaired with disorganized thinking and inattention. R7 had a history of wandering, no limitation of functional range of motion, supervision for bed mobility, partial/moderate assist for transfers and activities of daily living (ADLs). R7 had bowel and bladder incontinence. R7's diagnoses list included: Alzheimer's disease, major depression, anxiety, restlessness with agitation, osteoporosis, high blood pressure, and cerebral infarction (stroke). During an observation on 4/8/25 at 11:02 a.m., R7 sleeping at the table, staff offered to lay R7 down or wait for lunch. R7 laid down. During an observation on 4/8/25 at 12:17 p.m., R7 laying in bed hands under head, bed in normal position, wheelchair pushed against the wall, floor alarm in place, call light on lap. R7's provider orders included: furosemide (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure), carvedilol for high blood pressure, lorazepam for anxiety as needed, and venlafaxine for depression. R7's provider orders included check motion detector in room and at the desk for proper function daily. Replace batteries if not working correctly. R7's care plan included altered communication evidenced by difficulty with word find and speaking in sentences that do not make sense, assistance with ADLs and mobility requiring assist of 1 with walker for ambulation and transfers and extensive assist for ADLs. A fall care plan indicated R7 was at risk for falling related to impaired balance during transitions, use of antidepressant medications, history of falls resulting in fractured wrist, and frequent self-transferring. Interventions included: dicem (sticky material used to prevent slipping) between the seat of wheelchair and cushion at all times to help it from sliding out started 4/7/25. check motion detector in room and at the desk for proper function daily edited 10/21/24 observe frequently and place in supervised area when out of bed edited 9/25/24 provide toilet assistance every 2-3 hours edited 9/25/24 ensure auto-lock brakes on wheelchair remain in good , working order. If any issues or concerns arise with them, contact maintenance to assess or fix them dated 7/2/2024. Assure that resident is wearing proper, well-maintained footwear dated 5/23/24. encourage resident to participate restorative exercise as recommended by therapies. Encourage participation in group exercises when available that are led by activity staff edited 5/23/24. Encourage resident to use environmental devises such as hand grips, hand rails, etc. Remind resident to use assistive devices edited 5/23/24 Give resident verbal reminders not to ambulate/transfer without assistance. Follow physical and occupational therapy (PT/OT) recommendations for transfers and ambulation edited 5/23/24 Monitor overall condition for underlying infection that could contribute to altered mental status, weakness, and overall increased risk for falling edited 5/23/24, Provide an environment free of clutter. Always keep call light or pendant within reach. Keep personal items and frequently used items within reach edited 5/34/24. R7's cognitive loss/dementia care plan indicated R7 is unable to make daily decisions without cues/supervision related to her dementia, Alzheimer's, and anxiety diagnoses. Interventions include to monitor resident for exit seeking behaviors, wandering into unsafe areas, and entering other resident rooms uninvited, redirect when potential for injury is evident. Fall progress notes indicated the following: -On 9/8/24, resident found sitting on toilet with laceration to her head, sent to ER for sutures. Interventions included cold/ice, direct pressure to the wound Section titled Evaluation notes indicated Her careplan has been reviewed/revised, as necessary. -On 10/17/24 resident was observed reaching for floor alarm on floor and slid out of bed. Immediate intervention: put bed in lowest position. Careplan lacked documentation of intervention put in place. -On 11/14/24 resident found crawling on the floor. Motion detector was turned around so not alarming, bed in lowest position. Immediate interventions indicated none of the above. Evaluation notes indicated Her careplan has been reviewed/revised, as necessary. -On 12/27/24, resident observed sitting on the floor scooting into the hallway from her room. Resident was assisted to toilet, provided ADLs and assisted into bed. Resident was on Covid restrictions and had to use the restroom. Immediate interventions indicated none of the above. Summary of investigation indicated resident was assisted off the floor, toileting, received ADL's, and into bed for the night. Her careplan has been reviewed/revised, as necessary. -On 1/1/25, staff responded to motion sensor and found resident sitting on the floor of her room. Wheelchair and walker were not near her and resident was wearing 1 gripper sock. Sent to ER for evaluation of left leg. No fracture noted. Careplan has been reviewed/revised as necessary. Immediate intervention: rest. -On 3/19/25, resident had just been changed. Alarm was not put back in place. Immediate interventions, Got up in wheelchair to move around, rest -On 4/1/25, resident was found on floor by dietary staff. Immediate intervention: rest. Summary of investigation was left blank. During interview on 4/9/25 at 1:36 p.m., registered nurse (RN)-B stated R7 is very busy often responds with gibberish when asked questions. R7 tends to have days and nights mixed up and wanders throughout the unit going into other resident's rooms. R7 can be hard to redirect and has gotten aggressive. Falls are usually stemming from falling out of bed. Staff implemented rounding program every hour. Staff anticipate resident's needs for bathroom and eating. Motion sensor in resident's room. If self-transferring, staff get her up and let her wander around. Staff have also been instructed not to wake resident up in the middle of the night unless necessary. Staff also offer resident food and bring her out to the common area for distraction as resident likes to fidget. There are also photo albums and has a short attention span. Resident is on hospice and hospice has ordered morphine and lorazepam. Resident is also on scheduled Gabapentin (used to treat partial seizures, nerve pain from shingles and restless leg syndrome) to help with restlessness. Most of resident's falls occur in the evening and night. During interview on 4/10/25 at 10:22 a.m., RN-A stated unwitnessed falls require an assessment and neuros (assess an individual's neurological functions, motor and sensory response, and level of consciousness). The expectation is to paint a picture of what happened, and where they were. An email is sent out to everyone regarding the fall. RN-A mentioned to management last week they need to change how they look at falls. Currently, RN-A and the activity manager are assigned to monitor falls. Interventions are based on what type of fall. If resident's crawl out of bed, motion detectors are used. Referrals to PT/OT are made when appropriate. R7 had a couple falls when diagnosed with Covid due to being isolated to her room. When awake, R7 should be up and supervised out of her room. Current interventions include ambulation program, motions sensor, dicem under chair, toileting every 2-3 hours, autolock breaks on wheelchair, and nonstick footwear. They also increased her PRN (as needed) Ativan. RN-A confirmed the facility needs to do a better job at documenting interventions that have been put in place and need to get more people involved in fall investigation to do a better review of falls and appropriateness of interventions During an interview on 4/10/25 at 11:11 a.m., the director of nursing (DON) stated R7 has a history of behaviors and falls. The DON stated there isn't always a rhyme or reason for resident's falls as she does not feel they are all related to sundowning. R7 tends to be more active in the evening and has a history of spitting out medications. Staff attempt to distract R7. R7 can be very unpredictable. Current interventions include nonstick footwear, motion detector when in bed, antiroll back brakes, dicem in wheelchair and increased supervision. R7 is also toileted every 2-3 hours because R7 cannot really communicate toileting need. Staff encourage R7 to participate in restorative programs. Reminders to ask for assistance do not work for her [due to dementia diagnosis.] Staff also keep frequently used items close and allow resident to roam free when she is anxious. The DON also indicated staff do hourly rounding. She confirmed they need to do a better job at looking deeper into each fall and making sure all interventions are on the care plan. Heating Pad Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R28 was cognitively intact and had functional limitation in range of motion for both upper and lower extremities. R28's diagnoses list included displaced pelvic fracture, morbid obesity, anxiety, borderline personality disorder, bipolar II disorder, and left femur fracture. During observation on 4/7/25 at 7:30 p.m., R28 was sitting in her recliner with her legs up. R28 was wearing long pants and an abd bandage (a thick rectangular bandage used to absorb fluids and protect skin) on the left shin area. R28 placed a sheet over her legs and reached for her heating pad. R28 placed heating pad on top of the sheet over her left shin area. Heating pad did not contact bare skin. R28 turned heating pad on. R28's provider orders lacked order for use of heating pad. R28's careplan lacked documentation of use of heating pad. R28's hospital discharge summary lacked documentation for use of heat/heating pad. Progress notes dated 4/8/25 at 1:28 a.m., indicated R28 reported pain to lower left leg and did have her heating pad on the location for about 20 minutes. Progress notes dated 4/8/25 at 7:15 a.m., R28 does have a heating pad in her room. Progress notes dated 4/8/25 at 11:29 a.m., indicated R28 reported pain of 9 out of 10 to left leg with leg spasms. R28 was repositions and used heating pad. Progress notes dated 4/9/2025 at 3:42 a.m., indicated R28 does have her heating pad in her room. During interview on 4/8/25 at 2:59 p.m., licensed practical nurse (LPN)-C stated R28 takes muscle relaxer and narcotic pain medications every 4 hours for pain. R28 refuses ice and repositioning to help with pain control. LPN-C reported seeing the heating pad for the first time on 4/7/25 and thought R28's mother brought it in. LPN-C stated the heating pad should have been reported to the director of nursing (DON), however it slipped my mind. During interview on 4/9/25 at 9:35 a.m., registered nurse (RN)-C stated R28 will ask for pain medications routinely as soon as she is allowed to take them. RN-C reported seeing the heating pad in R28's room but assumed it had already been checked out by maintenance and approved. RN-C stated R28 does not usually use heating pad. RN-C confirmed electric items brought in from home have to be checked out by maintenance or policy has to be verified. During interview on 4/9/25 at 1:18 p.m., RN-B stated resident has struggled with pain control. Provider has evaluated and adjusted medications. RN-B stated she was not aware R28 had a heating pad in her room. RN-B stated R28 did ask about using a heating pad when she was first admitted . Staff informed R28 a heating pad has to have an automatic shut-off to be used in the facility. RN-B stated social services director (SS)-A told R28 if a heating pad was brought in, it needs to be checked out. RN-B stated R28's husband brought in the heating pad. During interview on 4/10/25 at 9:20 a.m., SS-A stated R28 asked about using a heating pad upon admission. R28 was informed she could bring one in but it would have to be evaluated to ensure it had the correct connection, indicate accurate temperature, and had an automatic shut off. SS-A stated R28's husband must have brought it in without telling anyone. SS-A was not made aware of heating pad until 4/8/25. During interview on 4/10/25 at 9:55 a.m., maintenance director (M)-A stated heating pads are required to have a grounded (3-prong) plug to be approved. M-A stated he was not aware R28 had a heating pad. During interview on 4/10/25 at 11:04 a.m., R28 stated her husband brought in the heating pad however, could not recall what date. During interview and observation on 4/10/25 at 11:27 a.m., the director of nursing (DON) stated she was not aware R28 had a heating pad. The director of nursing provided the heating pad which was observed to have an ungrounded 2-prong cord and temperature indicator of low, medium, high. The director of nursing stated using an ungrounded heating pad can increase the risk of an electrical short. There is also an increased risk of burns if resident were to fall asleep with the heating pad on due to the inability to determine exact temperature. A policy titled Portable Space Heaters/ Electric Blankets, HAREM- dated 4/2025 indicated With a doctor's order, electric blankets may be used provided they are new (dedicated to that resident only), UL listed, and are plugged directly into an electrical outlet (extension cords are not permitted). Facility fall prevention policy revised 4/2025 titled Fall Prevention indicated After an observed or probable fall, the staff will clarify the details of the fall, such as the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. This will be done by calling a Fall Huddle (see attached algorithm). -Nursing supervisor at the time will have all staff, working in the area of the fall, meet together to determine root cause analysis -Huddle will be called immediately after resident is stabilized -Staff will evaluate chain of events or circumstances preceding the fall (see attached fall huddle form) including: Time of day Whether fall was witnessed or not What the resident was doing What type of footwear did the resident have on What was the resident doing prior to the fall Distance of fall from starting location Location of fall ie. Bedside, between bed and bathroom, etc Last time resident had been to the bathroom and whether he/she was incontinent or not Mental status Gait assist devices -Staff will address any immediate interventions needed to prevent resident from falling again and communicate this to staff If fall is related to defective equipment, nursing supervisor will be responsible for taking this equipment out of service and notify the maintenance of need to examine and improvements can occur -Nursing supervisor will enter information gathered from huddle and interventions taken into the event form -Nursing supervisor will then place completed Safety Huddle Form in Director of Nursing's mailbox Review of falls -The interdisciplinary team reports on all falls daily at the stand-up meeting and reviews the details known about the fall. -The IDT team will review fall events in their group discussion at the next daily stand-up meeting and close the event, including: Occurrence, huddle findings' Root cause Interventions in place-Do they match RCA Are they weak, intermediate, or strong interventions? Suggestions? Protocol adherence-Are systems and operational changes needed? Any addition interventions desired through IDT analysis Monitoring subsequent falls and fall risk: -The staff will monitor and documents each resident's response to interventions intended to reduce falling or the risks of falling -If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measure are still needed if a problem that required the interventions (e.g. dizziness or weakness) has resolved -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue tor change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified -If a resident is noted to fall twice in a 2-month time period, referral to therapy will be made. If referral to therapy is not made, reasons for not referring will be documented on the fall investigation form -If a resident is noted to fall twice in a 2-month time period, need for pharmacy consult will be evaluated. If it is determined that thee is a need for a pharmacy consult, a referral be made, If referral is not made, reasons for not referring will be documented on fall investigation event form. -The staff and/or physician will document the basis for conclusion that specific irreversible risk factors exist that continue o present a risk for falling or injury due to falls

Based on interview and document review, the facility failed to ensure resident current wishes for resuscitation status were accurately documented in the medical record in a timely manner for 1 of 16 (R184) resident reviewed for advanced directives. Findings include: R184's Provider Orders for Scope of Treatment (POST) indicated Do not attempt resuscitation/DNR dated by the medical provider on [DATE] at 12:16 p.m. R184's electronic medical record (EMR) review on [DATE] at 5:36 p.m., lacked indication of code status in the identification banner. R184's Progress notes indicate R184 admitted to the facility on [DATE] at 11:15 without resident representation present. At 4:51 p.m., Social Worker (SW)-A attempted to reach R184's power of attorney Family member (FM)-A. At 7:49 p.m., RN-B left message for FM-A requesting immediate call back for direction regarding resident's care. On [DATE] at 2:46 a.m., facility staff left message for FM-A to return call. R184's Progress note dated [DATE] 11:59 p.m indicated FM-A returned call and stated R184 is to be a do not resuscitate (DNR) however, was not available to sign POST. R184's Progress notes indicate FM-A signed POST on [DATE]. Although on [DATE] at 9:02 a.m., R184's EMR continued to lacked indication of code status in the identification banner. During an interview on [DATE] at 01:39 p.m., LPN-A stated it is facility policy to verify code status with POST in the resident's hard chart. The first lace LPN-A would look at is the EMR identification banner for code status and then the hard chart if the EMR banner was not updated. LPN-A confirmed there was no indication of code status on R184's EMR identification banner. LPN-A stated not having a code status could lead to a resident having CPR performed when they didn't want it. LPN-A stated the nurse manager enters a resident's code status. During an interview on [DATE] at 2:45 p.m., the director of nursing (DON) stated advanced directives and code statuses are established at admission. She stated the facility had difficulty reaching R184's power of attorney to confirm R184's code status. DON stated R184 fell through the cracks due to the difficulty reaching the power of attorney. During interview on [DATE] at 9:53 a.m., SW-A stated she is not always the first person to see the residents upon admission to the facility. Code status is established by the nursing department in most cases. SW-A stated R184's health care directive from the hospital lacked indication of code status. SW-A stated facility policy indicates residents are considered full code until the POST form is signed for legal reasons to avoid potential for miscommunication. SW-A stated R184's power of attorney was informed R184 would be a full code until the form was signed. R184's POST was signed on [DATE] by FM-A and SW-A. During interview on [DATE] at 11:08 a.m., RN-A stated she would look at the POST to verify code status. If the POST was not signed, she would assume resident was full code. RN-A stated verbal confirmation of code status is not sufficient and a resident would still be considered a full code until a POST is signed. During interview on [DATE] at 12:51 p.m., R184's power of attorney (FM-A) recalled having a conversation with the facility regarding R184's code status and stated he did sign code status paperwork on [DATE]. He was unable to confirm being told R184 could be treated as full code until POST was signed. During interview on [DATE] at 12:59 p.m., RN-B stated she is responsible for putting the admission packet together, receipt of discharge paperwork, and inputting orders into EMR. Nursing floor staff are responsible for filling out consents for necessary equipment and going through POST with the resident or responsible party. RN-B stated she enters information into EMR. It was her understanding R184 would be enrolling in hospice upon admission and the power of attorney would be arriving with the resident. RN-B stated she entered R184's code status as DNR in the EMR, however removed it upon realizing the power of attorney would not be arriving with R184 to sign the POST. She acknowledged she should have indicated FULL CODE on the EMR banner until the POST could be signed. She stated she asked the DON and SW-A if a verbal confirmation of code status was acceptable prior to signature. They were both unsure as their policy indicates full code in the absence of a signed POST. She was also unaware hospice arrangement had not been made prior to R184's admission. RN-B stated the facility is in the process of changing their admission policy to ensure hospice arrangements and code status is established prior to or on the day of admission to ensure information is not missed in the future. A policy dated ,d+[DATE] titled CPR indicates the objective of the CPR policy is to provide basic life support based until emergency medical services arrives, consistent with the resident advanced directives, in the absence of an advance directive or do not resuscitate order and if the resident does not show signs of clinical death. Prompt initiation of CPR is essential as brain death begins four to six minutes following cardiac arrest if CPR is not initiated within that time. It continues, Advanced directive-means according to 42C.F.R. 489.100, a written instruction, such as living will or durable power of attorney for health care, recognized under state law (whether statutory or as a recognized by the courts of the State), relating to the provision of healthcare when the individual is incapacitated. Some states also recognize a documented oral instruction. It is the policy of [NAME] Harmony Care Center to provide basic life support, including CPR- Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advanced directives. Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place - Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present. -Initiating CPR could cause injury or peril to the rescuer. A facility policy dated ,d+[DATE] titled Advanced Directives indicates it is facility policy to identify if the resident has an advance directive upon admission. If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, [NAME] Harmony Care Center will give advance directive information to the individual's resident representative in accordance with Minnesota State law. The section titled Cardiopulmonary Resuscitation (CPR) indicates staff are educated to initiate CPR unless a valid DNR order is in place.

Based on observation, interview and record review the facility failed to ensure resident-to-resident sexual abuse were identified timely, and implement appropriate actions to prevent ongoing abuse for 1 of 1 resident (R1) who had severe cognitive impairment and unable to give consent. This deficient practice resulted in an immediate jeopardy (IJ) for R1, a reasonable person would have experienced severe psychosocial harm-dehumanization, and humiliation as a result of the sexual abuse. The IJ began on 5/13/23, when the facility failed to implement protection measures after staff observed R2 inappropriately touching R1's perineal area (in-between legs) which subsequently resulted in R2 continued inappropriately touching of R1. The administrator and clinical manager (CM)-A were notified of the IJ on 10/11/23 at 1:13 p.m. The facility implemented corrective action and the deficient practice was corrected on 9/30/23, prior to the survey and was issued at past non-compliance. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated R1's cognition was severely impaired with diagnoses of dementia, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), aphasia (a disorder that results from damage to portions of the brain that are responsible for language), anxiety disorder and delusional disorder. R1 used wheelchair for mobility and wandered for one to three days. R1's care plan dated 4/12/23, indicated intermittent episodes of affection toward other residents has been determined inappropriate for R1 as she does not have the capacity to give consent. Interventions dated 4/12/23, directed staff to allow hand holding with other residents if R1 chooses to do so and monitor relationships with other residents. R2's quarterly MDS dated [DATE], indicated R2 had intact cognition and diagnoses of Alzheimer's disease, dementia, and anxiety disorder. R2 was independent with moving around the facility in a wheelchair and displayed physical behavior symptoms directed towards others for one to three days. R2's care plan dated 5/25/22, indicated R2 will occasionally say inappropriate things to female staff members or female residents, has attempted to touch female staff members and another female resident inappropriately in the past. Interventions dated 5/25/22, that staff will redirect R2's conversation if it starts to head in an inappropriate direction. Reminding R2 how much he loves his wife. During an observation on 10/9/23, at 4:43 p.m. R1 was seated in a Broda chair with the left side of her body facing the fish aquarium seated up to the table. She was hanging onto a baby doll that was wrapped in a blanket. She had flat affect and was kicking her feet. At 4:44 p.m R2 was seated in a wheelchair with R2's right side facing the window. R2 turned his head towards R1 who was at the table furthest from R2 by the fish aquarium, and would glance over at this surveyor then look out the window, this was repeated several times. R2's progress notes dated 5/13/23, at 4:30 pm, indicated that R2 wheeled self over to R1 and stated to her, Do you want me to touch you, R2 then placed his hand in R1's inner leg/peri area, staff intervened and told R2 not to do that and removed R1 from the area. Another male resident (R4) stated to R2, I'm glad you got caught. R2 told R4, Fuck you. There was no indication the incident was reported. During an interview on 10/11/23, at 10:09 a.m. with R4 who according to his quarterly MDS dated [DATE], did not have cognitive impairment reported R2 used to be his roommate. R4 stated R2 was not very decent with the ladies. R4 reported he witnessed R2 grabbing in between R1's legs on 5/13/23, which was upsetting to him. R4 stated he yelled for licensed practical nurse (LPN)-A over. It was terrible. I told the nurse why you are allowing this? [R1] doesn't even know what is going on, it makes me sick. It just isn't right. R4 explained R2 used the f-word on me because he called him [R2] out for touching R1. R2's progress notes dated 6/1/23, at 9:56 p.m. indicated R2 wheeled self over to R1 and put his hand on R1's inner thigh, staff observed from a distance and removed R1 from the area. R2 went to his room. Staff will monitor for increased behaviors. There was no indication the incident was reported. R2's progress note dated 8/21/23, at 1:06 p.m. indicated R2 exhibited sexual behaviors towards R1. R2 was reaching and touching R1 between the legs. R2 was asked to stop and leave R1 alone despite this, R2 continued to exhibit the behavior two more times, R1 was then moved to another area. R2 later continued to approach R1 and was again asked to leave R1 alone and go find somewhere else to sit. Social worker (SW)-A intervened and directed R2's thoughts to a different subject. There was no indication the incident was reported or investigated. R1's progress note dated 9/30/23, indicated R1 was sitting in her chair in the TV lounge. R2 was observed to have his left hand on R1's left breast. Staff separated R1 and R2. R1 was showing no signs and symptoms of distress at this time. Order in place to monitor for distress. Staff completed event and notified Administration, director of nursing (DON), case manager (CM), social worker (SW), and family. During an interview on 10/9/23 at 1:59 p.m., nursing assistant (NA)-A and NA-B, NA-A indicated on a typical day staff assisted R2 with his morning cares; R2 liked to be up in his wheelchair by 8:30 a.m. NA-B stated during cares R2 would sometimes would grab you inappropriately. Staff would redirect and tell him the behavior was not appropriate. NA-A indicated R2 went from targeting staff to targeting R1. R2 was alert and knew to wait by the window every Saturday for his family, he knew where his room was, and he knew his old roommate R4. [R2] knows what he is doing is wrong. NA-A explained R2 needed to have supervision at all times when he is up in his wheelchair. R2 watched to see where staff were, if staff were not within his line of sight he would make a grab on someone, namely poor R1. During an interview on 10/9/23, at 4:59 p.m. NA-C indicated during morning cares, it was normal for R2 to try to touch body parts and kiss you. Tell him it's not appropriate and R2 apologized. NA-C indicated that R1 and R2 needed to be kept apart due to R2 touching R1 inappropriately. NA-C guessed R1 did not have the capacity to consent. R1 was still married, if R1 actually had the capacity to think, there was no way R1 would be ok with any male touching her like that. During an interview on 10/9/23, at 5:17 p.m. NA-D stated an awareness of R2's long standing sexually inappropriate behaviors that included innuendos, advances, grabbing for women's private parts, and strong sexual language. Staff were supposed to redirect R2 and explain the behavior was not appropriate. NA-D stated R1 hardly ever talked and thought R1 did not have the ability to say no. I feel bad for R1. NA-D would find it hard to believe R1 had the ability to consent or would consent to having anything like her boobs fondled or crotch grabbed. During an interview on 10/9/23, at 5:21 p.m. NA-E indicated R2 had a history of being sexually inappropriate with female staff and was not aware if R2 had been sexually inappropriate with female residents aside from R1. NA-D indicated he was working on 9/30/23 when R2 was fondling R1's breast. After the incident, initially both R1 and R2 were on 15-minute checks, but now we have to keep our eyes on R2 at all times, R2 can't be trusted. During an interview on 10/9/23 at 11:58 a.m., licensed practical nurse (LPN)-B indicated R2 had a long history of being sexually inappropriate with staff and now with R1. LPN-B explained they keep R1 and R2 apart, sit at separate tables away from each other during meals and activities. Staff also make sure R2 keeps his distance from other female residents. During a phone interview on 10/10/23, at 12:41 p.m. LPN-B indicated R2 had attempted to reach out and touch R1's groin area several times. R2 had been educated several times by nursing about being inappropriate, staying in his own space, and not touching others. LPN-B had discussed her concerns about R2's sexual behaviors with SW-A and director of nursing (DON) several times if it was safe for R2 to be around other residents when he demonstrated these behaviors. LPN-B explained This was R1's home and R1 should not have to deal with being constantly touched and prodded. LPN-B indicated R2 would always look around to see where staff were when R1 was in the vicinity, like he was waiting for staff to leave so he could approach R1. LPN-B indicated according to R2's family member, the sexual behaviors were nothing new and R2 had been like this for years. During an interview on 10/10/23, at 1:50 p.m. LPN-A indicated they were working on 5/26/23 and 6/1/23 and stated that R2 has had sexual behaviors towards staff since his admission a year and a half ago. LPN-A indicated R2 started to target R1 sexually in May of 2023. He seemed to constantly seek R1 out to inappropriately touch her groin and breast. LPN-A stated they would constantly redirect R2 away from R1 until R2 would go to bed, which was after supper. LPN-A indicated there were many near miss events where staff intervened before R2 could touch R1 and there may have been times where the sexual abuse was not documented. LPN-A indicated each event was reported to the DON. It was not until the incident on 9/30/23, when R2 was fondling R1's breasts that interventions of increased supervision was implemented to prevent R2 from touching R1. During an interview on 10/10/23, at 12:01 p.m. registered nurse (RN)-A indicated on 8/21/23, R1 was by the wall where the fish aquarium was on the right side facing the Memory Lane hallway. R2 was wheeling himself up to R1's left side and started talking with her. Then R2 put his right hand on R1's right inner thigh/peri area, it was on top of R1's pants not in them. RN-A intervened, moved R2 away and told him it was not appropriate, R2 apologized to RN-A, however, he attempted to do the same thing to R1 twice after that. RN-A indicated R1 was moved to the nurse's station where staff would be close and deter R2. RN-A indicated she had not reported the incident to facility administration on 8/21/23, because R2's sexual behaviors were so normalized in the facility. During a phone interview on 10/10/23, at 2:29 p.m. family member (FM)-A indicated R1 was Lutheran and followed her religion closely. R1 was married, had children and was previously an activity director at a LTC facility. R1 never showed public displays of affection with any of her husband's and was very private in that manner. Prior to R1's illness if another male were to ever touch her breasts or groin area it would have mortified and humiliated R1, especially in a public setting or in front of other people. R1 believed and preached no sex before marriage and would have been severely humiliated and mortified by these sexual touches. During a phone interview on 10/11/23, at 12:35 p.m. R1's guardian (G)-A indicated she was R1's guardian until the end of October (2023) then FM-A would take over guardianship. G-A indicated an awareness of R1 having her breasts fondled by an unknown male resident. R1 was a vulnerable adult and did not remember things. During a meeting in April it was determined R1 was not able to consent to sexual activities due to her dementia. During an interview on 10/10/23, at 3:05 p.m. social worker (SW)-A and DON indicated an unawareness of sexual touches to R1's groin on 5/13/23, 6/1/23 and 8/21/23. SW-A stated, if we had known we would have immediately protected R1, reported the abuse to the state and put prevention plans in place to protect all residents which is what we did when we knew R2 fondled R1's breasts on 9/30/23. Although R1 had severe cognition, unable to consent and had a flat affect the facility did not implement interventions to mitigate the risk of abuse occurring to R1 by R2. FM-A and guardian both identified R1 was usable to consent. FM-A identified how R1 would have responded to the abuse if she had the ability. As a result of this information the reasonable person concept was applied for R1. The facility policy, Abuse Potential/Vulnerable Adult/QAPI review revised 01/2023, indicated It is the policy of [NAME] Harmony Care Center to maintain an environment where residents are free from abuse, neglect. exploitation, and misappropriation of resident property and all residents, staff, families, visitors, volunteers, students, and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, exploitation, or misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. Generally sexual contact is nonconsensual if the resident either: appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur. G. Reporting and Response Abuse reporting requirements: [NAME] Harmony Care Center will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that may constitute reasonable suspicion of a crime are reported immediately, but not later than 2 hours after the allegation is made .Internal reporting: Employees must always report any abuse, suspicion of abuse, or suspicion of crime immediately to the Administrator. Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law. The past-noncompliance immediate jeopardy began on 5/13/23 and was removed on 9/30/23, when the facility implemented a systemic plan to ensure all residents were safe. The following actions were implemented prior to survey. -Review of R2's care plan dated identified continuous monitoring of his whereabouts. -Review of R1's progress notes dated 9/30/23 identified monitoring/assessing for R1's behaviors for any changes as a result of the abuse -Facility staff received abuse and sexual abuse training -During staff interviews from 10/9/23 to 10/11/23, identified direct care staff were able to articulate what constituted abuse and the facility's abuse reporting policy.

Based on interview and document review, the facility failed to ensure the State Agency (SA) were notified within 2 hours of staff witnessing three allegations of resident-to-resident sexual abuse for 1 of 1 residents (R1) when R2 inappropriately placed his hands in between R1's legs. Findings include: A Facility Reported Incident (FRI) submitted to the State Agency on 10/11/23 at 8:08 p.m., alleged resident to resident sexual abuse when staff witnessed R2 wheeled self over to R1 and stated to her, Do you want me to touch you, as R2 placed his hand in R1's inner leg/peri area, staff intervened and told R2 not to do that and removed R1 from the area. Another male resident [R4] stated to R2, I'm glad you got caught. R2 told [R4], Fuck you. The incident occurred on 5/13/23, at 4:30 p.m. which was approximately 151 days prior to the facility reporting the incident. During an interview on 10/11/23, at 10:09 a.m. with R4 who according to his quarterly MDS dated [DATE], did not have cognitive impairment reported R2 used to be his roommate. R4 stated R2 was not very decent with the ladies. R4 reported he witnessed R2 grabbing around in between R1's legs on 5/13/23, which was upsetting to him. R4 stated he yelled for licsensed practical nurse (LPN)-A over. It was terrible. I told the nurse why you are allowing this? [R1] doesn't even know what is going on, it makes me sick. It just isn't right. R4 explained R2 used the f-word on me because he called him [R2] out for touching R1. A FRI submitted to the State Agency on 10/11/23 at 8:56 p.m., alleged resident to resident sexual abuse when staff witnessed R2 wheel self over to R1 and put his hand on R1's inner thigh. The incident occurred on 6/1/23, at 8:09 p.m. which was approximately 132 days prior to the facility reporting the incident. A FRI submitted to the State Agency on 10/11/23 at 8:54 p.m., alleged resident to resident sexual abuse when staff witnessed R2 inappropriately was reaching and touching in between R1's legs, R2 place his hand inside R1's inner thigh. R2 was redirected to another area, despite this he did do the same behavior two more times. The incident occurred on 8/21/23 at which was approximately 51 days prior to the facility reporting the incident. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was severely impaired with diagnoses of dementia, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), aphasia (a disorder that results from damage to portions of the brain that are responsible for language), anxiety disorder and delusional disorder. R1 used wheelchair for mobility and wandered for one to three days. R1's care plan dated 4/12/23, indicated intermittent episodes of affection toward other residents has been determined inappropriate for R1 as she does not have the capacity to give consent. Interventions dated 4/12/23, directed staff to allow hand holding with other residents if R1 chooses to do so and monitor relationships with other residents. R2's quarterly MDS dated [DATE], indicated R2 had intact cognition and diagnoses of Alzheimer's disease, dementia, and anxiety disorder. R2 was independent with moving around the facility in a wheelchair and displayed physical behavior symptoms directed towards others for one to three days. R2's care plan dated 5/25/22, indicated R2 will occasionally say inappropriate things to female staff members or female residents, has attempted to touch female staff members and another female resident inappropriately in the past. Interventions dated 5/25/22, that staff will redirect R2's conversation if it starts to head in an inappropriate direction. Reminding R2 how much R2 loves his wife. During an interview on 10/10/23, at 1:50 p.m. LPN-A indicated working on 5/26/23 and 6/1/23 and stated that R2 has had sexual behaviors towards staff since his admission a year and a half ago. LPN-A indicated R2 started to target R1 sexually in May of 2023. He seemed to constantly seek R1 out to inappropriately touch her groin and breast. LPN-A stated they would constantly redirect R2 away from R1 until R2 would go to bed, which was right after supper. LPN-A indicated there were many near miss events where staff intervened before R2 could touch R1 and there may have been times where the sexual abuse was not documented. LPN-a indicated each event was reported to the DON. It was not until the incident on 9/30/23, when R2 was fondling R1's breasts that interventions of increased supervision was implemented to prevent R2 from touching R1. During an interview on 10/10/23, at 12:01 p.m. registered nurse (RN)-A indicated on 8/21/23, R1 was by the wall where the fish aquarium was on the right side facing the Memory Lane hallway. R2 was wheeling himself up to R1's left side and started talking with her. Then R2 put his right hand on R1's right inner thigh/peri area, it was on top of R1's pants not in them. RN-A intervened, moved R2 away and told him it was not appropriate, R2 apologized to RN-A, however, he attempted to do the same thing to R1 twice after that. RN-A indicated R1 was moved to the nurse's station where staff would be close and to detour R2. RN-A indicated she had not reported the incident to facility administration on 8/21/23, because R2's sexual behaviors were so normalized in the facility. During an interview on 10/10/23, at 3:05 p.m. social worker (SW)-A and DON indicated an unawareness of sexual touches to R1's groin on 5/13/23, 6/1/23 and 8/21/23. SW-A stated, if we had known we would have immediately protected R1, reported the abuse to the state and put prevention plans in place to protect all residents which is what we did when we knew R2 fondled R1's breasts on 9/30/23. The facility policy, Abuse Potential/Vulnerable Adult/QAPI review revised 01/2023, indicated It is the policy of [NAME] Harmony Care Center to maintain an environment where residents are free from abuse, neglect. exploitation, and misappropriation of resident property and all residents, staff, families, visitors, volunteers, students, and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, exploitation, or misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. Generally sexual contact is nonconsensual if the resident either: appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur. G. Reporting and Response Abuse reporting requirements: [NAME] Harmony Care Center will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that may constitute reasonable suspicion of a crime are reported immediately, but not later than 2 hours after the allegation is made .Internal reporting: Employees must always report any abuse, suspicion of abuse, or suspicion of crime immediately to the Administrator. Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law.

Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was used during cares of a catheter for 1 of 1 residents (R14) who was on transmission-based precautions. Findings include: During an observation on 5/25/21, at 10:05 a.m., registered nurse (RN-A) identified R14's catheter was found to be leaking. RN-A informed RN-B and both RN's entered R14's room washed hands and donned gloves to assess catheter. RN-B clamped the catheter, unhooked and cut tubing to avoid the tube kinking again. RN-B used a alcohol pad to wipe the tip of tubing and connected to catheter. R14 was on transmission-based precautions due to active [CONDITION(S)]-Resistant Staphylococcus aureus (MRSA) in his urine and both RN-A and RN-B failed to put a gown on prior to assessing and fixing catheter. During an interview on 5/25/21, at 11:40 a.m., RN-B stated that gowns are used when cares are performed with R14's catheter as he has MRSA in his urine. RN-B then verified that she did not followed proper infection control standards as she did not put a gown on prior to assessing catheter. During an interview on 5/25/21, at 1:44 p.m., RN-A was asked how the facility attempts to minimize the occurrence of symptomatic Urinary Tract Infections. RN-A stated that they perform daily site care, use alcohol wipes when changing, emptying and cleansing catheter bags. RN-A also stated they use proper personal protective equipment, especially with R14 as he has a history of MRSA in urine. Facility Contact Precautions, including Enhanced Barrier Precautions Policy last revised 12/13/2019 included the procedure for Contact Precautions is to wash hands, don gloves and gown upon entry into the room. In addition, a clean, non-sterile gown with long sleeves will be worn if direct care is anticipated. When such contact is anticipated, the gown should be put on before entering the room or approaching the resident.

Based on interviews and document review, the facility failed to evaluate and offer new non-pharmacological intervention prior to pain medication administration for 1 of 6 (R3) residents reviewed for unnecessary medications. Findings include: R3 Minimum Data Set (MDS) assessment included cognitively intact, no [CONDITION(S)], no [CONDITION(S)], no refusal of cares, extensive assist with cares, uses wheelchair and walker, on a pain medication regimen, frequent pain, and a pain intensity rated at 8. R3 resident face sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 orders included acetaminophen 500 mg [milligrams] twice daily as needed for mild pain; acetaminophen 1000 mg three times daily; [MEDICATION(S)] adhesive patch 5 % on the skin daily; [MEDICATION(S)] [pain medication] 50 mg every 6 hours as needed for pain; [MEDICATION(S)] 50 mg twice daily for pain; use of essential oils to support symptoms of pain every 4 hours as needed. R3 care plan dated 2/3/21 included R3 has complaints of chronic pain related to arthritis and low back compression fractures with interventions of: administer analgesics per orders and monitor and record effectiveness; assess past effective and ineffective pain relief measures; consider use of essential oils to support pain symptoms; position for comfort with physical support as necessary; and use non-medicated pain relief measures: (i.e. application of heat/cold, massage, physical therapy, stretching and strengthening exercises, etc.) and monitor effectiveness. During an interview on 05/26/21 at 01:48 p.m. R3 stated she has pain in right knee and it helps to recline in recliner. R3 stated [MEDICATION(S)] helps the best and that ice or heat do not help. R3 stated she will request as needed [MEDICATION(S)] if resting does not help. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note dated 04/12/2021 at 06:46 p.m., R3 requested as needed dose of [MEDICATION(S)] early in the afternoon for bilateral knee pain. Rated pain 8/10 and did not relate a cause. R3 stated it was effective and when she stays off of it they get better. Progress note dated 04/14/2021 at 09:09 p.m., included R3 stated that she would like a pain pill. Nurse administered as needed [MEDICATION(S)] at 9:04 p.m. which was effective as R3 did fall asleep shortly after administration. During an interview on 05/26/21 at 01:51 p.m., registered nurse (RN)-C stated R3 has pain mostly in knees, right hip, or low back area. RN-C stated R3 gets scheduled [MEDICATION(S)], as needed [MEDICATION(S)], and [MEDICATION(S)] patch. RN-C stated non-pharmacological interventions include ice or heat, rest and elevation of legs in recliner but R3 does not like to use ice or heat and will request as needed [MEDICATION(S)] for pain. RN-C stated the non-pharmacological interventions offered likely do not get documented but do make note of request of as needed pain medication. During an interview on 05/26/21 at 01:57 p.m., director of nursing (DON) stated a progress note of pain should be documented and it is expected to offer non-pharmacological interventions with note of effectiveness. Facility pain management policy dated 11/6/19 included the pain management program will develop pharmacological and/or non-pharmacological interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. It included non-pharmacological interventions such as altering the environment for comfort; physical modalities such as ice packs, heat, neutral body alignment, repositioning, massage, and essential oils; exercises; and cognitive/behavioral interventions such as relaxation techniques, diversions, activities, and music therapy. It indicated as needed medication may be used in adjunct or after attempting other interventions first. Documentation of assessment and reassessment is expected.

Based on observation, interview and document review, the facility failed to ensure medications were current and were labeled with current and accurate administration instructions to prevent medication errors for 1 of 1 residents (R30) reviewed for death record. Findings include: Please refer to 755 for disposition of narcotics and controlled substances. During an interview on 4/24/19 at 9:52 a.m. registered nurse (RN)-A said R30's [MEDICATION NAME] (narcotic pain medication) was placed in lock box to be destroyed on 12/11/18. RN-A said on 1/16/19 new order was received for the [MEDICATION NAME] and authorized RN-B to remove from disposition lockbox and place back in inventory. R30 safety events (medication errors) dated 1/25/18, 3/1/19, 3/6/19, 3/11/19 and 3/12/19, indicated medication ordered was [MEDICATION NAME] concentrate 20mg/1ml give 2mg po/sl (by mouth/sublingual) q (every)hour prn (as needed)pain 2 mg =0.1 ml. Description of error 0.25ml was given, as was previous order. R30 Medical Provider Progress Notes and Orders dated 12/10/18, indicated; D/C (discontinue) [MEDICATION NAME] (narcotic pain medication) d/t (due to) non-use. R30 Administration Record-Controlled Drugs/Meds dated 6/22/18, indicated [MEDICATION NAME] 28.5 ml transferred to different location (lockbox) on 12/11/18. R30 Administration Record-Controlled Drugs/Meds dated 6/25/18, indicated ms ([MEDICATION NAME]) 30ml transferred to different location (lockbox) on 12/11/18. R30 Medical Provider Progress Notes and Orders dated 1/16/19, indicated start [MEDICATION NAME] 20mg (milligrams)/1ml to give 2mg Q hour PRN-pain, dyspnea (difficult breathing). R30 Administration Record-Controlled Drugs/Meds dated 1/16/19, indicated [MEDICATION NAME] sulfate, directions-take 0.25 ml by mouth or under the tongue. During an interview on 4/23/19, at 2:59 p.m. pharmacist indicated the expectation of a discontinued medication is to be destroyed and if needed again to receive a new medication from the pharmacy not reuse an already discontinued medication. During an interview on 4/24/19, at 8:46 a.m. Director of nursing (DON) said education was given on 3/20/19 for the wrong labeling of the [MEDICATION NAME] for R30 although did not educate on removal of narcotics from the disposition box. On 4/24/19, at 10:07 a.m. DON would have expected to work with the pharmacy to receive the medication and not use a discontinued medication. On 4/24/19, at 10:10 a.m. pharmacy indicated on 1/16/19 new prescription received dated 1/16/19 although not filled until 3/11/19. Pharmacy added it was not filled right away due to payment needed. A form titled non-covered medication plan sent to the facility was to be signed and faxed back, for the cost of $15.63, but the pharmacy never received the form back and no additional follow up was completed. In addition, the pharmacy said they received two prescriptions one dated 1/16/19 on 3/11/19 and again on 3/13/19 with a change in dose. If there was a dose change they can place a sticker on the bottle and then let the pharmacy know for future refills. When asked regarding if the facility can take a discontinued medication and place back in inventory. The pharmacy sternly said, OH, NO NO NO NO, they can't do that, they need to send in the prescription. On 4/24/19, at 10:14 a.m. DON was aware of the narcotics back log in the lock box to be destroyed. On 4/24/19, at 10:58 a.m. RN-B verified she was told by RN-A to remove the [MEDICATION NAME] from the lock box and place back in inventory, but the label was never changed and this is why the medication errors occurred. Facility policy dated 4/2104 titled Adverse Consequences and Medication Errors reads, A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of professional(s) providing services. 6. Examples b. unauthorized drug-a drug is administered without a physician's orders [REDACTED]. wrong dose

Based on observation, interview, and document review the facility failed to monitor and complete [MEDICAL CONDITION] assessments for 1 of 1 residents (R1) reviewed for [MEDICAL CONDITION] that had a [DIAGNOSES REDACTED]. Findings include R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and did not have rejection of care behaviors. The MDS identified R1's [DIAGNOSES REDACTED]. R1's physician orders [REDACTED]. -Knee high Teds (compression socks) on in the morning and off at bedtime (start date 8/23/18, stop date 4/16/19) -Ace wrap both feet/ankles bilaterally and encourage to elevate them. On in the morning and off at bedtime. Re-evaluate [MEDICAL CONDITION] in one week (start date 4/16/19, stop date 4/22/19) -Knee high Teds on in the morning and off at bedtime (start date 4/23/19) -Weekly weights (start date 4/10/17, stop date 4/23/19) R1's [MEDICAL CONDITION] care plan dated 6/17/18, included R1 has [MEDICAL CONDITION] to lower extremities and has seen occupational therapy to establish treatment for [REDACTED]. The goal was [MEDICAL CONDITION] would not increase with collaborative effort by occupation therapy and nursing staff. Corresponding interventions directed staff to complete thorough cleansing and moisturizing with lotion, thigh high Ted stockings on both legs, encourage resident to complete lower extremity exercises, and encourage resident to keep legs elevated on leg rests, bed, or recliner at least twice daily. The care plan also included encourage (R1) to elevate her feet when they are swollen. Sometimes she will agree to sit in the recliner or lay down in bed. She does like to sit with friends at the dining room table for extended periods and attend activities and may not like to have her legs up. During an observation and interview on 4/22/19, at 1:38 p.m. R1 sat in the living room area in a recliner chair doing a word find puzzle. R1's legs were in the dependent position (not elevated), had compression wraps on both legs, both of R1's legs from foot to mid-calf observed to be swollen; left leg, and foot was worse than the right. R1 stated she sometimes had problems with [MEDICAL CONDITION]. During an observation on 4/22/19, at 5:38 p.m. R1 sat at the dining room table, legs in the dependent position, compression wraps on both legs from foot to below the knee. R1 legs were observed to be more swollen than previous observation. At 6:03 p.m. nursing assistant (NA)-B assisted R1 to the restroom and then directed R1 to sit in the recliner chair and did not encourage and/or assist R1 to evelate her legs. R1's weight record indicated an increase an 8-pound weight gain since 3/19/19: 3/19/19, weight 130 pounds (lbs.) 3/26/19, weight 131 lbs. 4/2/19, weight 134.5 lbs. 4/9/19, weight 134 lbs. 4/16/19, weight 134 lbs. 4/22/19, weight 137 lbs. 4/23/19, weight 138 lbs. R1's weekly skin assessment progress note dated 4/8/19, at 8:24 a.m. included Feet have bilaterally increased [MEDICAL CONDITION], left foot +4, right foot +2 [MEDICAL CONDITION]. Resident is wearing ted stocking but only elevates legs on sparring occasion. R1's nutrition progress note dated 4/8/19, at 9:48 a.m. indicated R1 weighed 134.5 lbs., up 4 lbs. from last month, and will monitor [MEDICAL CONDITION] status. R1's record lacked consistent monitoring and assessment for worsening [MEDICAL CONDITION] until 4/15/19; however, the assessment did not identify the extent of [MEDICAL CONDITION]. R1's weekly skin assessment dated [DATE], included lower extremities swollen foot to mid ankle but legs area virtually free from swelling. Going to try wraps instead of ted hose. Increase amount of time with legs elevated. R1's record reviewed from 4/15/19 through 4/23/19, lacked ongoing [MEDICAL CONDITION] monitoring and assessment. R1's progress note dated 4/23/19, at 4:04 p.m. included feet/ankles continue to show [MEDICAL CONDITION] without improvement with the use of ace wraps. [MEDICAL CONDITION] in right leg is 2_ to the top of foot (with measurement of 24 cm (centimeters) just below toes), 2+ to the top of ankle and 3-4+ to sides of ankle bilaterally (with a measurement of 33 cm circumference), and 2+ [MEDICAL CONDITION] to mid shin (with measurement of 27 cm). (R1) denies pain to the right leg with the exception of palpation of [MEDICAL CONDITION] to shin. (R1's) left leg shows a measurement of 23.5 cm just below toes, but [MEDICAL CONDITION] begins at approximately mid foot to 3+. Left ankle shows 3+ [MEDICAL CONDITION] to the top of the ankle with 4+ [MEDICAL CONDITION] to sides bilaterally (measuring 34.5 cm circumference). Left leg shows 2-3+ [MEDICAL CONDITION] up to mid shin an leg is shiny in appearance. There is a small, flat (not fluid filled), circular tan area on the outer aspect of left leg above the ankle but below the shin. (R1) denies pain to left leg at all. The note also included, Since ankles/[MEDICAL CONDITION] have not shown any improvement with wrapping ankles vs use of compression stockings, message was sent to provider at this time to address [MEDICAL CONDITION]/weight on her visit tomorrow morning for routine progress note. Of note, weight today is 138# on tub scale, fully clothed with an increase in weight noted over the past few weeks that provider will address as well. During an observation on 4/23/19, at 8:42 a.m. R1 sat at the dining room table with legs in the dependent position. R1 had tubi grips on both lower extremities with brown gripper socks on. Both of R1's legs continued to be [MEDICAL CONDITION], left worse than the right. When R1 completed her breakfast she was assisted to a recliner chair in the living room area by an unidentified nursing assistant (NA). R1 sat in the recliner with legs in the dependent position. R1's physician orders [REDACTED]. During an observation on 4/23/19, at 10:33 a.m. R1 sat in the recliner chair in the living room area with legs not elevated. During an observation on 4/23/19, at 11:53 a.m. R1 sat at the dining room table with tubi grips to both legs and slippers on, legs were in a dependent position. During an observation on 4/23/19, at 1:26 p.m. R1 sat in the recliner chair in the living room area with feet not elevated. At 2:26 p.m. R1 continued to sit in the recliner with legs not elevated. During an interview on 4/23/19, at 2:27 p.m. NA-abbey stated NA's applied compression stockings or tubi grips to residents and nurses applied the compression wraps. NA-A stated R1 was supposed to elevate her legs, historically would refuse however, was more compliant with elevating her legs now. NA-A stated R1's legs were not as big as they used to get, however, her legs were still swollen. NA-A indicated that if NA's noticed an increase in resident's [MEDICAL CONDITION] they would notify the nurse. During an interview on 4/23/19, at 2:43 p.m. registered nurse (RN)-A reviewed R1's record and verified the record lacked documentation of [MEDICAL CONDITION] monitoring and assessment and stated [MEDICAL CONDITION] should have been monitored daily if there was worsening the physician should have been notified. RN-A stated last week the physician gave an order for [REDACTED]. RN-A stated sometimes she refused, but with encouragement was easily redirected to elevate her feet. During an observation on 4/23/19, at 3:29 p.m. R1 continued to sit in the recliner chair in the living room; legs were not elevated. R1 indicated she did not have discomfort from the swelling in her legs. During an interview on 4/23/19, at 3:32 p.m. RN-A verified R1 was sitting in the recliner with her legs not elevated and confirmed R1 had tubi grips on. RN-A stated the order for compression wraps had a stop date of 4/22/19, because that was when the physician was supposed to reassess her. RN-A stated tubi grips were used under the compression wraps for skin protection, there was no current order for compression, and the Ted stockings probably wouldn't fit because of the [MEDICAL CONDITION]. RN-A indicated the order for compression wraps should have been continued until the physician could reevaluate. During a subsequent interview at 3:49 p.m. RN-A indicated she observed R1's legs and stated R1's legs were bigger than when she had last assessed her legs on 4/15/19, and that the legs had more than +2 pitting. RN-A stated R1 was just weighed, and had gained another pound, weight was 138 lbs. During an interview on 4/24/19, at 9:11 a.m. director of nursing (DON) stated nurses should be monitoring and assessing [MEDICAL CONDITION]. DON indicated staff should also be documenting if R1 refused to elevate her legs and notify a nurse. DON indicated R1's [MEDICAL CONDITION] should have been monitored daily since there was a change from here baseline. Policy was requested and not received.

Based on observation, interview and document review, the facility failed to ensure narcotics and controlled substance disposition was completed in a manner to detect potential diversion in 1 of 1 medication rooms reviewed. In addition, the facility failed to ensure [MEDICATION NAME] narcotic medication patches were disposed of in a manner to prevent potential diversion and/or ingestion. Findings include: On 4/23/18, at 1:39 p.m. the locked medication room was reviewed with registered nurse (RN)-B. The room contained a separate, affixed lockbox which housed discontinued and discharged resident narcotic and controlled substance medications. RN-B explained the narcotics were counted when discontinued or had a resident discharge, recorded in a booklet and placed in the lockbox until destroyed. The booklet contained affixed forms titled, Administration Record-Controlled Drugs/Meds and each form on the back titled, Controlled Drugs/Med Disposition. When each medication was discontinued, it was signed on the back of the form by the nurses and then folded in half indicating the medication was to be destroyed or was already destroyed. Once placed in the lock box the mediations are not counted again. RN-B added the last time the destruction of the medication occurred was by her and another nurse, around (MONTH) 2019. On 4/23/19, at 2:04 p.m. director of nursing (DON), RN-A and RN-B when asked regarding concerns with drug diversion, RN-A said there was none, although when asked how the facility knew. RN-A said, I just know DON added she used to destroy with the pharmacist monthly, but has not been completed. Further, a count of the narcotics in the lockbox was completed and found to be correct. Facility documents titled, Certificate of the Inventory and Destruction of Controlled substance dated: 7/20/18 identified 51 narcotics and controlled substances disposed of signed by 2 RN's. 1/22/19 identified 49 narcotics and controlled substances disposed of signed by 2 RN's. 4/23/19 identified 29 narcotics and controlled substances disposed of signed by 2 RN's. When interviewed on 4/23/19, at 2:51 p.m. pharmacy consultant (PC) said he assumed something was already in place for the disposition of the medications. When asked how often the mediations should be disposed of, PC said at least monthly for the size of the facility. PC added if not counted and tracked, drug diversion could occur. A facility Discarding and Destroying Medications policy dated 11/29/16, identified narcotics and controlled drugs must be destroyed in the presence of a licensed nurse and licensed pharmacist. On 4/23/19, at 3:15 p.m. DON explained the process for [MEDICATION NAME] destruction. Including removing the old patch and placing it in the sharps container attached to the medication/treatment carts. On 4/23/19, at 3:22 p.m. RN-A also identified [MEDICATION NAME]es are placed in the sharps container on the medication cart. A facility Discarding and Destroying Medications policy dated 11/29/16, identified unless otherwise instructed, tablets, capsules, liquids, contents of vials, [MEDICATION NAME]es (cut in half and backing removed), and suppositories should be destroyed using the Drug Buster Drug Disposal System. [MEDICATION NAME]es may be disposed of using sharps container. When interviewed on 4/24/19, at 12:10 p.m. DON verified the state operational manual under F-755. DON added she was not aware of the regulation and how they were to be disposed.

Based on interview and document review, the facility failed to immediately inform the resident's physician and representantive about a significant change in condition for 1 of 6 (R1) residents reviewed. The findings include: According to R1's medical record, R1 was oxygen dependent and had been found unresponsive on 4/27/18, with the oxygen concentrator off. Notifications to R1's physican and representative were not made until the following morning. R1 was later diagnosed with [REDACTED]. R1's admission data sheet dated (MONTH) 3, (YEAR), R1 had [DIAGNOSES REDACTED]. R1's care plan dated 4/7/18, indicated R1 required oxygen via nasal cannula to keep oxygen saturations (SpO2) greater than 88% or as needed. The provider was to be notified if oxygen saturations were unable to be maintained at greater than 88%, if the resident experienced pain with shortness of breath (SOB), and/or if low oxygen levels were accompanied by symptoms of infection (such as fever and a productive cough). The care plan also indicated staff were to provide assistance with transfers and ambulation to manage oxygen tubing. In a progress note dated 4/27/18 at 5:48 p.m., licensed practical nurse (LPN)-B documented (R1) makes needs known. Moderate assist of one with transfers, mobility, toileting and cares. Often becoming SOB with exertion. Requires continuous oxygen therapy, currently at 3 LPM (liters per minute) per NC (nasal cannula) with SpO2 at 92%, respirations regular, shallow at 21 and lung sounds diminished with crackles to bases per his baseline. Has complained this afternoon of lower back pain but again continues to deny need for warm pack or pain medication. No [MEDICAL CONDITION] noted. Evening meal provided in dining room, per orders no noted difficulty with eating noted. In a progress note dated 4/27/18 at 9:43 p.m., LPN-D documented that R1's evening medications were not given. R1 was not alert enough to respond to her or to swallow. R1 was resting but when she called his name, he started to fidget with the blankets or the oxygen tubing, but did not open his eyes. In a progress note dated 4/27/18 at 10:13 p.m., LPN-B documented having entered the room at 8:30 p.m. to apply bedtime creams and had found R1 unresponsive with uncontrolled movements and grabbing. The note indicated nursing Assistant (NA)-E attempted to provide bedtime cares and informed LPN-B that R1 was not responding to her. R1's tongue was hanging to the left side of his mouth. LPN-B attempted a sternal rub with no response from R1. Cyanosis was noted around R1's mouth and finger tips. LPN-B noted the oxygen concentrator was not on and immediately turned on the machine and increased the liter flow to 4.5 LPM for 10 minutes which increased his oxygen saturation level to 97%. At 8:50 p.m., with another sternal rub, R1 attempted to flutter his eyes open. His lung sounds had bilateral wheezes. No cough was noted, temperature 99.0, SpO2 at 93% on 3 LPM/NC continuously. R1 was assisted to bed with a Hoyer lift (mechanical lift). LPN-B further documented, nursing will continue to monitor his condition and update the provider, if needed. On 4/28/18 at 2:09 a.m., RN-C's documented in the progress notes R1 continued to be unresponsive to interaction. The note indicated R1's breathing and pulse were steady and regular. His oxygen saturation levels were 96-97%. Movement of his hands was observed. R1 appeared to be sleeping and snoring. On 4/28/18 at 8:54 a.m., LPN-F documented a progress note indicating R1 was unresponsive and an order from the physician had been obtained for R1 to be sent to the hospital. During interview with LPN-B on 8/7/18 at 4:38 pm, LPN-B stated when she'd entered R1's room to provide care on 4/27/18, she'd noticed that although the nasal cannula was attached to R1's nose, and attached to the concentrator, the oxygen concentrator was not on. LPN-B stated she'd turned the concentrator on and noted R1's oxygen saturation to be in the 70's. LPN-B stated she'd tried a sternal rub and R1 had aroused a little with eye fluttering and slightly grabbed her hand. LPN-B said she thought she'd turned up the oxygen from 2 to 3 liters in order to reoxygenate R1. LPN-B also said LPN-D was in the room around that time and had also witnessed R1's change in condition. LPN-B said she'd rechecked R1 two or three more times and noted his oxygen saturation was in the 80%s to low 90%s. When the shift was over, LPN-B said she'd reported R1's change in condition to the next nurse coming on shift. LPN-B stated she did not know the protocol for notification after a change in condition at the facility and was not aware she needed to notify the Director of Nursing (DON), administration or others. Although R1 had experienced a change in condition, LPN-B stated she didn't feel it was an emergent situation. LPN-B said in her nursing judgement, she thought R1 could be monitored for a couple of hours to see if he came around or not. LPN-B stated that for the hour and a half more she'd had with R1 (the remainder of her shift), she thought she'd monitored R1 appropriately. During interview with the DON on 8/14/18 at 1:35 p.m., she stated that after the incident with R1, staff completed re-education and the facility's policy of notifying family of residents was provided to staff. The DON also stated nurses must now be present when the oxygen concentrators and portable tanks are switched over to ensure they are working appropriately. RN-C stated during interview on 9/13/18 at 12:32 p.m., he thought LPN-B had followed protocol for an unresponsive resident. RN-C stated he talked to everyone that needed to be talked to and that if R1 needed to be watched overnight, his condition worsened, or he did not get better by morning, R1 would go to the hospital. RN-C stated R1's vital signs were fine. He stated he checked R1 throughout the night and R1 seemed to have more movement. He stated R1wore a hearing aid and that he was unsure whether R1 could hear him. RN-C also stated he had not been sure whether R1 was sleeping, but stated he'd been snoring. During interview with LPN-F on 9/13/18 at 2:58 p.m., LPN-F stated on 4/28/18 it had been reported to her that R1 had declined during the night. After checking on him, LPN-F stated she knew she had to get the family involved because that is what we have to do. Physician assistant (PA)-G was interviewed on 9/17/18 at 4:44 p.m., and stated she would have expected notification to be made to the resident's family and/or to the primary care provider at the time R1 was first noted to have the change in condition. The facility's Notification of Changes policy effective 8/22/17, indicated changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. The policy also included; All pertinent information will be made available to the provider by the Gundersen Harmony Care Center staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident, the resident's representative, and the physician to ensure the best outcomes of care for the resident.

Based on interview and document review, the facility failed to ensure all nursing staff possessed necessary competencies and skill sets to meet residents' needs for 1 of 6 (R1) residents reviewed who was oxygen dependent. The findings include: According to R1's medical record, R1 was oxygen dependent and had been found unresponsive on 4/27/18, with the oxygen concentrator off. Notifications to R1's physican and representative were not made until the following morning. R1 was later diagnosed with [REDACTED]. R1's admission data sheet dated (MONTH) 3, (YEAR), R1 had [DIAGNOSES REDACTED]. R1's care plan dated 4/7/18, indicated R1 required oxygen via nasal cannula to keep oxygen saturations (SpO2) greater than 88% or as needed. The provider was to be notified if oxygen saturations were unable to be maintained at greater than 88%, if the resident experienced pain with shortness of breath (SOB), and/or if low oxygen levels were accompanied by symptoms of infection (such as fever and a productive cough). The care plan also indicated staff were to provide assistance with transfers and ambulation to manage oxygen tubing. In a progress note dated 4/27/18 at 5:48 p.m., licensed practical nurse (LPN)-B documented (R1) makes needs known. Moderate assist of one with transfers, mobility, toileting and cares. Often becoming SOB with exertion. Requires continuous oxygen therapy, currently at 3 LPM (liters per minute) per NC (nasal cannula) with SpO2 at 92%, respirations regular, shallow at 21 and lung sounds diminished with crackles to bases per his baseline. Has complained this afternoon of lower back pain but again continues to deny need for warm pack or pain medication. No [MEDICAL CONDITION] noted. Evening meal provided in dining room, per orders no noted difficulty with eating noted. In a progress note dated 4/27/18 at 9:43 p.m., LPN-D documented that R1's evening medications were not given. R1 was not alert enough to respond to her or to swallow. R1 was resting but when she called his name, he started to fidget with the blankets or the oxygen tubing, but did not open his eyes. In a progress note dated 4/27/18 at 10:13 p.m., LPN-B documented having entered the room at 8:30 p.m. to apply bedtime creams and had found R1 unresponsive with uncontrolled movements and grabbing. The note indicated nursing Assistant (NA)-E attempted to provide bedtime cares and informed LPN-B that R1 was not responding to her. R1's tongue was hanging to the left side of his mouth. LPN-B attempted a sternal rub with no response from R1. Cyanosis was noted around R1's mouth and finger tips. LPN-B noted the oxygen concentrator was not on and immediately turned on the machine and increased the liter flow to 4.5 LPM for 10 minutes which increased his oxygen saturation level to 97%. At 8:50 p.m., with another sternal rub, R1 attempted to flutter his eyes open. His lung sounds had bilateral wheezes. No cough was noted, temperature 99.0, SpO2 at 93% on 3 LPM/NC continuously. R1 was assisted to bed with a Hoyer lift (mechanical lift). LPN-B further documented, nursing will continue to monitor his condition and update the provider, if needed. On 4/28/18 at 2:09 a.m., RN-C's documented in the progress notes R1 continued to be unresponsive to interaction. The note indicated R1's breathing and pulse were steady and regular. His oxygen saturation levels were 96-97%. Movement of his hands was observed. R1 appeared to be sleeping and snoring. On 4/28/18 at 8:54 a.m., LPN-F documented a progress note indicating R1 was unresponsive and an order from the physician had been obtained for R1 to be sent to the hospital. During interview with LPN-B on 8/7/18 at 4:38 pm, LPN-B stated when she'd entered R1's room to provide care on 4/27/18, she'd noticed that although the nasal cannula was attached to R1's nose, and attached to the concentrator, the oxygen concentrator was not on. LPN-B stated she'd turned the concentrator on and noted R1's oxygen saturation to be in the 70's. LPN-B stated she'd tried a sternal rub and R1 had aroused a little with eye fluttering and slightly grabbed her hand. LPN-B said she thought she'd turned up the oxygen from 2 to 3 liters in order to reoxygenate R1. LPN-B also said LPN-D was in the room around that time and had also witnessed R1's change in condition. LPN-B said she'd rechecked R1 two or three more times and noted his oxygen saturation was in the 80%s to low 90%s. When the shift was over, LPN-B said she'd reported R1's change in condition to the next nurse coming on shift. LPN-B stated she did not know the protocol for notification after a change in condition at the facility and was not aware she needed to notify the Director of Nursing (DON), administration or others. Although R1 had experienced a change in condition, LPN-B stated she didn't feel it was an emergent situation. LPN-B said in her nursing judgement, she thought R1 could be monitored for a couple of hours to see if he came around or not. LPN-B stated that for the hour and a half more she'd had with R1 (the remainder of her shift), she thought she'd monitored R1 appropriately. During interview with the DON on 8/14/18 at 1:35 p.m., she stated that after the incident with R1, staff completed re-education and the facility's policy of notifying family of residents was provided to staff. The DON also stated nurses must now be present when the oxygen concentrators and portable tanks are switched over to ensure they are working appropriately. RN-C stated during interview on 9/13/18 at 12:32 p.m., he thought LPN-B had followed protocol for an unresponsive resident. RN-C stated he talked to everyone that needed to be talked to and that if R1 needed to be watched overnight, his condition worsened, or he did not get better by morning, R1 would go to the hospital. RN-C stated R1's vital signs were fine. He stated he checked R1 throughout the night and R1 seemed to have more movement. He stated R1wore a hearing aid and that he was unsure whether R1 could hear him. RN-C also stated he had not been sure whether R1 was sleeping, but stated he'd been snoring. During interview with LPN-F on 9/13/18 at 2:58 p.m., LPN-F stated on 4/28/18 it had been reported to her that R1 had declined during the night. After checking on him, LPN-F stated she knew she had to get the family involved because that is what we have to do. Physician assistant (PA)-G was interviewed on 9/17/18 at 4:44 p.m., and stated she would have expected notification to be made to the resident's family and/or to the primary care provider at the time R1 was first noted to have the change in condition. The facility's Notification of Changes policy effective 8/22/17, indicated changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. The policy also included; All pertinent information will be made available to the provider by the Gundersen Harmony Care Center staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident, the resident's representative, and the physician to ensure the best outcomes of care for the resident.

Based on observation, interview and document review, the facility failed to ensure Minimum Data Set (MDS) an assessment were accurately coded for 1 of 1 resident (R6) reviewed for restraints. Findings include: R6's admission sheet included R6 had been admitted on [DATE]. R6's current care plan (no date) identified a limitation in bed mobility related to right sided weakness and impaired mobility with a goal to become more independent in bed with the use of two half rails. The quarterly MDS dated [DATE], indicated that R6 had bed rails and they were used as a physical restraint, a manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body and that the restraint was used daily. During an observation on 3/13/18, at 2:58 p.m., R6 was lying in bed with two half rails, both were pulled up and both were located on the upper half of the bed. During an interview with the director of nursing (DON) on 3/13/18, at 3:38 p.m., she verified that the two half rails were not used as a restraint. At the time of the quarterly assessment the MDS nurse was not at the facility and a pool person had replaced the nurse at that time. The DON did verify that the MDS had been coded incorrectly and they had just recently become aware of the discrepancy. The DON stated the bed rails are used for bed mobility and positioning, and to sit up in bed and to balance when standing to increase R6's independence. A policy regarding MDS coding accuracy was requested and none provided.

Based on observation, interview, and document review, the facility failed to provide supervision or assist according to the person-centered care plan during mealtime for 1 of 1 resident (R14) reviewed for activities of daily living. Findings include: R14's admission record included R14 had been admitted to the facility on [DATE]. Also [DIAGNOSES REDACTED]. R14's quarterly Minimum Data Set (MDS) an assessment dated [DATE], included that R14 had a decline in the areas of bed mobility and eating assistance. According to R14's current care plan (not dated) indicated R14 was to be provided set up assistance and should be provided supervision to extensive/total assist while eating. During an observation on 3/13/18, at 6:47 p.m. R14 was heard coughing in her room. Upon entering the room R14 was in bed at a 45 degree angle. An overbed table was in front of R14 with her meal which included ground meat, R14 was wearing a clothing protector and ground meat was scattered all over the bed. She continued to cough, then stated, this is no way to eat. No staff was present in the room during that time. A nurse was updated and did then go in and check on R14. During an interview with nursing assistant (NA)-A, on 3/13/18, at 7:20 p.m., she stated that R14 refused to get up for supper so her meal was brought to her room. NA-A stated that R14 did not want to sit upright due to back pain and that registered nurse (RN)-B was in the room at the time and said it would be okay. During an interview with RN-B on 3/13/18 at 7:24 p.m., she stated that R14 refused to get up about 50 percent of the time and will then eat in her room. RN-B stated that R14 eats independently in the dining room so RN-B stated it was okay. During an interview with the director of nursing (DON) on 3/14/18, at 3:02 p.m., the DON stated that her expectation would be that a staff member would be present if R14 chose to eat in her room. In a facility policy, Assisting the Resident with In-Room Meals, revised 12/2013, under the heading Preparation, the policy indicates the care plan should be reviewed for any special needs of the resident and the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward.

Based on observation, interview and document review, the facility failed to ensure oxygen therapy was provided as ordered for 1 of 1 resident (R26) reviewed for respiratory care. Findings include: R26's admission form included an admitted date of 3/27/17, and readmitted [DATE], from a hospital with [DIAGNOSES REDACTED]. R26's progress note dated 2/1/18, identified through an assessment by the provider, that R26 had acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (lack of oxygen). R26's current physician orders [REDACTED]. During an observation on 3/12/18, at 12:23 p.m., R26 was located at the dining room table with a compressed air oxygen tank secured to the back of his wheelchair. The gauge indicated the oxygen setting to be at 3 liters however, the level of oxygen indicated the tank was empty. Registered nurse (RN)-B was notified of the empty tank. RN-B stated she had changed the oxygen tank prior to R26 coming out to the dining room and had forgotten to open the tank. RN-B estimated the time R26 had been without oxygen therapy as about 10 minutes. During an observation on 3/13/18, at 5:15 p.m., R26 was sitting in his wheelchair at the dining room table. R26's compressed oxygen tank was full but the gauge indicated 0 liters of oxygen was running through the oxygen tubing. RN-B was notified and proceeded to turn on the oxygen flow. Upon request an O2 Saturation was obtained with a reading of 84 percent. RN-B verified that it is the nurse's responsibility to ensure there is oxygen in the tank and that the oxygen is running as ordered. During an interview on 3/12/18, at 12:29 p.m. with the director of nursing (DON), she confirmed that oxygen therapy was important for R26 due to his recent hospitalization for pneumonia and acute [MEDICAL CONDITION]. The DON stated it would be her expectation that R26 would have his oxygen on and running at all times per the physician's orders [REDACTED].>A facility policy revised 10/2010 Oxygen Administration, Step 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at 2-3 liters per minute. Step 12. Check the mask, tank, humidifying jar etc., to make sure they are in good working order.

Based on observation, interview and record review, the facility failed to revise the care plan for 1 of 3 residents (R2) related to missing teeth, who was reviewed for dental status and failed to develop a plan of care that included monitoring for side effects of an anti-coagulant medication ([MEDICATION NAME]) for 1 of 5 residents (R24) reviewed for unnecessary medications. Findings include: R2's care plan last reviewed/revised dated 9/16/16, identified dental care problem and has own teeth. Denies problems with dentition. Approach: assist setting up dental visit if should request this. Provide supplies for oral care. Set up and assist as needed for oral care. However, R2's care plan failed to identify R2 had missing teeth. On 1/10/17, at 2:07 p.m., observation of R2's teeth, identified R2 had missing teeth on the bottom gum line. R2 stated she had missing teeth on the top and bottom. R2's facility Oral Health Assessment, observation/date recorded date, 11/30/16, identified condition of teeth none of the above were present. Plan of care: continue current plan of care, denies problems with chewing, says she eats mostly soft foods. On 1/12/17, at 12:56 p.m., the director of nursing (DON) stated she would expect the facility oral assessment to identify missing teeth and missing teeth to be care planned if identified. LACK OF CARE PLANNING INTERVENTIONS ADDRESSING USE OF ANTICOAGULATION THERAPY: R24's current physician order's identified an order for [REDACTED]. R24's care plan, dated last reviewed/revised: 1/2/17, problem: has [DIAGNOSES REDACTED]. Approach: administer medications per provider's orders. Nursing staff will dispense and administer all medications. Monitor condition routinely by vital signs and weights per facility protocol. Obtain consults PRN (as needed). Obtain scheduled labs per provider's orders. Problem last reviewed/revised: 1/2/17: uses PPI (proton pump inhibitor) for [DIAGNOSES REDACTED]. Approach: Consider an attempt gradual dose reduction of PPI. If already on lowest scheduled dose, consider changing PPI to PRN prior to discontinuation and monitor symptoms and the use of PRN PPI use. Consult with dietary department to determine what foods may trigger increased symptoms [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease) and reduce the frequency of foods in diet or avoid them completely. Encourage resident to remain upright for at least 30 minutes after meals. Request pharmacy consultant review medications to determine if other medications are on regime that could make dyspepsia symptoms worse. Consider alternative medications if possible. However, R24's care plan had not addressed risk factors and interventions for excessive bleeding associated with the use of [MEDICATION NAME] in order to alert care givers the need to report bruising and bleeding timely to the nurse. On 1/12/17, at 12:57 p.m., the DON confirmed R24's care plan failed to include risk factors and interventions associated with the use of [MEDICATION NAME]. The facility policy Resident Care Plan, dated 11/26/16, indicated resident care plan documentation and use of the plan 5. The resident care plan must be kept current at all times. Concerns and problems Problem 2. Consider listing possible risks and complications. Approach/Plan 1. List all care to be provided for the problem listed. The care must be necessary and appropriate to accomplish the goal stated. 2. Coordinate all care to be provided to the resident for the most effective, efficient utilization of resources 3. Individualized care for the unique needs of the resident 4. Communicate vital information to all staff providing direct resident care.

Based on observation, interview and document review, the facility failed to apply a t-shirt or offer the use of a t-shirt during assist with dressing for 1 of 3 residents (R24) reviewed for activities of daily living. Findings include: R24's annual Minimum Data Set (MDS), dated [DATE], identified R24 required extensive assist of one for dressing and had moderate cognitive impairment. During interview of family member (FM)-B on 1/10/17, at 4:29 p.m., when asked does R24 get the help she needs getting dressed, toileting, or cleaning her teeth? FM-B had stated they (the staff) do not put enough clothes on her when she is dressed. She needs a t-shirt on, I brought some t-shirts for her to use. During observation on 1/11/17, at 10:42 a.m., nursing assistant (NA)-A assisted R24 with getting dressed. NA-A picked out a pink sweater and a pair of jeans from R24's closet and asked R24 if she wanted to wear the clothes. NA-A dressed R24 in the clothes. As R24 was being moved to the dining room by NA-A R24 stated to NA-A, I just do not want to be cold all the time. NA-A responded and asked R24 do you want another sweater? NA-A then went back to R24's room, obtained a blue cape and placed the blue cape over R24's shoulders. During observation on 1/11/17, at 1:52 p.m., R24 was sitting in the living area in her wheelchair. FM-B approached R24 and greeted R24. FM-B then stated to R24, Why don't you have a t-shirt on? FM-B then approached a staff person and asked for R24 to have a t-shirt put on. At 1:54 p.m., surveyor asked R24 if she was cold and R24 replied, I am a little cold. On 1/11/17, at 2:15 p.m., social worker (SW)-A stated she had just heard FM-B tell a nursing assistant he would like a t-shirt put on R24. SW-A (when queried if staff were aware R24 was to have a t-shirt on) stated R24 was to have a t-shirt on under clothes and this is communicated in the Huddle Book. The nurse manager had written the information in the Huddle Book on 1/5/17, when R24's care conference was held. The facility Huddle Book sheet dated 1/5/17, identified changes in plan of care, condition, medications, other: R24 always have a t-shirt on under sweatshirt or sweater per family request. On 1/11/17, at 11:21 a.m., NA-A stated R24 does complain about being cold a lot. NA-A stated R24 generally wears sweaters and we put the blue sweater (cape) over her shoulders. When queried if R24 had any t-shirts in her room to wear, NA-A showed surveyor R24 had t-shirt hanging in her closet for use. NA-A stated she was not aware R24 was to have a t-shirt on. I knew R24 had t-shirts, but was not aware she wanted a t-shirt on every day. On 1/12/17, at 1:00 p.m., the director of nursing (DON) stated communication huddles for staff were held at certain times throughout the day. If staff are not present during the huddle they are supposed to read the huddle communication book daily. The DON stated she would expect a t-shirt to be put on R24 when dressed as written in the huddle communication book. The facility policy Dressing and Undressing the Resident, dated revised 10/2010, indicated General Guidelines 2. Encourage the resident to choose the clothes that he or she will wear for the day.

Based on interview and document review, the facility failed to ensure documentation of education provided and documentation of consent for refusal signed by the resident or the resident representative for the influenza vaccination for 2 of 5 residents (R14 and R37) reviewed for immunizations. Findings include: On 1/11/17, surveyor had requested form the director of nursing R14's and R37's documented education provided and consent for administration of the influenza immunization. On 1/12/17, the following was provided by registered nurse (RN)-A: R14's Screening Questionnaire for Inactivated Injectable Influenza Vaccination was signed by the director of nursing on 10/31/16. The questionnaire failed to be filled out and failed to be signed by the resident or the resident representative. In addition, the questionnaire failed to address if education about the influenza vaccination was provided and failed to address if R14 consented to the administration of the influenza vaccination. R37's Screening Questionnaire for Inactivated Injectable Influenza Vaccination was signed by the director of nursing on 10/31/16. The questionnaire failed to indicate yes or no to the question is the person to be vaccinated sick today. The questionnaire failed to be signed by the resident or the resident representative. In addition, the questionnaire failed to address if education about the influenza vaccination was provided and failed to address if R37 consented to the administration of the influenza vaccination. During interview on 1/12/17, at 2:28 p.m., RN-A stated routinely verbal consent whether to administer the influenza vaccine or not was obtained by phone from the resident representative or by talking to the resident. RN-A stated she did not know if education about the influenza vaccine was provided. RN-A stated I do not have documentation education for the influenza vaccination was provided to R14 and R37 and I do not have documentation of consent for administration or refusal of the influenza vaccination for R14 and R37. The facility policy Influenza, Prevention and Control, dated revised 10/2010, indicated Seasonal Influenza Vaccine 1. The Infection Control Coordinator will promote and administer seasonal influenza vaccine. a. Unless contraindicated, all residents and staff will be offered the vaccine. The policy failed to address documentation education was provided for the influenza vaccination and documented consent of administration or refusal for the influenza vaccination was maintained in the resident record as required.

Based on observation, interview and document review, the facility failed to ensure proper infection control practices were used during the provision of peri-cares for 1 of 3 residents (R24) reviewed for activities of daily living. Findings include: R24 had been observed on 1/11/17, at 10:42 a.m., when nursing assistant (NA)-A assisted R24 with dressed. NA-A washed hands and donned gloves. NA-A had washed R24's front peri area and without changing soiled gloves NA-A assisted R24 to roll over, applied lotion to R24's back, cleansed R24's buttocks area, placed a clean incontinent product underneath R24, then completed dressing R24 before removing the soiled gloves. On 1/11/17, at 11:21 a.m., NA-A verified not changing soiled gloves when they should have. On 1/12/17, at 2:28 p.m., registered nurse (RN)-A stated after providing peri-cares staff should remove gloves and wash hands before touching anything else. On 1/12/17, at 1:00 p.m., the director of nursing (DON) stated staff should remove gloves and wash hands after providing peri-cares. The facility policy Perineal Care, dated revised 10/2010, indicated Steps in Procedure 7. Put on gloves. 9. b. Wash perineal area wiping front to back. e. Wash the rectal area thoroughly 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on document review and interview, the facility failed to ensure a pain assessment had been completed on admission, reassess if pain management was affective to control severe pain for 1 of 1 resident (R56)(closed record review) who was admitted from the acute care hospital following a kidney transplant with acute pain symptoms. As a result of overall lack of pain management and control R56 suffered harm at a G level. In addition, based on document review and interview, the facility failed to report weight according to physician's orders [REDACTED]. Findings include: LACK OF PAIN ASSESSMENT/REASSESSMENT & ONGOING PAIN MANAGEMENT: R56 was admitted to the facility on [DATE] post kidney transplant on 8/13/15, with [DIAGNOSES REDACTED]. R56's hospital discharge summary included, Upon discharge, he (R56) was tolerating a general diet, his pain was controlled on oral pain medications, he is able to move with assistance, he had normal bowel function, and was discharged with a foley catheter. The hospital summary included historical abdominal pain levels during therapy sessions on 8/14/15, 8/21/15, 8/24/15, and 8/25/15. The reported pain levels did not exceed five when using a zero to ten (ten-highest pain level) pain rating scale. The summary included instruction to call the transplant coordinator for increase in pain. R56's record did not reflect an initial pain evaluation upon admission nor was there an initial care plan developed before the comprehensive care plan was completed to address pain management needs and interventions. The Admission Observation included two questions pertaining to pain; How much bodily pain have you had in the last 4 weeks?, and Is this pain new or chronic? The evaluation indicated R28 had very severe pain in the last 4 weeks and the pain was new. R56's initial care plan which should be developed on admission and used until the Comprehensive care plan is completed to address pain management needs and interventions. The initial care plan areas that were addressed (activities of daily living, dietary, transfers, and mobility) indicated staff would meet R28's needs however; the plans were incomplete as to how these assessed needs were to be met and not individualized to include level of assistance or need. The initial care plan did identify R28 had an abdominal incision that could not be submerged and to monitor for skin irregularities. R56's physician orders [REDACTED]. · Tylenol 325 milligrams (mg) 2 tablets as needed for acute pain. Special instructions: do not take more than 2000 mg in 24 hour period do to kidney transplant. · [MEDICATION NAME] 5 mg. Special instructions: give 2 tabs for pain rated 7 or higher and 1 tab for less than 7 for pain not relieved by [MEDICATION NAME] as needed every four hours. The pain scale was based on a 0 to 10 rating with 10 being the most excruciating pain possible. R56's record reflected a physician assistant (PA)-D note from a visit on 8/28/15 that was dictated into the medical record on 8/31/15. PA-D reported, He continues with pain in the abdomen at the site of incision, for which he has been using [MEDICATION NAME] p.r.n. (as needed)., and Nursing staff will continue to monitor and will notify of any changes or decompensation in patient condition. The following is an outline of R56's reported pain from admission on 8/27/15 through discharge to emergency roiagnom on [DATE] and the facility's response to the pain: 8/27/15 at 3:45 p.m. R56's progress note indicated arrival to the facility between 12:45-1:00 p.m. The progress note did not address pain or mention R56 had pain upon arrival to the facility. 8/27/15 at 5:01 p.m. a progress note indicated potential discharge plan, supportiveness of the family, explanation of the resident's Bill of Rights, and a plan the social worker would visit daily the first week assist with adjustment as needed. 8/27/15 at 11:40 p.m. the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The record does not reflect results of the non-pharmacological interventions. However, did indicate effectiveness of the medication (no time stamp for evaluation of efficacy). The record does not reflect physician or transplant coordinator notification for change in pain intensity. Even thought R56's discharge summary from the hospital included the directive to contact the transplant coordinator for increase in pain. 8/28/15 at 2:42 a.m. the MAR indicated [REDACTED]. Documentation did not reflect a pain description, an evaluation of the pain intensity or attempt of non-pharmacological interventions. A corresponding progress note written at 3:34 a.m. summarized the administration of the [MEDICATION NAME] administration and effectiveness, without mention of non-pharmacological interventions attempted. 8/28/15 at 5:08 a.m. the MAR indicated [REDACTED]. The record does not reflect amount of [MEDICATION NAME] administered a the time. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. However, a pain rating was not completed to determine what is meant by somewhat effective. Documentation reflected the pain evaluation prior to the administration and evaluation for effectiveness was performed by a trained medication assistant (TMA)-A. The record did not reflect a licensed nurse performed a pain assessment or evaluation of the newly reported pain location, or performed a re-assessment of pain when the [MEDICATION NAME] was only somewhat effective (no other information was provided, i.e. how long the pain lasted or if it was resolved). ***note: In the state of Minnesota only a licensed staff can assess for signs and symptoms of pain and determine what pain intervention is appropriate depending on the severity of the pain as well as other symptoms. This does not include a trained medication aide as they work under the license of the licensed nurse to administer medications. The record does not reflect physician or transplant coordinator had been notified of R56's increased periods of pain, newly reported pain locations, and change in effectiveness of a narcotic pain medication. 8/28/15 at 12:09 p.m. the record does not reflect any pain relieving interventions, monitoring, or follow-up until 12:09 p.m., seven hours after the [MEDICATION NAME] was only somewhat effective. Documentation does not indicate how long and how much pain R56 had during that period. 8/28/15 at 12:09 p.m. the MAR indicated [REDACTED]. No description of the pain was evident nor evidence of attempted non-pharmacological interventions. The record indicated the Tylenol was effective (no time stamp on follow-up eval). A corresponding progress note written by the TMA-A at 1:53 p.m. conflicted with the MAR indicated [REDACTED]. PRN Tylenol was given this afternoon. His (family member-A) stated he gets 'out of it' when he has [MEDICATION NAME]. The progress note omitted the mention of back pain. The record did not reflect a licensed staff had evaluated the 10/10 pain rating, re-assessment of the incision area that had previously not been causing pain or an evaluation for effectiveness of the [MEDICATION NAME]. The record still had not reflected notification to the physician or transplant coordinator for increased severe pain levels rated 10 of 10 or the new location of pain. 3/28/15 at 3:22 p.m. the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The record reflected use of non-pharmacological interventions, however did not indicate effectiveness. The follow-up pain evaluation indicated the [MEDICATION NAME] was again somewhat effective. 8/28/15 at 5:07 p.m. a corresponding progress note written by an RN-B conflicted with the documentation of the LPN-D who gave the [MEDICATION NAME]. RN-B progress note stated, Therapy noted (R56) was SOB (short of breath) during therapy. (R56) received 10 mg of [MEDICATION NAME] at 2:45 for c/o (complaint of) pain. At 4:00 p.m. c/o pain on right side . Occupational therapy note dated 8/28/15 at 3:12 p.m. completed by Occupational therapist-E included, pt (patient) in severe pain with report of being freezing cold, shivering with increase in SOB. nursing notified of symptoms and vitals check was pt has SPO2 decrease to 87% on room air with increased breathlessness. BP 167/60, 158/60 2nd reading, manually and 160's/117 with automatic BP (blood pressure) cuff initially with suspicious of accuracy of reading. per PT (physical therapy) minimum assist and standing tolerance limited due to severity of right surgical site pain. The note also indicated, Exhibits cardio-pulmonary limitations as evidenced by Borg Scale of PE: 5 severe breathlessness impacting need for fluctuation in SPO2 level on room air with 10 of 10 right sided surgical pain. The record still did not reflect the physician or transplant coordinator notification for another complaint by R56 of having severe pain rated 10/10 and now it is located on the right side of body. 8/28/15 at 4:25 p.m. a progress note written by director of nursing (DON) read, Called to resident room by staff because of low oximetry (blood oxygen level), resident shaking, complaining of cold and pain. Because he has had complaint of 10 out of 10 pain earlier, staff had given two more tabs as ordered due to unrelenting discomfort (clarified with DON that no extra stat doses given, administration only at 5:08 a.m. and 3:22 p.m.). Family had mentioned earlier that he had not done well in hospital when he received pain medication-stating that it wipes him out. Resident observed in bed with 02 at 2 lpm (liters per minute) per standing order sats now wnl (within normal limits), and When asked to point to where it hurts he vaguely indicates a large portion of his abdomen-more so to the right. His abdomen is rounded and tympanic with rushing bowel sounds in upper right, and left upper and lower quadrants. No sounds heard in lower right quadrant. This is surgical site., and Resident does have shaking of the arms and some occasional jerking of legs. This could be side effect of narcotic. Will maintain on oxygen at this time due to somnolence. Staff notified that may not be tolerating oxy ([MEDICATION NAME]) and to try Tylenol per family report that this what was done in the hospital. Plan to monitor and notify the provider if increased symptoms or symptoms do not improve. Warm pack applied to right chest wall and feet for comfort. Repositioned. Requests to stay laying flat and he is able to rest without dyspnea (difficulty breathing) or change in color. RN notified of status and to watch VS (vital signs). Despite the documented unrelenting discomfort, need for supplemental oxygen, absence of bowel sounds, and jerking of hands and legs thought to be a medication side effect, the record did not reflect notification to the physician or transplant coordinator. In addition, the record did not reflect evaluation of the interventions of applying heat to chest wall and feet to relieve the severe abdominal pain or when and how the pain was decreased or resolved to a tolerable level. 8/28/15 at 9:54 p.m. the MAR indicated [REDACTED]. The documentation did not reflect pain intensity, locations, description of pain, or attempts of non-pharmacological interventions. The follow-up evaluation (not time stamped) indicated not effective. The record did not identify what was done as a result of the pain medication not being effective or if and when the pain was resolved to a tolerable level. 8/28/15 at 10:20 p.m. a progress note written by RN-C indicated R56 had a poor appetite that evening so amount of ordered insulin was reduced. 8/29/15 at 6:44 a.m. an LPN-B wrote a summary note for the night shift worked which included: R56 was awake on and off all night and was given Tylenol instead of [MEDICATION NAME] for pain, this was partially effective, and BP (blood pressure) was fine and temp was fine. The record did not reflect ongoing monitoring of symptoms or vital sign monitoring as indicated by the DON. The record did not reflect notification to the physician or transplant coordinator for pain symptoms not improving. 8/29/15 at 11:22 a.m. the MAR indicated [REDACTED]. No description or intensity of the pain was evident nor evidence of attempted non-pharmacological interventions. TMA-B documented Tylenol was somewhat effective. The record did not reflect a licensed staff member evaluated the pain, evaluated for effectiveness, or re-assessed the pain for further interventions. 8/29/15 at 2:54 p.m. a corresponding progress note written by the TMA-B included, He (R56) c/o pain in his abdominal region. TMA gave him PRN Tylenol 325 mg 2 tabs. Those were somewhat effective., and Per family request they don't want him to have Oxy ([MEDICATION NAME])unless he is in extreme pain at night to help him sleep. Again the record did not reflect communication to the physician or transplant coordinator of the ongoing pain or possible side affects to the [MEDICATION NAME] so a stronger pain medication could replace the [MEDICATION NAME] for pain control especially when the pain is rated at a 5 or more. 8/29/15 at 3:50 p.m. a progress note written by DON included, Happened to be in the facility, and was notified around 2:30 (p.m.) that resident was vomiting bile colored fluid and had decreased output from foley. Nurse concerned about bowels because of distended abdomen continues. The note further reported, no bowel sounds, nothing to eat since yesterday, dark urine, and pitting +2 pedal [MEDICAL CONDITION]. The progress note indicated at the time of the assessment R56 denied pain. 8/29/15 at 4:07 p.m. a progress note written by an LPN-E included, resident was vomiting clear to bile fluid continuous since 1400 (2:00 p.m.), his abdomen was distended and I had (DON) come help me with his assessment and she heard no bowel sounds., and He was transported by ambulance at 1545 (3:45 p.m.) ( hospital) A complaint from the Office of Health Facility Complaints in regards to the care and treatment of [REDACTED]. Discharge orders from (hospital) clearly state to call the transplant coordinator if (R56) is experiencing a great deal of pain. While visiting (R56) on August 29th at approximately 2:00 p.m. his condition was alarmingly critical, he was having extreme abdominal pain and he began to projectile vomiting a brown colored bile. FA-A explained once at the hospital R56's stomach was pumped resulting in several liters of bile removed. During an interview on 3/17/16, at 2:00 p.m. DON indicated she was not aware of TMAs scope of practice and stated TMAs were allowed to pass as needed medication without a licensed staff members assessment prior to administration and evaluation of efficacy following the administration. During an interview on 3/18/16, at 1:44 p.m. DON clarified the progress note she had written on 8/28/15; indicated R28 had not received an extra stat dose of [MEDICATION NAME], only received the early morning dose then the afternoon dose. DON stated she applied the heat for comfort, DON indicated her progress note was not clear if pain was reduced or resolved related to the use of non-pharmacological interventions, looked like he got better after a while stated family was really after not using [MEDICATION NAME]. DON indicated she had instructed staff about using non-pharmacological measures in place of the [MEDICATION NAME] for pain relief. DON stated she would have expected a nurse to do an assessment for pain and discomfort on the evening of 8/28/16. DON stated, was not sure what time R28 was seen by PA-D on 8/28/15 related to diarrhea. In response to the question, What kind of things would you communicate to the physician? DON responded, by the time the resident is admitted here they should have clear lung sounds and bowel sounds and all of those things. Also bowel function is not something that we should be monitoring on every shift because there was not a physician's orders [REDACTED]. DON further explained the facility did not have routine order to address vital signs for a week and comfort every shift. DON explained, family reported all that was given for pain in the hospital was Tylenol, again explained family reported R28 got sleepy and was difficult to arouse when taking [MEDICATION NAME]. DON indicated, at the time she felt that they just had to monitor and watch the pain, explained R28 wasn't there long enough for us to get to know what his pain was. We didn't consider the pain to be a change because we needed to see how he was. DON was asked to view the initial pain assessment to find out about his pain. DON read the questions, and indicated a problem with the computer software questions, not enough documentation was completed. DON stated a nurse should be following up 1/2 hour after most pain medication was given to evaluate for effectiveness of the pain medication to lesson pain, and if a resident is still having pain the physician should be contacted. Facility policy Medications Administration, Documentation, Storage, and Destruction of Medications dated 11/2/15 included, Medication shall be administered, as prescribed, and in a safe and timely manner. The facility will utilize the services of Trained Medication Aides (TMA), certified nursing assistant who have completed a college level course that meets the Minnesota state requirements .the TMA may administer PRN medications with approval from the supervising nurse, the TMA may administer narcotic medication with the supervising nurse providing a second signature in the narcotics log. The policy lacks and does not reflect standards of practice for supervising nurse responsibility over the TMA. The policy informed staff, Medications must be administered in accordance with the orders, including any required time frame. The definition of timely includes administration within the defined interval period or at the specified order time, but will also include an administrative window of one hour before and one hour after such period. The exception to the one hour window is any stat order or any medication that specifies administration relative to another medication or activity that would counter that window. The pharmacy has provided an emergency supply of medications in case a supply of medications is not available. If the emergency supply does not contain the medication needed, a nurse must contact a medical provider to notify then that the ordered medication is not available and to request an alternate order. All person authorized to administer medications are expected to practice safely and utilize available resources when giving unfamiliar medications or if questions arise regarding stand practice or new procedures. Each nurse's station will have a current medication reference available and nurses may contact the contracted pharmacy for guidance related to medication questions. Facility policy for pain was requested and not received. LACK OF REPORTING WEIGHT GAIN AS DIRECTED BY PHYSICIAN: R42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R42's 30 day Minimum Data Set (MDS) identified the [DIAGNOSES REDACTED]. R42's physician's orders [REDACTED]. physician's orders [REDACTED]. R42's care plan provided by the facility on 3/18/16 identified the [DIAGNOSES REDACTED]. However, the care plan lacked a plan of care for heart failure and was not revised to reflect daily weight monitoring per physician orders. In addition, the care plan lacked identification of diuretic use and management and monitoring for dehydration and fluid volume depletion which is a possible side affect from the use of a daily diuretic use to control fluid/[MEDICAL CONDITION]. R42's record of daily weights include an overnight weight gain of 6.5 pounds (lbs.) from 128.5 lbs. on 2/24/16 to 135 lbs. on 2/25/16. The weight monitoring also indicated weight gain of 10 lbs from 3/8/16 at 128 lbs. to 138 lbs on 3/12/16. Nurse progress note indicated poor food intake on 3/9 and 3/10. The record lacks identification, evaluation, and physician notification of the weight gains. R42's treatment administration record (TAR) for February and March 2016 indicated application of [MEDICAL CONDITION] deterrent (TED) stockings (helps reduce or prevent [MEDICAL CONDITION] in lower legs) in the morning and removed in the evening. R42's nursing progress notes reviewed from 2/8/16 through 3/18/16 lacked monitoring for [MEDICAL CONDITION] and lacked evaluation of TED stocking use. physician progress notes [REDACTED]. During an interview on 3/17/16, at 3:55 p.m. registered nurse (RN)-B stated weights should be monitored by charge nurse and brought to the attention of the case managers. RN-B stated charge nurses should make a progress note indicating weight evaluations. During an interview on 3/18/16, at 11:00 a.m. director of nursing (DON) indicated an issue with following policy and procedure and the complexity of comparing weights in the electronic charting system. DON stated, It's still the nurses responsibility to know to either notify the physician or give the information to the RN manager. It comes down to reading the instructions. LACK OF NOTIFICATION OF PHYSICIAN IF WEIGHT GAIN PER PHYSICIANS ORDERS: R18's Physician order [REDACTED]. Both medications are diuretics (medication to remove excess fluid from the body). Physician order [REDACTED]. Review of R18's weights obtained from 1/15/16 through 3/16/16 revealed 11 incidents with a weight increase of two or more pounds. Review of R18's progress notes for the same time period lacked any notation of contacting the physician or physician's assistant (PA) of the weight increase. On 3/17/16 at 10:34 a.m. the director of nursing (DON) stated she was unaware of R18's baseline weight and did not know if the physician had been contacted with weight changes as ordered. On 3/17/16 at 10:49 a.m. registered nurse (RN)-B, nurse manager, stated, I can't find a baseline weight that is specifically written down. You can't know if he is five pounds over his baseline weight. I can't know if 1/15/16 or 1/29/16 was reported (to the physician)for weight gain. I'm not finding any documentation that is was reported. Usually I'm alerted and I look, don't always get it charted. If it's reported I go look depending if it's a nurse or a TMA (trained medication aide), if he has swelling the PA is alerted.

Based on record review and interview, the facility failed to notify the physician in a timely manner regarding significant changes in health condition post kidney transplant for 1 of 1 resident (R56) who was admited from an acute care hospital following a kidney transplant. The failure to notify the physician regarding significant health changes caused harm, including increased pain and hospitalization for R56. Findings include: R56 was admitted to the facility on [DATE] post kidney transplant on 8/13/15. R56 [DIAGNOSES REDACTED]. R56's hospital discharge summary included, he was tolerating a general diet, his pain was controlled on oral pain medications, he is able to move with assistance, he had normal bowel function, and was discharged with a foley catheter. The hospital summary included historical abdominal pain levels during therapy sessions on 8/14/15, 8/21/15, 8/24/15, and 8/25/15. The reported pain levels did not exceed five when using a zero to ten (ten-highest pain level) pain rating scale. The summary included instruction to call the transplant coordinator if systolic blood pressure was greater than 180 and diastolic blood pressure greater than 90, temperature over 100.5 fahrenheit, and for increase in pain. The summary indicated acute changes in respiratory status should be treated by applying oxygen and would require contact with the primary care physician as soon as possible (ASAP). At the time of discharge, the hospital discharge summary indicated no concerns with respiratory status, abdomen was soft, non-tender, and non-distended. The summary also explained during the hospital course a computerized tomography (CT) scan showed a possible ileus (bowel stops movement of waste) however signs and symptoms had resolved. Review of R56's record did not reflect an initial pain evaluation at the time of admission. An Admission Observation dated 8/27/15, included two questions pertaining to pain; How much bodily pain have you had in the last 4 weeks? and Is this pain new or chronic? The evaluation indicated R28 had reported having experienced very severe pain in the last 4 weeks and that the pain was new. The Admission Observation further indicated, R28 had no trouble sleeping at night, had trouble with bladder control and bowel control, had kidney problems, no respiratory concerns, heart rate was regular, no [MEDICAL CONDITION] present, had diarrhea, abdomen was soft and non-distended, guarding/tenderness present on right and left lower quadrant, bowel sounds active in all four quadrants. The evaluation futher indicated R56 had a Foley catheter draining clear yellow urine, and no musculoskeletal concerns were noted. R56's physician orders [REDACTED]. Tylenol 325 milligrams (mg) 2 tablets as needed for acute pain. Special instructions: do not take more than 2000 mg in 24 hour period do to kidney transplant. [MEDICATION NAME] 5 mg. Special instructions: give 2 tabs for pain rated 7 or higher, and 1 tab for less than 7, for pain not relieved by [MEDICATION NAME] as needed every four hours. R56's record reflected a physician assistant (PA)-D note with a visit on 8/28/15 (visit time was not recorded) dictated into the medical record on 8/31/15. PA-D's note included: He continues with pain in the abdomen at the site of incision, for which he has been using [MEDICATION NAME] p.r.n. (as needed). PA-D remarked, R56 had been eating, blood sugars were stable, continued to have loose stools, no acute distress, heart rate was regular with no murmur, upper abdomen was somewhat distended but soft with active bowel sounds, and no lower extremity [MEDICAL CONDITION]. The PA-D also noted, Nursing staff will continue to monitor and will notify of any changes or decompensation in patient condition. 8/27/15 at 11:40 p.m. the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The record did not reflect results of the non-pharmacological interventions however, effectiveness of the medication (no time stamp for evaluation of efficacy) was recorded. Even though R56's discharge summary from the hospital included the directive to contact the transplant coordinator for increase in pain, there was no documented evidence the physician or transplant coordinator had been notified regarding R56's change in pain intensity. 8/28/15 at 12:09 p.m. the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was no documented evidence that non-pharmacological interventions had been utilized, and documentation on the MAR indicated [REDACTED]He c/o (complained of) pain around incision site. PRN Tylenol was given this afternoon. His (family member-A) stated he gets 'out of it' when he has [MEDICATION NAME]. There was no documentation to indicate R56's pain rated 10/10 had been assessment by licensed nursing staff and the physician was not contacted. An occupational therapist (OT) note documented by OT-E on 8/28/15 at 3:12 p.m. included: pt (patient) in severe pain with report of being freezing cold, shivering with increase in SOB (shortness of breath). Nursing notified of symptoms and vitals check, pt has SPO2 (oxygen saturation level) decrease to 87% on room air with increased breathlessness. BP (blood pressure) 167/60, 158/60 2nd reading, manually and 160's/117 with automatic BP cuff initially with suspicious of accuracy of reading. Per PT (physical therapist) minimum assist and standing tolerance limited due to severity of right surgical site pain. The note also indicated, Exhibits cardio-pulmonary limitations as evidenced by Borg Scale of PE (perceived exertion): 5 severe breathlessness impacting need for fluctuation in SPO2 level on room air with 10 of 10 right sided surgical pain. The medical record lacked any evidence the physician or transplant coordinator had been notified of the findings documented by OT-E on 8/28/15. However on 8/28/15 at 3:22 p.m. the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A follow-up pain evaluation indicated the [MEDICATION NAME] was somewhat effective. 8/28/15 at 4:25 p.m. a progress note written by director of nursing (DON) included: Called to resident room by staff because of low oximetry (blood oxygen level), resident shaking, complaining of cold and pain. Because he has had complaint of 10 out of 10 pain earlier, staff had given two more tabs as ordered due to unrelenting discomfort (clarified with DON that no extra stat doses given, administration only at 5:08 a.m. and 3:22 p.m.). Family had mentioned earlier that he had not done well in hospital when he received pain medication-stating that it wipes him out. Resident observed in bed with 02 at 2 lpm (liters per minute) per standing order sats now wnl (within normal limits), and when asked to point to where it hurts he vaguely indicates a large portion of his abdomen-more so to the right. His abdomen is rounded and tympanic with rushing bowel sounds in upper right, and left upper and lower quadrants. No sounds heard in lower right quadrant. This is surgical site. The DON's note also included, Resident does have shaking of the arms and some occasional jerking of legs. This could be side effect of narcotic. Will maintain on oxygen at this time due to somnolence. Staff notified that may not be tolerating oxy ([MEDICATION NAME]) and to try Tylenol per family report that this is what was done in the hospital. Plan to monitor and notify the provider if increased symptoms or symptoms do not improve. Warm pack applied to right chest wall and feet for comfort. Repositioned. Requests to stay laying flat and he is able to rest without dyspnea (difficulty breathing) or change in color. RN notified of status and to watch VS. Despite the documented unrelenting discomfort, need for supplemental oxygen, absence of bowel sounds, and jerking of hands and legs thought to be potential medication side effect, the record did not reflect notification to the physician or transplant coordinator. In addition, the record did not reflect evaluation of interventions including application of heat to chest wall and feet to relieve the severe abdominal pain, or when and how the pain was decreased or resolved to a tolerable level. The MAR for 8/28/15 at 9:45 p.m., reflected an LPN had administered Tylenol 650 mg for body pain. The documentation did not reflect pain intensity, location, description of pain, or attempts to use non-pharmacological interventions prior to the medication. A follow-up evaluation (not time stamped) indicated not effective. The record did not identify what was done as a result of the pain medication not being effective, or if and when the pain was resolved to a tolerable level. There was no information a stronger pain medication was given nor if the physician or transplant coordinator had been contacted to evaluate the current pain management regimen. On 8/29/15 at 6:44 a.m., LPN-B had documented a summary note for the preceeding night shift worked which included: R56 was awake on and off all night and was given Tylenol instead of [MEDICATION NAME] for pain this was partially effective and BP was fine and temp was fine. The record did not reflect ongoing monitoring of symptoms or vital sign monitoring as indicated by the DON. The record did not reflect notification to the physician or transplant coordinator for pain symptoms which had not improved. On 8/29/15 at 11:22 a.m., the MAR indicated [REDACTED]. No description or intensity of the pain was evident nor evidence of attempted non-pharmacological interventions. The TMA had documented the Tylenol was somewhat effective. The record did not reflect whether a licensed staff member had evaluated the pain, evaluated effectiveness of the medications used to treat pain, and/or re-assessed the pain for further interventions. On 8/29/15 at 2:54 p.m., a corresponding progress note had been written by the TMA who'd administered the tylenol at 11:22 a.m.; He (R56) c/o pain in his abdominal region. TMA gave him PRN Tylenol 325 mg 2 tabs. Those were somewhat effective., and Per family request they don't want him to have Oxy ([MEDICATION NAME]) unless he is in extreme pain at night to help him sleep. The record still did not reflect communication to the physician, or transplant coordinator, related to the resident's ongoing pain, or possible side affects of the [MEDICATION NAME], so a stronger pain medication could replace the [MEDICATION NAME] for pain control. On 8/29/15 at 3:50 p.m., a progress note written by DON included, Happened to be in the facility, and was notified around 2:30 (p.m.) that resident was vomiting bile colored fluid and had decreased output from foley. Nurse concerned about bowels because distended abdomen continues. The note further indicated the resident had no bowel sounds, nothing to eat since yesterday, dark urine, and pitting +2 pedal [MEDICAL CONDITION]. The progress note indicated at the time of the assessment R56 had denied pain. On 8/29/15 at 4:07 p.m., a progress note written by LPN-C included, resident was vomiting clear to bile fluid continuous since 1400 (2:00 p.m.), his abdomen was distended and I had (DON) come help me with his assessment and she heard no bowel sounds. LPN-C further documented, He was transported by ambulance at 1545 (3:45 p.m.) ( hospital) The hospital transplant coordinator was interviewed by phone on 3/17/16 at 12:37 p.m She stated I would have expected them (nursing home staff) to call and to have evaluated the pain somebody should have evaluated the resident, suggestive of an illeus. During interview with the DON at 1:44 p.m. on 3/18/16, she said that at the time she'd felt the staff just had to monitor and watch the pain. She further explained that R28 hadn't been there long enough to get to know what his pain was. When questioned why staff hadn't contacted the physician for R56 when his pain was over a 7/10, and the pain medication given was not affective in releiving pain, the DON said, We didn't consider the pain to be a change because we needed to see how he was first. The DON was asked to view the initial pain assessment regarding R56's pain. The DON stated there was a problem with the software because the assessment itself was lacking pertinent information regarding pain assessment and control. The DON also stated the nurse should follow up 1/2 hour after pain medications were given to evaluate for effectiveness, and that if a resident was still having pain, the physician should be contacted. A facility policy related to physician notification of change in condition was requested, but was not received.