Every finding on record at Heritage Living Center

Based on interview and document review, the facility failed to maintain a facility-wide infection surveillance system that identified, collected, analyzed, and trended signs and symptoms of possible infections and communicable diseases, including those that did not result in antimicrobial treatment. This deficient practice had the potential to affect all 41 residents who resided in the facility. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 of 1 resident (R5) reviewed for assistance with activities of daily living (ADLs) and wound care. Findings include: SURVEILLANCE: The facility's infection surveillance line list dated May 2026 identified resident name, location, infection date, infection type, diagnosis, medication, provider, outcome, resolution date, and bacteria. The line list identified two lower respiratory infections, two cases of cellulitis, one oral infection, one episode of diarrhea with incontinence, one pyelonephritis (kidney infection), two yeast infections, and one wound infection. All infections identified on the May 2026 line list were treated with antimicrobial medications. The line list did not identify signs or symptoms of possible infections or communicable diseases that did not result in antimicrobial treatment or viral illnesses. The facility's infection surveillance line list dated June 2026 identified resident name, location, infection date, infection type, diagnosis, medication, provider, outcome, resolution date, and bacteria. The line list identified one fungal infection, one lower respiratory infection, one wound infection, two cases of cellulitis, three urinary tract infections, and one case of anaplasmosis (a tick-borne disease caused by the bacterium Anaplasma phagocytophilum). The line list did not identify signs or symptoms of possible infections or communicable diseases that did not result in antimicrobial treatment or viral illnesses. The facility's infection surveillance line list dated July 2026 identified resident name, location, infection date, infection type, diagnosis, medication, provider, outcome, resolution date, and bacteria. The line list identified one case of cellulitis, five urinary tract infections, and one case of shingles. The line list did not identify signs or symptoms of possible infections or communicable diseases that did not result in antimicrobial treatment or untreated viral illnesses. The facility's infection surveillance line list for August 2026 was requested but was not received. During an interview on 8/5/26 at 11:29 a.m., the director of nursing (DON) stated she had served as the facility's infection preventionist (IP) since January 2026. The DON stated she tried to review antibiotics that had been ordered and entered into the facility's system weekly. Once each month, the DON gathered the infection information for review at the Quality Assurance and Performance Improvement (QAPI) meeting. The DON stated the facility planned to transition to a different dashboard portal in September 2026, which would make the surveillance process smoother. The DON had not completed the infection surveillance tracking for August 2026 because she generally collected the information during the first week of the following month. The DON stated when an antibiotic was initiated, nursing staff were responsible for beginning antibiotic monitoring. At times, a medical provider requested infection monitoring before a medication was ordered. Nursing staff were also expected to enter a nursing progress note for signs and symptoms of infection, and those notes were reviewed during interdisciplinary team (IDT) meetings. Although the DON stated infection information was reviewed during IDT meetings, the facility was unable to provide IDT meeting documentation demonstrating the review, analysis, or trending of infection surveillance information. The DON stated she did not track signs or symptoms of possible infections when the symptoms did not result in treatment, such as common cold symptoms. The DON acknowledged that tracking those signs and symptoms and conducting infection surveillance in the moment would allow staff to identify possible infections and take measures to prevent the potential spread of infection. During a telephone interview on 8/5/26 at 12:36 p.m., the administrator stated tracking and trending infection information in the moment allowed staff to identify infections and prevent the potential spread of infection. The facility's undated Infection Surveillance Overview policy identified infection prevention began with routine and ongoing surveillance to identify possible communicable diseases or infections before they could spread to other persons in the facility or potentially cause an outbreak. The policy identified the facility had established a system, based on national standards of practice and the facility assessment, to closely monitor all residents who exhibited signs or symptoms of infection through ongoing surveillance. The surveillance system was to include a systematic method for collecting, analyzing, and interpreting data, followed by dissemination of the information to identify infections, infection risks, and outbreaks to individuals who could improve outcomes. The policy identified the intent of surveillance was to identify possible communicable diseases or infections before they could spread to other persons in the facility. Surveillance was identified as crucial to promptly identifying possible clusters, changes in prevalent organisms, or increases in infection rates. Surveillance results were to be used to plan infection control activities, determine the need for corrective action, direct in-service education, and identify individual resident problems requiring intervention. EBP: R5's significant change Minimum Data Set (MDS) dated [DATE] identified the assessment was completed due to R5's admission to hospice care. R5 had intact cognition and was dependent with most activities of daily living (ADLs), including dressing, grooming, and toileting. R5 was dependent with transfers and unable to ambulate. R5 had an indwelling Foley catheter and was always incontinent of bowel. Diagnoses included right above-the-knee amputation, heart failure, chronic obstructive pulmonary disease (COPD), diabetes, anxiety, and a history of transient ischemic attack and cerebral infarction (stroke). R5's care plan, revised 7/13/26, identified R5 had an indwelling urinary catheter. Interventions directed staff to position the catheter bag and tubing below the level of the bladder, change the catheter every four weeks and as needed, and monitor and document intake and output according to facility policy. R5 had actual impairment to skin integrity. Staff were directed to elevate R5's heels while in bed, encourage good nutrition and hydration, keep R5's skin clean and dry, observe for signs of infection, and use a pressure-relieving mattress in bed and cushion in the chair. Staff were directed to assist R5 with morning and evening care. R5 required total assistance of one staff member with dressing and grooming. During an observation on 8/4/26 at 9:59 a.m., registered nurse (RN)-E and hospice aide (HA)-D assisted R5 with a bed bath. An EBP sign was posted outside R5's room and directed staff to wear gloves and a gown when assisting R5 with ADLs, including bathing, dressing, grooming, transfers, catheter care, and wound care. A personal protective equipment (PPE) cart was located in the hallway immediately next to R5's door and contained disposable gowns and gloves. A large, dark gray, round bin was located inside R5's room and contained used gowns. RN-E and HA-D wore disposable gloves but did not wear gowns while providing R5's care. RN-E applied a clean, self-adhesive dressing over an ulcer on R5's lower right buttock. A second clean, self-adhesive dressing was observed directly above the buttock wound covering R5's coccyx wound and was dated with RN-E's initials and the current date. RN-E and HA-D then assisted R5 into a pair of jeans. HA-D emptied the wash basin into the sink, removed her gloves, and washed her hands. RN-E removed her gloves, applied alcohol-based hand rub (ABHR), and began completing a nursing assessment with R5. A joint interview was conducted with HA-D and RN-E on 8/4/26 at 10:05 a.m. HA-D stated she had not worn a gown over her clothing while assisting R5 with his bed bath that morning. HA-D stated she thought a disposable gown was required only when providing catheter care. HA-D stated the facility had never instructed her to wear PPE when providing care to a resident on precautions. RN-E stated she also thought PPE was required only when providing catheter care and stated the facility had never instructed her regarding when PPE was required when caring for residents on EBP. RN-E acknowledged she should have worn a gown while assisting R5 with care and dressing changes. During a telephone interview on 8/5/26 at 11:09 a.m., the administrator stated the facility took EBP very seriously and routinely completed audits to ensure staff compliance. The administrator stated she did not think facility staff were aware the hospice staff were not following EBP guidance because clear signage was posted on residents' doors to direct staff regarding required precautions. The administrator stated the hospice staff were educated and the problem was corrected. During an interview on 8/5/26 at 12:21 p.m., the director of nursing (DON) stated residents who required EBP had signage posted on their doors that clearly instructed staff regarding the PPE required when providing care. The DON stated she educated the staff involved and reviewed EBP and contact precautions with them. The facility's Enhanced Barrier Precaution policy dated April 2025, identified EBP was an infection prevention intervention requiring gown and glove use during specified high contact resident care activities to reduce multi drug resistant organisms (MDRO) spread. The policy applied to all staff, contractors, consultants, students, volunteers, residents and visitors within the facility managed communities and across all applicable licensure types. High contact activities when EBP was required included dressing, bathing, transferring, hygiene assistance, changing linens or briefs, toilet assistance, wound care and care or use of indwelling medical devices. Donning of gown and gloves would be required immediately before performing high contact resident care activities. The facility's Hospice and Nursing Facility Services Agreement, dated 6/10/25, identified the facility would institute, implement, and maintain administrative policies, procedures, and patient care protocols in accordance with recognized professional standards of care and as necessary to implement the provisions of the agreement.

Based on observation, interview, and document review, the facility failed to ensure a medication label accurately reflected the current physician-ordered dose for 1 of 1 resident (R43) reviewed for medication labeling. The incorrect label contributed to R43 receiving 5 milligrams (mg) of morphine sulfate instead of the prescribed 2 mg dose.Findings include:R43's significant change Minimum Data Set (MDS) dated [DATE] identified R43 had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia.R43's physician orders dated 7/30/26 identified the following:morphine sulfate concentrate oral solution 100 mg/5 milliliters (mL): place and dissolve 2 mg (0.1 mL) buccally (between the gum and inner lining of the cheek) every four hours for pain.morphine sulfate concentrate oral solution 100 mg/5 mL: place and dissolve 5 mg (0.25 mL) buccally every hour as needed (PRN) for breakthrough moderate to severe pain rated 4-10 out of 10 or shortness of breath.During an observation on 8/3/26 at 4:04 p.m., registered nurse (RN)-B withdrew 0.25 mL (5 mg) of morphine sulfate concentrate 100 mg/5 mL using the syringe provided with the medication. RN-B brought the medication into R43's room and administered the medication buccally.RN-B returned to the medication cart, removed the narcotic record book from the drawer, and documented the date, time, and that 0.1 mL of morphine sulfate had been administered.RN-B stated she administered 0.25 mL to R43 because the medication label identified 0.25 mL. RN-A stated she was the unit manager and R43's order had recently changed. RN-A stated 0.1 mL was the correct scheduled dose. However, RN-B explained and confirmed to RN-A that she had administered 0.25 mL. RN-A stated, That's an error, and asked whether R43 was okay.RN-A and RN-B assessed R43 following the medication error. R43's vital signs and condition remained unchanged. RN-A stated when a medication dose changed, a sticker should be applied to the medication label to alert staff to the change and ensure staff double-checked the dose. RN-A stated a medication error report would be completed and the director of nursing (DON) would be notified.R43's morphine sulfate concentrate oral solution 100 mg/5 mL medication label directed staff to place and dissolve 5 mg (0.25 mL) buccally every four hours for pain. The medication label did not reflect R43's current scheduled physician order for 2 mg (0.1 mL) every four hours for pain. No sticker or other notification identifying the change in the scheduled dose was attached to the medication.During an interview on 8/5/26 at 11:52 a.m., the DON stated RN-B followed the directions on the medication label and there was no sticker attached to the medication to alert staff that the dose had changed. The DON stated facility-wide education was provided and staff were expected to follow facility policy to ensure resident safety.During a telephone interview on 8/5/26 at 12:36 p.m., the administrator stated she expected staff to follow facility policy for medication administration to ensure resident safety.During a telephone interview on 8/5/26 at 1:11 p.m., the consultant pharmacist stated facility staff were expected to follow facility policy to ensure medications were administered safely.The facility's General Medication Pass Policy, revised 1/2025, directed staff to read medication labels three times before dispensing medications and follow the six rights of medication administration, including the right dose and right documentation. The policy did not identify a process for ensuring medication labels were updated or otherwise modified when a physician's medication order changed.

Based on observation, interview, and document review, the facility failed to ensure a resident was free from a significant medication error when a registered nurse (RN) administered 5 milligrams (mg) of morphine sulfate instead of the prescribed 2 mg dose for 1 of 1 resident (R43) reviewed for medication administration. Findings include:R43's significant change Minimum Data Set (MDS) dated [DATE] identified R43 had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia.R43's physician orders dated 7/30/26 identified the following:morphine sulfate concentrate oral solution 100 mg/5 milliliters (mL): place and dissolve 2 mg (0.1 mL) buccally (between the gum and inner lining of the cheek) every four hours for pain.morphine sulfate concentrate oral solution 100 mg/5 mL: place and dissolve 5 mg (0.25 mL) buccally every hour as needed (PRN) for breakthrough moderate to severe pain rated 4-10 out of 10 or shortness of breath.R43's electronic medication administration record (EMAR), reviewed on 8/5/26, identified R43 received the scheduled 2 mg (0.1 mL) dose of morphine sulfate at 4:00 p.m. The EMAR further identified R43 had not received a PRN dose of 5 mg (0.25 mL).During an observation on 8/3/26 at 4:04 p.m., RN-B withdrew 0.25 mL (5 mg) of morphine sulfate concentrate 100 mg/5 mL using the syringe provided with the medication. RN-B brought the medication into R43's room and administered the medication buccally.RN-B returned to the medication cart, removed the narcotic record book from the drawer, and documented that 0.1 mL of morphine sulfate had been administered.RN-B stated she administered 0.25 mL to R43 because the medication box label identified 0.25 mL. RN-A stated she was the unit manager and R43's medication order had recently changed. RN-A stated 0.1 mL was the correct dose. However, RN-B explained and confirmed to RN-A that she had administered 0.25 mL. RN-A stated, That's an error, and asked whether R43 was okay.RN-A and RN-B assessed R43 following the medication error. R43's vital signs and condition were unchanged. RN-A stated when a medication dose changed, a sticker should have been applied to the medication label to ensure staff double-checked the dose. RN-A stated a medication error report would be completed and the director of nursing (DON) would be notified.During a telephone interview on 8/5/26 at 10:54 a.m., RN-E stated she was notified of R43's medication error on 8/3/26 at approximately 4:45 p.m. RN-E stated because R43 had been routinely receiving morphine sulfate, the medication error was not a concern that required further evaluation.During an interview on 8/5/26 at 11:52 a.m., the DON stated RN-A reported the medication error immediately after it occurred. The DON spoke with RN-B, who acknowledged the error. RN-B received education regarding the importance of completing the five rights of medication administration: right resident, right medication, right dose, right route, and right time. The DON stated RN-B followed the directions on the medication label; however, facility policy required staff to follow the EMAR. The DON sent an alert to all trained medication aides (TMAs) and nursing staff and provided facility-wide education. The DON stated she expected staff to follow facility policy to ensure resident safety.During a telephone interview on 8/5/26 at 12:36 p.m., the administrator stated she expected staff to follow facility policy for medication administration to ensure resident safety.During a telephone interview on 8/5/26 at 1:11 p.m., the consultant pharmacist stated R43 could have experienced increased drowsiness from the medication error but did not expect adverse effects because R43 had already been receiving morphine sulfate. The consultant pharmacist stated staff were expected to follow facility policy to ensure medications were administered safely.The facility's Liquid Narcotic Administration Policy, revised 1/2025, identified the purpose of the procedure was to provide guidelines for the safe administration of oral liquid narcotic medications. The policy directed staff to:Verify there was a physician's order for the medication to be administered.Review the resident's care plan for special needs.Assemble necessary equipment and supplies.Place the EMAR within easy viewing distance.Unlock the medication cart and narcotic drawer.Select the medication from the medication cart.Check the medication label and confirm the medication and dose with the EMAR.Prepare the correct dose of medication. When using a syringe, staff were required to use the syringe provided with the medication and draw up the correct amount. An ordered amount of less than 5 cubic centimeters (cc) required use of a syringe.Contact hospice for approval of an initial hospice medication dose; subsequent doses did not require approval unless otherwise indicated.Check the narcotic record against the previous drug count and medication supply and report discrepancies to the DON and complete an incident report for errors.

Based on observation, interview, and document review, the facility failed to consistently implement and evaluate individualized interventions to address persistent expressions of distress for 1 of 1 resident (R31) reviewed for dementia care. This resulted in prolonged periods of R31 hollering without staff intervention and contributed to distress for another resident (R7), who had a known history of post-traumatic stress disorder (PTSD) with loud noises identified as a trigger.Findings include:R31R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had a severe cognitive impairment and had diagnoses that included Alzheimer's disease, dementia, delusional disorders, and depression. R31 exhibited facial expressions (e.g. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) as indicators of pain or possible pain and received scheduled pain medication and non-medication interventions for pain. R31's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 2/23/26, identified R31's goal was to maintain by management of symptoms and behaviors. Staff would encourage R31 to make as many choices as possible, needs anticipated by staff when needed. R31's Behavioral Symptoms CAA dated 2/23/26, identified R31's goal was to improve by utilizing behavioral interventions. Medications administered to manage depression and behavioral symptoms, monitored routinely.R31's Pain CAA dated 2/23/26, identified R31's goal was to maintain with current pain management regimen effective. R31 had scheduled medications, non-medication interventions, and as needed (PRN) medications available. R31's care plan revised 5/6/26, identified R31 had behaviors of yelling out, grabbing at staff, and swearing related to dementia, and Alzheimer's disease, delusional disorder, and depression. Interventions included:Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove the situation and take R31 to alternate location as needed.Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, people involved, and situations. Document behavior and potential causes.When R31 was exhibiting verbal/physical behaviors (yelling out; declining cares; grabbing; swearing) leave R31 in a safe space and return later to provide task.R7 R7's Trauma Informed Care dated 11/25/24, identified R7 had a history of childhood neglect and abuse which can make R7 feel angry/irritable, anxious and distraught. There was no pattern to how often the feeling related to the situation occurred. Loud noises were a trigger for R7. A close relationship with siblings and other family members helped make R7 feel better. Preference for private room and R7 used tv or a white noise machine to block out neighboring sounds.R7's quarterly MDS dated [DATE], identified R7 had severe cognitive impairment and diagnoses included Post-Traumatic Stress Disorder (PTSD), depression, migraine and cirrhosis of the liver. R7 required cleanup/set up assistance with eating but was independent with all other care areas. R7 exhibited no behaviors R7's care plan revised 7/22/26, identified R7 had actual or potential for post-traumatic stress disorder related to childhood neglect and abuse. Interventions included the following: observe for changes in mood/behavior/sleep/eating and side effects of medications.During an observation on 8/3/26 at 11:04 a.m., R31 was sitting in her wheelchair in the common area in front of the tv. R31 was hollering incoherently and loudly. R31 could be heard throughout the wing. Licensed practical nurse (LPN)- stated R31 was having mouth pain, and staff were trying to figure out what to do. R31 had been given pain medication.At 11:16 a.m., R31 continued to holler out. R31's eyes were closed and she was sitting with her feet elevated and a pillow behind her head. At 11:38 a.m., R31 was assisted to the dining room for her noon meal. R31 continued to holler out loudly but the other residents weren't acknowledging her hollering. LPN-A, R31 and two other residents were in the dining room.At 11:48 a.m., R31 continued to holler out incoherently. R31's tablemates joined her at the table but neither said anything when R31 hollered out. The other residents quietly sat with their eyes closed waiting for the meal to start. At 12:01 p.m., R31 continued to holler uhhhhhh loudly. Nursing assistant (NA)-B stated R31 hollered a lot like that. R31 was in a lot of pain. It's been going on a while now. During an interview on 8/3/26 at 1:39 p.m., family member (FM)-A stated R31 did have problems with her teeth and staff had been working with insurance to get R31 to an oral surgeon because R31 would not open her mouth for the regular dentist and R31 ground her teeth. FM-A stated he was told staff could feel where R31's teeth were broken off. Staff applied a numbing gel to R31's gums/teeth and R31 had pain medications as well. However, FM- stated the doctor said it shouldn't hurt R31. R31 did the hollering. FM-A wasn't sure if it was pain or if R31 had a behavior. FM-A knew if you held R31's hand or rubbed her feet, R31 calmed down.During an observation on 8/3/26 at 5:58 p.m., NA-A assisted R31 to the common area and stated, you probably don't want to sit here because she's going to be noisy. R31 was hollering loudly until registered nurse (RN)-A brought an oral soothing device. The oral soothing device was a fabric pouch with a plastic handle that could be filled with ice. RN-A stated R31 ground her teeth, and the facility has been unable to get her a mouth guard. The oral soothing device was filled with lemon flavored icy to help soothe R31's oral pain. R31 did suck and chew on the oral soothing device but continued to holler out around it.At 6:01 p.m., R31 opened her mouth and RN-A removed the oral soothing device. RN-A went down the hall and R31 began hollering again.At 6:06 p.m., R31 continually hollered loudly. RN-A returned with an ice pack and held it against R31's check. R31 continued hollering and RN-A asked if it was too cold. R31's hollering remained unchanged. RN-A asked R31 if she wanted to go for a walk. R31 continued hollering and kicked her feet into the air. RN-A told R31 to squeeze RN-A's hand if the ice pack was too cold. R31 lightly held RN-A's hand.At 6:10 p.m., R31 had continually hollered. RN-A pushed R31's wheelchair past the nursing assistants and asked if it was normal for R31 to holler like this. The nursing assistants nodded and said yes. At 6:14 p.m., RN-A and the director of nursing (DON) brought R31 to her room. The DON stated hollering was R31's norm and left the room. At 6:17 p.m., RN-A brought R31 back to the common area in front of the tv. RN-A then left the area.At 6:24 p.m., R31 hollered non-stop. R7 was inside her room, which as adjacent and shared a wall the tv area, with the door shut and could be heard clearly yelling shut up! through the shut door. R31 continued hollering.At 6:26 p.m., R31 continued hollering. R7 was sitting in her recliner and was trying to watch tv. R7 is scowling and shaking her head and yelled Shut up! It's just nonstop. Day and night. It drives me nuts! R7 stated it didn't do any good to say anything to the staff, but seriously can't they just move her somewhere else? R7 stated she understood R31 lived at the facility but R31 didn't have to sit right outside R7's room.At 6:32 p.m., R31 hollered nonstop with tone and intensity increased. Staff did not move R31 or approach R31 or R7 to attempt redirection.During an interview on 8/4/26 at 10:12 activity aide (AA)-A sat next to R31 talking softly and assisted R31 to eat an icy while holding/stroking R31's hands. R31 occasionally made sound, but the sound had decreased in tone and intensity significantly. At 10:33 a.m., AA-A told R31 AA-A needed to go chart and would see R31 later.During an interview 8/4/26 at 10:37 a.m., AA-A stated R31 had hollering behaviors for quite a while now. AA-A stated the nurses were working with R31's insurance to get an oral procedure approved. AA-A stated R31's hollering lessened when some sat with R31 and held her hands. It also increased when R31's family had visited and had to leave. AA-A stated R31 had the behavior prior to the dental problem being identified. AA-A stated she was unsure if it was pain or did the pain increase the behavior and the behavior just continued. The other residents did complain. Another resident recently moved upstairs so she wouldn't have to listen to it anymore. R7 complained as well. Sometimes staff tried to move R31 to the dining room because there was a tv there too when R7 complained. AA-A stated she did not know if there was anything else the staff could do. During an observation on 8/4/26 at 10:44 a.m., R31 started hollering again. NA-C was sitting at the desk, and housekeeping was going room to room. No staff approached R31. At 10:51 a.m., R31 hollered nonstop. NA-C left the desk but never approached R31. Housekeeping continued going room to room. At 11:09 a.m., NA-C approached R31 and placed a wedge cushion between R31 and R31's left wheelchair armrest. NA-C told R31 she would be back to get her for lunch shortly.At 11:11 a.m., RN-A approached R31, put on a pair of gloves and applied essential oils to R31's neck. RN-A stated sometimes the essential oils and neck rub helped R31. R31 did stop hollering while R31 rubbed R31's neck. At 11:19 a.m., RN-A walked away from R31 and R31 began hollering.At 11:21 a.m., RN-A returned with a nutritional shake and R31 drank the shake using a straw. R31 stopped hollering.During an interview on 8/4/26 at 2:17 p.m., NA-D stated R31 screamed all the time, every day. R31 was in a lot of pain, and the hollering was the only way for R31 to communicate. R31 had an oral soothing device that R31 could chew on that helped. When R31's family was there, that helped too. Staff believed R31 was scared to be alone and hollered because of that as well. Other residents did complain about R31's hollering. R7 complained but was usually good about it. R7 just shut her door and tried to ignore it. At 2:21 p.m., NA-D returned with the oral soothing device and a towel. NA-D stated R31 would not always open her mouth and rubbed R31' lips with the device telling R31 that it would feel good. NA-D placed the device in R31's mouth, placed the towel in R31's lap and walked away. Let's see if that helps for a little bit. R31 continued to holler around the device.At 2:28 p.m., R31's hollering increased in tone and loudness, yelling approximately every 15 seconds. R7 was in her room with the door shut and can be heard clearly yelling Shut up! Just shut up! There were 5 staff sitting at the desk for afternoon report. No staff approached either resident. R31 and R7 continued hollering. At 2:31 p.m., NA-D approached R31 and placed the oral soothing device back into R31's mouth. You just have to keep sticking it in her mouth. R31 chewed on the device but continued hollering in a muffled hum. NA-D went back to the desk. At 2:36 p.m., the oral soothing device fell out of R31's mouth and R31 is screaming incoherently. R7 screamed Shut up! behind her closed door but could be clearly heard. Staff continued to sit at the desk without approaching R31 or R7.At 2:40 p.m., shift report was done and staff stood up from the desk. R31 and R7 were hollering. NA-E approached R31 and assisted R31 to an upright position. R31 continued to scream. No staff checked on R7. NA-E walked away from R31 with R31's oral soothing device and walked with the other 4 staff down the hall. R31 and R7 continued hollering.At 2:44 p.m., NA-E brought R31's oral soothing device to R31 and placed it in R31's mouth. R31 chewed and sucked on the device. NA-E stated R31 hollered every day, all day. Sometimes rubbing R31's legs helped because R31's muscles would get stiff. Sometimes the chewing ice helped. That was all staff usually did. NA-E then stated staff didn't always have to hold R31's device for R31 but NA-E chose to at that time to prevent R31 from spitting it out. R7 did get really upset about R31's hollering. R7 had behaviors too and screamed at R7 which wasn't right either. R31 couldn't help it. Staff were supposed to go in and talk to R7 and just try to calm her down.At 2:50 p.m., NA-E placed the oral soothing device in R31's mouth, removed her gloves and walked away from R31. R7 hollered shut up but NA-E did not go in and talk to R7. At 2:53 p.m., R31 spit out the oral soothing device and was hollering again. R7 repeatedly hollered in her room. At 2:57 p.m., NA-E sat down at the desk, didn't approach either resident and was working on the electronic tablet. R31 and R7 continued hollering. During an interview on 8/4/26 at 3:07 p.m., NA-A stated R31 yelled and screamed all day, every day. Sometimes R31 was quiet in the mornings but by 2:00-3:00 p.m., R31 hollered until she went to bed at 7:00 p.m. After that, R31 tended to be quieter. Staff gave R31 ice. R31's oral soothing device had fallen into R31's lap where it melted and R31 had an approximately 6-inch circle of wet on her left thigh. Sometimes R31 would hold the oral soothing device in her mouth but staff really should hold it for R31. Sometimes R31 would be quiet for about 1 minute. R31 liked to go outside too and like it when it was quiet and peaceful. R7 did get upset by R31's hollering and screamed shut up. NA-A stated staff couldn't put R31 in her room because that would isolate R31. At 3:13 p.m., NA-A walked away telling R31 he would be right back. R31 immediately began hollering again. During an interview on 8/5/26 at 10:44 a.m., RN-A stated she was the unit manager for R31 and R7. R31 had ongoing teeth pain, and this had been a consistent concern for a few months. The first sign was R31 had cheek/face swelling. She was seen and treated with an antibiotic and a dental referral was sent. A local dentist had been able to do an evaluation but R31 requires an oral surgeon. Insurance approval has been difficult and R31 was going to have additional imaging. R31 did have pain medications as well as non-pharmacy interventions such as food, drink, ice, heat, essential oils, massage, and repositioning. RN-A felt the staff had been trying their best to manage R31's pain but had met every barrier possible. However, RN-A expected staff to follow R31 and R7's care plans to address behaviors.During an interview on 8/5/26 at 11:52 a.m., the DON stated she expected staff to acknowledge resident behaviors and to follow care plans to ensure resident needs were met.During a telephone interview on 8/5/26 at 12:36 p.m., the administrator stated she expected staff to follow resident care plan regarding dementia care to meet the residents' needs. Document review identified the facility had not completed an assessment of R31's persistent hollering to determine the underlying cause or contributing factors, including whether the hollering was related to pain, dementia-related distress, fear of being alone, environmental factors, or a combination of factors. Although staff identified multiple possible causes for R31's hollering and individualized interventions that reduced or stopped the hollering, the information had not been incorporated into an individualized approach that differentiated interventions for possible pain from interventions for R31's dementia-related behavioral symptoms.A dementia care policy was requested but not received.

Based on interview and document review, the facility failed to ensure a resident received ongoing nursing assessment and monitoring following an acute change in condition for 1 of 2 residents (R5) reviewed for changes in condition. Findings include:R5's significant change Minimum Data Set (MDS) dated [DATE] identified the assessment was completed due to R5's admission to hospice care. R5 had intact cognition and was dependent with most activities of daily living (ADLs), including dressing, grooming, and toileting. R5 was dependent with transfers and unable to ambulate. R5 had an indwelling Foley catheter and was always incontinent of bowel. R5 did not exhibit rejection of care or other behaviors during the assessment period. Diagnoses included right above-the-knee amputation, heart failure, chronic obstructive pulmonary disease (COPD), diabetes, anxiety, and a history of transient ischemic attack and cerebral infarction (stroke).R5's care plan, revised 7/13/26, identified R5 had altered respiratory status related to heart disease, asthma, anemia, COPD, and a history of tuberculosis. Goals included maintaining a normal breathing pattern and pulse oximetry above 90 percent. Staff were directed to monitor, document, and report breathing abnormalities to the physician, administer nebulizers and inhalers as ordered, and obtain vital signs weekly and as needed. The care plan identified R5 had altered elimination related to bowel incontinence and an indwelling urinary catheter. Staff were directed to provide perineal care after each incontinent episode and record the amount and consistency of bowel movements.The care plan identified R5 had diabetes with a goal to experience no complications related to diabetes. Interventions directed staff to administer medications as ordered, monitor for side effects, and monitor, document, and report to the physician as needed symptoms of hypoglycemia or hyperglycemia, increased thirst and appetite, weight loss, and fatigue.R5's progress notes identified the following:On 6/28/26, R5 woke early and ordered four ice creams for breakfast and stated they were for his diarrhea. Later, R5 was heard shouting for help and was seated in his wheelchair at the end of the bed. R5 denied pain, breathing difficulty, or chest pain and refused to allow staff to obtain his vital signs. R5 stated he did not know what was going on with him. Staff notified the on-call physician, who ordered laboratory testing, which R5 initially refused. Later during the day shift, R5 allowed staff to attempt to obtain blood for the ordered laboratory testing twice; however, the samples hemolyzed and could not be used. R5 was confused and hallucinating. Staff updated the on-call physician, who stated another provider would see R5 the following day.On 6/28/26 at 10:34 p.m., staff documented R5 had been incontinent of seven large, loose, tarry stools. Staff made several attempts to convince R5 to go to the emergency room for evaluation; however, R5 refused. R5 also refused all oral intake during the evening shift.On 6/29/26 at 10:07 a.m., R5 was transferred to the hospital due to increased stools and hypotension. R5's blood pressure was 55/36, pulse was 53 beats per minute, and temperature was 99.2 degrees Fahrenheit.R5's medical record lacked evidence a licensed nurse assessed R5 or that staff monitored R5's vital signs and clinical condition during the evening and night shifts following his acute change in condition, which included seven large, loose, tarry stools and refusal of oral intake.R5's Blood Pressure Summary identified staff recorded R5's blood pressure two to three times per day from 6/16/26 through 6/27/26; however, no blood pressure was recorded on 6/28/26 or prior to R5's assessment and transfer to the hospital on 6/29/26.During an interview on 8/4/26 at 2:43 p.m., licensed practical nurse (LPN)-B stated the second floor was usually staffed with a trained medication assistant (TMA) and a nursing assistant (NA). If the TMA needed assistance, such as when a resident experienced a change in condition or required insulin administration, a nurse from the first floor would go to the second floor and provide the necessary nursing services. If an LPN or registered nurse (RN) was scheduled on the second floor, the nurse completed their own assessments. LPN-B stated assessments were documented in the resident's progress notes.During an interview on 8/4/26 at 2:47 p.m., RN-A stated when she began her shift on 6/29/26, she reviewed the shift report and went to assess R5. RN-A stated she first obtained R5's vital signs because R5 was sweaty and did not feel well. RN-A discussed R5's condition with him, and R5 agreed to go to the emergency room for evaluation. RN-A stated she had been informed R5 previously refused hospital evaluation. RN-A stated she would have expected increased monitoring and vital sign assessments during the previous shifts due to R5's change in condition. RN-A was unable to locate evidence staff monitored R5's condition and stated it appeared staff did not obtain R5's vital signs during the evening or night shift.During a telephone interview on 8/4/26 at 3:42 p.m., LPN-C stated she worked the evening shift on 6/28/26 and remembered R5 repeatedly refused to go to the emergency department for evaluation. LPN-C thought the TMAs obtained R5's vital signs twice during the shift. LPN-C stated she did not document the vital signs in R5's medical record and acknowledged the vital signs should have been documented. LPN-C stated she knew the on-call provider had been notified during the day shift; therefore, staff did not update the provider during the evening shift because R5 continued to refuse transfer to the emergency department for evaluation.During an interview on 8/4/26 at 5:40 p.m., RN-D stated she worked the day shift on 6/28/26 and remembered R5 experienced significant hallucinations. RN-D stated she was told R5 wanted four cups of ice cream for breakfast and wondered whether R5's symptoms were related to his blood glucose because he had diabetes. RN-D contacted the on-call provider because of R5's confusion and attempted to obtain blood for the ordered laboratory testing; however, the samples clotted and could not be used.RN-D stated she attempted to obtain R5's blood pressure, but the machine repeatedly displayed an error. RN-D then attempted to palpate R5's pulse and blood pressure but was unable to obtain them. R5 would not allow staff to place a blood pressure cuff on him, and when staff were able to attempt it, the machine continued to display an error.RN-D stated the on-call provider said R5 needed to go to the emergency room; however, R5 was his own person and refused to go. RN-D stated R5 was sweating but would not allow staff to touch him to obtain his vital signs or blood glucose. R5 hollered for help throughout the shift, but when staff entered his room, R5 stated he had not asked for help and directed staff to leave. RN-D stated R5 became more like himself toward the end of the day shift, which was when staff were able to attempt obtaining the blood samples; however, R5 allowed staff to provide care for only a short time before he again refused to be touched.During an interview on 8/4/26 at 5:33 p.m., TMA-A stated she worked the evening shift on 6/28/26. Staff offered R5 several opportunities to go to the emergency room because of his condition. R5 was not eating or drinking but repeatedly stated he wanted to wait. TMA-A thought her coworker had obtained R5's vital signs but was unsure where they would have been documented. TMA-A stated R5 appeared grayish, and staff offered him everything they could offer. TMA-A stated TMAs and NAs were trained to obtain vital signs. Routine weekly vital signs were prompted for documentation by the electronic medical record. If additional vital sign monitoring was needed, staff wrote the results on paper and gave them to the nurse. TMAs and NAs used a vital sign form to record residents' vital signs, which identified normal ranges. If a vital sign was outside the range identified on the form, staff alerted the nurse.TMA-A stated she was busy administering medications that evening and her coworker was working with R5. Staff had monitored R5's vital signs twice daily from 6/17/26 through 6/27/26 because R5 had been receiving an antibiotic and facility policy required daily monitoring. When a resident completed an antibiotic, staff usually discontinued the daily monitoring.During an interview on 8/5/26 at 5:19 a.m., LPN-D stated she was aware R5 had been declining but did not work the night of 6/28/26. LPN-D stated R5 could be difficult to work with. R5 was noncompliant and rude but was his own person and staff could not force him. LPN-D stated she would document R5's vital signs if he allowed staff to obtain them or document his refusal. LPN-D stated she would document R5's appearance and behavior and document if R5 refused transfer to the emergency room or refused to allow staff to monitor his vital signs.During an interview on 8/5/26 at 6:23 a.m., NA-F stated she worked on 6/28/26 and R5 had been really confused. NA-F stated staff were in R5's room anywhere from every five minutes to every 30 minutes. Usually, R5 was very independent and called staff only when he really needed assistance; however, R5 used his call light frequently that morning and was very confused. NA-F stated R5 would not allow the RN to obtain his vital signs. Staff attempted to use the blood pressure cuff on both arms but repeatedly received an error. NA-F stated R5's routine was very different. R5 would not eat or change his clothes. NA-F remembered R5's nose was running frequently and R5 was leaning heavily over his lap. R5 appeared to be in pain but refused to go to the doctor.During a telephone interview on 8/5/26, at 11:09 a.m. the administrator stated she was not sure of all the details regarding R5's acute change in condition on 6/28/26 but would look into it further. [no further details were received]During an interview on 8/5/26 at 12:21 p.m., the director of nursing (DON) stated staff were expected to document the care and monitoring they provided. The facility's Change in a Resident's Condition or Status Policy, revised October 2024, identified the facility would promptly notify the resident, attending physician, and resident representative of changes in a resident's medical or mental condition and/or status. The policy directed the RN manager to document information related to changes in the resident's condition in the resident's medical record.

Based on observation, interview and document review the facility failed to ensure fall prevention strategies were assessed and fall interventions were implemented to protect from accidents for 1 of 3 residents (R1) who was at risk for falls and had a fall with injuries. This resulted in actual harm to R1 who fell and sustained a scalp laceration, a tibial (shin bone) fracture, femur (the longest, strongest, and heaviest bone in the human body, extending from the hip to the knee) fracture and a bimalleolar (a severe, unstable ankle injury involving fractures to both the medial malleolus (inner tibia) and lateral malleolus (outer fibula) fracture of right lower leg. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance.Findings Include: R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnoses included dementia, vertebral and sacral fractures and age-related osteoporosis. R1's annual Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. The MDS identified lower extremity impairments on both sides and frequent urinary incontinence. The MDS indicated R1 had sustained one fall since the previous assessment. R1's Fall Risk assessment dated [DATE], indicated predisposing diseases that included arthritis, osteoporosis, dementia, unsteadiness and muscle spasm. The assessment identified frequent incontinence, inability to independently come to a standing position and the need for hands on assistance to move from place to place. Fall precautions and devices included high/low bed, call light in reach, and mechanical stand for transfer. At the time of assessment, most recent fall occurred 1/26/26. Staff to use a mechanical stand and total assist of one for all transfers. R1's care plan updated 2/4/26, identified a risk for falls related to impaired mobility, history of falls, impaired cognition, poor safety awareness and a history of fractures. The care plan identified the following interventions: 12/30/23, keep call light in reach and encourage use. 12/30/23, Bed in lowest position and fall mat on floor next to bed when R1 was in bed. 2/3/26, Gripper socks to be worn at all times. Nursing Home Internal Report submitted to the State Agency on 2/4/26, indicated on 2/3/26, R1 was found on the floor in her room. Staff report that she was laying between her bed and recliner, on her side. She had a head laceration and was laying with one leg in a twisted position underneath her. Her bed was in high position without fall mat in place. Ambulance was called and resident not moved due to pain when staff touched lower extremities. Hospital returned patient last evening with Urinary Tract Infection (UTI) and head laceration. R1 returned to emergency room (ER) on 2/4/26 at 0300 am due to severe pain with movement or when touched. ER reported at this time indicated she had two fractures found in right leg. Resident has dementia and is impulsive. Resident attempted to self-transfer and fell. Resident stated she was trying to get up. Staff heard a quiet help coming from her room. R1's Progress Notes indicated the following: 1/26/26, R1 sustained a fall in her room at 3:45 p.m. R1 was seen in the supine (lying horizontally on the back with the face and torso facing upward) position on the floor near her bed. R1 tried to ambulate independently wearing compression stockings. 1/28/26, R1 had been seen at dining area in her wheelchair. R1 appeared confused and verbalized that she needed to go out as she had no place to stay and kept looking for her wheelchair. 2/2/26, R1 was reviewed for falls. R1 had been found alongside her bed on 1/26/26. R1 had compression socks on but no Gripper socks. Root cause of fall indicated slipping on the floor. Intervention included to encourage and place gripper socks over compression stockings. 2/3/26, R1 fell at 2:35 p.m. R1 stated she was trying to get out of bed and fell. R1 was laying on her left side, right leg was twisted and [NAME] under her left leg. Left arm was pinned under her left side. Large pool of blood around R1's head. R1 stated her leg and head hurt. R1's Bed was in the raised position and fall mat was not in place. R1 was in stocking feet. 2/3/26, R1 returned from the emergency department (ED) at 8:15 p.m. R1 had significant head and right leg pain. Head laceration, bruising to left hand and arm and swelling below right knee. 2/4/26, R1 complained of much pain in right leg. Noted leg to be swollen and firm to touch from knee to foot. When leg was touched R1 complained of pain. When repositioning leg on pillow R1 winced and complained of pain. R1 stated she did not get an x-ray on her legs. Confirmed with ED. R1 was in severe pain and sent back to the ED. 2/4/26, Staff spoke with ED nurse. R1 had scan of head along with x-ray of right leg. R1 was found to have a femur fracture and right tibial fracture. 2/5/26, Staff placed call to hospital to inquire if x-ray of right ankle had been performed. Hospital nurses confirmed x-ray completed with result of malleoli fracture. Also informed R1 was not a candidate for surgery due to her bones. R1 was non-weight bearing. 2/6/26, R1 returned from hospital. Primary diagnosis included right tibial plateau fracture, right femur fracture, acute head injury, laceration to left forehead and urinary tract infection. R1's hospital Discharge summary dated [DATE], indicated she admitted for management of multiple fractures involving the right leg and inability to bear weight. Discharge diagnosis included tibial plateau fracture, femur fracture, bimalleolar fracture and scalp laceration. R1 had been stable and was ready for discharge with hospice services. Terminal diagnosis was severe Alzheimer's dementia, Secondary diagnosis includes femur fracture, tibial plateau fracture and ankle fracture. During observation on 2/9/26 at 12:13 p.m., R1 was lying on bed in her back. R1 had sutures and bruising on the left side of her forehead, bruising surrounding her left eye and extending down below her cheek bone. R1 was covered to her chest with her left arm outside the blanket. R1's left arm had purple bruising extending down to her left hand. When spoken to, R1 did not respond, only stared. During interview on 2/9/26 at 12:47 a.m., nursing assistant (NA)-A stated on 2/3/26, she had been floating between hallways on the unit. NA-A said it had been busy and when she had laid R1 down in bed, she had forgotten to put the bed down and had not placed the fall mat next to the bed. NA-A said the interventions were listed on the care plan and said after R1 fell, she had received education related to following the care plan. NA-A stated R1 always wanted to be in bed after lunch and stated it had been unusual for her to attempt to get up until a few weeks prior to the fall. NA-A said R1 had made a few attempts to get out of bed in the past few weeks. During interview on 2/9/26 at 1:02 p.m., NA-B stated the few weeks preceding R1's fall, she would kind of stare but could tell staff what she wanted. NA-B said R1 was typically content when she was lying down but said a few times she had gone into her room and found her seated on the side of the bed. NA-B said since R1's recent fall, she was on full bed rest and said she had a lot of pain when she was touched or repositioned. During interview on 2/9/26 at 2:15 p.m., registered nurse (RN)-A stated at the time of R1's fall on 2/3/26, care planned fall interventions included bed in lowest position, fall mat in place and gripper socks. During interview on 2/9/26 at 2:02 p.m., the administrator stated she felt the root cause of R1's fall was related to her attempt to self-transfer and felt the injuries were a result of her bone condition and the way R1 had twisted when she fell. The administrator said after the incident she created a policy related to following the plan of care, educated staff to the policy, audited care plans for all residents at risk for falls. The administrator further stated care plan audits had been implemented. The Past Noncompliance began on 2/3/26. The deficient practice was corrected by 2/3/26, after the facility developed a policy related to following the care plan, initiated education related to following the care plan and completed an audit of care plans to ensure accuracy.The education was verified through interview and document review.

Based on interview and document review, the facility failed to have a consent prior to administering a mood stabilizer ( mental health medication used to alter a person's mood) medication. This affect 1 of 5 (R36) residents reviewed for unnessary medications.Findings included, R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated R36 had significant mental impairment. Diagnoses included depression and coronary artery disease. R36's Medication Review Report dated 2/13/25, identified Depakote oral tablet delayed release (anti-seizure medication that is also used as a mood stabilizer in mental health) 125 milligrams two times a day by mouth was ordered. Diagnosis attached to the order was major depressive order, recurrent, severe with psychotic symptoms. R36's medical record lacked documentation consent was given prior to administration of the medication. During an interview on 8/27/25 at 8:23 a.m., licensed practical nurse (LPN)-A stated when a psychotropic medication is ordered the registered nurse would educate the family about the medication and then obtain either a signed or verbal consent to administer the medication prior to the first dose. During an interview on 8/27/25 at 8:43 a.m., the assistant director of nursing (ADON) stated either she or one of the other registered nurses would talk with the resident and/or the patient representative about the new psychotropic medication ordered. Education would be given and then either a verbal or signed consent would be obtained. Nobody at the facility obtained consent to administer the Depakote prior to first dose because the staff thought of the medication as an anti-seizure medication and not also a mood stabilizer. During an interview on 8/27/2025 9:24 a.m. The consultant pharmacist (CP) confirmed Depakote could be used as an anti-seizure medication and a mood stabilizer which would be considered a psychotropic medication when given as a mood stabilizer. When used as a mood stabilizer then there would need to be a consent obtained prior to first dose given. Facility policy Psychotropic Medication Policy, last amended 1/25, indicated informed consent discussion would be held with the resident and/or resident representative when or prior to starting a psychotropic medication or a dose change. The informed consent form would also be completed at that time.

Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were properly labeled and dated. Furthermore, the facility failed to ensure refrigerated food items were disposed of after expiration date. This deficient practice had the potential to harm any resident or visitor using facility refrigerators to store food. Findings include: During observation on [DATE] at 1:47 p.m., north unit fridge was reviewed. In the freezer the following items were found: -small, white, square [NAME] brand cold pack, no name or label attached. -large rectangular blue cold pack, resident label attached. -plastic grocery bag with two bags of frozen vegetables, no label attached. -one open box of frozen fruit bars, no label attached. During observation on [DATE] at 1:53 p.m., west unit fridge was reviewed. In the freezer was a [NAME] brand vegan pizza, expiration date of [DATE]. In the fridge was a clear tupperware container with leftover corn, resident name on post-it note, no date. During observation on [DATE] at 1:58 p.m., second floor unit fridge was reviewed. In the door of the fridge was a small take out box with resident name and no date. During observation on [DATE] at 1:31 p.m., fridge in first floor serving kitchen was reviewed. In the freezer was a box of fried rice without name or date. During interview on [DATE] at 1:22 p.m., certified nursing assistant (CNA)-A stated resident leftovers or food brought in for residents should be tabled with the resident name and the date. CNA-A further stated there was no official process for staff to label food. During interview on [DATE] at 8:14 a.m., licensed practical nurse (LPN)-A stated resident food should be labeled with their name and date. LPN-A further stated they would dispose of old food whenever working. LPN-A stated there was no task to check the fridges. On [DATE] at 2:05 p.m., dietary manager (DM) and executive director (ED) stated expectation for staff to label resident food with initials and date. DM and ED confirmed presence of multiple cold packs in north unit fridge. DM and ED also confirmed plastic grocery bag of frozen vegetables, and box of frozen fruit bars. DM and ED reviewed fridge on west unit and confirmed presence of frozen vegan pizza and expiration date of [DATE]. DM and ED confirmed presence of unlabeled box of frozen fried rice in first floor serving kitchen. ED stated, staff probably brought that in, maybe for a resident, and forgot about it. DM and ED confirmed presence of take out box with resident name and no date in second floor fridge. DM and ED discarded all expired or unlabeled foods. On [DATE] at 2:10 p.m., DM and ED stated there was not a process to ensure food was being check in unit fridges. DM and ED stated it was important to clean out unit fridges to prevent any possible harm to residents and families. DM and ED further stated expectation for staff to check unit fridges for expired food and to discard it if found. Facility policy, Food Brought In By Visitors last amended ,d+[DATE], stated any food not labeled or dated is discarded. Policy did not identify any time limit as to when food should be disposed.

Based on interview and document review the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R4, R13, R17, R23, R25) reviewed for immunizations. Findings include: R4's Admission Record dated 8/23/23, identified R4 was admitted on [DATE], and was [AGE] years old. R4's diagnoses included chronic obstructive pulmonary disease (COPD), and diabetes. R4's Minnesota Immunization Information Connection (MIIC) dated 11/3/21, identified R4 received the pneumococcal polysaccharide vaccine (PPSV23) on 10/20/03. R4's electronic health record (EHR) did not include evidence R4 or R4's representative received education regarding pneumococcal vaccine booster and there was no indication R4 was offered the pneumococcal vaccine per CDC guidance. R13's Admission Record dated 8/23/23, identified R13 was admitted on [DATE], and was [AGE] years old. R13's diagnoses included dementia and chronic kidney disease. R13's undated MIIC identified R13 received the pneumococcal conjugate vaccine (Prevnar 13) on 11/30/16, and pneumococcal polysaccharide vaccine (PPSV23) on 12/30/02. R13's EHR did not include evidence R13 or R13's representative received education regarding pneumococcal vaccine booster and there was no indication R13 was offered the pneumococcal vaccine per CDC guidance. R17's Admission Record dated 8/23/23, identified R17 was admitted on [DATE], and was [AGE] years old. R17 had diagnoses including toxic encephalopathy and chronic obstructive pulmonary disease (COPD). R17's MIIC dated 11/3/21, identified R17 had not received or declined pneumococcal vaccinations. R23's Admission Record dated 8/23/23, identified an admitted [DATE], and was [AGE] years old. R23 had diagnoses that included dementia, heart failure, and acute kidney failure. R23's MIIC dated 4/19/23, identified R23 received the pneumococcal polysaccharide vaccine (PPSV23) on 2/1/208, and pneumococcal conjugate vaccine (Prevnar 13) on 1/20/15. R23's EHR did not include evidence R23 or R23's representative received education regarding pneumococcal vaccine booster and there was no indication R23 was offered the pneumococcal vaccine per CDC guidance. R25's Admission Record dated 8/23/23, identified an admitted [DATE], and was [AGE] years old. R25 had diagnoses that included atherosclerotic heart disease, and cerebral infarct (stroke). R25's MIIC dated 11/2/22, identified R25 received the pneumococcal polysaccharide vaccine (PPSV23) on 5/15/12, and pneumococcal conjugate vaccine (Prevnar 13) on 10/7/15. R25's EHR did not include evidence R25 or R25's representative received education regarding pneumococcal vaccine booster and there was no indication R25 was offered the pneumococcal vaccine per CDC guidance. During interview on 8/23/23 at 11:36 a.m., registered nurse (RN)-B stated she was aware of the new guidance for pneumococcal vaccinations. RN-B stated thought about how the facility was going to proceed with the vaccinations although had not started implementing a plan yet. The facility Vaccination of Residents policy revised 10/19, identified all residents were to be offered vaccines unless the vaccine was contraindicated or the resident had already been vaccinated. Prior to vaccination, the resident or legal representative would be provided information and education regarding the benefits and potential side effects of the vaccination. The staff would enter a note in the residents EHR indicating the education provided, administration information or declination. The facility Pneumococcal Vaccine policy revised 3/22 identified all residents were to be offered the pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infections and were administered in accordance with current CDC recommendations at the time of the vaccination.

Based on observation, interview and document review, the facility failed to properly disinfect a glucometer (a device to check blood sugar) after resident use for 1 of 1 residents (R24) observed having blood sugar checked. This had the potential to affect 3 residents (R24, R15, R21) on the unit who required blood sugar checks and shared the same glucometer. Findings included: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of diabetes mellitus (DM) (a condition where the body cannot regulate its own blood sugar effectively). R24 did not have any identified blood born illnesses. R24's provider order dated 2/5/23, identified blood sugar checks four times a day for DM. R15's quarterly MDS dated [DATE], identified a diagnosis of DM. R15 did not have any identified blood born illnesses. R15's provider order dated 10/12/22, identified blood sugar checks two times a day for DM. R21's quarterly MDS dated [DATE], identified a diagnosis of DM. R21 did not have any identified blood born illnesses. R21's provider order dated 10/12/22, identified blood sugar checks four times a day for DM. On 8/22/23 at 4:37 p.m., trained medication assistant (TMA)-A reviewed orders for blood sugar check and retrieved the community glucometer from the medication cart. TMA-A stated the glucometer was disinfected after every use with Sani-Cloth Germicidal Disposable Wipe (purple top Sani-wipes). TMA-A gathered the supplies needed and washed her hands. TMA-A went to R24's room and blood sugar check was completed. TMA-A returned to the med cart and went to disinfect the glucometer. TMA-A opened the bottom drawer of the medication cart and opened the purple top Sani-wipe container, and it was empty. TMA-A would have to replace it but did not have time to do it now. TMA-A then proceeded to take alcohol pads and wiped down the glucometer and placed it in a paper towel and back into the medication cart. TMA-A stated I think it was ok to use alcohol pads to disinfect the glucometer if she did not have any purple top Sani-wipes available. During an interview on 8/23/23 at 1:15 p.m., the assistant director of nursing (ADON) stated glucometers were to be disinfected between every resident with purple top Sani wipes. They are supposed to use the wipes and then wrap it to ensure it remains wet for three minutes. Alcohol wipes would not be sufficient. During an interview on 8/23/23 at 2:50 p.m., the director of nursing (DON) stated staff were expected to use the purple top Sani wipes to clean the glucometer between each use. The DON thought the glucometers could be cleaned with alcohol wipes; it may damage the glucometer. She would expect the facility policy to be followed. The undated page of the manufacturer's instructions on for TRUEresult glucometer identified the glucometer was to be cleaned by Occupation Safety and Health Administration (OSHA) approved disinfectant. Do not use alcohol to clean meter. Cleaning the meter with alcohol will cause damage. The facility's Blood Sampling-Capillary (Finger Sticks) policy dated [DATE], identified to use approved Environmental Protection Agency (EPA) registered disinfectants for cleaning of glucometer. Follow the manufacturer's instructions for cleaning and disinfection of reusable equipment. The undated manufacturer's guidelines for use for purple top Sani-wipe identified you were to unfold a clean wipe and thoroughly wet surface of area or item to be cleaned and allow area or item to remain wet for 2 minutes. Let air dry. The Centers for Disease Control (CDC) Guidelines for Disinfection and Sterilization in Healthcare Facilities dated 2008 identified In the healthcare setting, alcohol refers to two water-soluble chemical compounds-ethyl alcohol and isopropyl alcohol-that have generally underrated germicidal characteristics 482. Food and Drug Administration (FDA) has not cleared any liquid chemical sterilant or high-level disinfectant with alcohol as the main active ingredient.

Based on observation, interview and document review, the facility failed to ensure proper wound care practices were completed to promote healing and prevent infection for 1 of 1 residents (R32) reviewed for non pressure related skin concern. Findings include: R32's significant change Minimum Data Set (MDS) dated [DATE], identified R32 had a moderate cognitive impairment and had a surgical wound. Diagnoses included Alzheimer's disease and dementia. R32's care plan revised 8/3/23, identified R32 had a potential/actual impairment to skin integrity related to breast cancer, left mastectomy and an abdominal hysterectomy that dehisced (burst or gape open) with open wound. Interventions included: - Observe for signs / symptoms infection and report to physician. - Weekly treatment documentation to include measurement of each area of skin breakdown. - Wound / Skin treatments as ordered. R32's Order Summary Report dated 6/26/23, identified the following: - Abdominal binder at all times. - Dry packing 1 inch deep hole on top of incision. Be sure to push 4x4 gauze in there, then ABD pad and abdominal binder over top. Lightly pack all of open incision twice a day. It would be good to unpack wound then shower. Okay to have soap and water run over open incision. On 8/23/23 10:13 a.m., registered nurse (RN)-A was observed to assist R32 to lie down in bed to complete R32's dressing change. RN-A gathered dressing supplies from R32's cupboard and placed them unopened onto R32's overbed table. RN-A removed the abdominal binder and ABD pad covering R32's wound to expose iodoform gauze (a narrow strip of sterile gauze used to pack wounds to prevent closure on the outside when drainage from the inside is needed). While looking at the gauze, RN-A stated they must have changed orders on me. RN-A turned on R32's call light. RN-A removed the soiled iodoform gauze and stated the wound had no foul smell, no tunneling that she could determine and that the wound was measured the day prior. The wound was a large, gaping wound that started at approximately R32's naval and traveled to approximately 2 inches above R32's pubic area. The wound was approximately 3.5 inches long, 2 inches wide and 1 inches deep. The area was beefy red in color, smooth texture with no bloody drainage. RN-A removed her gloves, used hand sanitizer and stepped to door where she asked a staff person to have a nurse look at R32's wound dressing order. RN-A stated she did review the order prior to starting the dressing change, but not in it's entirety. - At 10:28 a.m., RN-A covered R32 up to the bottom of R32's wound for privacy and stepped out of R32's room. However, RN-A left R32's wound exposed. R32 began scratching her skin and wound until the wound began to bleed. R32 then attempted to pick up the unopened dressing packages on the overbed table but could not reach. - At 10:31 a.m., RN-A returned to the room telling R32 good job. RN-A stated R32's order was for dry packing and did not change. RN-A completed R32's wound dressing as ordered. Upon interview, RN-A stated she should not have left R32 unattended. RN-A should have covered R32's wound so she could not touch it. During an interview on 8/23/23 at 1:50 p.m., the assistant director of nursing (ADON) stated RN-A should have covered R32's wound prior to leaving her bedside because R32's scratching could lead to infection. During an interview on 8/23/23 at 2:13 p.m., the director of nursing stated staff were expected to review wound dressing orders prior to begining a dressing change. Staff were expected to not leave wounds exposed in order to promote healing and prevent infection. The facility policy Dressings, Dry/Clean revised September 2013, identified the purpose of the procedure was to provide guidelines for the application of dry, clean dressings. Staff were directed to the following: - Verify that there was a physician's order for the procedure. - Review the resident's care plan, current orders, and diagnoses to determine if there were special resident needs. - Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening (unless product is single use). Wipe nozzles of wound with alcohol pledget or facility disinfectant wipe. - Explain procedure to the resident and provide privacy.

Based on observation, interview and document review, the facility failed to ensure eating assistance was provided for 1 of 1 residents (R13) observed to struggle during meals. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had a severe cognitive impairment and required assistance with eating. Diagosis included dementia. R13's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) summary dated 12/15/22, identified, during R13's look back period, R13 required up to supervision with eating. R13 needed extensive to dependent assistance with most of her activities of daily living (ADLs). R13's care plan revised 4/16/23, identified R13 had an ADL self-care performance deficit. R13 required up to extensive assistance by (1) staff to eat. R13 left 25% or more of food uneaten at most meals and needed staff assistance and cueing for oral intake. Interventions included: R13 needed a calm, quiet setting at meal times with adequate eating time. R13 preferred to sit (1st North dining room). Encourage R13's socialization and interaction with table mates during meals. Provide and serve diet as ordered. Regular diet, please assist R13 as needed with small bites and sips and cue R13 to continue eating. During a continuous observation on 8/21/23 at 5:42 p.m., R13 was sitting in the dining room at a table with R85 and R27. - At 5:46 p.m., R13 was served her meal of buttered bread, meatballs, mashed potatoes with gravy and steamed vegetables. Nursing assistant (NA)-A told R13 she would be back to help R13 and R13 picked up her buttered bread taking a bite. - At 5:49 p.m., R13 continued to not have assistance and picked up a meatball with her fingers and ate it. - At 5:53 p.m., R13 continued to eat her buttered bread without staff assistance. - At 5:55 p.m., R13 finished her bread and began eating all her meatballs with her fingers. Staff have not offered assistance nor given encouragement to use her utensils. - At 5:58 p.m., R13 finished her meatballs. R13 picked up a few vegetables with her fingers and attempted to eat them, but they fell on to her apron before reaching her mouth. - At 5:59 p.m., staff had continued to not offered assistance to R13 or given cues to use utensils. R13's tablemate encouraged R13 to use her utensils. - At 6:00 p.m., NA-A passed out ice cream dixie cups around the room, including R13. R13 grasped her dixie cup and attempted to open it herself; however, R13's face showed confusion and turned the dixie cup different ways in an attempt to open. Staff did not offer to help R13 and another resident at the table asked R13 if she could open the dixie cup for R13. The other resident opened the dixie cup for R13 and pointed to R13's spoon and stated use this. R13 did not pick up her spoon and began scooping out ice cream with her right index finger. Staff assistance was not provided. - At 6:03 p.m. R13 continued to eat her ice cream with her fingers, licking her fingers and hand after each bite. R13 did not attempt to use her spoon and staff have not offered assistance to R13. R13's tablemates finished their meals, but continue to sit with R133 with concern on their faces. - At 6:06 p.m., R13 continued to eat her ice cream with her fingers. One of the tablemates laughed and shook her head at R13. One of the tablemates stood up and used R13's spoon to scoop a large bite of ice cream and placed the spoon in R13's right hand. R13 proceeded to put the bite of ice cream in her mouth, picked up her napkin and wiped her mouth, then licked fingers. Once the ice cream was gone from her spoon, R13 looked at her spoon blankly then placed the spoon on table. R13 proceeded to eat her ice cream with her fingers. Staff did not provide any assistance or cues to R13. R13 had melted ice cream running down her right hand, arm and onto her clothing protector. - At 6:08 p.m., NA-A approached R13 and stated you ate all your meatballs. Then asked R13 is she liked her ice cream. NA-A did not offer to assist R13. - At 6:10 p.m., R13 continued to eat ice cream with her fingers. NA-A giggled and stated maybe you want to use your spoon. It would help you eat your ice faster. NA-A did not place the spoon in R13's hand, show the spoon to R13 nor offered to assist R13. - At 6:17 p.m., R13 was holding her dixie cup upside down. R13 continued to lick her fingers and her right hand with ice cream running down her hand, arm and onto her clothing protector. - At 6:18 p.m., NA-A approached R13 and removed R13's plate, then took R13's dixie cup from R13's hand. NA-A wiped R13's hands with her clothing protector. NA-A did not offer to re-heat the rest of R13's meal nor offered assistance to R13. During an interview on 8/22/23 at 4:35 p.m., NA-A stated sometimes R13 did really well with eating and she could eat on her own. Sometimes, R13 was just out of it and needed help. The previous evening, R13 did really well. She had finger food and was able to eat on her own. R13 had meatballs and ice cream. NA-A stated she did not offer the spoon because she had done that before but R13 just looked at it like it was a foreign object. That's why R13 did better with finger foods. However, NA-A stated mashed potatoes, steam vegetables nor ice cream were finger foods. NA-A should have been assisted with her meal. During an interview on 8/23/23 at 12:15 p.m., registered nurse (RN)-A stated R13 did really well with meals. R13 used her utensils, did not need reminders, and R13 was able to drink all of her drinks. Staff should always assist a resident who was struggling with a meal. Also other resident should never be allowed to assist another resident due to safety concerns. R13 should have been assisted with her meal. During an interview on 8/23/23 at 1:52 p.m., assistant director of nursing (ADON) stated R13's ability varied by the day. Some days, R13 needed no assistance and other days R13 just did not eat. Staff were expected to monitor/watch R13 and to help her eat when she was struggling. Staff were expected to intervene when a resident attempted to assist another resident with eating. During an interview on 8/23/23 at 2:07 p.m., the director of nursing (DON) stated, for the most part, R13 ate on her own but did prefer finger foods. The DON updated R13's care plan that morning on 8/23/23, to inlcude finger foods because of that. Other residents were never expected to assist R13 because that was staff responsibility. The facility policy Assistance with Meals revised March 2022, identified residents shall receive assistance wtih meals in a manner that met the individual needs of each resident.

Based on interview and document review the facility failed to ensure the accuracy of a significant change Minimum Data Set (MDS). Findings included: R25's significant change MDS dated [DATE], identified severe cognitive impairment. Diagnoses included palliative care and medically complex condition. It did not identify resident was receiving hospice services in section O. R25's provider's order dated 5/30/23, identified R25 was to be admitted to hospice care. R25's progress note dated 5/30/23, identified R5 was admitted to hospice services. During an interview on 8/23/23 at 1:50 p.m., the director of nursing (DON) stated the reason the significant change MDS dated [DATE], was done was due to R25 being admitted to hospice care. The significant change MDS was reviewed by her, and care plans were updated. The area to mark for hospice was not marked and should have been. It was missed during review and was not accurate. The facility's Comprehensive Assessment policy dated March 2022, did not address ensuring accuracy of comprehensive assessments used to complete a significant change MDS.

Based on observation, interview and document review, the facility failed to ensure a dignified dining experience for 1 of 1 (R13) residents observed to struggle during meals. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had a severe cognitive impairment and had diagnoses that included dementia. R32 required assistance with eating. R13's care plan revised 4/16/23, identified interventions of : R13 needed a calm, quiet setting at meal times with adequate eating time. R13 preferred to sit (1st North dining room). Encourage R13's socialization and interaction with table mates during meals. Provide and serve diet as ordered. Regular diet, please assist R13 as needed with small bites and sips and cue R13 to continue eating. During a continuous observation on 8/21/23 at 5:42 p.m., R13 was sitting in the dining room at a table with R85 and R27. - At 5:46 p.m., R13 was served her meal of buttered bread, meatballs, mashed potatoes with gravy and steamed vegetables. Nursing assistant (NA)-A told R13 she would be back to help R13 and R13 picked up her buttered bread taking a bite. - At 5:49 p.m., R13 continued to not have assistance and picked up a meatball with her fingers and ate it. - At 5:53 p.m., R13 continued to eat her buttered bread without staff assistance. - At 5:55 p.m., R13 finished her bread and began eating all her meatballs with her fingers. Staff have not offered assistance nor given encouragement to use her utensils. - At 5:58 p.m., R13 finished her meatballs. R13 picked up a few vegetables with her fingers and attempted to eat them, but they fell on to her apron before reaching her mouth. - At 5:59 p.m., staff had continued to not offered assistance to R13 or given cues to use utensils. R13's tablemate encouraged R13 to use her utensils. - At 6:00 p.m., NA-A passed out ice cream dixie cups around the room, including R13. R13 grasped her dixie cup and attempted to open it herself; however, R13's face showed confusion and turned the dixie cup different ways in an attempt to open. Staff did not offer to help R13 and another resident at the table asked R13 if she could open the dixie cup for R13. The other resident opened the dixie cup for R13 and pointed to R13's spoon and stated use this. R13 did not pick up her spoon and began scooping out ice cream with her right index finger. Staff assistance was not provided. - At 6:03 p.m. R13 continued to eat her ice cream with her fingers, licking her fingers and hand after each bite. R13 did not attempt to use her spoon and staff have not offered assistance to R13. R13's tablemates finished their meals, but continue to sit with R133 with concern on their faces. - At 6:06 p.m., R13 continued to eat her ice cream with her fingers. One of the tablemates laughed and shook her head at R13. One of the tablemates stood up and used R13's spoon to scoop a large bite of ice cream and placed the spoon in R13's right hand. R13 proceeded to put the bite of ice cream in her mouth, picked up her napkin and wiped her mouth, then licked fingers. Once the ice cream was gone from her spoon, R13 looked at her spoon blankly then placed the spoon on table. R13 proceeded to eat her ice cream with her fingers. Staff did not provide any assistance or cues to R13. R13 had melted ice cream running down her right hand, arm and onto her clothing protector. - At 6:08 p.m., NA-A approached R13 and stated you ate all your meatballs. Then asked R13 is she liked her ice cream. NA-A did not offer to assist R13. - At 6:10 p.m., R13 continued to eat ice cream with her fingers. NA-A giggled and stated maybe you want to use your spoon. It would help you eat your ice faster. NA-A did not place the spoon in R13's hand, show the spoon to R13 nor offered to assist R13. - At 6:17 p.m., R13 was holding her dixie cup upside down. R13 continued to lick her fingers and her right hand with ice cream running down her hand, arm and onto her clothing protector. - At 6:18 p.m., NA-A approached R13 and removed R13's plate, then took R13's dixie cup from R13's hand. NA-A wiped R13's hands with her clothing protector. NA-A did not offer to re-heat the rest of R13's meal nor offered assistance to R13. During an interview on 8/22/23 at 4:35 p.m., NA-A stated R13's dining experience was not very dignified and NA-A would not like to eat that way. During an interview on 8/23/23 at 12:15 p.m., registered nurse (RN)-A then stated maybe finger foods would be more appropriate for R13 and RN-A would not want to eat thay way because it was not dignified During an interview on 8/23/23 at 1:52 p.m., assistant director of nursing (ADON) it was not a dignified way to eat and ADON would not want to eat that way. During an interview on 8/23/23 at 2:07 p.m., the director of nursing (DON) stated R13's dinig experience was not dignified. The facility policy Dignity revised February 2021, identified each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on interview and document review the facility failed to ensure routine testing for staff not up-to-date with COVID-19 vaccination requirements were tested according to county transmission rate; failed to conduc outbreak testing as directed by Center for Disease Control (CDC); and failed to track and monitor staff testing to ensure testing was implemented when required. This had the potential to affect all 29 residents that resided in the facility. Findings include: The CDC guidance Interim Infection Prevention and Control (IPC) Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 2/2/22, identified nursing homes must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and health care personnel (HCP) to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. In nursing homes, HCP who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: -In nursing homes located in counties with substantial to high community transmission, these HCP should have a [CONDITION(S)] test twice a week. -If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). Per recommendations above, these facilities should prioritize resources to test symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents or HCP. On 9/12/22 at 2:37 p.m. a joint interview with the director of nursing (DON) and the infection preventionist (IP) nurse was conducted. The IP stated the registered nurses (RN)'s communicated with each other regarding who needed to test, and the IP talked directly to all staff reminding them to test. The IP stated the staff who needed to test knew they needed to test. On 9/13/22, at 8:39 a.m. a subsequent joint interview with the DON and IP was conducted. The DON stated staff not up-to-date tested for COVID-19 twice a week depending on their schedules. Residents and up-to-date staff would test if they became symptomatic or had a high-risk exposure. Further, all residents in the facility were vaccinated. The DON stated the staff vaccination list identified unvaccinated and vaccinated staff. Unvaccinated staff were required to have an approved exemption in place and were required test twice weekly. Vaccinated staff were required to test when symptomatic. All staff and residents were tested if the facility had a high-risk staff exposure or a positive staff member. The DON stated there were two residents and five staff who tested positive for COVID-19 during August 2022 and September 2022. The DON was uncertain if all facility staff were tested during the outbreaks in August and September 2022 - At 1:57 p.m. the IP stated the county in which the facility was located currently had a moderate community transmission rate but fluctuated between low to high over the past couple months. After looking at the rates, it was determined the facility was not monitoring the Community Transmission Rate, but was monitoring the COVID-19 Community Level. The DON stated she thought an outbreak was when three or more staff and/or residents test positive for COVID-19. There were four RN's responsible for tracking staff testing and would document the test results on a spreadsheet as well as communicate via shift-to-shift report regarding who needed to test and when. The IP stated staff not-up-to-date knew when they needed to test. ROUTINE STAFF TESTING: The facility provided undated, untitled vaccination document, listed staff names and the corresponding vaccination status; the facility provided undated and untitled testing form was reviewed along with the facility's staff schedules; and CDC's county transmission rate, which was high since the week 8/8/22, and identified the following: Week of 8/8/22 through 8/14/22, identified the following: Nursing assistant (NA)-P worked on 8/11/22, and did not test. Licensed practical nurse (LPN)-B worked 8/12/22 and 8/14/22, and did not test. Registered nurse (RN)-I worked 8/12/22, and did not test. Week of 8/15/22 through 8/21/22, identified the following: NA-A worked 8/15/22 and 8/16/22 and did not test. NA-V worked 8/15/22 and 8/16/22 and did not test. NA-Q worked 8/17/22, 8/18/22, 8/19/22, 8/22/22, and 8/23/22, and tested on e time during the week. NA-V worked 8/18/22, 8/19/22, 8/20/22, 8/21/22, 8/23/22 and did not test. Trained medical assistant (TMA)-A worked 8/17/22, 8/18/22, 8/20/22, and 8/21/22, and did not test. RN-I worked 8/15/22, 8/16/22, 8/17/22, 8/18/22, 8/19/22, and tested on e time. Week of 8/22/22 through 8/28/22, identified the following: NA-C worked 8/24/22, 8/25/22, and tested on e time. NA-N worked 8/27/22 and 8/28/22 and tested on e time. NA-Q worked 8/24/22, 8/25/22, 8/26/22, and did not test. NA-R worked 8/25/22 and did not test. NA-S worked 8/24/22, 8/25/22, 8/26/22, and did not test. NA-T worked 8/20/22, 8/21/22 and tested on e time. NA-U worked on 8/26/22 and did not test. Week of 8/29/22 through 9/4/22, identified the following: NA-A worked 8/31/22, 9/1/22, 9/3/22, 9/4/22 and tested on e time. NA-M worked 8/31/22, 9/1/22, 9/2/22, 9/4/22, and 9/5/22 and did not test. NA-O worked 8/31/22, 9/3/22, 9/4/22, 9/5/22, 9/6/22 and tested on e time. NA-Q worked 8/29/22, 8/30/22, 8/31/22, 9/1/22, 9/2/22, and did not test. NA-U worked on 9/3/22, 9/4/22, and did not test. NA-V worked 9/3/22 and 9/4/22 and did not test. TMA-A worked 8/31/22, 9/1/22, 9/2/22, 9/3/22, and 9/4/22 and did not test. LPN-B worked 8/31/22 and 9/1/22 and tested on e time. Week of 9/5/22 through 9/11/22, identified the following: NA-A worked 9/7/22, 9/9/22, and did not test. NA-C worked 9/7/22, 9/8/22, 9/9/22, and did not test. NA-M worked 9/9/22, 9/10/22, 9/11/22, and 9/13/22 and did not test. NA-O worked 9/7/22, 9/8/22, 9/9/22, and did not test. NA-Q worked 9/7/22, 9/8/22, 9/9/22, and did not test. NA-S worked 9/7/22, 9/8/22, 9/9/22 and did not test. NA-T worked 9/10/22, 9/11/22, and did not test. TMA-A worked 9/8/22, 9/9/22, 9/10/22, and 9/11/22 and did not test. LPN-B worked 9/8/22, and did not test. During interview on 9/12/22, at 12:56 p.m. NA-I stated staff not up-to-date were supposed to be tested every Tuesday and Thursday. Up-to-date staff could get tested on ce weekly if they so choose. During interview on 9/13/22, at 4:04 p.m. NA-L stated she was working at the facility for one week and was tested today, otherwise was not aware of when she would need to test again. During interview on 9/13/22, at 4:21 p.m. DA-B stated staff not up-to-date tested twice per week and up-to-date staff only tested if they had symptoms. DA-B was tested that morning due to a positive staff member. During interview on 9/13/22, at 4:30 p.m. the dietary manager (DM) stated staff not-up-to-date were required to test twice weekly and up-to-date staff were to test when symptomatic. The DM stated it was her belief the staff were testing when they needed too, nursing tracked the test results, and if she didn't hear from nursing a dietary staff member needed to test she figured there were no concerns that needed to be followed up on. During interview on 9/14/22, at 7:33 a.m. licensed practical nurse (LPN)-B stated she had an itchy throat and just not feeling well. LPN-B was tested when they arrived at work and prior to going to the floor. During joint interview with the DON and IP on 9/14/22, at 10:44 a.m. the DON stated testing was completed on Tuesdays and Thursdays. The testing logs are reviewed on Wednesday's and before the weekend. The on-coming staff would be notified, via shift-to-shift report, of those staff that needed to test. The DON stated she trusted staff were testing and .we don't babysit them. The IP stated it was on the honor system staff tested when they needed to. Further, the DON stated staff come and go at different times and there was a potential that staff would work without being tested . OUTBREAK TESTING: R226's undated Admission Record and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R226's progress note (PN) dated 8/9/22, identified the facility was notified R226 had a high-risk exposure from a family member but did not identify the date of exposure. R226 was moved to a private room and placed on isolation precautions. R226's COVID-19 Testing - V2 identified resident tested negative for COVID-19 on 8/8/22, 8/9/22 and 8/10/22. The report identified R226 tested positive for COVID-19 on 8/12/22. R226's progress notes dated 8/11/22 through 8/24/22, identified resident had complained of productive cough, headache, and congestion. The untitled documents dated 8/12/22, 8/14/22, and 8/25/22 identified the facility tested all residents with no further resident positive cases; however, the facility failed to identify and documented what staff had contact with R226 and if there were any high risk exposures warranting outbreak testing of staff. The facility provided undated, Contact Tracing for COVID 19 August for which listed names of staff, dates of COVID-19 and date of exposure and included the following: Nursing assistant (NA)-J, dates of COVID were identified as 8/10/22 through 8/20/22. Date of exposure was listed as 7/30/22,and was exposed by a family member. The documentation failed to identify when and if NA-J developed symptoms, last time they worked in the facility and if there were any close contacts with residents or any high risk exposures to healthcare personal (HCP) warranting outbreak testing NA-D, dates of COVID were identified as 8/13/22 through 8/17/22. Date of exposure was listed as 8/13/22, but was not sure of the source of exposure. The documentation failed to identify when and if NA-D developed symptoms, last time they worked in the facility and if there were any close contacts with residents or any high risk exposures to HCP warranting outbreak testing Housekeeper (HSK)-A, dates of COVID were identified as 8/22/22, through 8/27/22. Date of exposure was identified as 8/15/22, and HSK-A contracted COVID-19 from their spouse. The documentation failed to identify when and if HSK-A developed symptoms, last time they worked in the facility and if there were any close contacts with residents or any high risk exposures to HCP warranting outbreak testing During joint interview with the DON and IP on 9/14/22, at 8:33 a.m. the IP stated outbreak testing was communicated via the grapevine as well as a sign on the front door and employee door directing all staff to be tested due to a positive result. At 2:35 p.m. the DON stated a person could change quickly from negative to positive and could potentially spread COVID-19 to others and it was important to track timely. During joint interview with the IP and DON on 9/15/22, at 9:07 a.m. the DON stated when there was a positive test result the facility would complete contact tracing with the specific individual (resident/family and/or staff). There was no evidence the facility completed a thorough investigation for contact tracing, to ensure all resident close contacts and any HCP high risk exposures were tested , when R226, NA-J, NA-D and HSK-A turned positive for COVID-19. Further, there was not evidence the facility used a broad base facility approach and tested all residents and staff per the CDC outbreak testing frequency when R226, NA-J, NA-D and HSK-A turned positive for COVID-19. During interview on 9/15/22, at 11:57 a.m. the DON stated outbreak testing occurred after a positive result, and all staff and residents were tested daily for seven days. Outbreak testing was removed after the positive individual had two consecutive negative tests and no additional positive results in the facility with in the seven day testing period. If another positive test resulted in the same timeframe the outbreak testing process would start over. During the month of August 2022, the facility staff either didn't understand the testing requirements for outbreak testing or they didn't complete the testing. The Center for Clinical Standards and Quality/Survey and Certification Group- QSO-20-38 revised 3/10/22, identfied the following: - Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. (refers to residents and visitors) - Higher-risk exposure refers to exposure of an individual ' s eyes, nose, or mouth to material potentially containing [CONDITION(S)]-CoV-2, particularly if present in the room for an aerosol-generating procedure. This can occur when staff do not wear adequate personal protective equipment during care or interaction with an individual. (refers to HCP) - A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, testingshould begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction ' s public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. The facilities COVID-19: Infection Prevention & Control policy dated 10/11/21, indicated COVID-19 testing was a priority to help inform clinical care and infection prevention and control practices within the facility. All residents and staff would be tested if they develop symptoms and a low threshold for testing would be maintained. The facility testing of residents and staff would be conducted at minimum in accordance with Centers for Medicare & Medicaid Services (CMS) regulatory guidelines. Unvaccinated staff would be routinely tested for COVID-19 at least weekly.

Based on observation, interview and document review, the facility failed to provide supervision while eating 1 of 2 residents (R24) reviewed who were at risk for choking. Findings include: R24's admission Minimum Data Set (MDS) dated [DATE], identified R24 had moderate cognitive impairment and required supervision and limited assistance for eating. R24 had signs and symptoms of possible swallowing disorder of coughing or choking during meals or when swallowing medications and complaints of difficulty or pain with swallowing. Diagnoses included aftercare following surgery on the digestive tract, history of disease of the digestive system, adult failure to thrive, gastroesophageal reflux disease and dysphagia (a condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink). R24's physician telephone order(s) dated 8/22/22, identified an order for regular diet, level 6 (the lump size is no bigger than 1.5 centimeter (cm) x 1.5 cm, which is about the width of a standard dinner fork and soft enough, the food is completely squashed and does not regain its shape when pressed with a fork) soft and bite sized texture and level 0-thin liquids consistency. R24's care plan revised 8/29/22, identified R24 was independent with eating. R24 had a swallowing problem and would cough or choke during meals or when swallowing medications. Interventions included the following: alternate small bites of food with liquids and to use a teaspoon for eating; follow the International Dysphagia Diet Standardization Initiative (IDDSI) diet with minced and moist meats that had a sauce or gravy; instruct R24 to eat in an upright position, to eat slowly, and to chew each bite thoroughly; monitor/document and report any symptoms of dysphagia; R24 may refuse her diet orders and make her own meal choices; and speech therapy was to treat as needed and the registered dietician was to evaluate and make diet change recommendations as needed. The care plan did not identify the staff should supervise R24 while eating, even though she was at risk for coughing and choking. During observation on 9/13/22, at 9:19 a.m. R24 was seated in a wheelchair in her room, facing the door. The privacy curtain was closed between the open door and R24 was not visible from the hall. An unidentified nursing assistant (NA) entered her room with R24's breakfast tray, consisting of hot cereal, a small glass of milk and a small glass of juice. The NA took R24's blood pressure and uncovered her food and drink items on the tray and exited the room. R24's curtain remained closed and R24 was not visible outside of her room. R24 remained alone in her room eating her breakfast. R24 did not cough or choke while consuming the meal. R24 consumed half of her cereal and glass of milk. On 9/13/22, at 6:00 p.m. NA-C was observed to deliver a supper tray to R24. R24 was seated in her wheelchair with the bedside table in front of her. The privacy curtain was drawn closed in front of her, and she was not visible from the hallway. R24 did not cough or choke while consuming the meal. When interviewed on 9/13/22, at 7:10 p.m. NA-B stated he was not aware R24 was at risk for choking. NA-B was told R24 needed to sit up in the wheelchair to eat or have the head of the bed raised to 45-degree angle if R24 wanted to remain in bed. Resident diets were not listed on the aide care sheets. When interviewed on 9/13/22, at 7:15 p.m. NA-C stated they were never told to check on R24 when eating alone in her room or needed frequent monitoring due to a risk for choking. If a resident had a special need like supervison the nurses would tell the aides or it would be on their care plans. During interview on 9/14/22, at 8:32 a.m. NA-E stated R24 was supposed to have a mechanical soft diet but frequently refused. They would ask her if she wanted ground or regular and she usually chose regular meat. She needed to have her head elevated at 45 degrees or up in her wheelchair to eat. R24 usually came out to the dining room for breakfast, otherwise they positioned her so she was facing the room door when she ate and staff would peek in at her or go in and check on her frequently as she ate her meal. During interview on 9/14/22, at 1:25 p.m. the director of nursing (DON) stated she completed a task sheet for the NA's that indicated R24 should be supervised for meals and liquids because the facility knew she had swallowing issues. The nursing staff should know based on communication R24 needed supervision with meals. Maybe the task sheet was not clear enough to direct staff to provide the needed supervision when R24 ate. The need for supervision with eating should have been care planned for R24 and it was not.

Based on observation, interview and document review, the facility failed to ensure insulin from a KwikPen (single dosing system which uses a new needle attached each time) was administered in accordance with manufacturer directions to ensure proper dosing for 1 of 1 resident (R10) observed to receive insulin during the survey. Findings include: R10's significant change Minimum Data Set (MDS) dated [DATE], identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's provider order dated 9/5/22, identified [MEDICATION(S)] KwikPen Solution pen-injector 100 units/milliliter (long-acting insulin) was to be used to inject 26 units of insulin in the morning and inject 50 units of insulin at bedtime for diabetes mellitus. R10's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's blood sugars ranged from 66-581. During observation on 9/14/22, at 9:32 a.m. licensed practical nurse (LPN)-B prepared medications for R10 on the medication cart and stated R10 was scheduled her morning dose of [MEDICATION(S)] KwikPen. LPN removed the KwikPen from the medication cart, removed the cap, cleaned the end with an alcohol wipe. LPN-B attached the needled to the KwikPen, reviewed the required dose of 26 units of insulin from the medical administration records (MAR), checked the expiration date, dialed up 26 units of insulin and went to R10's room. LPN-B did not prime the needle with insulin to ensure R10 was receiving the correct dose. LPN then injected the insulin into the right lower abdomen of R10. During an interview on 9/14/22, at 9:43 a.m. LPN-B stated she did not prime the needle on the KwikPen because she was never instructed to prime the needle prior to giving insulin from a pen. LPN-B stated the only education received on the use of insulin pens was to open cap, clean top, place needle, and dial up dose. LPN-B stated she never knew she had to prime the needle on an insulin pen. On 9/14/22, at 1:22 p.m. a call was placed to the consulting pharmacist. There was no answer, and a message was left to return call. During an interview on 9/14/22, at 1:40 p.m. the director of nursing (DON) stated staff were trained when hired on how to administer medication and included how to administer insulin using a pen injector. Once the needle was placed on the pen, the needle would need to be primed with two units of insulin to ensure to get all the air out of the needle and in case there was an air bubble in the insulin pen. When the needle was not primed the resident would be receiving the incorrect dose of insulin, which could affect the health of the resident. The manufacturer's instructions for the [MEDICATION(S)] KwikPen identified once the needle was placed on the pen it was to be primed with two units of insulin to ensure the pen would work correctly. If you do not prime before each injection, you may give too much or too little insulin. The facility's Insulin Administration Policy dated September 2014, identified the nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to use. The facility's policy did not address the use of insulin pen injectors.

Based on observation, interview, and document review, the facility failed to ensure expired medications were not available for use in 2 of 2 medication rooms reviewed for medication storage. This had the potential to affect 2 of 2 residents (R86, R87) newly admitted to the facility. Findings include: On 4/28/21, at 2:46 p.m. the first floor medication room was reviewed for medication storage and labeling with registered nurse (RN)-A and licensed practical nurse (LPN)-A. The medication refrigerator contained an opened vial of [MEDICATION(S)] (tuberculin purified protein derivative (used for [CONDITION(S)] skin testing)). A sticker was affixed to the vial with a handwritten date of 3/23/21. RN-A stated the vial should have been discarded after 30 days. She also stated a resident had been admitted the previous day who had received a TB [[CONDITION(S)]] test and was not sure if the resident had received the expired medication. R86's Admission Record identified R86 was admitted to the facility on [DATE]. R86's Medication Administration Record (MAR) dated 4/1/2021-4/30/2021, included an order for [MEDICATION(S)] inject 0.1 milliliter (ml) intradermally every evening shift for new admit until 4/27/21. The MAR identified the order was administered on 4/27/21. On 4/28/21 at 3:06 p.m. the second floor medication room was reviewed for medication storage and labeling with trained medication assistant (TMA)-A. The medication refrigerator contained an opened vial of [MEDICATION(S)]. A sticker was affixed to the vial with a handwritten date of 3/17/21. TMA-A stated she was not aware of the expiration date of [MEDICATION(S)] once opened and indicated the RN would know. During interview on 4/28/21, at 3:30 p.m. RN-B stated [MEDICATION(S)] should be discarded 30 days after opening. She had administered a dose of the medication to a new admission the previous evening, but indicated she had used medication from the first floor medication refrigerator as that medication was fresher. When asked if she had opened a new vial, RN-B stated she had administered the medication from a previously opened vial. R87's Admission Record identified R87 was admitted to the facility on [DATE]. R87's MAR dated 4/1/2021-4/30/2021, included an order for [MEDICATION(S)] inject 0.1 ml intradermally every evening shift for new admit until 4/27/21. The MAR identified the order was administered on 4/27/21. During interview on 4/28/21, at 3:50 p.m. the director of nursing stated [MEDICATION(S)] should be dated when opened and discarded after 30 days. She stated they could not confirm the newly admitted residents had not received expired medication. She also stated they recognized their audit for expired medications had not included the medication refrigerators but would from now on. The Vials and Ampules of Injectable Medications policy revised April 2014 directed medication in multidose vials should not be used beyond 28 days after initially entering or opening (e.g. needle punctured) unless specified otherwise by the manufacturer. The Sanofi Pasteur manufacturer's storage recommendations for [MEDICATION(S)] directed a vial of [MEDICATION(S)] which had been entered and in use for 30 days should be discarded.

Based on observation, interview and document review the facility failed to ensure medication labels reflected the correct physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential to affect 2 of 2 residents (R86, R87) newly admitted to the facility. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's Order Summary Report Dated 4/20/21, included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if BS [blood sugar] below 100. The order start date was 4/19/21. During observation of medication pass on 4/27/21, at 5:23 p.m. registered nurse (RN)-B removed an insulin pen from the medication cart for R27, checked the computer for the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order identified on the label was for insulin [MEDICATION(S)] [MEDICATION(S)], inject 15 units subcutaneously three times daily with meals. RN-B stated they usually had the pharmacy update the label as soon as possible after an order was changed. During observation of medication storage and labeling of the 2 North medication cart on 4/28/21, at 3:20 p.m. R27's insulin pen remained labeled with the incorrect dosage instructions. During review of medication storage and labeling of the first floor medication room with RN-A and licensed practical nurse (LPN)-A, the medication refrigerator contained two boxes of [MEDICATION(S)]. Inside one of the boxes was an opened, undated, partially used vial. RN-A stated the vial had been dispensed from the pharmacy on 3/18/21, but since it had not been dated when it had been opened she could not tell how old the medication was and it should be discarded. During interview on 4/28/21, at 3:50 p.m. the director of nursing stated when a medication order was changed, they had a sticker to place on the medication label which directed staff to view the eMAR (electronic medication administration record) until the label could be updated by the pharmacy which she expected to be done as soon as possible. If the sticker was not on the label increased the risk the wrong dose could be given if the staff member was not following their five rights (the right patient, the right drug, the right dose, the right route, and the right time). The DON also stated when [MEDICATION(S)] was opened it should be dated. The Storage of Medications Policy dated 4/07, directed Drug containers that have missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. The policy did not address the dating of opened medications.

Based on observation, interview, and document review, the facility failed to provide a private room to quarantined residents who were being monitored for signs and symptoms of COVID-19 to prevent or minimize the risk of potential spread of COVID-19 for 3 of 4 residents (R1, R2, R3) who were newly admitted to the facility from the hospital, and 1 of 4 residents (R4) who had a previous potential exposure to COVID-19. This had the potential to affect all residents residing in the facility. Findings include: On 10/14/20, at 8:50 a.m. the director of nursing (DON) identified the facility currently did not have any residents positive for COVID-19 in the facility. However, the DON stated one resident had been tested on [DATE], and the facility had been notified of a positive test result on 10/1/20, and that resident had been subsequently transferred to the hospital on [DATE]. Additionally, the DON stated the facility had two employees test positive for COVID-19. The DON stated the facility currently had four residents who required transmission-based precautions: two residents (R4 and R5) due to close contact with the COVID-19 positive resident while smoking, and two residents (R1 and R2) newly admitted from the hospital on modified isolation precautions due to fourteen day quarantine. Review of the Resident Census provided upon entrance revealed R1 and R2 were cohorted in the same room, and R3 and R4 were also cohorted in the same room, all on the 1 West unit. The Resident Census also indicated R5 resided in a private room. -At 9:52 a.m. a three-drawer cart containing personal protective equipment (PPE) was positioned outside of a double room on the 1 West unit assigned to R1 and R2. Another three-drawer cart containing personal protective equipment (PPE) was positioned outside another double room on the 1 West unit which was assigned to R3 and R4. Additionally, a tray table containing gowns was positioned on the opposite side of R3 and R4's room door. Signage on each room door directed staff the residents were on droplet precautions, and the use of gloves, eye protection, masks and gowns were required. Nursing assistant (NA)-A, wearing a mask and eye protection, obtained gloves from the three-drawer cart outside R3 and R4's room and entered the room. -At 9:53 a.m. NA-A exited R3 and R4's room and applied hand sanitizer. NA-A then walked across the common area and obtained a mechanical lift from the room across the hall, returned to R3 and R4's room, donned a gown and gloves, entered the room with the mechanical lift and shut the door. -At 10:11 a.m. NA-A exited the room no longer wearing the gown, applied hand sanitizer, and brought the mechanical lift to the nurse's station. NA-A obtained a wipe and cleaned the surfaces of the lift, and then washed and dried her hands at the nurse's station sink. On 10/14/20, at 2:03 p.m. NA-A verified the carts stationed by the rooms were for residents who required isolation precautions. NA-A stated these residents did not come out of their rooms until isolation was up after 14 days. NA-A stated if the residents in isolation required direct care, staff were required to wear gloves, gown, masks and eye protection, however, only masks and eye protection were required for non-direct care tasks. On 10/14/20, at 2:31 p.m. licensed practical nurse (LPN)-A verified R1 was newly admitted to the facility and both she and her roommate, R2 had been admitted from the hospital. LPN-A stated R1 remained on isolation precautions, while R2 had met the 14 day requirement and no longer required isolation precautions. LPN-A also verified roommates R3 and R4 were both in isolation, and stated R3 was newly admitted , and R4 had been exposed to a resident who tested positive for COVID-19. On 10/14/20, at 3:07 p.m. licensed social worker (LSW)-A stated resident room assignments were discussed as a team in their daily stand up meeting. LSW-A verified R1 and R2 had both been admitted from the hospital, and were placed in a room together. LSW-A also verified R3 and R4 shared a room, and stated R4 had potentially been exposed to COVID-19 and R3 was a new admission from the hospital. LSW-A stated when COVID-19 first started, the facility still had their transitional care unit (TCU) open. LSW-A stated they started with everyone in their own room, then as they shut down the TCU, they designated certain rooms for quarantine. On 10/14/20, at 3:14 p.m. during a follow-up interview, the DON verified the facility staff worked as a team to determine new admission room assignments. The DON stated the ideal situation was to have a private room for new admissions or quarantined residents when possible, however, stated they were not able to accommodate private rooms for R1, R2, R3, and R4 as there were no other rooms available. The DON stated their TCU was shut down. The DON stated if they couldn't give a newly admitted resident a private room, they would consider the resident's admission day and look to cohort residents together who were admitted at the same time. The DON stated for R1 and R2, one resident did not use the bathroom, so they were able to isolate her to one side of the room. The DON stated R3's last day of isolation was that day and R4's was the following day. The DON stated R4 had smoked outside with a resident who had tested positive for COVID-19 and they could not confirm they had stayed six feet apart. The DON stated because they could not rule out R4's exposure, they took the safe route and placed him in isolation. The DON stated the TCU was shut down due to low census and staffing, stated they wanted to consolidate residents to the same area for staffing purposes, and did not have enough resources to staff the TCU. On 10/15/20, at 11:17 a.m. the DON stated the facility utilized the State Agency (SA) guidance for cohorting residents. The DON verified they had rooms physically available to provide private rooms for quarantine for R1, R2, R3, and R4, however, had closed down the TCU so she hadn't considered those rooms available. The DON acknowledged quarantined residents cohorted together were at risk for potential spread of COVID-19. The MDH COVID-19 Toolkit dated 6/5/20, directed facilities to isolate and restrict incoming residents discharged from hospitals, or other facilities, to their room for 14 days. The toolkit also directed plans to cohort, or group, residents should be carefully established in advance, before testing results are received, and they should be centered on implementation of robust IPC (infection prevention and control) practices. The toolkit further provided additional information from MDH: Interim Guidance for Hospital Discharge to Home or Admission to Congregate Living Settings and Discontinuing Transmission-Based Precautions dated 5/2/20. The guidance directed patients investigated for possible COVID-19 with a negative test or patients with no clinical concern (e.g., no presence of symptoms consistent with COVID-19), could be discharged from a hospital to a congregate living setting. In both instances, the resident should be placed in a single-person room with private bathroom or in a separate admission/re-admission observation area, for monitoring of signs and symptoms of COVID-19. Residents could be transferred out of the observation area to the main facility if they remained afebrile and without symptoms for 14 days after admission.

Based on observation, interview and document review, the facility failed to notify the physician of a decline in status for 1 of 1 resident (R39) who had identified increased shortness of breath, lethargy, drowsiness, was refusing to eat/drink, and had not voided. The facility's failure to contact the physician resulted in actual harm for R39 who required hospitalization for significant dehydration, aspiration pneumonia and acute kidney injury. In addition, the facility failed to notify the physician regarding significant weight gain for 1 of 1 resident (R47) who received diuretics and had experienced rapid weight gain. Findings include: R39's MD/Nursing Communications form dated [DATE], indicated R39's [DIAGNOSES REDACTED]. R39's 14 day Minimum Data Set ((MDS) dated [DATE], indicated R39 had intact cognition, received scheduled and as needed (PRN) pain medication on a daily basis for pain rated at a 5 (on a scale of ,[DATE]), life expectancy was greater than six months, and R39 also received antidepressant, anticoagulant (blood thinner) and diuretic (fluid reducing) medication daily. The MDS also indicated R39 required extensive assistance with most activities of daily living, was always continent of bowel and bladder, had shortness of breath only with exertion, and was not at risk of acquiring a pressure ulcer. R39's Urinary Incontinence Care Area Assessment (CAA) dated [DATE], indicated R39 was continent of both bowel and bladder. R39's Nutritional CAA dated [DATE], indicated R39 was at risk for nutrition due to body mass index (BMI) too high upon admission, although now was within range. R39's Care Plan dated [DATE], indicated the following: - R39 had altered cardiovascular status and directed staff to assess for shortness of breath (SOB) and cyanosis every shift. Monitor/document/report any changes in lung sounds, [MEDICAL CONDITION] or weight changes. Monitor/document/report any signs or symptoms of chest pain or pressure, heartburn, nausea and vomiting, SOB, excessive sweating, dependent [MEDICAL CONDITION], changes in capillary refill or color/warmth of extremities. - R39 was receiving anticoagulant (blood thinner) therapy and directed staff to monitor/document/report blood tinged or blood in urine, black tarry stools, dark or bright red blood in stool, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. - R39 was on pain medication and directed staff to monitor/document/report altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, itchy skin, respiratory distress/decreased respirations, sedation, and/or [MEDICAL CONDITION]. - R39 received antidepressant medication and directed staff to monitor/document/report changes in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawn, decline in ability to perform activities of daily living, incontinence, no voiding, constipation, fatigue, appetite loss, and weight loss. - R39 had [MEDICAL CONDITION]/[MEDICAL CONDITIONS] and directed staff to monitor/document/report chest pain, increased difficulty breathing, increased coughing and/or wheezing. Review of R39's Progress Notes revealed the following: - On [DATE], at 6:16 p.m. R39 has been sleeping this shift. States, I'm just tired. Refused supper, and all medications except pain medication. Resident states, It's too many to swallow. - On [DATE], at 7:11 p.m. Resident very weak. Resident had only ate a few bites. This nurse offered to help resident, when she stated: it's too hard to swallow. Refused all medications except pain and bowel medications. Resident noticeably had a hard time swallowing. This nurse offered to put medications in pudding or applesauce, resident declined. Spoon fed resident medication one at a time. Unable to hold water cup in hand d/t (due to) weakness. Also noticed difficulty in keeping head up off pillow d/t weakness as well. The note indicated the nurse left R39 with her call light within reach and would continue to monitor her status through the rest of the shift. - On [DATE], at 7:55 a.m. Resident slept all night and woke up at approximately 3:00 a.m. with increasing anxiety. Noted oxygen was off and lying on the side of mattress. Oxygen sats decreased to 84%. No further notation was made regarding staff response to the identified symptoms. - At 12:03 p.m. This morning it was reported that R39 had not voided during the overnight shift. At this time, resident has still not voided. The writer straight catheterized resident with no output. Resident cold to touch but refused to get covered. Vital signs in normal range. The note indicated staff would continue to monitor 02 status and voiding, Milk of Magnesia was given for bowels due to no bowel movement since hospital return. - At 8:47 p.m. Resident in bed this shift. Awake off and on. Rates pain ,[DATE]. Pain medication given as ordered. This nurse attempted to help resident eat, but resident stated she could not eat, and wanted it taken away. No bowel movement this shift, and did not void. Note also indicated R29 was resting comfortably in low bed, with the head of the bed elevated, oxygen in place, call light in reach, vital signs stable. - On [DATE], at 3:38 p.m. indicated R39 had been seen by the nurse practitioner (NP) for a previous hospitalization follow up visit. R39 to have a follow up chest x-ray tomorrow. R39's family was notified. Review of R39's Post hospital follow-up note by the NP dated [DATE], at 1:58 p.m. indicated R39 had been resting in bed comfortably this afternoon. R39 appeared tired, actually falling asleep during the assessment. R39 appeared pale in color and ill in nature. R39 reported mild SOB with exertion and was noted to be with any minor movement in bed, R39 became very SOB with pursed lip breathing. R39 was noted to have lower extremity [MEDICAL CONDITION]. [MEDICATION NAME] would be increased to 40 mg daily due to the underlying swelling and crackles in lungs. Chest X-ray ordered to rule out pneumonia. The Progress Note lacked mention or evidence of R39's inability to void, failure to eat or drink, difficulty swallowing, increased weakness, and increased pain. A Progress Note dated [DATE], at 4:01 p.m. indicated R39 had been in bed all day. R39 had [MEDICAL CONDITION] +2 ( slight indentation in skin after pressure applied, skin rebounds in 15 seconds) and NP was notified. On [DATE], from 6:19 p.m. until 7:23 p.m. R39 was observed in her room, with a meal tray on the over bed table which remained untouched. During this observation, no staff had entered R39's room. On [DATE], at 7:32 p.m. R39 was observed lying in bed, her left hand was swollen and her breathing was labored. - At 7:43 p.m. R39's granddaughter was at her beside and stated R39 had slept most of the day and had not consumed any solid foods. R39's Progress Note dated [DATE], at 3:45 a.m. indicated R39 was very confused during the night, was yelling help and when staff would arrive at R39's room, she would be sleeping, having no idea she was yelling. R39 was becoming very confused/delusional as was looking for her mother. R39 had an episode where she was trying to get out of bed because she needed to get to her mother. Resident showed non-verbal signs of pain. On [DATE] from 5:17 a.m. until 7:01 a.m. R39 was observed lying in bed with notable labored (puffing) breathing. - At 7:20 a.m. nursing assistant (NA)-L & NA-J provided incontinence care as R39 had a moderate size, black, tarry stool. NA-L stated this was the first time R39 had been incontinent of stool and the first black tarry stool noted. - At 8:23 a.m. R39 was heard yelling out somebody help me please - At 8:25 a.m. R39 was moaning, panting when breathing, SOB, and crying out Please help me. NA-L & NA-J entered R49's room, swabbed out R39's mouth, and repositioned her onto her right side with pillows behind back. No further yelling heard. - At 10:18 a.m. Family member (FM)-D was at R39's bedside upset that the facility had not called to let her know of R39's change in condition. FM-D stated she tried to call the facility three times this morning to check on the status of the R39, however, no one answered the phone. At this time, R39 was observed to have oxygen on via a nasal cannula which was positioned in her mouth as R39 was experiencing SOB. At this time, the facility was making arrangements to have R39 transferred to the hospital for an evaluation. A Progress Noted dated [DATE], at 8:23 a.m. indicated R39 had a tarry, smelly bowel movement and also had two, little opened areas on her skin. [MEDICATION NAME] and [MEDICATION NAME] tablet was given for pain rated 10 on a ,[DATE] pain scale. Some confusion noted. An additional Progress Note at 10:46 a.m. indicated FM-D was at the facility to talk with R39 about going to the emergency room due to her declining health status in which R39 agreed to go for an evaluation. R39 has declined since last admission to this facility, was more SOB, was having dark, black stools, was refusing to eat or come out of her room, and was more lethargic and drowsy. Review of R39's Bladder Elimination record dated from [DATE] - [DATE], indicated R39 had not voided from 7:16 p.m. on [DATE], until 10 a.m. on [DATE], - a total of 39 hours without voiding. On [DATE], at 10:33 a.m. registered nurse (RN)-H reviewed R39's nursing notes and verified they lacked notation related when R39 had voided. RN-H confirmed R39 did not void from 7:15 p.m. on [DATE], until 10 a.m. on [DATE]. RN-H stated R39 should have been on a strict intake and output monitoring and her physician should have been notified about not being able to void and having not output when catheterized. RN-H confirmed she was not aware of R39's voiding concerns until the surveyor had discussed it with her. On [DATE], at 7:50 p.m. a telephone interview was conducted with R39's physician who verified he was the admitting physician for R39's admission on [DATE], and also and her most recent hospitalization . The physician stated R39 presented on [DATE], more confused and lethargic, and it was reported that she had not been eating or drinking for several days. The physician stated he had not been made aware of any recent health status condition changes which had occurred since she had returned from her most recent hospitalization , and should have been. On [DATE], at 8:48 a.m. RN-D verified R39's physician order [REDACTED]. RN-D verified that according to R39's bladder elimination record and Progress Notes, R39 did not void for 39 hours and the physician had not been notified. At 9:38 a.m. RN-D confirmed R39 had been more lethargic, confused, was not eating/drinking, had not voided for 39 hours and had an overall rapidly declining condition and verified the symptoms of R39's declining condition since her hospital return on [DATE], had not been communicated to the physician. - At 10:30 a.m. nursing assistant (NA)-L stated they report anything unusual mind wise, skin color or changes - temp, wheezing, coughing, not eating/drinking, no bowel movement or urine output to the nurse NA-L also stated she had worked last weekend and noted R37 had been declining as she was not wanting to eat, sleeping more, and not wanting to get up. It took two staff to get R39 into the shower chair whereas usually it only took one staff person. NA-L stated R39 had went a couple shifts without voiding which she had reported to the nurse. NA-L stated the last time R39 had been out of was [DATE], for a shower, which took two staff to transfer. On [DATE], at 11:38 a.m. the director of nursing (DON) stated it was her expectation for staff to notify the physician of any change in condition. In addition, The DON stated R37 should have been placed on strict intake and output monitoring when her condition began to decline. On [DATE], at approximately 2:00 p.m. RN-D stated R39 was sent to the emergency roiagnom on [DATE], was transferred to a Fargo hospital and subsequently died while there. On [DATE], at 4:45 p.m. the nurse practitioner (NP) was interviewed by telephone. The NP confirmed she performed rounds at the nursing home 3x per week and recently up to 4x per week. When performing rounds the NP would see residents for their routine checks which rotated with their primary care physician (PCP). If there were specific concerns brought forward by the staff during the rounds, she would see those individuals and/or write orders for labs to be performed. The NP stated the staff were to report concerns to the NP on the days she performed rounds from 8am - 5pm. After 5pm and until 7am there would be an Essentia provider on-call to contact. The NP stated some residents had a specific primary care physician (PCP) who wanted resident concern calls made directly to that PCP. Any resident who utilized Sanford health services, those calls would need to go through through the Sanford on-call physicians. The NP confirmed she was familiar with R39 and had evaluated her on [DATE]. The NP stated she had never been made aware of R39's inability to void and recalls writing orders specifically for this resident if no voiding in 8 hours, the staff were to complete a bladder scan and catheterize. The NP stated she would have expected to be called when this occurred and 100% should have been notified after the catheterization did not provide any urine output. NP stated she had been made aware of R39 having difficulty swallowing, however, when she evaluated R39 on [DATE], the nurse on duty stated R39 was no longer experiencing difficulty swallowing and was reported to be eating and drinking. The NP also stated on [DATE], she was aware of the increase in [MEDICAL CONDITION] and in turn ordered an increase in [MEDICATION NAME] (diuretic to reduce fluid buildup) and a chest X-ray. However, the NP was not notified that the chest X-ray had not been performed as ordered. In addition, the NP stated the only medication errors that she had been made aware of were the ones in which she had written orders for on [DATE]. The NP stated she did not directly communicate with the PCP for Sanford residents (R39's PCP was a Sanford physician) and that the nursing home was responsible for that communication. The NP indicated that she had left for vacation on [DATE], therefore was not made aware of the changes in R29's condition which took place that morning. R47's admission MDS dated [DATE], indicated R47 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS indicated R47 required extensive assist of two staff for bed mobility, transfer, dressing and toilet use and extensive assist of one staff for personal hygiene. The MDS also indicated R47 received oxygen therapy while at the facility. R47's ADL Functional/Rehabilitation Potential CAA dated [DATE], indicated R47 required extensive assistance of ,[DATE] staff with ADL's and mobility due to weakness and tremors secondary to [MEDICAL CONDITION]. He was receiving skilled PT and OT for strengthening, gait and self cares. His goal was to gain enough strength to return to his home once he met his therapy goals. R47 required assistance with ADL's when he was at home as well, but hopefully, he could get back to his baseline. R47's Nutrition CAA dated [DATE], indicated R47 was at risk for nutrition due to BMI (body mass index) too high upon admission, and was on diuretic upon admission. R47's Order Summary Report dated [DATE], included pharmacy orders for [MEDICATION NAME] give 40 mg by mouth one time a day for [MEDICAL CONDITION]/hypertension and also [MEDICATION NAME] give 25 mg by mouth one time a day for [MEDICAL CONDITION]. R47's undated Care Plan provided on [DATE], indicated R47 had [MEDICAL CONDITION] and directed staff to implement interventions which included: -Monitor/document/report, as needed (PRN), any signs or symptoms of [MEDICAL CONDITION] such as dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea (discomfort when breathing while lying down flat), weakness and/or fatigue, increased heart rate ([MEDICAL CONDITION], lethargy and disorientation. -Weight monitoring daily. The Care Plan also indicated R47 had [MEDICAL CONDITION] related to [MEDICAL CONDITION] and directed staff to implement interventions which included: -Elevate feet when sitting up in chair to help prevent dependent [MEDICAL CONDITION]. -Monitor and report changes in mental status such as lethargy, tiredness, fatigue, tremors, [MEDICAL CONDITION]. -Monitor for signs/symptoms of hypovolemia (increased pulse, increased respirations, decreased systolic, sweating, anxiousness)or hypervolemia (jugular vein distention, increased blood pressure, lung crackles, headache, shortness of breath, dependent [MEDICAL CONDITION]). -Monitor/document/report PRN the following signs/symptoms: [MEDICAL CONDITION]; weight gain of over 2 pounds (lbs) a day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, peripheral pulses, level of consciousness, and to monitor breath sounds for crackles. -Weight (daily). Weigh at the same time under the same conditions i.e. same amount of clothing. On [DATE], at 5:52 a.m. R47 was observed in bed, with eyes closed. Breathing was labored. Ace wraps noted on both lower legs. The left leg wrap was falling off. -At 6:32 a.m. NA-J assisting R47 with morning cares. NA-J asked R47 if staff had left his leg wraps on all night again and indicated they had been left on during the overnight a couple of times that week. NA-I removed the ace wraps and stated she would leave them off for a while. Once the wraps were removed, large indentations were observed in R47's lower legs. R47 was also noted to have a congested cough. On [DATE], at 8:13 a.m. R47 was observed in the dining area, seated in a wheelchair, independently eating breakfast. A portable oxygen tank was located on the back of the wheelchair and R47 was receiving oxygen via a nasal cannula. R47's color was pink, his respirations were regular and no acute distress was noted. -At 8:52 a.m. R47 wheeled himself from the dining room area and was noted to have a wet sounding, gurgling, non-productive cough. -At 2:14 p.m. R47 rested in bed with the head of the bed elevated approximately ,[DATE] degrees while watching television. R47 verified he had been admitted to the facility after a hospital stay and confirmed he had [MEDICAL CONDITION], had been on oxygen and had had difficulties with his breathing for some time. R47 stated he had not felt short of breath or any chest tightness recently, rather just felt very tired. R47 stated he had ongoing problems with lower extremity [MEDICAL CONDITION] and proceeded to uncover his feet. R47 was wearing gripper socks and both feet/ankles were noted to be [MEDICAL CONDITION] and bulging. R47 stated he was wearing wraps on his legs and indicated he had been measured for compression stockings however they had not come in yet. Oxygen concentrator was set at 3.5 liters and delivered via a nasal cannula. R47 was in no acute distress, was breathing normally, able to carry on conversation without shortness of breath, his face was pink, and his hands were warm. Review of R47's clinical record from [DATE] to [DATE], revealed the following weight fluctuations: -[DATE], at 9:39 a.m. 280.8 lbs -[DATE], at 10:17 a.m. 287.5 lbs (6.7 lb gain in one day) R47's progress note (PN) dated [DATE], indicated oxygen via nasal cannula was in place and R47 had a 93% oxygen saturation. The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other signs/symptoms of [MEDICAL CONDITION]. -[DATE], at 1:25 p.m. 290.6 lbs -[DATE], at 10:37 a.m. 297.9 lbs (7.3 lb gain in one day) The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other signs/symptoms of [MEDICAL CONDITION]. -[DATE], at 8:28 a.m. 288.5 lbs -[DATE], at 12:20 a.m. 295.9 lbs (7.4 lb gain in one day) The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other signs/symptoms of [MEDICAL CONDITION]. -[DATE], at 5:20 p.m. 300.6 lbs (12.1 lb gain in one week) R47's PN dated [DATE], indicated no [MEDICAL CONDITION] at this time. The record lacked documentation regarding the weight gain or other signs/symptoms of [MEDICAL CONDITION]. -[DATE], at 1:19 p.m. 286.9 lbs -[DATE], at 11:15 a.m. 290.0 lbs (3.1 lb gain in one day) R47's PN dated [DATE], indicated R47 became short of breath with exertion. The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. -[DATE], at 12:15 p.m. 287.4 lbs -[DATE], at 10:27 a.m. 292.5 lbs (5.1 lb gain in one day) R47's PN dated [DATE], indicated R47 used oxygen at 3 liters and utilized [MEDICAL CONDITION] at night. The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. -[DATE], at 8:55 a.m. 296.0 lbs (3.5 lb gain in one day, and 8.6 lb gain in two days) R47's PN dated [DATE], completed by the dietary manager indicated R47 triggered for a review of a significant weight fluctuations since admission. Is on diuretic medication. Daily weights to monitor at this time. Continue plan of care. R47's PN dated [DATE], completed by nursing, indicated R47 had no complaints of SOB or chest pain and had 3+ [MEDICAL CONDITION] in bilateral lower extremities. The PN also indicated R47 utilized O2 via nasal cannula at 3 liters/minute continuously. -[DATE], at 1:04 p.m. 298.4 lbs (2.4 lb gain in one day, and 11 lb gain in 3 days) R47's PN dated [DATE], completed by the dietary manager, indicated R47 triggered for review of a significant weight gain for the month. Has weight fluctuations related to [MEDICAL CONDITION], is on two diuretic medications at this time. Will continue to monitor per MD order. The record lacked nursing documentation of the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. -[DATE], at 3:28 p.m. 295.9 lbs -[DATE], - no weight documented -[DATE], at 1:44 p.m. 302.1 lbs - a 6.2 lb gain in two days The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. On [DATE], at 2:19 p.m. NA-R indicated the NA's received a list of residents' who required weights and vitals signs from the nurse. NA-R indicated once the NA's had completed the tasks, the list was returned to the nurse with the results documented. NA-R also indicated the nurse would let them know if a resident needed to be reweighed. NA-R verified she worked with R47 and confirmed he had swelling in his feet. NA-R stated they started wraps on his lower extremities about two weeks ago. NA-R verified R47 was short of breath at times and stated sometimes they had to stop during his cares so he could catch his breath. On [DATE], at 2:27 p.m. LPN-H indicated she received the list of resident weights from the NA's and would enter them into the computer and she would review the past weights and looked for gains and losses. LPN-H also stated ordinarily they notified the NP of significant weight gains. LPN-H indicated she used a weight gain of more than 3 lbs in a day or 5 lbs. in a week as a rule of thumb. R47's weight gains as listed above were reviewed with LPN-H who indicated she had not identified any of the weight gains and stated if the provider had been notified it would have been documented in the Doctor (Dr.) Day Book. -At 2:33 p.m. the Dr. Day Book was reviewed with LPN-G who verified there were no entries in the book regarding R47's weight gains. LPN-G indicated for something like a 7 lb. weight gain, she would have notified the physician and obtained an order. -At 2:40 p.m LPN-H indicated for residents experiencing issues with [MEDICAL CONDITION], lung sounds would also be listened to and would be documented in the progress notes. LPN-H verified there were no progress notes documenting R47's lung sounds related to his weight gains. On [DATE], at 2:52 p.m. R47 was observed resting in bed with the head of the bed elevated approximately ,[DATE] degrees. R47 requested cough medicine for a cough at this time. LPN-G removed the ace wraps on R47's lower extremities which were wrapped from knees to toes. Indentations from wraps observed from knee to toes. LPN-G reported R47 had 2+ [MEDICAL CONDITION] at his foot and 3+ at the calf for right lower extremity with the calf more pitting (indentation of finger remained). LPN-G unwrapped R47's left leg and indentations from the wraps were visible from R47's knee to toes. LPN-G reported 3+ [MEDICAL CONDITION] in R47's calf and 2+ in the foot. LPN-G listened to R47's lungs and reported wheezing in R47's upper left lobe with crackles heard in the left lower lobe and also in the upper and lower lobes on the right. On [DATE], at 11:21 a.m. the DON stated it depended on the residnet, but usually they would monitor for a 3 lb weight gain in a day or 5 lb weight gain in a week. The DON indicated they usually asked the physician for a parameter to monitor. The DON verified she would have expected staff to contact the physician with a weight gain outside of these parameters and stated if it was a 7 lb weight gain, she would have expected the staff to call the physician on call. The DON verified R47's aforementioned weight fluctuation and stated they should have been communicated to the provider for further follow up. The facility's Change in a Resident's Condition or Status policy dated ,[DATE], indicated our facility shall promptly notify the resident, his or her attending physician and resident representative of changes in the resident's medical/mental condition or status. The nurse would notify the resident's attending physician or physician on call when there has been a (an): - accident or incident involving the resident - discovery of injuries of unknown source - adverse reaction to medication - significant change in the resident's physical/emotional/mental condition - need to alter the resident's medical treatment significantly - refusal of treatment or medication two or more consecutive times - need to transfer the resident to hospital A significant change of condition was a major decline or improvement in the resident's status that: - will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention; - impacted more than one area of the resident's health status - required interdisciplinary review and/or revision to the care plan - ultimately was based on the judgement of the clinical staff

Based on observation, interview and document review, the facility failed to comprehensively assess a change in condition for 1 of 1 resident (R39) who was observed to have a decline in food/fluid intake, difficulty swallowing, increased sedation, weakness, increase [MEDICAL CONDITION] and shortness of breath. This failure resulted in actual harm for R39 due to having been rehospitalized with [DIAGNOSES REDACTED]. R39 subsequently died while in the hospital. The facility also failed to identify weight fluctuations and assess for signs and symptoms of exacerbation of [MEDICAL CONDITIONS] for 1 of 1 resident (R47) who experienced multiple excessive weight gains and was diagnosed with [REDACTED]. Findings include: R39's 14 day Minimum Data Set ((MDS) dated [DATE], indicated R39 had intact cognition, required extensive assistance for most activities of daily living (ADL), was always continent of bowel and bladder, received both scheduled and as needed (PRN) pain medications daily for almost constant pain, experienced shortness of breath (SOB) with exertion, life expectancy was more than six months, no swallowing difficulties, not at risk for pressure ulcers, and received antidepressant, anticoagulant (blood thinner), diuretic (reduces fluid), and opioid (pain) medications daily. R39's MD/Nursing Communications form dated [DATE], indicated R39's [DIAGNOSES REDACTED]. R39's ADL function Care Area Assessment (CAA) dated [DATE], indicated R39 required physical assistance with ADL's and mobility due to weakness and pain related to metastatic [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. R39 had SOB with exertion related to [MEDICAL CONDITION] & [MEDICAL CONDITION]. R39's Urinary Incontinence CAA dated [DATE], indicated R39 was continent of both bowel and bladder but required assistance to the toilet and with toileting hygiene due to weakness, pain and SOB with exertion. R39's Pressure Ulcer CAA dated [DATE], indicated R39 required assistance with bed mobility due to weakness and pain. Staff were to assist with repositioning every two hours, and as needed. R39 had a pressure relieving mattress on bed and cushion in wheelchair. R39's Pain CAA dated [DATE], indicated R39 had [MEDICAL CONDITION] with metastases to the bone and possibly liver. R39's pain medication had been increased with some relief. R39's Care Plan dated [DATE], indicated R39's advance directive was full code - provide cardiopulmonary resuscitation (CPR). The plan indicated R39 was independent with eating, continent of bowel and bladder, had no behavior problems, and intact skin. R39 had ADL self-care performance deficit related to weakness and pain which required extensive staff assistance with ADL's. The Care Plan also identified the following: R39 had altered cardiovascular status and directed staff to: - assess for SOB and cyanosis (blue color) every shift - monitor/document/report any changes in lung sounds on auscultation (i.e. crackles), [MEDICAL CONDITION] and changes in weight - monitor/document/report any signs/symptoms of [MEDICAL CONDITION] (CAD): chest pain or pressure especially with activity, heartburn, nausea, vomiting, SOB, excessive sweating, dependent [MEDICAL CONDITION], changes in capillary refill, color/warmth of extremities R39 was on anticoagulation therapy and directed staff to: - complete daily skin inspections - monitor/document/report blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs R39 was on pain medication and directed staff to: - monitor/document/report altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting itchiness, respiratory distress/decreased respirations, sedation or [MEDICAL CONDITION] R39 had [MEDICAL CONDITION]/[MEDICAL CONDITION] and directed staff to: - monitor for difficulty breathing on exertion, anxiety, confusion, restlessness, SOB at rest, cyanosis (turning blue), increased difficulty breathing, increased coughing or wheezing R39's Hospital Discharge Summary dated [DATE], indicated R39 was hospitalized [DATE], with [DIAGNOSES REDACTED]. discharged on twice daily subcutaneous (sq) [MEDICATION NAME] (blood thinner). Gastroencology and oncology recommend staying away from Eliquis (blood thinner) at least for the next couple weeks until hemoglobin was stable. Patient was lethargic and drowsy during hospital stay. discharged with recommendations to hold [MEDICATION NAME] and [MEDICATION NAME] and discharged with as needed [MEDICATION NAME] for pain. Review of R39's Progress Notes revealed the following: - On [DATE], at 6:16 p.m. R39 has been sleeping this shift. States, I'm just tired. Refused supper, and all medications except pain medication. Resident states, it's too many to swallow. - On [DATE], at 7:11 p.m. Resident very weak. Resident had only ate a few bites. This nurse offered to help resident, when she stated: it's to hard to swallow. Refused all medications except pain and bowel medications. Resident noticeably had a hard time swallowing. This nurse offered to put medications in pudding or applesauce, resident declined. Spoon fed resident medication one at a time. Unable to hold water cup in hand d/t (due to) weakness. Also noticed difficulty in keeping head up off pillow d/t weakness as well. The note indicated the nurse left the R39 with her call light within reach and would continue to monitor her status through the rest of the shift. - On [DATE], at 7:55 a.m. Resident slept all night and woke up at approximately 3:00 a.m. with increasing anxiety. Noted oxygen was off and lying on the side of mattress. Oxygen (O2) sats decreased to 84%. No further notation was made regarding staff response to the identified symptoms. - At 12:03 p.m. This morning it was reported that R39 had not voided during the overnight shift. At this time, resident has still not voided. The writer straight catheterized resident with no output. Resident cold to touch but refused to get covered. Vital signs in normal range. The note indicated staff would continue to monitor O2 status and voiding, Milk of Magnesia was given for bowels due to no bowel movement since hospital return. - At 8:47 p.m. Resident in bed this shift. Awake off and on. Rates pain ,[DATE]. Pain medication given as ordered. This nurse attempted to help resident eat, but resident stated she could not eat, and wanted it taken away. No bowel movement this shift, and did not void. Note also indicated R29 was resting comfortably in low bed, with the head of the bed elevated, oxygen in place, call light in reach, vital signs stable. - On [DATE], at 3:38 p.m. indicated R39 had been seen by the nurse practioner (NP) for a previous hospitalization follow up visit. R39 to have a follow up chest X-ray tomorrow. R39's family was notified. Review of R39's Post hospital follow-up note by the NP dated [DATE], at 1:58 p.m. indicated R39 had been resting in bed comfortably this afternoon. R39 appeared tired, actually falling asleep during the assessment. R39 appeared pale in color and ill in nature. R39 reported mild SOB with exertion and was noted to be with any minor movement in bed, R39 became very SOB with pursed lip breathing. R39 was noted to have lower extremity [MEDICAL CONDITION]. [MEDICATION NAME] would be increased to 40 mg daily due to the underlying swelling and crackles in lungs. Chest X-ray ordered to rule out pneumonia. The Progress Note lacked mention or evidence of R39's inability to void, failure to eat or drink, difficulty swallowing, and increased pain. However, R39's clinical record lacked evidence of the check X-ray having been performed. A Progress Note dated [DATE], at 4:01 p.m. indicated R39 had been in bed all day. R39 had [MEDICAL CONDITION] +2 ( slight indentation in skin after pressure applied, skin rebounds in 15 seconds) and NP was notified. On [DATE], from 6:19 p.m. until 7:23 p.m. R39 was observed in her room, with a meal tray on the over bed table which remained untouched. During this observation, no staff had entered R39's room. On [DATE], at 2:30 p.m. A telephone interview was conducted with family member (FM)-D. FM-D stated R39 had been discharged from the hospital on [DATE], and returned to the facility at approximately 3:30 p.m. FM-D stated that the nurse on duty indicated she had not received a copy of the R39's new medication orders therefore FM-D provided a copy for the facility at approximately 10 p.m. prior to her leaving for the night. The next morning, FM-D stated she had requested a meeting with staff, to include the director of nursing (DON), to discuss concerns with R39 not receiving the correct medications after returning from the hospital. FM-D stated the DON indicated that all medications would be reviewed for accuracy. On [DATE], at 7:32 p.m. R39 was observed lying in bed, her left hand was swollen and her breathing was labored. - At 7:43 p.m. R39's granddaughter was at her bedside and stated R39 had slept most of the day and had not consumed any solid foods. R39's Progress Note dated [DATE], at 3:45 a.m. indicated R39 was very confused during the night, was yelling help and when staff would arrive at R39's room, she would be sleeping, having no idea she was yelling. R39 was becoming very confused/delusional as was looking for her mother. R39 had an episode where she was trying to get out of bed because she needed to get to her mother. Resident showed non-verbal signs of pain. On [DATE] from 5:17 a.m. until 7:01 a.m. R39 was observed lying in bed with notable labored (puffing) breathing. - At 7:20 a.m. nursing assistant (NA)-L & NA-J provided incontinence care as R39 had a moderate size, black, tarry stool. NA-L stated this was the first time R39 had been incontinent of stool and the first black tarry stool noted. - At 8:23 a.m. R39 was heard yelling out somebody help me please - At 8:25 a.m. R39 was moaning, panting when breathing, SOB, and crying out Please help me. NA-L & NA-J entered R49's room, swabbed out R39's mouth, and repositioned her onto her right side with pillows behind back. No further yelling heard. On [DATE], at 7:57 a.m. registered nurse (RN-H) stated many medication errors had occurred as result of R39's medications not being transcribed timely and correctly upon return from hospital on [DATE]. A Progress Noted dated [DATE], at 8:23 a.m. indicated R39 had a tarry, smelly bowel movement and also had two, little opened areas on her skin. [MEDICATION NAME] and [MEDICATION NAME] tablet was given for pain rated 10 on a ,[DATE] pain scale. Some confusion noted. An additional Progress Note at 10:46 a.m. indicated FM-D was at the facility to talk with R39 about going to the emergency room due to her declining health status in which R39 agreed to go for an evaluation. R39 has declined since last admission to this facility, was more SOB, was having dark, black stools, was refusing to eat or come out of her room, and was more lethargic and drowsy. On [DATE], at 10:18 a.m. FM-D was at R39's bedside upset that the facility had not called to let her know of R39's change in condition. FM-D stated she tried to call the facility three times this morning to check on the status of R39, however, no one answered the phone. At this time, R39 was observed to have oxygen on via a nasal cannula which was positioned in her mouth as R39 was experiencing SOB. At this time, the facility was making arrangements to have R39 transferred to the hospital for an evaluation. Review of R39's clinical record lacked evidence R39's physician had been notified of the decline in condition since her most recent hospital return on [DATE]. R39's Bladder Elimination record dated from [DATE] - [DATE], revealed R39 did not void from 7:16 p.m. on [DATE], until 10 a.m. on [DATE] - a total of 39 hours without voiding. On [DATE], at 9:31 a.m. RN-D stated on [DATE], she had given the emergency room staff member a report on R39's status. This report included concerns related to R39 having been more SOB, not getting out of bed, not eating, new black tarry stool, and respiratory changes to include mouth breathing and [MEDICAL CONDITION]. However, RN-D stated she did not report to the emergency room staff member that R39 had went 39 hours without voiding. RN-D verified R39 requested full life sustaining treatments. RN-D stated she would have expected the staff to implement strict intake and output monitoring and would have initiated right away for any other resident but, being we knew why R39 was deteriorating, they did not begin the monitoring. - At 10:33 a.m. after reading R39's clinical record documentation, RN-H verified R39 went for 39 hours without voiding. RN-H stated strict intake and output should have been initiated, a bladder scan should have been performed after 8 hours without a void, and catheterization should also have occurred. RN-H stated the physician should have also been notified of the decline in condition. - At 7:50 p.m. a telephone interview was conducted with R39's hospital admitting physician for both the admission on [DATE], as well as [DATE]. The physician stated R39 had presented on [DATE], more confused and lethargic, and it was reported that she had not eaten or drank in several days. The physician stated the main [DIAGNOSES REDACTED]. On [DATE], at 8:48 a.m. RN-D verified the physician's orders [REDACTED]. RN-D verified the progress note dated [DATE], indicated R38 had not voided the entire shift and the physician orders [REDACTED]. RN-D reviewed the Nursing Home Note by the NP dated [DATE], and stated it did not appear the NP was made aware of R39's inability to void, not eating/drinking, difficulty swallowing, increased weakness, or the increased pain. - At 10:30 a.m. NA-L stated the staff reported anything unusual mind-wise, skin color or changes, temp, wheezing, coughing, not eating/drinking, no bowel movement or urine to the nurse NA-L stated she had worked this past weekend and she had noted R37 had been declining due to not eating, was slow, sleeping more and not wanting to get up. NA-L stated it took two staff to get R39 into the shower chair whereas it usually took only one staff person to transfer her. NA-L also stated R39 had went a couple of shifts without voiding in which she had reported to the nurse. NA-L stated the last time R39 had been out of bed was [DATE], for a shower, which took two staff to transfer. On [DATE], at 11:38 a.m. the director of nursing (DON) stated it was her expectation for staff to identify, assess and notify the physician of any change in condition in a resident. In addition, The DON stated R37 should have been placed on strict intake and output monitoring when her condition began to decline On [DATE], at approximately 2:00 p.m. RN-D stated R39 was sent to the emergency roiagnom on [DATE], was transferred to a Fargo hospital and subsequently died while there. On [DATE], at 4:45 p.m. the nurse practioner (NP) was interviewed by telephone. The NP confirmed she performed rounds at the nursing home 3x per week and recently up to 4x per week. When performing rounds the NP would see residents for their routine checks which rotated with their primary care physican (PCP). If there were specific concerns brought forward by the staff during the rounds, she would see those individuals and/or write orders for labs to be performed. The NP stated the staff were to report concerns to the NP on the days she performed rounds from 8 am - 5 pm. After 5pm and until 7am there would be an on call provider to contact. The NP stated some residents had a specific primary care physician (PCP) who wanted resident concern calls made directly to that PCP. The NP confirmed she was familiar with R39 and had evaluated her on [DATE]. The NP stated she had never been made aware of R39's in ability to void and recalls writing orders specifically for this resident that if no void in 8 hours, the staff were to complete a bladder scan and catheterize. The NP stated she would have expected to be called when this occurred and 100% should have been notified after the catheterization did not provide any urine output. NP stated she had been made aware of R39 having difficulty swallowing, however, when she evaluated R39 on [DATE], the nurse on duty stated R39 was no longer experiencing difficulty swallowing and was reported to be eating and drinking. The NP also stated on [DATE], she was aware of the increase in [MEDICAL CONDITION] and in turn ordered an increase in [MEDICATION NAME] (diuretic to reduce fluid buildup) and a chest X-ray. However, the NP was not notified that the chest X-ray had not been performed as ordered. The NP stated she did not directly communicate with R39's PCP who worked with a different clinic (Sanford) rather the nursing home was responsible for communicating/notifying R39's PCP of any changes in condition. The NP indicated that she had left for vacation on [DATE], therefore was not made aware of the changes in R29's condition which took place that morning. Note The facility's Change in a Resident's Condition/Special Needs Charting policy dated May/2019, indicated the purpose of the policy was to ensure the clinical record contained accurate information about each resident, that changes in condition were monitored and interventions documented. The purpose also included to provide early interventions and prevent hospitalization to the degree possilbe and to accurately document care that had been provided. The policy directed a resident's condition be assessed and reported immediately if the resident experienced: -a fall or incident resulitng in an injury -vital signs that vary significatnly from the resident's normal limits and have been monitored for an ,[DATE] hour period and have not improved with basic nursing intervention -dramatic fluctuation in diabetic status -[DIAGNOSES REDACTED] -cardiac/respiratory arrest -crisis behavior -uncontrolled bleeding -grossly adnormal lab values -unanticipated discharge of the resident -any other significant chagne in condition as determined by a licensed nurse. A significant change of condition was a major decline or improvement in the resident's status that: - will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention; - impacted more than one area of the resident's health status - required interdisciplinary review and/or revision to the care plan - ultimately was based on the judgement of the clinical staff R47's admission MDS dated [DATE], indicated R47 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS indicated R47 required extensive assist of two staff for bed mobility, transfer, dressing and toilet use and extensive assist of one staff for personal hygiene. The MDS also indicated R47 received oxygen therapy while at the facility. R47's ADL Functional/Rehabilitation Potential CAA dated [DATE], indicated R47 required extensive assistance of ,[DATE] staff with ADL's and mobility due to weakness and tremors secondary to [MEDICAL CONDITION]. He was receiving skilled PT and OT for strengthening, gait and self cares. His goal was to gain enough strength to return to his home once he met his therapy goals. R47 required assistance with ADL's when he was at home as well but hopefully, he could get back to his baseline. R47's Nutrition CAA dated [DATE], indicated R47 was at risk for nutrition due to BMI (body mass index) too high upon admission, and was on diuretic upon admission. R47's Order Summary Report dated [DATE], included pharmacy orders for [MEDICATION NAME] give 40 mg by mouth one time a day for [MEDICAL CONDITION]/hypertension and also [MEDICATION NAME] give 25 mg by mouth one time a day for [MEDICAL CONDITION]. R47's undated Care Plan provided on [DATE], indicated R47 had [MEDICAL CONDITION] and directed staff to implement interventions which included: -Monitor/document/report, as needed (PRN), any signs or symptoms of [MEDICAL CONDITION] such as dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea (discomfort when breathing while lying down flat), weakness and/or fatigue, increased heart rate ([MEDICAL CONDITION], lethargy and disorientation. -Weight monitoring daily. The Care Plan also indicated R47 had [MEDICAL CONDITION] related to [MEDICAL CONDITION] and directed staff to implement interventions which included: -Elevate feet when sitting up in chair to help prevent dependent [MEDICAL CONDITION]. -Monitor and report changes in mental status such as lethargy, tiredness, fatigue, tremors, [MEDICAL CONDITION]. -Monitor for signs/symptoms of hypovolemia (increased pulse, increased respirations, decreased systolic, sweating, anxiousness)or hypervolemia (jugular vein distention, increased blood pressure, lung crackles, headache, shortness of breath, dependent [MEDICAL CONDITION]). -Monitor/document/report PRN the following signs/symptoms: [MEDICAL CONDITION]; weight gain of over 2 pounds (lbs) a day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, peripheral pulses, level of consciousness, and to monitor breath sounds for crackles. -Weight (daily). Weigh at the same time under the same conditions i.e. same amount of clothing. On [DATE], at 5:52 a.m. R47 was observed in bed, with eyes closed. Breathing was labored. Ace wraps noted on both lower legs. The left leg wrap was falling off. -At 6:32 a.m. NA-J assisting R47 with morning cares. NA-J asked R47 if staff had left his leg wraps on all night again and indicated they had been left on over night a couple of times that week. NA-I removed the ace wraps and stated she would leave them off for awhile. Once the wraps were removed, large indentations were observed in R47's lower legs. R47 was also noted to have a congested cough. On [DATE], at 8:13 a.m. R47 was observed in the dining area, seated in a wheelchair, independently eating breakfast. A portable oxygen tank was located on the back of the wheelchair and R47 was receiving oxygen via a nasal cannula. R47's color was pink, his respirations were regular and no acute distress was noted. -At 8:52 a.m. R47 wheeled himself from the dining room area and was noted to have a wet sounding, gurgling, non-productive cough. -At 2:14 p.m. R47 rested in bed with the head of the bed elevated approximately ,[DATE] degrees while watching television. R47 verified he had been admitted to the facility after a hospital stay and confirmed he had [MEDICAL CONDITION], had been on oxygen and had had difficulties with his breathing for some time. R47 stated he had not felt short of breath or any chest tightness recently, rather just felt very tired. R47 stated he had ongoing problems with lower extremity [MEDICAL CONDITION] and proceeded to uncover his feet. R47 was wearing gripper socks and both feet/ankles were noted to be [MEDICAL CONDITION] and bulging. R47 stated he was wearing wraps on his legs and indicated he had been measured for compression stockings however they had not come in yet. Oxygen concentrator was set at 3.5 liters and delivered via a nasal cannula. R47 was in no acute distress, was breathing normally, able to carry on conversation without shortness of breath, his face was pink, and his hands were warm. Review of R47's clinical record from [DATE] to [DATE], revealed the following weight fluctuations: -[DATE], at 9:39 a.m. 280.8 lbs -[DATE], at 10:17 a.m. 287.5 lbs (6.7 lb gain in one day) R47's progress note (PN) dated [DATE], indicated oxygen via nasal cannula was in place and R47 had a 93% oxygen saturation. The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other signs/symptoms of [MEDICAL CONDITION]. -[DATE], at 1:25 p.m. 290.6 lbs -[DATE], at 10:37 a.m. 297.9 lbs (7.3 lb gain in one day) The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other signs/symptoms of [MEDICAL CONDITION]. -[DATE]. at 8:28 a.m. 288.5 lbs -[DATE]. at 12:20 a.m. 295.9 lbs (7.4 lb gain in one day) The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other signs/symptoms of [MEDICAL CONDITION]. -[DATE], at 5:20 p.m. 300.6 lbs (12.1 lb gain in one week) R47's PN dated [DATE], indicated no [MEDICAL CONDITION] at this time. The record lacked documentation regarding the weight gain or other signs/symptoms of [MEDICAL CONDITION]. -[DATE], at 1:19 p.m. 286.9 lbs -[DATE], at 11:15 a.m. 290.0 lbs (3.1 lb gain in one day) R47's PN dated [DATE], indicated R47 became short of breath with exertion. The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. -[DATE], at 12:15 p.m. 287.4 lbs -[DATE], at 10:27 a.m. 292.5 lbs (5.1 lb gain in one day) R47's PN dated [DATE], indicated R47 used oxygen at 3 liters and utilized [MEDICAL CONDITION] at night. The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. -[DATE], at 8:55 a.m. 296.0 lbs (3.5 lb gain in one day, and 8.6 lb gain in two days) R47's PN dated [DATE], completed by the dietary manager indicated R47 triggered for a review of a significant weight fluctuations since admission. Is on diuretic medication. Daily weights to monitor at this time. Continue plan of care. R47's PN dated [DATE], completed by nursing, indicated R47 had no complaints of SOB or chest pain and had 3+ [MEDICAL CONDITION] in bilateral lower extremities. The PN also indicated R47 utilized O2 via nasal cannula at 3 liters/minute continuously. -[DATE], at 1:04 p.m. 298.4 lbs (2.4 lb gain in one day, and 11 lb gain in 3 days) R47's PN dated [DATE], completed by the dietary manager, indicated R47 triggered for review of a significant weight gain for the month. Has weight fluctuations related to [MEDICAL CONDITION], is on two diuretic medications at this time. Will continue to monitor per MD order. The record lacked nursing documentation of the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. -[DATE] 15:28 295.9 lbs -[DATE] - no weight documented -[DATE] 13:44 302.1 lbs - a 6.2 lb gain in two days The record lacked documentation regarding the weight gain or presence of [MEDICAL CONDITION] or other sign/symptoms of [MEDICAL CONDITION]. On [DATE], at 2:19 p.m. NA-R indicated the NA's received a list of residents' who required weights and vitals signs from the nurse. NA-R indicated once the NA's had completed the tasks, the list was returned to the nurse with the results documented. NA-R also indicated the nurse would let them know if a resident needed to be reweighed. NA-R verified she worked with R47 and confirmed he had swelling in his feet. NA-R stated they started wraps on his lower extremities about two weeks ago. NA-R verified R47 was short of breath at times and stated sometimes they had to stop during his cares so he could catch his breath. On [DATE], at 2:27 p.m. LPN-H indicated she received the list of resident weights from the NA's and would enter them into the computer and she would review the past weights and looked for gains and losses. LPN-H also stated ordinarily they notified the NP of significant weight gains. LPN-H indicated she used a weight gain of more than 3 lbs in a day or 5 lbs. in a week as a rule of thumb. R47's weight gains as listed above were reviewed with LPN-H who indicated she had not identified any of the weight gains and stated if the provider had been notified it would have been documented in the Doctor (Dr.) Day Book. -At 2:33 p.m. the Dr. Day Book was reviewed with LPN-G who verified there were no entries in the book regarding R47's weight gains. LPN-G indicated for something like a 7 lb. weight gain, she would have notified the physician and obtained an order. -At 2:40 p.m LPN-H indicated for residents experiencing issues with [MEDICAL CONDITION], lung sounds would also be listened to and would be documented in the progress notes. LPN-H verified there were no progress notes documenting R47's lung sounds related to his weight gains. On [DATE], at 2:52 p.m. R47 was observed resting in bed with the head of the bed elevated approximately ,[DATE] degrees. R47 requested cough medicine for a cough at this time. LPN-G removed the ace wraps on R47's lower extremities which were wrapped from knees to toes. Indentations from wraps observed from knee to toes. LPN-G reported R47 had 2+ [MEDICAL CONDITION] at his foot and 3+ at the calf for right lower extremity with the calf more pitting. LPN-G unwrapped R47's left leg and indentations from the wraps were visible from R47's knee to toes. LPN-G reported 3+ [MEDICAL CONDITION] in R47's calf and 2+ in the foot. LPN-G listened to R47's lungs and reported wheezing in R47's upper left lobe with crackles heard in the left lower lobe and also in the upper and lower lobes on the right. On [DATE], at 11:21 a.m. the DON stated it depended on the residnet, but usually they would monitor for a 3 lb weight gain in a day or 5 lb weight gain in a week. The DON indicated they usually asked the physician for a parameter to monitor. The DON verified she would have expected staff to contact the physician with a weight gain outside of these parameters and stated if it was a 7 lb weight gain, she would have expected the staff to call the physician on call. The DON verified R47's aforementioned weight fluctuation and stated they should have been communicated to the provider for further follow up. R35's quarterly MDS dated [DATE], indicated R35 had moderate cognitive impairment and [DIAGNOSES REDACTED]. The MDS also indicated R35 required limited assist of one staff person for transfers, but was independent with ambulation. R35's ADL/ Functional/Rehabilitation CAA dated [DATE], indicated the amount of assistance R35 needed fluctuated with his health status. When his [MEDICAL CONDITIONS] exacerbated, R35 needed more assistance. R35's Care Plan dated [DATE], indicated R35 had an ADL self-care performance deficit related to oxygen desaturation with exertion (an abnormally-low partial pressure of oxygen in the arterial blood during episodes of exercise) and R35's need for assistance with ADL's and mobility fluctuated with health status changes. The Care Plan indicated R35 could usually move between surfaces using a walker independently, but with health status changes R35 required up to extensive assistance from one staff to transfer. The Care Plan further directed staff to give aerosol or [MEDICATION NAME][MEDICATION NAME] as ordered and to monitor/document any side effects and effectiveness, assist R35 to have the head of the bed elevated to ,[DATE] degrees or when out of bed to be upright in a chair during episodes of difficulty breathing, identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes, etc; to monitor for difficulty breathing (Dyspnea) on exertion and to remind R35 not to push beyond endurance. To monitor for signs/symptoms of acute respiratory insuff (TRUNCATED)

Based on observation, interview and document review, the facility failed to ensure medications were administesred without significant error for 2 of 5 residents (R39, R158) reviewed. This caused harm for R39 who experienced a decline in condition following hospital discharge, requiring rehospitalization ; and harm for R158 who didn't receive medications according to the physician's orders [REDACTED]. Findings include: R39's 14 day Minimum Data Set (MDS) assessment dated [DATE], indicated R39 had intact cognition, received scheduled and as needed (PRN) pain medication on a daily basis for pain rated at a 5 (on a scale of 1-10 with 1 being the lowest pain), life expectancy of greater than 6 months, and indicated R39 also utilized antidepressant, anticoagulant (blood thinner) and diuretic (fluid reducing) medications on a daily basis. R39's Care Plan dated 6/20/19, indicated R39 received anticoagulation therapy (blood thinners) and pain medication therapy related [MEDICAL CONDITION] directing staff to administer medications as ordered by the physician. R39's Hospital Discharge Summary dated 7/25/19, indicated R39 had been hospitalized [DATE], with [DIAGNOSES REDACTED]. On 7/25/19, R39 had been discharged from the hospital with orders for twice daily subcutaneous (sq) [MEDICATION NAME] (a blood thinner). The Discharge Summary indicated both [MEDICATION NAME] and oncology had recommended R39 stay away from Eliquis (blood thinner) for at least the next couple weeks until the resident's hemoglobin was stable. The Discharge Summary also indicated R39 was lethargic and drowsy during the hospital stay, and had been discharged with recommendations to hold [MEDICATION NAME] and [MEDICATION NAME], with orders for as needed [MEDICATION NAME] to treat pain. On 7/30/19, at 2:30 p.m. family member (FM)-D was interviewed by telephone. FM-D stated (R39) was discharged from the hospital on [DATE], and had returned to the nursing home at approximately 3:30 p.m. FM-D stated the nurse on duty stated she had not received a copy of R39's new medication orders. FM-D said she'd provided the facility a copy of the discharge orders at approximately 10 p.m. prior to her leaving (R39's) side for the night. The next morning, FM-D stated she had subsequently requested a meeting with the staff, including the director of nursing (DON), to discuss concerns with (R39) not receiving the correct medications after returning from the hospital. FM-D stated the DON had stated all R39's medications would be reviewed for accuracy. FM-D stated she always felt the need to double check (R39's) medication orders with the staff because there had been errors in the past. Upon review, R39's Hospital return physician orders [REDACTED]. - start [MEDICATION NAME] (blood thinner) 5000 units/milliliter (ml) inject one ml subcutaneous (sq) twice daily - start [MEDICATION NAME] (stomach acid reducer) 20 milligrams (mg) 1 capsule twice daily before meals - Eliquis (blood thinner) 5 mg by mouth twice daily - HOLD UNTIL PCP (primary care physician) FOLLOW-UP - [MEDICATION NAME] (muscle relaxer) 10 mg take 0.5 tablet every night at bedtime - HOLD UNTIL PCP FOLLOW-UP - [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME], a pain medication) 10-35 mg take 0.5 tablet every 6 hours PRN for moderate or severe pain - [MEDICATION NAME] sulfate (pain) 15 mg ER (extended release) take one tablet by mouth twice daily - HOLD UNTIL PCP FOLLOW-UP - [MEDICATION NAME] CR 650 mg take 650 mg by mouth twice daily PRN for mild to moderate pain - [MEDICATION NAME] (used to treat nerve pain) 100 mg capsule take two capsules (200 mg) by mouth every night at bedtime - stop taking [MEDICATION NAME] (acid reflux) 150 mg tablet twice daily. Physician orders [REDACTED]. - resume [MEDICATION NAME] 15 mg ER twice daily - resume [MEDICATION NAME] 5 mg at bedtime - resume previous order for [MEDICATION NAME] 10/325 mg one tab every 6 hours PRN - okay to hold [MEDICATION NAME] today Due to R39's hospital return physician orders [REDACTED]. - Eliquis was administered in error on the evening of 7/25/19, and morning of 7/26/19 - [MEDICATION NAME] was not started until 7/27/19 - [MEDICATION NAME] was administered in error on 7/25/19 at bedtime - [MEDICATION NAME] CR (controlled release) 650 mg was not changed from the previous order of [MEDICATION NAME] ER 500 mg twice daily and R39 received a total of 10 doses in error until the order was corrected on 7/31/19 - [MEDICATION NAME] order was not updated and R39 received 200 mg at bedtime along with the previous order of 100 mg twice daily which should have been discontinued. This continued until 7/31/19, which resulted in 11 doses having been administered in error. - [MEDICATION NAME] was administered in error the evening of 7/25/19 and morning of 7/26/19 before being discontinued - [MEDICATION NAME] was not administered until 7/26/19 resulting in one missed dose - [MEDICATION NAME]-[MEDICATION NAME] previous order indicated a whole tablet and new order was for 0.5 tablet to be administered. This resulted in R39 receiving the incorrect dose the evening of 7/25/19 - [MEDICATION NAME] sulfate was to be held pending PCP review, one dose was given in error on 7/25/19 On 7/30/19, at 7:32 p.m. R39 was observed lying in bed on her back. R39 appeared asleep with oxygen on, and was observed to have labored (puffing) breathing. - At 7:43 p.m. FM-D was at R39's bedside and stated R39 had been sleeping most of day and had not eaten any solid foods the entire day. On 7/31/19, from 5:17 a.m. until 7:01 a.m. R39 was observed lying in bed with notable labored breathing. - At 7:20 a.m. nursing assistant (NA)-L & NA-J provided incontinence care for R39. R39 was observed to have had a moderate size black tarry stool. NA-L stated this was the first time R39 had been incontinent of stool, and stated this was the first black tarry stool R39 had. - At 8:23 a.m. R39 was heard yelling out somebody help me please - At 8:25 a.m. R39 was heard moaning and panting when breathing. R39 was short of breath (SOB), and was crying out Please help me. NA-L & NA-J entered R39's room swabbed the resident's mouth, and repositioned R39 onto her right side with pillows behind her back. No further yelling was heard. - At 10:18 a.m. FM-D was observed at R39's bedside. FM-D expressed being upset because the facility had not contacted her regarding the change in R39's condition. FM-D stated she had called the facility three times this morning to check on R39's status and nobody answered the phone. Review of R39's Progress Notes (PN) from 7/26/19-7/31/19, revealed a progressive decline in status which included: lethargy, shortness of breath, some confusion, failure to eat/drink, inability to void, incontinent episode of a black, tarry, smelly stool, and [MEDICAL CONDITION]. On 7/31/19, R39 was transferred to a local hospital for evaluation, but was then transferred to a larger hospital in Fargo North Dakota, where R39 later passed away. On 7/31/19 at 7:57 a.m. registered nurse (RN)-H verified R39 had returned to the facility from the local hospital on [DATE] at approximately 3:00 p.m. RN-H stated the floor nurse was ultimately responsible to transcribe physician orders [REDACTED]. In addition, RN-H said the RN was responsible to audit the orders as soon as possible for accuracy however, verified R39's order audit had not started until 7/30/19. - At 10:29 a.m. R39's medication orders and eMar documentation were reviewed with RN-H and RN-D. Neither RN-H or RN-D were aware of the medicaiton errors which had occurred. When RN-H and RN-D were informed of each of the identified errors, they verified the failure to reconcile the medications timely upon R39's hospital return, had resulted in R39 receiving medications in error. In addition, they verified the medications had not been transcribed on 7/25/19, even though R39 had returned to the facility at 3 p.m. on that date. On 8/1/19, at 9:31 a.m. RN-H and RN-D stated the nurse practioner (NP) had been notified of the medication errors on 7/26/19, and had fixed all the medication orders. However, they confirmed the NP had not been made aware of the errors related to the [MEDICATION NAME] or Tylenol. On 8/1/19 at 2:10 p.m., nursing assistant (NA)-M was interviewed. NA-M stated she is a trained medication aide (TMA) and also works as a ward clerk. NA-M stated she had received R39's readmission orders [REDACTED]. NA-M stated she herself would often reconcile and enter the medications into the computer system, but stated she did not have time that day. NA-M stated RN-D was also working on 7/25/19. On 8/1/19 at 4:26 p.m., a telephone interview with the consulting pharmacist (CP) was conducted. The CP stated side effects that could occur with increased doses of [MEDICATION NAME] would include: sedation, drowsiness and dizziness. The CP stated when used with [MEDICAL CONDITION] medications, the [MEDICATION NAME] could cause over sedation. At 7:50 p.m. on 8/1/19, a telephone interview was conducted with the admitting physician from R39's 7/31/19 hospitalization . The physician verified he had worked with R37 during each of her recent hospitalization s. The physician stated R39 had presented with more confusion and lethargy on 7/31/19, and stated it was reported she had not been eating or drinking in several days. The physician stated he had not been made aware of any recent medication errors that had occurred since R39's previous hospital discharge 7/25/19. The medication errors were then reviewed with the physician who stated he could not say that the errors had resulted in the resident's current hospitalization . However, the physician stated the errors definitely could have been a contributing factor to her lethargy which led to R39's inability to eat/drink. On 8/2/19, at 2:12 p.m. the director of nursing (DON) stated the RN working was expected to obtain the faxed physician's orders [REDACTED]. After that, an LPN was suppose to double check the order and as soon as possible an RN was suppose to complete an audit for accuracy. The DON confirmed she had met with FM-D on 7/26/19, and thought they had corrected all the orders with the NP. The DON stated she was not aware of the medication errors that continued to occur after 7/26/19. The DON stated any new facility staff were trained by other staff working at facility and were not to transcribe orders alone the first time. When requested, the DON could not provide competency assessments for transcription of medications for licensed staff. On 8/13/19, at 4:45 p.m. the NP was interviewed by telephone. The NP confirmed she was familiar with R39 and had evaluated her on 7/29/19, and had reviewed her medications. However, the NP stated the only medication errors she had been made aware of were the ones for which she had written orders on 7/26/19. R158's admission MDS dated [DATE], indicated R158 had intact cognition, and [DIAGNOSES REDACTED]. The MDS indicated R158 did not have delusions or hallucinations and received as needed medications for frequent, moderate pain that caused difficulty sleeping and limited day to day activity. R158's [DIAGNOSES REDACTED]. R158's Cognitive Loss Care Area Assessment (CAA) dated 7/27/19, indicated R158 had intact cognition, experienced panic attacks and anxiety for which she was prescribed medication for panic attacks. CAA indicated R158 at times was tearful, worried about her husband and was anxious to return to her apartment to be near her husband. R158's Behavioral Symptoms CAA dated 7/27/19, indicated R158 had anxiety and panic attacks and during these attacks may forget what she had been previously told by staff. The CAA indicated R158 would get upset about medications not being given correctly when in fact they were given per orders. R158 received [MEDICATION NAME] (antianxiety) medication. R158's Pain CAA dated 7/27/19, indicated R158 had sustained a fall and had fractured ribs and pelvis. R158 reported pain, and received pain medications. R158's initial Nursing assessment dated [DATE], identified R158 took [MEDICATION NAME] for anxiety and had pain in multiple places from fractured ribs, pelvis and left leg.The assessment indicated R158 indicated the pain medication alleviated the pain, but waiting too long for pain medication made the pain worse. R158's [MEDICAL CONDITION] Medication assessment dated [DATE], indicated R158 received scheduled [MEDICATION NAME] 0.5 milligrams (mg) three times daily for panic attacks caused by anxiety. An analysis indicated R158 appeared anxious and that R158 had reported the medication helped her a lot with anxiety. R158's Baseline Careplan dated 7/21/19, indicated R158's admitted was 7/19/19, and R158 had multiple fractures, weakness, pain, was anxious and tearful, and experienced panic attacks. R158's Order Summary Report dated 8/2/19, indicated the following medications were ordered upon admission: - [MEDICATION NAME] 0.5 mg give 1 tablet by mouth three times daily for panic attacks - [MEDICATION NAME] 5 mg take one tablet two times daily for hypertension - [MEDICATION NAME] sodium 100 mg as needed (PRN) at bedtime for constipation - [MEDICATION NAME] 400 mg every 6 hours PRN pain - milk of magnesia 400 mg/5 ml give 30 ml every 24 hours PRN for constipation - [MEDICATION NAME] HCI 4 mg by mouth every 4 hours PRN for nausea & vomiting - poluethylene [MEDICATION NAME] powder give 17 grams PRN daily for constipation - senna-[MEDICATION NAME] sodium tablet 8.6 - 50 mg give one tablet by mouth daily for constipation - [MEDICATION NAME] HCI give 5 mg every 6 hours PRN pain - vitamin D3 give 2000 units by mouth one time daily as supplement During interview with R158 on 7/29/19 at 2:46 p.m., R158 stated she was without medications for the first 24 hours after admission. During a subsequent interview on 8/2/19 at 2:47 p.m., R158 stated, I had a bad start here. I did not get here until 5 p.m., they did not have any pills for me and I had a panic attack. I was scared and wanted to go to the emergency room (ER) that first night because I was having a panic attack. I begged to go to the ER and they refused to let me go. I begged for them to get me something to help with the anxiety. I did not get my medication for anxiety until 3 p.m. the next day. I cried and had to beg for my pills. I was afraid of this place and scared to death. R158's Progress Note (PN) dated 7/20/19, at 6:50 a.m. indicated R158 had a difficult time adjusting to facility. (R158) is very teary eyed since 6 p.m. Stated she was unhappy and would leave. Staff attempted to comfort (R158) with juices, water and snacks. (R158) refused to be comforted and continued crying. (R158) stated she took some pills from her purse, was upset that medication could not stay in her purse. R158's Orders-Administration Note dated 7/20/19, at 10:39 a.m. indicated [MEDICATION NAME] tablet 0.5 mg - waiting on pharmacy. No other notes were made regarding R158 from the time of admission on 7/19/19, at 5 p.m. until 7/20/19, at 6:50 a.m. Review of Call Light log indicated that R158 utilized her call light 9 times on 7/19/19, from 8:40 p.m. until 11:55 p.m. R158 used her call light 26 times on 7/20/19, from 12:50 a.m. until 11:03 p.m. According to the Medication Administration Audit Report dated 8/5/19, R158 received medications as follows: - [MEDICATION NAME] 0.5 mg was administered on 7/20/19, at 3:30 p.m. (missed evening dose on 7/19/19 and morning dose on 7/20/19) - [MEDICATION NAME] 5 mg was administered on 7/20/19, at 9:37 a.m. (missed evening dose on 7/19/19) - [MEDICATION NAME] 400 mg was administered 7/21/19, 8:47 p.m. (ordered as needed for pain) - [MEDICATION NAME] HCI 5 mg was administered 7/20/19, at 8:46 p.m. (could have used every 6 hours PRN pain) Review of items available in the Emergency Medication Kit (E-Kit) dated 7/28/19, indicated [MEDICATION NAME] (a pain medication) 5 mg tablet and [MEDICATION NAME] (antianxiety medication) 0.5 mg tablets were available. On 8/2/19, at 3:17 p.m. registered nurse (RN)-D verified an admission progress note for R158 was not completed. RN-D stated R158 had been admitted around 5 p.m. on 7/19/19, and the last pharmacy run was at 4 p.m. RN-D stated if the main pharmacy was closed staff were to use the back-up pharmacy (a local pharmacy) and she did not know why that process had not occurred. RN-D initially stated she thought some of R158's medications had been obtained from the E-Kit, but upon checking verified that had not occurred. RN-D also verified R158 had not received her [MEDICATION NAME] (for anxiety) until 3:30 p.m. on 7/20/19, missing two doses. RN-D stated when R158 was experiencing anxiety on 7/19/19, the on-call physician should have been notified. RN-D could not find documentation of what time medications were delivered to the facility. On 8/5/19, at 11:42 a.m. the DON stated staff should have obtained medications from the E-kit, and if not available there, should have called the local pharmacy to have the medications delivered. The DON stated she was not aware R158 had no medications available from admission on 7/19/19 until 7/20/19 at 3:30 p.m On 8/6/19, at 2:08 p.m. licensed practical nurse (LPN)-G recalled being the nurse working on 7/19/19, when R158 was admitted . LPN-G stated some of R158's medications were not available and specifically remembered neither the pain medication or [MEDICATION NAME] were available. LPN-G stated, Generally we would call the pharmacy and see what is going on and then get the authorization to get the medication from the e-kit. However, LPN-G verified that had not occured. LPN-G added, R158 was tearful when she first came in because she was away from her husband and was worried about him. LPN-G could not verify if orders had been transcribed for R158 on 7/19/19, as she remembered having an admission, two discharges, and no other nurse to assist besides being the Charge Nurse for the unit that evening. On 8/6/19 at 2:19 p.m., NA-P was interviewed by telephone. NA-P stated she remembered working with R158 on 7/19/19, and stated R158 was very anxious, crying and scared. She kept saying she needed her medications and wanted to go to heaven. She was on the call light frequently. I reported this to the nurse. The facility's Reconciliation of Medications on Admission procedure included in the 11/2014, Admission, Transfer and Discharge nursing services policy and procedure manual: purpose- to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. The facility's Heritage Steps for order processing procedure dated 1/16/19, indicated: The charge nurse responsible for the patient is responsible for completing the orders. Place the NEW ORDERS in the chart and place in a designated area ON THE DESK. The chart DOES NOT get put away until ALL elements of the order are complete. Enter orders in point click care (PCC) and document a note in PCC. Remove any old medications from the cart. Sign/date the paper copy of the new order in the chart. Ask another staff person to confirm the order.

Based on interview and document review, the facility failed to ensure fifteen minute visual safety checks were implemented as directed in order to minimize the risk for potential unwitnessed injuries for 1 of 1 resident (R205) who sustained injuries of unknown origin. This caused harm for R205 who suffered multiple bruises, abrasions, a possible shoulder dislocation and fractured finger. In addition, the facility failed to assess 1 of 1 resident (R35) at risk of falling for the safe use of a power lift recliner. Findings include: R205's [DIAGNOSES REDACTED]. R205's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R205 had moderate cognitive impairment and required extensive assist of two persons for bed mobility, transfer, dressing and toilet use, and extensive assist of 1 person for locomotion on and off unit, eating and personal hygiene. The MDS also indicated R205 had functional limitations in range of motion of upper and lower extremities on both sides, and indicated R205 had experienced two or more falls without injury since the prior assessment. In addition, the MDS indicated R205 was on Hospice. R205's ADL (activities of daily living) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated [DATE], indicated R205's dementia had progressed and was recently admitted to Hospice on [DATE]. Her participation in ADL's fluctuated related to her dementia, confusion and weakness. She was requiring more physical assistance in ADL's. R205's Urinary Incontinence and Indwelling Catheter CAA dated [DATE], indicated R205 was occasionally incontinent of urine, and was on a scheduled toileting program, as able. R205's Falls CAA dated [DATE], indicated R205 had progressing dementia and received Hospice services. The CAA further indicated R205 was alert and orientated to self, did not always use call light and received safety checks, and staff anticipated her needs. In addition the CAA indicated R205 utilized a low bed, and wore gripper socks or non skid shoes. R205's Care Plan dated [DATE], indicated R205 had a history of [REDACTED]. Interventions included usual bedtime ,[DATE] p.m., offer alternatives other than medication for relaxation, and provide a quiet/calm environment one hour prior to going to bed. The care plan identified R205 had an ADL self-care performance deficit and required total assistance to extensive assist of one to two staff for bed mobility, was weight bearing, required extensive physical assist of one to two with use of walker and safety belt for transfers and toilet use and was not to be left on the toilet unattended. The care plan also indicated R205 was a fall risk and had impaired physical mobility related to fall with spinal compression fractures, pain/discomfort, weakness, [MEDICAL CONDITION] joint disease, diabetes mellitus type 2 with diabetic [MEDICAL CONDITION], Alzheimer's dementia with severe cognitive impairment, impaired balance and a history of falls. The care plan further indicated R205's family requested no ambulation for R205 due to unsteadiness, knees buckling and her high risk for falls. The care plan indicated the family was aware R205 would at times get up on her own and walk about her room and into hallway. Interventions included: anticipate and meet needs, assist with toileting at 5:00 a.m., keep in sight when restless and wandering/do not lay down in bed at these times, do not leave in room by self when up in chair, assist to day room and give coffee, monitor so does not get up on own, provide even floors free from spills and/or clutter; adequate, glare-free light; call light in reach, personal items within reach, low bed, non-skid shoes, or gripper socks on during the day and gripper socks on at bedtime, and 15 minute checks per family request. R205's undated Morse Fall Scale indicated R205 was at high risk for falls. R205's Incident Report dated [DATE], indicated a nursing assistant (NA) went to get R205 up for the day at 7:30 a.m. and noted R205's right middle finger and hand swollen and blue/black in color, raised lump on the left side of head in hairline, abrasions on left knee and outer side of left leg, bruises on right arm and left shoulder was swollen and warm to touch with red abrasions. R205 was unable to give a description of the incident. The report indicated the director of nursing (DON) and charge nurses spoke with staff who had worked with resident, but none of the staff were aware of R205 having any recent falls or incidents. The facility made a report to the State Agency (SA) [DATE]. The report indicated an NA went in to help R205 to breakfast and found injuries including: bruise on left forehead, left shoulder pain, multiple bruising on arms and legs, scraping on left knee, swollen and bruised right middle finger. The report to the SA indicated the facility was Uncertain of what happened. Investigation started and call was placed to family. Resident will be seen by nurse practitioner this a.m Action taken to protect resident included: investigation started, staff will monitor every 15 minutes, and resident will be seen by nurse practitioner (NP). The facility's 5-Day investigation report submitted to the SA on [DATE], indicated NA-H stated she had found R205 in bed with the injuries. During the night there had been two staff caring for her, nursing assistant (NA)-N and licensed practical nurse (LPN)-E. R205's was last checked on at 5:30 a.m. and was sleeping. No injuries noted throughout the night. Staff working the previous p.m. shift were interviewed and stated no injuries noted throughout their shift. Since R205 had a history of [REDACTED]. There were no concerns identified related to the process followed for the incident. Actions taken to prevent reoccurrence were identified to include: care plan reviewed for toileting needs, pain management, and review of individual needs, two staff present for all cares provided, care plan updated. Unable to determine the cause of R205's injury, suspected fall but unable to verify with any witnesses. R205 unable to tell staff what happened. She normally transferred with assistance of one and could bear weight. She had self transferred in the past. The report further indicated R205 had been harmed, and indicated R205 was a Hospice patient. Although the incident happened on [DATE], and the nurse practitioner (NP), ordered tests that day, R205's family declined to send her to the emergency room (ER) for evaluation. Progress notes indicated on [DATE], R205 had been alert but had new bruising noted behind her right ear and under her chin. Additional progress notes indicated on [DATE], R205 became non-responsive, and at 1:30 a.m. on [DATE], R205 died . R205's Nursing Home Note, completed by the nurse practitioner (NP) on [DATE], indicated R205 presented with a history of progressing dementia to the point where she was now being followed by Hospice. The note further indicated staff reported concerns of a possible/presumed fall overnight as the morning staff had noticed a significantly swollen, bruised right middle finger as well as swelling and increased discomfort to left shoulder, progressive bruising and abrasion noted to the left outer forehead and abrasions down the left leg. The NPs note included, Upon physical exam, (R205) was noted to have obvious swelling and discomfort to the left shoulder as well as increased pain to the right middle finger. (R205) could not recall any recent falls. Denied any headaches, blurred vision, difficulty breathing. The impression and plan concluded: Fall. At this time, family was okay to proceed with a left shoulder and right middle finger X-ray. However, upon further discussion with Hospice, family decided against this and would like to just treat for pain management. Hospice is in agreement to start [MEDICATION NAME]. On [DATE], at 4:57 p.m. family member (FM)-A was interviewed. FM-a stated he was contacted by the director of nursing (DON) on [DATE], and had been informed R205 had some bumps and bruises and was asked if the family wanted R205 seen in the ER. FM-A stated the family had not wanted R205 sent to the ER if there were only bumps and bruises, as she had fallen before. FM-A indicated FM-B and FM-C were contacted and went to the facility to see R205 and had also spoken to the Hospice nurse in person at that time. FM-A stated after discussion with the Hospice nurse, the decision was made to keep R205 comfortable as an ER transfer would have been painful for her. FM-A further stated after the incident, a family member stayed with R205 at all times, R205 continued to decline, and passed away on [DATE]. FM-A stated the facility administrator had spoken with the family on [DATE], and had indicated the facility would launch an investigation and interview all staff. FM-A stated he thought the administrator had reported back to the family the next day, and informed them no one had any knowledge of what had happened. FM-A confirmed R205 had a history or falling. On [DATE], at 8:42 p.m. LPN-E verified she was working the night of the incident with R205 and stated throughout the night, she had assisted R205 to the bathroom as well as administered medications, and stated no injuries were noted for R205. LPN-E also stated R205 and her roommate were always busy in their room, so the nurses performed hourly checks and the NA's performed visual checks every 15 minutes. LPN-E confirmed the last time she had checked R205 was at 5:15 a.m. and at that time, she had been in bed sleeping with no injuries noted. LPN-E stated she felt R205 would have been capable of getting back up off the floor if she had fallen. LPN-E further stated the time at issue was from 5:15 a.m. to 7:15 a.m., which LPN-E referred to as a tough time for staff to complete their safety checks, because they are doing rounds and giving shift report. On [DATE], at 5:20 a.m. NA-F confirmed she had been working the night of R205's incident. NA-F stated rounds were completed every two hours but indicated R205 required every 15 min checks. NA-F further clarified it had been a normal night and nothing unusual occurred. On [DATE], at 10:38 a.m. LPN-C stated R205 received 15 minute checks due to her fall risk and history of falls. LPN-C stated NA-H reported R205's injury to her at 7:15 a.m. and after an assessment was completed, R205's Hospice nurse had also been notified and came over to the facility right away. LPN-C also said the NP was at the facility and evaluated R205 by 9 a.m. On [DATE], at 11:08 a.m. NA-H stated she had started work on [DATE], at 6:00 a.m. NA-H stated she got report from NA-N and at 6:15 a.m., had looked in on R205 who was sleeping on her right side, facing the wall with her covers pulled up to her head. NA-N said she had checked R205 again at 6:30 a.m. and her eyes were open but she was still facing the wall. NA-N stated at 6:45 a.m., R205 had moved onto her back and NA-H said she (NA-H) stood watching to see if R205 was awake, but added, (R205) had not been ready to get up yet. NA-H stated she had returned to R205's room after assisting another resident and at that time, R205's heels were over the edge of the bed. NA-H stated she greeted R205 who had responded by asking NA-H why she was so bright eyed that day. NA-H further stated as she uncovered R205 to assist her up for the day, NA-H saw a scuff on R205's left knee and bruises on her shin. NA-H stated she put R205 back to bed and went to get the nurse. NA-H stated she wasn't able to find the nurse right away and was concerned R205 would self transfer out of bed, so had returned to R205's room to provide care. NA-H said she then noticed R205's right finger was the deepest purple she had ever seen. NA-H stated she knew she had to get the nurse right away. NA-H indicated R205 had otherwise responded like normal that morning, and verified R205 could self transfer and would get up and walk without supervision so staff had to keep a close eye on her. NA-H stated, When she was ready to go, she was ready to go. NA-H said LPN-C and RN-D were the nurses who completed assessment of R205's injuries. On [DATE], at 8:30 a.m. the DON stated she arrived at work at 6:45 a.m. on [DATE], and completed rounds of the facility. The DON said she was called into R205's room at approximately 7:15 a.m The DON stated after assessing and caring for R205 and notifying her family, she (the DON) had begun her investigation. The DON stated she immediately went to the night shift nurse LPN-E, who was still in the building. The DON said LPN-E had told her nothing had been reported to her regarding any incidents with R205 that night. The DON said NA-N had already left that morning, so she'd called her back in. The DON said NA-N had also reported nothing out of the ordinary had occurred. The DON said she interviewed the night shift staff, as well as the staff who had worked the previous evening, all of whom reported nothing unusual had occurred. The DON stated R205 required hourly checks at night and 15 minute checks when up. After the incident, she implemented 2 staff to care for R205 at all times. In addition to an initial interview, the DON said she had staff provide written statements and then did another interview with the night shift staff because she had identified the time period of any potential incident to have been between 5:30 a.m.-7:15 a.m. The DON stated she had also interviewed six other residents on R205's wing to see if they were aware of any concerns. Further, the DON stated she'd had NA-H, LPN-E and NA-N demonstrate how the R205 had been laying in bed and what they had done. The DON stated their stories did not change, there was nothing to indicate staff were being dishonest; no nervousness, staff maintained eye contact, and staff weren't defensive so she believed the staff. Thee DON stated R205 had been capable to self transfer and had done so in the past, but was not sure if R205 could get back into bed by herself. However, the DON said R205 was very close with her roommate and perhaps the roommate had tried to assist. On [DATE], at 12:22 p.m. when asked about the care plan indicating staff should check on the resident every 15 minutes per the family's request, the DON confirmed if the care plan directed indicated safety checks were to be performed every 15 minutes, they should have been done every 15 minutes. On [DATE], at 1:35 p.m. NA-N stated she had worked a double shift on the night in question. NA-N stated she was on the 1st floor for the first shift, and had reported to the 2nd North floor at 10 p.m. NA-N stated after she received report, she and the other NA looked in on a few residents. NA-N stated they did not do any rounds on R205 at midnight as the evening shift staff had just done rounds on her and they did not want to disturb R205 or her roommate. NA-N stated R205 required assistance of 1 or 2 staff depending on how she was feeling. NA-N stated the nurse was in R205's room at 12:30 and took R205 to the bathroom. NA-N then stated she'd checked in R205 at 2:30 a.m. but did not physically check her because she was sleeping. NA-N further stated when she had completed rounds at 4:30 a.m., she had checked and changed R205 in the bed. NA-N stated the nurse was in the room again at 5 a.m. NA-N stated she checked R205 frequently throughout the night, however, was not aware R205 needed 15 minute checks, and stated she had not documented her checks anywhere. NA-N stated there had been no concerns with R205 throughout the night. NA-A stated R205 could self transfer and get out of bed, and could walk. NA-N stated there had been an incident where she had done so the previous evening. However, NA-N stated she had not known of any concerns with R205 until she was contacted by the DON. R205's Documentation Survey Report for (MONTH) 2019, directed the staff to perform every 15 minute visual safety checks beginning at 12 midnight through 11:45 p.m. Review of the report from [DATE] at 12:00 a.m. through [DATE], at 6:15 a.m., revealed the following: -Shift beginning ,[DATE]: 26 of 31 safety checks were blank -Shift beginning ,[DATE]: all 31 safety checks were blank -Shift beginning ,[DATE]: 28 of 31 safety checks were blank -Shift beginning ,[DATE]: all 31 safety checks were blank On [DATE], at 11:05 a.m. the schedule and Documentation Survey Report were reviewed with the DON. The DON verified the night shift started at 10:00 p.m. and worked into the following calendar day. The DON said therefore, the assignment would be noted as the third shift. The DON explained, if a shift was documented on the ,[DATE] assignment sheet, it would be from 10 p.m. on ,[DATE] to ,[DATE] at 6 a.m. The DON confirmed R205's safety checks had not been documented for the aforementioned shifts but stated they should have been. On [DATE], at 12:23 p.m. the administrator stated their investigation had determined R205 had been checked on frequently but had determined a window of time from 5:15 a.m. to 7:15 a.m. that was unaccounted for. The administrator confirmed if a resident required every 15 minute checks, he would have expected they be documented per procedure. On [DATE], at 2:59 p.m. the DON stated the facility did not have a formal written policy related to safety checks however, stated they had a reference guide in the electronic medical record for nursing assistants which provided documentation guidance. The facility's undated Understanding Frequencies in Point of Care (P[NAME]) Quick Reference Guide, indicated tasks identified with a specific time must be documented at a specific time. R35's quarterly MDS dated [DATE], indicated R35 had [DIAGNOSES REDACTED]. The MDS also indicated R35 required limited assist of one staff person for transfers, but was independent with ambulation. R35's Annual MDS dated [DATE], indicated R35 required assist of one staff person for transfers and ambulation. R35's ADL Functional/Rehabilitation CAA dated [DATE], indicated the amount of assistance R35 needed fluctuated with his health status. The CAA indicated when his [MEDICAL CONDITION] or [MEDICAL CONDITION] exacerbated, R35 needed more assistance. R35's Falls CAA dated [DATE], indicated R35 had not fallen during the quarter. The CAA further indicated R35 was usually alert, oriented and safety-aware but on occasion, R35 did overestimate his ability and would fall. R35 had a history of [REDACTED]. The CAA also indicated R35 was usually consistent with call light use. R35's Morse fall scale dated [DATE], revealed R35 was at high risk for falls. R35's Care Plan dated [DATE], indicated R35 had an ADL self-care performance deficit related to oxygen desaturation with exertion (an abnormally-low partial pressure of oxygen in the arterial blood during episodes of exercise) and R35's need for assistance with ADL's and mobility fluctuated with health status changes. The Care Plan directed staff that R35 could usually move between surfaces using a walker independently but with health status changes, R35 required up to extensive assistance from one staff. On [DATE], at 6:43 p.m. R35 was observed in his room, sleeping in a power lift recliner which was elevated to a 30 degree incline. R35's legs were extended out in front of him, while bracing his feet against the floor. R35 appeared as though he was attempting to stand up out of the recliner. R35 was wearing slipper socks. The oxygen concentrator was on at 2.5 L (liters)/min (minute), but the nasal cannula was hanging off the side of R35's power lift recliner. On [DATE], at 2:34 p.m. R35 was observed in his room, seated in the power lift recliner which was elevated to a 30 degree forward incline. R35's legs were extended out in front of him while his feet braced against the floor. Again, R35 appeared as though he was trying to stand up out of chair. R35's oxygen concentrator was on but R35 was not using it. On [DATE], at 7:38 p.m. R35 was observed sleeping in the power lift recliner which was elevated to a forward 30 degree incline. R35's legs were extended out in front of him with his feet bracing the floor. R35 slipper socks were on. R35 oxygen concentrator was on at 2.5 L/min, but the nasal cannula was hanging off the side of R35 power lift recliner. On [DATE], at 5:17 a.m. R35 was observed seated in the power lift recliner, snoring. R35 was dressed for the day, and his room ceiling lights and TV were one. The recliner was elevated to a 30 degree forward incline with R35 legs extended out in front of him with his feet bracing the floor. R35 appeared as though he was attempting to stand up out of the chair. R35 was wearing his oxygen and slipper socks. On [DATE], at 9:33 a.m. licensed practical nurse (LPN)-A stated R35 had slid out of his wheelchair previously, but never out of the recliner. LPN-A verified R35's power lift recliner should always be in the lower position, closer to the floor in order to promote safety. On [DATE], at 11:27 a.m. LPN-A stated R35's oxygen saturation was frequently low daily and when it was low, R35 would become really confused. LPN-A stated R35 had gone to the emergency room in the past because of falls. LPN-A furthered stated R35 sometimes experienced low oxygen saturations which could have be related to his falls because it would cause him to be confused. LPN-A then stated staff would only chart something if R35 fell , or if there were concerns about R35's pulse oximeter readings. On [DATE], at 4:01 p.m. RN-A stated R35 had not fallen within the last year however, RN-A verified R35 was at high risk for falls. RN-A confirmed a risk vs. benefit had not been completed with R35 related to the risks of his sleeping in the recliner in an elevated position. RN-A further stated R35's physical ability fluctuated due to his health, and stated R35's power lift recliner should be set in the lowest position level to ensure R35's safety, and to prevent R35 from sliding onto the floor. On [DATE], at 2:06 p.m. a copy of R35's power lift recliner manufacturer's instructions were requested but none were provided. On [DATE], at 3:39 p.m. the DON verified any resident could be at risk for falls. The DON also verified a risk assessment for R35's power lift recliner had never been completed, and verified it would be a fall risk for any resident that sat in a power lift recliner in an inclined position. The facility's ,[DATE] Fall Risk Assessment policy, indicated the staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable.

Based on observation, interview, and document review, the facility failed to provide supervision during weekend activities which resulted in the potential for serious harm, injury, or impairment to 1 of 3 residents (R1) who was identified at risk for wandering, had cognitive impairment, and had wandered one mile away from the facility unattended. The lack of supervision during activities resulted in an Immediate Jeopardy (IJ) for R1. This practice had the potential to affect 3 of 3 residents (R1, R2, R3) who had history of wandering behaviors and utilized a Code Alert. The IJ began on 5/19/19, when R1 attended a weekend activity, left the activity area, exited the building undetected, and wandered into the community approximately approximately one mile from the facility. The local police were notified by a local business that R1 was at their location, and having difficulty breathing. R1 was escorted to the hospital by the police, and the police checked with the facility regarding a missing resident at which time the police and the facility confirmed it was R1. The administrator and director of nursing (DON) were notified of the IJ on 5/24/19, at 2:04 p.m. The IJ was removed on 5/24/19, at 8:19 p.m. but noncompliance remained at the lower scope and severity of a D, which indicated an isolated incident with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A Nursing Home Incident Report (NHIR) dated 5/19/19, indicated R1 had attended an activity in the facility chapel and left the facility. R1 was found approximately 8 blocks (1 mile) away from the facility at a fast food restaurant. The fast food restaurant's employees identified R1 was experiencing difficulty breathing and called the police. The police officers arrived at the scene and escorted R1 to the hospital emergency room . The officers then inquired if the R1 was a resident at the facility, at which time the facility was notified R1 was at the emergency room . R1 was admitted to the hospital for observation, and was also diagnosed with [REDACTED]. R1's annual Minimum Data Set ((MDS) dated [DATE], and quarterly MDS dated [DATE], indicated R1 had severe cognitive impairment, and [DIAGNOSES REDACTED]. The annual MDS indicated R1 did not display any type of behaviors. The quarterly MDS indicated R1 displayed wandering behaviors 1-3 days during the assessment period. Both MDS's indicated R1 was able to ambulate independently with supervision. The MDS's did not indicate R1 required the use of a personal alarm, including wander alarms which would sound if R1 exited through a door equipped with an alarm system. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 1/23/19, indicated the staff were to provide supervision, guidance and cues as needed due to dementia. The Activities of Daily Living CAA and Behavioral CAA completed at the time of the annual MDS did not trigger as needing a comprehensive analysis. R1's Elopement Risk assessment dated [DATE], indicated R1 was at low risk for elopement, did not have a history of wandering, and enjoyed sitting outside with others. R1's Elopement Risk assessment dated [DATE], indicated R1 was at moderate risk for elopement, had previously been found wandering in the building on 3/10/19, but did not leave the facility. Family member (FM)-A approved the use of a Code Alert monitor to be initiated at that time. The staff were to observe R1 closely for attempted elopement. At that time, R1 was also evaluated for a potential transfer into a locked memory care unit. R1's Elopement Risk assessment dated [DATE], identified R1 at high risk for elopement. The assessment indicated R1 utilized a Code Alert Monitor, yet had eloped from the facility on 5/19/19. The DON, FM-A, and county social services had been contacted regarding a potential admission into a memory care assisted living. R1's care plan dated 2/21/19, indicated R1 was at low risk for elopement, and was independent with ambulation with a walker. R1's family had reported to the facility R1 may be at risk for elopement when the weather was nice as R1 enjoyed being outside, and family resided less than one block from the facility. The care plan directed the staff to monitor R1's Code Alert (wanderguard alert system) weekly, observe, report any attempts to leave the facility unattended, and to invite R1 to activities. R1's progress notes dated 5/19/19, indicated at 9:00 p.m. during the 3:00 p.m. medication pass, licensed practical nurse (LPN)-C had identified R1 was not on his identified unit. An activity had taken place in the chapel at 2:00 p.m. however, R1 had not been seen after the activity. LPN-C began searching for R1 outside of the facility when the city police arrived at the facility. The police reported a man who was only able to identify himself with his first name had been picked up at a fast food restaurant, and brought to the hospital. The hospital was contacted, and R1 had been admitted with pneumonia. R1's family had been informed. A second progress note dated 5/20/19, at 2:40 p.m. indicated R1 returned to the facility. R1's hospital Discharge Summary dated 5/20/19, indicated R1 had been admitted to the hospital with [REDACTED]. R1 was treated with intravenous (IV) antibiotics, and returned to the nursing home on 5/20/19, with orders to continue oral antibiotics. R1's clinical record lacked documentation related to behaviors upon return to the facility. On 5/23/10, at 11:47 p.m. R1 was observed seated in the dining room with three other gentlemen, eating the noon meal. R1 was observed to be alert, and well groomed. R1 did not display any type of behaviors during the meal. -At 12:07 p.m. R1 stood up from the dining room chair, walked to the counter and obtained a package of Oreo cookies for himself and tablemate. R1 handed one package of cookies to his tablemate, sat down, opened the cookies and ate them without difficulties. -At 12:35 p.m. R1 tied his shoe, stood up and walked out of the dining room without any type of physical assistance devices. R1 walked down the hallway until he met dietary aide (DA)-A and asked for the restroom. DA-A escorted R1 to his room and pointed out the restroom. R1 entered the restroom independently, and upon exiting the restroom, sat in a recliner in his room. On 5/23/19, at 2:02 p.m. FM-A was interviewed at the facility. FM-A confirmed R1 had wandered away from the facility on 5/19/19. FM-A stated R1 had previously resided in an apartment building across the parking lot from the facility, and at FM-A's home approximately 600 yards from the facility. However, FM-A stated R1 walked to a fast food restaurant which was in the opposite direction from his former residences. FM-A also stated R1 had experienced increased memory loss/confusion over the past three years. FM-A stated while residing at FM-A's home, R1 had wandered out of the house on one occasion. At that time, R1 had not left the city block to which he lived. FM-A stated R1's dementia had progressed, and the facility had applied a wanderguard alarm on R1 to ensure the staff were aware of when/or if R1 attempted to leave the facility. R1 did not have a history of wandering away from the facility. FM-A stated he did not think R1 intended on going to the fast food restaurant as it was not a routine place to visit, nor was it routine for R1 to visit the local park/river approximately 1/2 city block from the restaurant. FM-A stated there were multiple streets including a main highway (Hwy 71) in order to arrive at the restaurant. FM-A stated he had signed papers to move R1 to the upper level of the facility approximately 15 minutes ago as the exits on second floor were equipped with a wandergaurd system including the elevator which would alarm upon exiting and entering. FM-A stated the facility was working on transferring R1 to a locked memory care unit. -At 2:23 p.m. nursing assistant (NA)-A stated she had worked on 5/19/19, until 2:30 p.m. The facility had a special music program in the chapel (located next to the front door) at 2:00 p.m. NA-A stated R1 had attended the activity, and when she had left the facility at 2:30 p.m. R1 was in the first floor west unit living room. NA-A stated R1 had a history of [REDACTED]. NA-A stated the facility did not have activity staff on the weekends, and the nursing assistants did not attend the activity in order to provide supervision for the residents who attended the activity. NA-A stated the volunteers who ran the activity were supposed to supervise the residents who attended. No specific staff member was assigned to supervise the residents who attended the activity. NA-A stated when R1 returned from the hospital, the staff started every 15 minute checks and R1 was to move to second floor. -At 2:30 p.m. NA-B stated she had worked on 5/19/19, until 2:30 p.m. NA-B stated when she left the facility at 2:30 p.m. R1 was in the lower west unit living room. NA-B stated the facility did not have activity staff on the weekends. The weekend activities were conducted by volunteers, and they were to supervise the residents in the activities. The NA's were to escort the residents to and from the activities, but did not stay and supervise the activity. NA-A stated R1 utilized a wanderguard system even though R1 rarely attempted to leave the facility. NA-B stated the staff had discussed moving R1 to the secure memory care unit but, that had not happened rather, R1 was to move to the upper level on 5/23/19. -At 2:45 p.m. the environmental service director (ESD) and housekeeper (HSKP)-A were observed removing items from R1's walls and packing his personal belongings. ESD-A stated he had been directed approximately one hour ago to move R1 to the upper level. -At 2:46 p.m. NA-C stated she had worked on the upper level during the evening shift of 5/19/19. NA-C confirmed R1 had left the facility unattended and was escorted to the hospital by the police. NA-C stated on the weekends, the NA's escort residents to the activities however, the nursing staff did not stay with the residents during the activities. NA-C stated she did not know if the facility had activity staff on the weekends or not, but knew she had not been directed to monitor the residents during weekend activities. -At 2:55 p.m. activity aide (AA)-A stated the facility did not schedule any activity staff on the weekends. The weekend activities usually included a movie and popcorn in the chapel, which was conducted and supervised by a former employee/volunteer. The music activity which was held on 5/19/19, was a special activity in which a group called and asked to provide music on that day. AA-A stated she had added this activity to the weekend activity boards, and the staff were to escort the residents to and from the activity. AA-A confirmed the facility did not assign a specific staff member to monitor the residents while at weekend activities, as the facility did not routinely provide formal activites on Saturday or Sunday. AA-A stated R1 had sat through entire activities from start to finish in the past however, the past 1-2 months R1 had started wandering away from the activities. AA-A stated the facility had not made any type of changes to R1's activity care plan. -At 3:05 p.m. LPN-A stated she had worked at the facility on 5/19/19. LPN-A left the facility between 2:30-3:00 p.m. and was unaware R1 was missing. LPN-A stated weekend activities were rare, but when they happened the nursing staff were to escort the residents to and from the activity. The facility did not have activity staff members on the weekends, and the nursing staff were not assigned to monitor the weekend activities. LPN-A stated the nursing staff were to monitor the residents residing on the units, and not when they were in activities. - At 3:23 p.m. LPN-B stated she had worked from 6:00 a.m. to 8:00 p.m. on 5/19/19. LPN-B stated LPN-C had notified her that R1 was missing, and they proceeded to search the facility. LPN-B stated R1 utilized a wanderguard however, the exit door R1 went out, which was down the administrative hallway, was not equipped with an alarm system. LPN-B stated if a resident exited that door, the door automatically locked behind them and required a facility employee badge to open it again. LPN-B stated she did not know which door R1 left from, but knew not all doors were equipped with alarms. LPN-B stated the police officers informed the facility R1 had been brought to the emergency room . LPN-B verified no staff were assigned to monitor the residents who attended the activity, and the volunteers providing the activity were responsible for monitoring. LPN-B stated she was also working on 5/20/19, when R1 returned to the faciltiy. LPN-B stated R1 was very confused upon returning, and he wandered up and down the hallway and was agitated. R1 was started on every 15 minute visual checks on 5/21/19, and R1 was to move to the upper level as soon as possible. -At 3:38 p.m. R1 moved to the upper level of the facility. -At 3:40 p.m. LPN-C stated she had identified R1 was missing from the facility on 5/19/19, around 3:00 p.m. LPN-C stated she had identified R1 was not in his assigned area, alerted other staff members, and began searching the facility. LPN-C exited the facility via the administrative hallway exit and was searching the outside grounds when two police cars arrived at the facility. The police officers asked LPN-C if the facility was missing a male resident with R1's first name, at which time it was confirmed it R1 had been located. LPN-C stated the facility did not have staff members assigned to monitor the residents while attending weekend activities off the unit. -At 3:59 p.m. registered nurse (RN)-A stated when R1 returned from the hospital on [DATE], R1 displayed increased behaviors. R1's primary physician had been contacted and ordered R1 to receive his bedtime dose of [MEDICATION NAME] (antidepressant) 15 milligrams (mg) and [MEDICATION NAME] (antianxiety medication) 0.5 mg immediately in order to calm R1 due to the increased agitation. RN-A reviewed R1's progress notes, and confirmed the clinical record lacked notes regarding R1's behaviors, yet R1's Physician order [REDACTED]. RN-A stated R1 had a history of [REDACTED]. R1 utilized a wanderguard system however, he may have left the facility via the administrative hallway exit door which lead directly to the outside. RN-A stated the administrative doorway did not have any type of alarm system. The facility did not utilize video cameras so the exact time of when R1 left the facilty or the door that he exited could not be determined. RN-A stated he had updated R1's care plan to ensure the wanderguard system was being monitored regularly however, RN-A confirmed he had not updated the care plan to ensure the every 15 minute checks were completed, which RN-A had initated on 5/21/19, (24 hours after R1 had returned from the hospital.) RN-A stated the weekend activities were to be monitored by the volunteers or other visitors providing the activity. RN-A stated the nursing staff assist the residents to the activities, and confirmed the facility did not assign staff members to monitor weekend activities. -At 4:39 p.m. the dietary director (DD)/safety director stated the wanderguard system was monitored weekly as directed by the manufacturer. The DD stated the main entrance, the coffee shop exit, the resident elevator on the upper and lower level, and the employee hallway on the lower level were all equipped with the wanderguard system to alert staff when a resident was near the doors. The other lower level exit doors were equipped with an alarm which would sound when the door opened. Initially the door would lock, but if held for 15 seconds the door would alarm and then release. The DD stated the only door in the facility that was not equipped with an alarm was the exit door at the end of the administrative hallway which went to the assisted living, and also included an exit door which lead directly to the outside. Anyone who exited the facility via the administrative exit door would require an employee badge to return to the facility. The assisted living corridor did have an exit door to the parking lot that was not equipped with an alarm system. DD was unsure which door R1 exited. -At 5:10 p.m. the administrator stated the facility was not sure which door R1 utilized to exit the facility but may have left via the administrative hallway door. At this time, the administrative hallway exit was observed to have a magnetic connection alarm, a Caution banner across the door, and a sign which read This Is Not An Exit. A wet floor sign had also been placed in front of the door to deter residents and visitors from utilizing the door. The administrator stated the facility had ordered an additional wanderguard system to be installed at the egress of the administrative hallway. The administrator stated the facility had not utilized weekend activity staff for several years, and any activities on the weekends were conducted on the nursing units or in the chapel. The chapel activites were to be monitored by the volunteers providing the activities, and the nursing staff were to tag team the monitoring of the activities. The adminstrator verified the facility did not assign a specific staff member to provide supervision during the weekend activities, and they were unaware of which door R1 used to exit the facility. On 5/24/19, at 7:09 a.m. NA-D stated he had worked the morning of 5/19/19. NA-D stated he did not assist any of the residents from the upper level to the music activity on 5/19/19, nor had he been assigned to monitor the residents attending the activity. -At 7:23 a.m. LPN-D stated she was unaware as to who was to supervise the residents during weekend activities. -At 7:35 a.m. R1 was observed sleeping in a dining room chair in the north upper level dining room. At 7:48 a.m. R1 ambulated from the upper level north dining room to the west dining room. R1 was able to ambulate independently without the use of assistive devices. R1's gait was observed to be steady. -At 8:15 a.m. NA-E stated the facility occasionally had activities on the weekends however, there were no activity staff members present. NA-E stated the NA's were to assist the residents to the activities, but no staff members were assigned to supervise the residents during the activities. -At 9:06 a.m. LPN-E stated the facility did not have a staff member assigned to monitor activities on the weekends. -At 9:53 a.m. NA-F stated the nursing staff did not monitor weekend activities. - 10:03 a.m. RN-B reviewed R1's MDS assessments, and confirmed the assessments had not been coded correctly to reflect the use of personal alarms. RN-B stated she was unaware who was to monitor the weekend activities. -At 10:40 a.m. the licensed social worker (LSW) stated she had assisted with room arrangements to ensure R1 was able to transfer to the upper level of the facility. R1 was also to receive every 15 minute visual safety checks, and the staff were to monitor his whereabouts. LSW stated she had been working with R1's family, the county staff members, and the assisted living to transfer R1 into a secure memory care unit at the assisted living. LSW stated she did not work the weekends, and did not have knowledge regarding supervision at weekend activities. -At 10:55 a.m. the DON stated the music activity on 5/19/19, was a special event in which a community member had offered to provide music to the residents. The nursing staff assisted the residents to the music activity, including R1. R1 had the ability to ambulate independently and had walked from the chapel to the west lower level unit by himself. At some point, R1 left the facility, had found the fast food restaurant, was escorted by the police from the fast food restaurant to the emergency room , and the police informed the facility of R1's location. Since that time, the facility had implemented every 15 minute checks, completed a new elopement assessment which identified R1 at high risk for elopement, and moved R1 to the upper level of the facility which was not a locked unit, but was equipped with a wanderguard system upon entering and exiting the elevator. In addtion, the facility had added a temporary alarm to the administrative exit door along, with signage encouraging individuals to not use the door. An additional wanderguard system would be installed the week of 5/28/19. The DON reviewed R1's clinical record and confirmed the MDS had not been coded correctly, the care plan did not reflect the every 15 minute visual monitoring, and the staff had not documented R1's behaviors since returning to the facility, including adverse behaviors which required additional medications. The DON stated the interdisciplinary team had been working on ensuring R1's safety. When questioned if the DON had reviewed the supervision during weekend activities, the DON stated the nursing staff were unaware that there were no activity staff members present on 5/19/19. The music activity was an extra, unscheduled activity, and due to a lack of communication with the activity department, the facility had not assigned any staff member to monitor the music activity. -At 11:51 a.m. the administrator stated the weekend activities such as movie day and church were conducted by volunteers. The volunteers who provided the activity were to monitor the residents. The administrator stated the volunteers had provided weekend activities for many years without activity staff. If there was an extra activity, the activity staff members were to adjust their hours to provide the weekend supervision as needed. The administrator confirmed the residents while at activities required supervision however, the facility did not have a specific staff member assigned to monitor the residents. -At 1:00 p.m. the DD/safety director accompanied the State Agency (SA) staff to the administrative hallway exit. A magnetic alarm was observed on the door along with a caution banner and a sign indicating this door was not an exit. A wet floor sign was on the floor in front of the door. Upon opening the door, the magnetic door alarm did not sound. The DD and SA staff were able to exit the door without problems. The corridor to the assisted living had an exit door to the parking lot, which did not alarm when opened. A door which lead to the kitchen area was to be closed. The DD stated the door required an employee badge to open however, the door opened without difficulties. The lobby area of the assisted living had two doors which lead into the memory care unit. Both doors were locked. The DD stated the door to the kitchen needed to be reset, which the memory care assistant completed immediately. Upon returning to the administrative exit door, the DD utilized her employee badge and opened the door. The administrator greeted the DD and SA staff and stated the code required to be reset. The administrator reset the alarm and opened the door. The door sounded. Review of the Temporary Door Alarm sheet indicated the temporary door alarm had been installed on 5/21/19, at 6:45 p.m. The alarm system had been tested daily since installation. The alarm had last been tested on [DATE], at 8:39 a.m. Policy Review: The Centers for Medicare/Medicaid Service (CMS) Resident Assessment Instrument (RAI) manual version 3.0, Section P directed the staff to identify on the MDS when a resident utilized a personal alarm, including a wanderguard. The Elopement Policy dated 5/2011, directed the staff to asses the resdient for the risk of elopement prior to and/or at admission, and on an ongoing basis as needed. The residents' who were identified at risk for elopement were to have care plan interventions implemented to help prevent elopement. The Safe Precautions for Activities policy from the Activities Policy Manual dated 1996, directed the activity staff to provide supervision and safety for all residents during activity programs in order for the activities to run smoothly and without any adverse incidents occurring. The policy indicated the activity staff were to assure responsibility for supervision while engaged in activity programs and musing staff were to assist upon request. The facility did not have a policy related to the placement of the temporary door alarm system. On 5/24/19, at 2:05 p.m. the administrator and DON were informed of the IJ related to lack of supervision for R1 during activities on 5/19/19, which resulted in R1 wandering away from the facility unattended. -At 3:45 P.M. the environmental service director (ESD) and DON tested the temporary door alarm. The ESD stated when the door alarm sounded, a code was required to turn the alarm off however, when the door is opened, the alarm was deactivated and needed to be reset. This is completed by re-entering the code. If the door is not closed and the code is not re-entered, the alarm system would not function correctly. The IJ that began on 5/19/19, was removed on 5/24/19, at 8:19 p.m. when the facility had completed the following interventions: -R1 was comprehensively assessed for wandering behaviors. -R1's care plan had been revised. -A Root Cause Analysis of the events of 5/19/19, had been completed. -A functional temporary door alarm had been installed. -The Activities policy had been updated to include supervision when activity staff members were not present. -A policy related to temporary door alarms was developed and implemented. -All staff were educated on the revised policies and procedures.

Based on interview and document review, the facility failed to ensure their system for communication of changes in resident orders was implemented timely for 1 of 1 resident (R1) who was given oral fluids and provided water at bedside against physician prescribed orders upon hospital return resulting in re-hospitalization for aspiration pneumonia. This deficient practice resulted in an immediate jeopardy (IJ) for R1. The facility also failed to ensure [MEDICATION NAME] (a diuretic) was administered according to prescribed orders for 1 of 1 resident (R2) who failed to receive the correct dose of medication on three days. The IJ began on 9/18/18, at 1:10 p.m. when R1, with a [DIAGNOSES REDACTED]. The break down in communication led to R1 being provided oral fluids against physician orders, and R1 later that day had increased congestion and difficulty breathing requiring re-hospitalization . The administrator was notified of the IJ on 10/29/18, at 6:05 p.m The IJ was removed on 10/31/18, at 11:30 a.m. but noncompliance remained at the lower scope and severity of G-isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact and required extensive assistance with all activities of daily living including eating. The MDS indicated R1 demonstrated signs/symptoms of swallowing disorder such as: coughing or choking during meals or when swallowing medications, and complaints of pain or difficulty with swallowing. The MDS indicated R1 had a feeding tube, required a mechanically altered diet and received 51% or more of calories through the [MEDICATION NAME] or tube feeding. R1's Care Plan dated 9/24/18, indicated R1 had a swallowing problem related to pausing and pooling of fluid with eating, required a mechanically altered diet, tube feeding, and supervision to extensive assistance with oral feeding, and required total assistance with tube feedings provided for 10 hours at night. The Care Plan also indicated R1 had a history of [REDACTED]. Sign in his room on his bedside stand for reminders. NO straws, keep head of bed elevated at 30 degrees during and after tube feedings to prevent aspiration. Crush meds as ordered, and all medications to be administered via [DEVICE]. Monitor for shortness of breath, choking, labored respirations, lung congestion and update MD/NP (physician/nurse practitioner) and family. If aspirates notify MD/NP, family and initiate aspiration protocol. Monitor/document/report as needed (PRN) any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Provide supervision to extensive assistance with oral feeding and encourage and remind to sit up at a 90 degree angle due to history of aspiration. A Vulnerable Adult Report dated 9/19/18, indicated: R1 had a [DEVICE] placement secondary to continued aspiration resulting in pneumonia. R1 had an ongoing cough and had a hard time tolerating the tube feeding. Tests showed R1 had no feeling in the back of his throat. R1 was put on nectar thick liquids but continued to have difficulty with coughing. R1 continued to want to drink liquids and he was not always compliant with instructions to sit upright after taking oral intake. R1 also experienced nausea and emesis with oral intake and with feeding tube intake. On 9/8/18, he was admitted to St. Joseph Hospital in Park Rapids related to altered mental status, aspiration pneumonia, dysphagia, dementia and [MEDICAL CONDITION]. R1 returned to the facility on [DATE], at 12:50 p.m. with an order for [REDACTED]. R1 was sent to the emergency room to be evaluated. R1 returned to the facility on [DATE], and was placed on Hospice. Resident's medications and tube feeding were discontinued. On 9/23/18, at 3:50 a.m. R1 passed away in the facility. R1's medical record was reviewed from 12/31/17, to the time of death 9/23/18, and revealed R1 had a history of [REDACTED]. R1's hospital Discharge Summary dated 9/18/18, indicated R1 was admitted to the hospital on [DATE], with lethargy and weakness secondary to aspiration pneumonia. R1 had a second aspiration episode while in the hospital and was felt to have aspirated tube feedings. The tube feedings were held and over the next few hours he developed progressive hypoxic [MEDICAL CONDITION] to the point he required intubation and mechanical ventilation. He was extubated from the ventilator after only a few days and gradually improved from that point. R1 was noted to have recurrent episodes of aspiration with thin and even thickened liquids and the decision was made that he should be kept nothing by mouth (NPO) to prevent further episodes of aspiration and pneumonia. On discharge to the nursing home, he will be kept NPO to hopefully avoid further episodes of aspiration. R1's Order Summary Report dated 9/18/18, included the following physician orders: - Regular diet, Pureed texture, Nectar consistency. The order start date was 1/5/18. - Acapella (an airway clearance device used to help clear the airways) four times a day for aspiration (inhaled bacteria through food, drink, saliva, or vomit) into your lungs. The order start date was 2/27/18. - ASPIRATION MONITORING: Observe for signs of aspiration, dehydration, nausea, vomiting, distention, diarrhea, reflux, and constipation. Document N if none observed. Document Y if any of the above noted, select Other/See Nurses Notes and document every shift. The order start date was 8/8/18. R1's hospital Long Term Care Transfer Form dated 9/18/18, included the following discharge orders: Diet: NPO (nothing by mouth) Special Treatments: tube feeding at 45 milliliters (mls)/hour continuous, water flush tube 180 mls every 6 hours. However, the Current Home Medications list included orders for the following medications to be given orally: -[MEDICATION NAME] (Tylenol) 650 milligrams (mg) oral every 4 hours as needed for pain -aspirin 81 mg oral daily -[MEDICATION NAME] 1 capsule oral three times daily -calcium [MEDICATION NAME] (Tums) 200 mg oral as needed for acid reflux -magnesium [MEDICATION NAME] (Milk of Magnesia) 30 ml oral every two days as needed for constipation -magnesium oxide 400 mg oral daily -[MEDICATION NAME] 20 mg oral daily -[MEDICATION NAME] ([MEDICATION NAME]) 4 mg oral every 4 hours as needed for nausea/vomiting -[MEDICATION NAME] ([MEDICATION NAME]) 5 mg oral daily -sennosides 1 tab oral daily as needed for constipation R1's Nutrition assessment dated [DATE], for readmission from the hospital did not identify the updated diet order of NPO. R1's progress note (PN) dated 9/18/18, at 1:48 p.m. indicated R1 returned from the hospital at 1:10 p.m. Vitals signs were within normal limits. Resident was alert. R1's PN dated 9/19/18, at 1:01 a.m. indicated licensed practical nurse (LPN)-A answered R1's call light at midnight, R1 stated he felt nauseous and began to have an emesis. LPN-A elevated R1's head of the bed up to 90 degrees, and disconnected the feeding tube, and encouraged R1 to cough. R1's lungs sounded congested bilaterally and his blood pressure was 165/100, pulse: 129, respirations: 24, and oxygenation level was 91% on room air. A NA stayed with R1 while LPN-A called R1's daughter to inform her of R1's status who stated she would like R1 to be in the hospital if anything were to go wrong. LPN-A informed R1's daughter she would update the on-call NP and would continue to monitor him. LPN-A returned to check on R1 and he had a few smaller emesis and could not cough up what was in his throat. R1 stated he felt like he could not breath and LPN-A noted he was turning red in the face. Oxygen saturation was 94% on 2 liters. The NP was called and an order was received to send R1 to the emergency room to be evaluated. The ambulance arrived at 1:00 a.m. and the resident's daughter was called and updated. R1's medical record lacked any additional documentation from time of readmission on 9/18/18, at 1:10 p.m. until he returned to hospital on [DATE], at 1:00 a.m R1's hospital Discharge Summary dated 9/21/18, indicated R1 was admitted with respiratory compromise secondary to recurrent aspiration and probable pneumonia. R1 was frustrated by his recent decline and ongoing difficulty with aspiration as well as compromise of his breathing. R1 requested not to pursue further aggressive interventions or evaluations, but to be managed for comfort only. IV (intravenous) fluids and antibiotics were discontinued and he received [MEDICATION NAME] (narcotic [MEDICATION NAME]) and [MEDICATION NAME] (antianxiety) as needed for comfort. R1 was discharged back to the facility with Hospice admission for ongoing management for comfort. Activity as tolerated and clear liquid diet per his request. On 10/26/18, at 2:50 p.m. LPN-B confirmed he had been working 9/18/18, when R1 had returned from the hospital. LPN-B stated R1 had usually been alert and could use the call light. LPN-B stated he believed R1 had returned to the facility with an NPO status, however, stated R1 had made it clear he had not intended to follow that. On 10/26/18, at 2:58 p.m. NA-A confirmed she had been working the evening of 9/18/18. NA-A stated she had not given R1 any water but stated NA-B had done so. NA-A stated LPN-B had called her into R1's room later in the shift to assist and verified R1 had a water pitcher within reach on the bedside table. NA-A stated LPN-B had been very upset as the head of R1's bed was flat and he had a pitcher of water within reach. NA-A verified the liquids were thickened but indicated the pitcher was not supposed to be near R1. NA-A stated there had been signs posted all over his room and it had also been noted all over his Care Plan that R1 needed to be up at a 90 degree angle and also needed to be supervised when he drank. NA-A also indicated R1 had been capable of drinking on his own. NA-A confirmed the NAs had access to resident care information on their iPads. NA-A retrieved an iPad, demonstrated its use and stated they also had paper care sheets to refer too. NA-A stated the iPad had any care plan instructions/instructions needed in order to provide care for the residents. On 10/26/18, at 3:08 p.m. NA-C and NA-D verified they had access to resident care requirements on the iPads and also indicated any new resident care information would also be shared in report. NA-D stated she had not been aware of R1 having any problems coughing or choking when eating/drinking. On 10/26/18, at 3:11 p.m. LPN-C and NA-D stated they were not aware of R1's order for NPO status upon hospital return, however, LPN-C was not positive. On 10/26/18, at 3:21 p.m. NA-A indicated R1 had not usually coughed or choked when drinking thickened water, however, stated he sometimes swallowed wrong but had then coughed and cleared it right away. NA-A verbalized awareness of not leaving water at the bedside within R1's reach. On 10/26/18, at 3:35 p.m. the licensed social worker (LSW) verified she had submitted the VA report to the State Agency (SA) regarding R1. LSW stated when R1 had returned from the hospital, he had gone to play Bingo. LSW stated at about 3:00 p.m. when R1 returned to his room from Bingo, he had asked for water and NA-B had given him water to drink. LSW stated R1 had tended to seek out the water and verified he was cognitively intact. LSW stated since R1 had just returned from the hospital, NA-B should have gone to the floor nurse prior to giving R1 the water in order to see if he had returned with any new care directives/order. The LSW verified R1 had a physician's orders [REDACTED]. On 10/26/18, at 4:04 p.m. the director of nursing (DON) stated when R1 had returned from the hospital 9/18/18, the resident had gone to Bingo. The DON thought R1 might have gotten to the water fountain but they were not sure. The DON stated she went to see R1 after Bingo and thought he was congested. The DON stated she and LPN-B had assisted R1 to sit up in bed and R1 had coughed and his color and vital signs were good. The DON stated at about 3 p.m. on 9/18/18, R1 had asked an aid for water and she had given it to him. On 10/26/18, at 4:25 p.m. NA-B confirmed when R1 had asked for water she had just brought him the water and stated to her knowledge, it was OK to give R1 water to drink, as long as he was seated upright at 90 degrees. NA-B verified she had given R1 a drink from the water mug and had put it back on his bedside table, within his reach. NA-B stated R1 had done very well and denied R1 having any coughing or choking. NA-B stated she had stayed with R1 after giving him the water to be sure everything was ok and had then moved the water mug out of reach, but was unsure of where she had put it. NA-B stated R1 wanted to lay back down, so she positioned the head of the bed at 45 degrees and had then left the room. NA-B stated she could not remember if R1 was supposed to remain upright for any length of time after drinking and indicated she had only worked with him for a short amount of time. NA-B stated she did not have any other contact with R1 after giving him the water. NA-B also stated she was not aware R1 had NPO orders as NAs had not received any information regarding R1's care after return from the hospital and would not have known of any changes unless the nurse told them. On 10/26/18, at 4:40 p.m. LPN-B stated on 9/18/18, he had come on duty at 2:00 p.m. and at around 8:00 p.m. had been walking down the hall when he had heard R1 coughing. When LPN-B had entered R1's room, he noted R1's color was off and he was having trouble with his cough. LPN-B stated he called for NA-A who assisted him to scoot R1 up in bed and put the head of his bed up. LPN-B also stated R1 had chocolate bars at his bedside which he thought R1 had won at Bingo. When asked about R1's NPO order, LPN-B stated physician orders [REDACTED]. LPN-B stated he had clarified the medication orders were to be given via R1's [DEVICE] and verified R1's tube feeding, however, had not clarified R1's NPO status. LPN-B stated he thought the facility was going to get clarification regarding oral intake from the physician during physician facility rounds the following morning. LPN-B verified he had not communicated R1's NPO status to the NAs. On 10/26/18, at 4:54 p.m. NA-A verified she had not been told R1 was NPO and stated neither the Care Plan nor the iPad had been updated with the new order. LPN-B confirmed R1 should have remained NPO until the order was clarified. On 10/26/18, at 5:01 p.m. DON verified R1's diet order had been for NPO. However, also stated she did not think R1 should have been NPO due to his wishes not to adhere to that. The DON verified the order was being clarified, however, stated she was not sure what they had been doing to clarify the orders. DON verified the discharge orders should have been clarified that night and education regarding the risks and benefits of ignoring the order should have been provided to R1, if he chose to have oral intake. On 10/29/18, at approximately 9:30 a.m. the activity aid (AA) verified the afternoon activity on 9/18/18, included Bingo and that prizes had included candy bars. However, AA stated she could not recall if R1 had won any candy bars. On 10/29/18 at approximately 9:45 a.m. the DON verified R1 had a long history of aspiration and pneumonia. The DON indicated R1 had even choked on his own saliva. The DON indicated R1 had gone to his room after Bingo and she had followed. R1 had wanted to go to bed so DON stepped out while the NAs assisted him to lay down. LPN-B had come down the hall and DON stated he had listened to R1's lungs and indicated the congestion was in his upper airway. The DON stated LPN-B had stated he would take vital signs and keep and eye on him and chart if anything came up. The DON verified R1's medical record lacked documentation of the coughing episode the evening of 9/18/18, and confirmed she would have expected LPN-B to document any issues which occurred on his shift. The DON stated they were not sure what had happened to R1 to cause his hospitalization and did not want to wait for the investigation to make their report. In addition, the DON stated the cause of the incident was a failure in communication of the new orders to the staff on duty. The DON stated usually the LPN reported changes in resident orders to the NAs on duty and the NAs reported off at shift change. The DON stated staff also posted notice signs in residents' rooms. The DON stated the LPN should have notified the NAs of the updated NPO order, R1 should have remained NPO and an NPO sign should have been posted in R1's room until the order was clarified. The DON indicated she had provided education on following the process to the staff working on the unit after the incident had occurred. On 10/29/18, at approximately 2:00 p.m. the physician confirmed the intention was for R1 to be NPO upon discharge from the hospital. The MD verified the risks of R1 not adhering to the NPO status were further aspirations with complications which included potential death. On 10/29/18, at 4:13 p.m. NA-B indicated there had not been a straw in R1's mug and stated she thought she had assisted R1 to drink from the mug, however, he sometimes had drank by himself so she was not positive. On 10/29/18 at 4:25 p.m., the DON confirmed R1's record lacked evidence that the risks and benefits of oral intake had been provided to R1 prior to giving him the drink or water. The facility's Therapeutic Diets policy dated 10/30/18, indicated when an altered consistency diet has been ordered, the staff nurse receiving the order will complete the order processing through the electronic medical record and notify staff working of the change in orders as soon as possible; the nurse will verbally notify all nursing assistants who are working the current shift of the change in altered consistency. Each subsequent shift will be notified of the diet change through the report between shift process. The policy also indicated for any discrepancy in diet order, the most restrictive order would be provided until the orders have been clarified. The Nursing Admission Checklist updated 10/30/18, indicated tasks to be completed included notify nursing assistants working of any special diet orders and general care needs with a verbal report. The Hospital Return Checklist updated 10/30/18, indicated tasks to be completed included if NPO or thickened liquids are ordered, ensure resident room has the appropriate liquids in place and staff are aware of the orders. The IJ that began on 9/18/18, was removed on 10/31/18, at 11:30 a.m. when the facility had revised their Therapeutic Diet policy to include more detailed information about implementation of orders, and the communication process for those orders, and had also revised the admission criteria policy to include reference to the admission/readmission checklist which included step by step details on each step of an admission/readmission, including communication with staff of any care related orders. In addition, the facility had also educated all staff on the revised policy and procedures. R2's [DIAGNOSES REDACTED]. R2's quarterly MDS dated [DATE], indicated R2 was cognitively intact and required extensive assistance with dressing, toilet use, personal hygiene and was independent or required supervision with the remainder of activities of daily living. R2's Care Plan reviewed 9/19/18, indicated R2 had altered cardiovascular status related to chronic [MEDICAL CONDITION] and a prosthetic heart valve. The Care Plan indicated R2 had [MEDICAL CONDITION] related to stage 3 [MEDICAL CONDITION] and directed staff to implement interventions which included to monitor/document/report as needed any changes [MEDICAL CONDITION], weight and a weight gain of over 2 pounds (lbs) a day. Obtain R2's weight as ordered. R2's Nursing Home Note dated 10/15/18, indicated R2 had a history of [REDACTED]. The weight gain had been gradual and progressive. The Impression & Plan section of the note identified severe lower extremity [MEDICAL CONDITION] associated with weight gain and included an order to increase [MEDICATION NAME] (diuretic)to 60 mg twice daily for five days to determine if there was any possible effect that may be beneficial for her. R2's PN dated 10/30/18, indicated R2 had received an order to be administered [MEDICATION NAME] ([MEDICATION NAME]) 60 mg once daily after having received 60 mg twice daily for five days. The note indicated the following: -R2 was to have received 60 mg twice daily on 10/13, through 10/17/18, followed by: -Starting on 10/18, was to have resumed taking 60 mg once daily However, the electronic Medication Administration Record [REDACTED]. The nurse practitioner (NP) was notified during facility rounds on 10/29/18. R2's eMAR dated 10/1/2018 - 10/31/2018, included the following orders: -[MEDICATION NAME] tablet give 60 mg by mouth in the morning for [MEDICAL CONDITION]. The order start date was 7/17/18, and was to be discontinued on 10/15/18. The medication was documented as administered daily 10/1/18, through 10/15/18. -[MEDICATION NAME] tablet give 60 mg by mouth two times a day for [MEDICAL CONDITION] until 10/21/18, 12:00 then resume 60 mg every day. Re-evaluate 1 week. The order start date was 10/15/18. The medication was documented as administered twice daily 10/16/18, through 10/20/18, and once daily on 10/21/18. -Ok to use extra 20 mg [MEDICATION NAME] once daily if weight increases by 3 pounds in a day or 5 pounds in a week. The order start date was 10/18/18, and the order discontinue date was 10/29/18. The medication was documented as administered 10/19, 10/20, 10/22, 10/24, 10/25, 10/26, and 10/28. -[MEDICATION NAME] tablet give 60 mg one time a day for [MEDICAL CONDITION]. The order start date was 10/29/18. Review of R2's weights revealed the following: 10/30/2018 12:41 214.5 lbs 10/29/2018 13:59 214.6 lbs 10/28/2018 08:17 213.8 lbs 10/27/2018 07:07 212.8 lbs 10/26/2018 12:09 214.0 lbs 10/25/2018 11:33 211.7 lbs 10/24/2018 07:43 211.0 lbs 10/23/2018 11:51 215.3 lbs (a gain of 4.7 lbs) 10/22/2018 08:00 210.6 lbs 10/21/2018 11:29 211.6 lbs 10/20/2018 08:39 209.5 lbs 10/19/2018 08:01 211.1 lbs 10/18/2018 13:57 210.8 lbs On 10/30/18, at approximately 2:30 p.m. trained medication assistant (TMA)-A stated yesterday she had brought to RN-A's attention that R2's weight was up. TMA-A stated in passing meds she had noted R2's MAR indicated [REDACTED]. TMA-A stated she usually worked on R2's wing on the day shift so was familiar with R2's medications. TMA-A stated she had not worked in awhile so had been confused about R2's MAR indicated [REDACTED]. On 10/30/18, at approximately 3:00 p.m. RN-A verified there had been an issue with R2's [MEDICATION NAME] administration. RN-A indicated he had discussed the discrepancy with the DON and both determined that three doses of R2 's [MEDICATION NAME] 60 mg had been missed. RN-A indicated physician orders [REDACTED]. A health unit coordinator (HUC) or nurse entered the orders into the computer system and then the yellow, duplicate copy of the written orders were given to another HUC, unit manager or nurse for confirmation of the orders. RN-A stated the second nurse or HUC confirmed the order entry in the computer using the duplicate sheet and then placed the sheet in the medical records office for filing. RN-A verified the [MEDICATION NAME] order and stated the order had been entered into the electronic computer system by HUC-A who was the person who consistently entered medication orders. RN-A stated the order had not not entered into the computer system per facility training, therefore the way it had been entered, caused the confusion. RN-A verified the order had been entered as one single order and should have been entered as two orders. RN-A indicated R2's orders had been confirmed by LPN-D. RN-A stated LPN-D should have caught the order had not been entered in the best possible manner. The MAR indicated [REDACTED]. RN-A indicated the only way to know what had been given had been to review the actual medication remaining in the medication cart. RN-A stated he could not explain what had happened with the documentation. RN-A indicated he had identified the issue yesterday and reported to the NP who reviewed R2's weights but had not required further orders be implemented. R2's weights were reviewed with RN-A who verified R2 experienced a 4.7 lb weight gain on 10/23/18, and also verified based on the documentation, R2 had not received any [MEDICATION NAME] on that date. RN-A confirmed R2 should have received a scheduled 60 mg dose as well as a 20 mg PRN dose as ordered. On 10/30/18, at approximately 3:30 p.m. DON verified R2's order was for 60 mg bid x 5 days and then to resume 60 mg once daily. DON indicated RN-A had written up a medication error report and brought it to to the NPs attention yesterday. DON verified the documentation of [MEDICATION NAME] administration should not have been entered under the PRN order. DON stated they determined the medication used was the 60 mg dose and confirmed there had been 3 doses not used. DON stated none of the 20 mg PRN doses had been used. DON verified the documentation in the MAR indicated [REDACTED]

Based on observation, interview, record and policy review, the facility failed to ensure that all residents who entered the facility without pressure sores did not develop pressure sores as based on a comprehensive assessment of all risk factors involved and unless the individual's clinical condition demonstrated that they were unavoidable for 2 of 2 residents (R89, R21) reviewed in the sample who had developed pressure ulcers while in the facility. As a result, R89 sustained actual harm from the development of two Stage 4 pressure ulcers that remained unhealed and still painful for the resident. Findings included: R89, who was admitted to the facility without documented pressure ulcers, developed two Stage 4/unstagable pressure ulcers within 30 days of admission. R89's comprehensive assessment lacked accurate identification of all significant risk factors. Additionally, recommendations for effective interventions to prevent the development of the pressure ulcers were not reassessed or fully developed and/or revised in the care plan. As a result, R89 sustained actual harm from the development of two Stage 4 pressure ulcers that remained unhealed and still painful for the resident. R89 was admitted [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], identified R89 as cognitively intact with the ability to understand and be understood. The MDS also identified R89 required extensive physical assistance of 2 staff for bed mobility, and was non-ambulatory. In addition, R89 was identified with frequent urinary incontinence, frequent moderate pain, and at risk of development of pressure ulcers with no pressure ulcers currently present. Pressure reduction device use for bed and chair were noted on the MDS. The Care Area Assessment (CAA) for Pressure Ulcers dated [DATE], and skin assessment dated [DATE], did not include a comprehensive analysis of all significant risk factors, appropriate interventions, comorbid medical conditions and other factors that were noted during the initial assessment period. While the assessments did identify friction/shearing potential and a Braden scale (tool to predict pressure ulcer risk) dated [DATE], identified R89 at moderate risk for pressure ulcer development, these tools did not accurately identify or perform full analysis of tissue tolerance of all areas, lower extremity [MEDICAL CONDITION] present, pain issues, effects of [MEDICAL CONDITION]/dysuria, bedfast condition, proper positioning and use of positioning devices and non-compliance with positioning of legs on pillows and a method for monitoring of pressure reduction effectiveness. No pressure ulcers were identified on the hospital transfer information completed [DATE], before admission, the facility admission summary and head to toe skin check dated [DATE], skin assessments dated [DATE], or nurses notes dated [DATE]-[DATE], prior to the discovery of a blistered area on the right bottom heel on [DATE] and on the left lateral heel on [DATE]. The facility ADL (activities of daily living) summary dated [DATE], identified R89 required extensive assistance for bed mobility and had sleep concerns. The skin diagram dated [DATE], included bruises, abrasions and an incision on the hip and did identify there were no mushy or discolored heels, ulcers or problems with the feet. An initial care plan by pre-defined text check boxes was completed at admitted d [DATE], that included identification of problems for risk of skin breakdown, bed mobility assist, reposition every two hours, "float feet," "check for bladder distention" and "pain" was added. The initial care plan did not identify or check heel protector use, behavior/compliance or cognition issues. The format of the initial care plan primarily identified problem issues by check box; however, interventions were not detailed or described fully. The final version of the full care plan with greater details on interventions and approaches was not completed until [DATE], after the two pressure ulcers had developed. This version did elaborate on the care of the pressure ulcers. An additional care plan supplement specific for skin risk problems was also completed on [DATE]. None of the narrative nurses notes reviewed from admission to the time of development of the pressure ulcers on ,[DATE]-,[DATE] identified or addressed the problem of R89 being non-compliant with keeping legs on the pillows; however, there were several entries that indicated [REDACTED]. A resident status summary dated [DATE] also did not identify any skin issues or positioning compliance issues; the status summary dated [DATE] noted, "Bilateral heel Stage 2 present...Prafo boots on when in bed." The pressure ulcers were observed [DATE] at 9:20 a.m. during wound treatment rounds and noted to be deep and unstagable with a black eschar coverage. The treatment sheets noted the size initially was 6 by 6.5 cm. on the right and 2 by 2.5 cm. on the left. Current measurements were 4.2 by 3.2 cm right and 1.2 by 1.75 cm. left. Eschar cover remained attached with some foul drainage had been noted coming from under the left eschar area. Antibiotic (Cipro) treatment for 10 days was ordered by physician on [DATE]. Dressing treatment consisted of Prafo boots and spray with skin prep/cover with gauze pad and wrap three times daily. In addition, R89 also developed a 1 by 1 cm. Stage 2 pressure ulcer on the coccyx first noted on interdisciplinary nurses note dated [DATE], that was healing and still receiving treatment with rash relief ointment per wound treatment sheet dated [DATE]. During staff interview with the director of nursing (DON) on [DATE], at 4:25 p.m. the DON verified two Stage 4 pressure ulcers on heels since [DATE], that were getting smaller. The DON reported R89 had come from the hospital with the heels red and thought the staff had not done a complete assessment of all factors or a thorough head to toe evaluation that included the heel areas. The unit registered nurse manager-A (RN-A) verified during interview on [DATE], at 12:50 p.m. R89 had developed significant [MEDICAL CONDITION] in the legs/feet and the right hip was infected with some drainage. RN-A also reported the heels were supposed to be floated on pillows at admission and the intervention was included on the initial temporary care plan; however, R89 was not compliant with positioning, was restless, confused and wanted to lie on the back and would move the feet around and off the pillows. RN-A reported the Prafo boots, "were not put on everyone," but were specially ordered on [DATE], and arrived and were used by [DATE]. RN-A could not recall any other interventions used other than the pillows prior to the Prafo boots. In addition, RN-A stated a re-assessment review had not been completed nor were other interventions or additional staff monitoring for proper positioning recommended by re-assessment or added to the care plan based on R89's non-compliance, increased confusion, discomfort and restlessness. . Nursing assistant-B (NA-B) reported during interview on [DATE], at 2:10 p.m. she could clearly recall the care specifics for R89 during June. NA-B verified R89, "would not keep her legs on the pillows and probably still wouldn't if we didn't have the Prafo boots." NA-B also reported there were, "some other better Velcro closure type heel pads," that were sometimes used by staff during June after the pressure ulcers developed and before the Prafo boots arrived but NA-B was not sure where they now were. Identical pads (Spenco boot pads) were located in another resident's room, but there was no documentation located in the record that they were ordered or recommended by re-assessment for R89. R89 reported during interview on [DATE], at 9:05 a.m. the pressure ulcers did not develop at the hospital. R89 stated, "They took about a week here to get; I spent too much time in bed with my heels on the mattress. They are still painful." On [DATE], at 11:30 a.m., the DON again verified R89's assessment was not complete after admission and a review of the assessment had not been completed until after the pressure ulcers developed. Tissue tolerance records were requested, but not located and the DON was not sure if the heel inspection was included in the original tissue tolerance screening. The DON reported she was aware R89 was largely non-compliant with pillow positioning or that Spenco boot pads were briefly used only after the pressure ulcers developed. R21, who was admitted to the facility without documented pressure ulcers, developed Stage 1 and Stage 2 pressure ulcers within and after 21 days of admission. R21's comprehensive assessment lacked accurate identification of all significant risk factors. Additionally, recommendations for effective interventions to prevent the development of the pressure ulcers were not fully developed, reassessed or revised in the care plan. R21 was admitted [DATE], with [DIAGNOSES REDACTED]. The admission MDS dated [DATE], identified R21 with cognitive independence, no behaviors or significant mood indicators, and requiring extensive assistance for bed mobility, transfers and ambulation. The MDS also identified limitations in one side lower extremity range of motion, shortness of breath, oxygen use, and intact skin. Pressure reduction device use in bed/chair were noted on the MDS. The CAA dated [DATE], for pressure ulcers was triggered related to R21's assistance with bed mobility. No analysis was performed in the CAA; it indicated refer to skin assessment and proceed to care plan. The skin assessment tool dated [DATE], identified only friction/shearing potential and subdural bleed. The analysis portion noted skin intact, no pressure ulcers...impaired mobility related to weakness...able to make independent adjustments in position as needed... Braden score 20 (low risk)...proceed to care plan. The assessment failed to identify all significant comorbid medical conditions or [MEDICAL CONDITION] disease, breathing difficulty in supine positioning, resident choice issues, [MEDICAL CONDITION] or arthritic pain/discomfort and a recommendation for repositioning interval determination for bed or chair. The admission information sheet dated [DATE], did not identify any skin issues other than dryness. The head to toe body diagram noted only the saline lock in place on the right arm. The initial temporary care plan dated [DATE], by pre-defined check box format noted pressure relief bed/chair equipment, reposition every 2 hours in bed, pressure relief and follow skin protocol. Repositioning sitting was not checked on the care plan. The final comprehensive care plan was not completed until [DATE], forty-seven (47) days after admission. This care plan also did not address the issue of sleeping in the recliner and only noted pressure relief devices of mattress in bed and cushion in the wheelchair. Interdisciplinary progress notes noted skin intact on [DATE]. On [DATE] the progress note identified, "Resident sleeps in recliner due to shortness of breath when attempting to sleep in bed. Noted medium pink skin with noted dryness on bilateral inner buttocks. Resident is at risk for skin breakdown. Will monitor." The facility's "Tissue Tolerance Data Worksheet-Sitting/Lying" was completed ,[DATE]-,[DATE]. The lying portion identified, "Res states she is unable to tolerate lying in bed due to shortness of breath. Spends night in recliner, refused to elevate legs. has 2 areas on each side of coccyx on inner buttocks which are dark pink and with dry skin.... 4 cm long by 1.5 cm. wide....refuses to reposition...at risk for breakdown...A&D applied. The sitting portion on [DATE], after 2 hours identified, "Resident observed to have some redness on buttocks after sitting. Darker areas inner buttocks. After an additional one hour sitting period it noted, "No change, able to move and reposition self." There were no additional notations made during the subsequent one hour of sitting evaluation and a recommendation summary for sitting interval not made on the form. Physician orders [REDACTED]. Interdisciplinary progress notes dated [DATE], identified, "Resident has dark red areas on bilateral inner buttocks on both sides near coccyx...area measures 9 cm long by 7 cm wide. Skin prep applied and covered with Allevyn for protection. Unable to sleep in bed due to shortness of breath...sleeps in recliner." Treatment records identified Allevyn was used only one time in May, on [DATE], and not at all during the period of [DATE] to [DATE]. Progress notes dated [DATE] identified, "Noted a full thickness pressure sore on left buttocks. Allvyen applied. Right buttocks red and sore...A&D applied." Progress notes dated [DATE] identified, "Asked res to lay in bed for a while so her bottom didn't get any more sore....Res refused and said, ' I have sat like this for [AGE] years and am not going to change now '." The note continued, "Resident has open area to left buttocks, with right buttock red and sore as well. Plan is to lay in bed for two hours after breakfast and lunch. Occupational Therapy (OT) is to bring a new pressure relieving cushion for her wheelchair as her current one is very thin." Discharge planning was on-going until the conference of [DATE]. Progress note dated [DATE] identified, "Two open areas noted to left buttock... ,[DATE] (.8) by ,[DATE](.7) cm and ,[DATE] (.3) by ,[DATE] (.2) cm. Entire buttocks red and sore...Allevyn dressing applied to open areas." Subsequently, R21 continued to decline medically in both physical and mental status over the next 12 days and expired on [DATE]. The MDS coordinator Registered Nurse-B (RN-B) verified during interview on [DATE] at 10:40 a.m. the facility did not complete the care plan for R21 in a timely manner and it should have been finalized by day 21. RN-B further verified only the initial temporary care plan was in effect until day 47 and after the pressure ulcer problems actually developed. RN-B also reported the tissue tolerance assessment should be completed in the first few days for those at risk of pressure ulcer development. RN-B could not explain why the temporary admission care plan did not identify a sitting repositioning interval or recommendation not made after the tissue tolerance evaluation. Additionally, RN-B could not explain how R21 could be expected to sleep in a sitting position all night when redness was produced after only one to two hours or why OT had not re-evaluated the thin chair cushion until [DATE], some two months after admission and after development of the pressure ulcers. RN-B reported these details of the comprehensive assessment were missed, and not done for R21. RN-B also reported risk/benefit educational information related to repositioning residents not fully compliant with recommendations had not been provided or completed. Facility policy for skin assessment and care dated [DATE], identified each resident who entered the facility without pressure sores should receive the necessary care and services... to not develop them unless the clinical condition demonstrated they were unavoidable. Assessment was to be completed upon admission, on a routine basis and as needed. Skin will be checked over bony prominences for signs of pressure intolerance, pain, and [MEDICAL CONDITION].the comprehensive assessment results are used to develop a care plan addressing individual needs of each resident and determined with consideration of resident choice, provide appropriate, pressure re-distributing, non-irritating support surfaces....provide daily monitoring of skin condition with at least weekly documentation. Review of the comprehensive assessment and care plan will occur at least quarterly and more frequently if there is a change in the resident's condition.