Every finding on record at Interfaith Care Center

Based on interview and document review, the facility failed to implement appropriate monitoring for a resident taking an anticoagulant medication for 1 of 1 resident (R4) reviewed for anticoagulant medication.Findings include:R4's admission minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries, and atrial fibrillation (an irregular heart rhythm which can lead to blood clots) The MDS also identified R4 had an anticoagulant medication.R4's care area assessment (CAA) worksheet identified the daily use of anticoagulants increases the risk for bruising and skin injury as well as extending the healing time for wounds. R4's care plan dated 1/29/26, identified a focus statement for stroke and to give medications as ordered by the physician and to monitor and document side effects and effectiveness. The care plan didn't identify to monitor for bruising or bleeding. R4's provider orders didn't reflect monitoring for bruising or bleeding. On 4/19/26, an order for apixaban (an anticoagulant medication) 5 milligrams (mg), one tab twice daily related to atrial fibrillation.During an interview on 4/22/26 at 8:39 a.m., licensed practical nurse (LPN)-A stated they did medication monitoring for things like antidepressant medication, if a resident were on an antidepressant and were crying more often, they would make progress notes and update the provider. During an interview on 4/22/26 at 8:49 a.m., LPN-B stated medications that would need monitoring would be diabetic medications, psychotropic medications, and for anticoagulant medications they would watch for bleeding and making sure related labs were getting done. LPN-B thought the monitoring would be on the treatment administration record (TAR) but was unable to find it.During an interview on 4/22/26 at 9:02 a.m., registered nurse (RN)-A, a nurse manager for R4, stated they should have bleeding and bruising monitoring for residents on coumadin and Eliquis, or any anticoagulant medication. RN-A reviewed R4's orders and didn't identify monitoring for bruising or bleeding. RN-A stated it is important to do monitoring in the case they started having bleeding or gastrointestinal bleeding they would need to update the provider right away.During an interview on 4/22/26 at 10:15 a.m., the director of nursing (DON) stated they needed to be monitoring residents on anticoagulant medications because if they started bleeding, they may not stop so it would be important to update the provider. A policy, Medication Monitoring dated 4/22/26, identified its purpose was to ensure that all medications administered in the skilled nursing facility are appropriately monitored for effectiveness, safety, and necessity in accordance with Minnesota regulations and federal requirements, including prevention of adverse drug events and unnecessary medications. For high-risk medication monitoring enhanced monitoring is required for anticoagulants (e.g., INR monitoring), Diabetic medications (blood glucose monitoring), Opioids (sedation, respiratory status, bowel function), Antibiotics (response and side effects).

Based on interview and document review the facility failed to honor residents right to refuse medications for 1 of 3 residents reviewed (R1) when she was administered morphine after telling staff she did not want the medication.R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1's Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment.R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. The care plan identified behaviors that included calling out and refusal of medications. The care plan directed staff to allow R1 to make decisions about her treatment regime as able and to provide a sense of control and directed if R1 resisted cares or medication, reassure her, leave and return later to try again.An Employee Statement Form dated 10/10/25, indicated nursing assistant (NA)-B heard R1 yelling out and asked her what was wrong and the nurse, registered nurse (RN)-C, said she was going to give R1 pain medication. While trying to calm R1 down, RN-C approached R1 to give pain medication and R1 said no and kept turning her head. RN-C was yelling at NA-B and said to hold R1's hands down, then put the medication in R1's mouth. NA-B wrote, R1 called RN-C a name and said, she gave me meds [medications] I didn't want, and asked NA-B why she didn't say anything.An Employee Statement Form written by dietary aide (DA)-A, dated 10/10/25, indicated R1 had been yelling help and seemed really upset and when asked, said I'm sick of being tied down. DA-A reported RN-C walked by and said, you're not tied down, ha ha ha and laughed at R1 to her face while she was distressed.During interview on 10/16/25 at 8:38 a.m., the activities director (AD) stated DA-A had reported the incident to her on Monday or Tuesday and let her know she had filed a report on RN-C the previous Friday. The AD said DA-A was disturbed about how the RN-C had basically forced R1 to take Morphine after saying no. The AD said she had spoken to the nurse who was on-call, RN-A, who reported she had been aware of the incident.During interview on 10/16/25 at 9:45 a.m., RN-A stated she had been the nurse on call the night of the incident and said she had received a call from the scheduler that some staff were upset because of the way RN-C had administered R1's morphine. RN-A said she called the unit and talked to RN-C who said R1 had been hollering out for 15 - 30 minutes, was not re-directable and was in a lot of pain. RN-A said RN-C told her she went to administer Morphine to R1 and R1 said no and swatted her hand away. RN-A said RN-C told her she had a nursing assistant (NA) hold R1's arms out of the way to get the morphine into her mouth. RN-A said she felt RN-C was using her nursing judgement because she felt R1 needed pain medication.During interview on 10/16/25 at 11:48 a.m., the DON stated RN-A had called her on Friday evening and reported to her a staff member had been upset about the situation with RN-C and R1. The DON stated RN-A told her RN-C had held R1's hands down to give her pain medications and staff were very upset. The DON stated per facility policy, restraints were not used in the facility.Facility policy Physical Device Policy/Restraints dated 5/1/25, indicated the facility used the least restrictive device possible for the resident to ensure residents were free form physical or chemical restraints imposed for purposes of discipline or staff convenience.

Based on interview and document review the facility failed to ensure residents reserved the right to remain free from restraints for 1 of 3 resident (R1) when staff held her hands and administered morphine against her wishes.R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1s Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment.R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. The care plan identified behaviors that included calling out and refusal of medications. The care plan directed staff to allow R1 to make decisions about her treatment regime as able and to provide a sense of control and directed if R1 resisted cares or medication, reassure her, leave and return later to try again.R1's Order Summary Report dated 10/17/25, identified an order for Morphine Sulfate oral solution 20 milligrams (mg) per milliliter. Give 10 mg by mouth every two hours as needed for pain.An Employee Statement Form dated 10/10/25, indicated Staff heard R1yelling out and asked her what was wrong and the nurse, registered nurse (RN)-C, said she was going to give R1 pain medication. While trying to calm R1 down, RN-C approached R1 to give pain medication and R1 said no and kept turning her head. RN-C was yelling at the staff member and said to hold R1's hands down, then put the medication in R1's mouth. The staff member wrote, R1 called RN-C a name and said, she gave me meds [medications] I didn't want, and asked the staff why she didn't say anything.An Employee Statement Form dated 10/10/25, indicated R1 had been yelling help and seemed really upset and when asked, said I'm sick of being tied down. The staff reported RN-C walked by and said you're not tied down, ha ha ha and laughed at R1 to her face while she was distressed.During interview on 10/15/25 at 3:58 a.m., nursing assistant (NA)-A stated R1 required total care and said she usually went to bed late because she liked to crawl out of bed. NA-A said R1 did not usually complain about pain but said I think she could tell us.During interview on 10/15/25 at 4:09 p.m., trained medication aide (TMA)-A said R1 was usually very pleasant. TMA-A said he felt R1's pain was well controlled with scheduled pain medications. During interview on 10/15/25 at 4:17 p.m., licensed practical nurse (LPN)-A stated R1 was usually pretty happy and did not get upset very often. LPN-A said R1's pain was pretty well controlled, and he did not often need to use as needed medications. LPN-A said if R1 was hurting, she would tell staff, would say ow and became a little more down. During interview on 10/15/25 at 4:32 p.m., dietary aide (DA)-A stated on Friday evening, October 10th 2025, around 7:00 p.m., she was on R1's unit and as she was going down the hall, R1 was sitting with a NA at the charting desk which was unusual. DA-A said the aide was holding R1's hand and comforting R1 who was yelling help, which was not unusual. DA-A stated she asked R1 what was wrong and R1 said she was sick of being tied down here. DA-A said she talked to some of the other NA's and they told her the nurse on the unit, RN-C made one of the staff hold down R1's hands to administer medication. DA-A said the NA was very upset and said R1 told her she was scared and felt unsafe. DA-A said RN-C walked by and said no one is trying to tie you down and then laughed about it. DA-A said she had filled out a grievance form. During interview on 10/16/25 at 8:38 a.m., the activities director (AD) stated DA-A had reported the incident to her on Monday or Tuesday and let her know she had filed a report on RN-C the previous Friday. The AD said DA-A was disturbed about how the RN-C had basically forced R1 to take Morphine after saying no. The AD said she had spoken to the nurse who was on-call, RN-A, who reported she had been aware of the incident. During interview on 10/16/25 at 9:45 a.m., RN-A stated she had been the nurse on call the night of the incident and said she had received a call from the scheduler that some staff were upset because of the way RN-C had administered R1's morphine. RN-A said she called the unit and talked to RN-C who said R1 had been hollering out for 15 - 30 minutes, was not re-directable and was in a lot of pain. RN-A said RN-C told her she went to administer Morphine to R1 and R1 said no and swatted her hand away. RN-A said RN-C told her she had a NA hold R1's arms out of the way to get the morphine into her mouth. RN-A said she reported the incident to the director of nursing (DON) and the administrator that night via e-mail. RN-A stated staff should never restrain a resident. During interview on 10/16/25 at 9:57 a.m., RN-B stated R1 had behaviors at times that included yelling out, had some care refusals and would swing her arms up at times but that was about all. RN-B said R1 sometimes displayed pain in different ways but did not actually report pain. RN-B said R1 would disrobe on occasion when she had pain from the wound on her chest and if staff asked about pain, sometimes she will say yes. RN-B said R1's pain was largely controlled by scheduled medication, and she rarely required the use of as needed medication and often did not want to take them. RN-B said if a resident did not want to take medications it was not appropriate to hold their arms down. During interview on 10/16/25 at 11:48 a.m., the DON stated RN-A had called her on Friday evening and reported to her a staff member had been upset about the situation with RN-C and R1. The DON stated RN-A told her RN-C had held R1's hands down to give her pain medications and staff were very upset. The DON stated RN-C was an agency staff nurse and was no longer working at the facility. Facility policy Physical Device Policy/Restraints dated 5/1/25, indicated the facility used the least restrictive device possible for the resident to ensure residents were free form physical or chemical restraints imposed for purposes of discipline or staff convenience.

Based on interview and document review the facility failed to report an allegation of abuse to the state agency (SA) for 1 of 3 residents (R1) reviewed who was physically restrained by staff and administered medication against her wishes.R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1's Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment.R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. The care plan identified behaviors that included calling out and refusal of medications. The care plan directed staff to allow R1 to make decisions about her treatment regime as able and to provide a sense of control and directed if R1 resisted cares or medication, reassure her, leave and return later to try again.R1's Order Summary Report dated 10/17/25, identified an order for Morphine Sulfate oral solution 20 milligrams (mg) per milliliter. Give 10 mg by mouth every two hours as needed for pain.An Employee Statement Form dated 10/10/25, indicated Staff heard R1 yelling out and asked her what was wrong and the nurse, registered nurse (RN)-C, said she was going to give R1 pain medication. While trying to calm R1 down, RN-C approached R1 to give pain medication and R1 said no and kept turning her head. RN-C was yelling at the staff member and said to hold R1's hands down, then put the medication in R1's mouth. The staff member wrote, R1 called RN-C a name and said, she gave me meds [medications] I didn't want, and asked the staff why she didn't say anything.An Employee Statement Form dated 10/10/25, indicated R1 had been yelling help and seemed really upset and when asked, said I'm sick of being tied down. The staff reported RN-C walked by and said, you're not tied down, ha ha ha and laughed at R1 to her face while she was distressed.During interview on 10/16/25 at 11:48 a.m., the director of nursing (DON) stated she had been contacted over the weekend by staff who were upset about the way RN-C had administered medication to R1. The DON said the on- call nurse, RN-A reported she had spoken to RN-C. RN-C reported to RN-A, she had staff hold R1's hands to administer medication. RN-A told DON staff had been very upset. The DON stated she considered holding a resident's hands down to administer medication a restraint. The DON said the incident was not reported to the SA because RN-A had spoken to RN-C and did not feel she intended to be malicious when administering the medications.Facility policy Abuse Prevention Plan dated 2024, indicated all residents residing in the facility will be protected from Maltreatment. Suspected abuse of any kind needs to be reported IMMEDIATELY (within 2 hours) and any other suspected maltreatment needs to be reported IMMEDIATELY (within 24 hours).

Based on interview and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) who was physically restrained and administered morphine against her wishes. In addition, the facility failed to implement measures to protect other residents from the alleged abuse.R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1s Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment.R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. The care plan identified behaviors that included calling out and refusal of medications. The care plan directed staff to allow R1 to make decisions about her treatment regime as able and to provide a sense of control and directed if R1 resisted cares or medication, reassure her, leave and return later to try again.R1's Order Summary Report dated 10/17/25, identified an order for Morphine Sulfate oral solution 20 milligrams (mg) per milliliter. Give 10 mg by mouth every two hours as needed for pain.An Employee Statement Form dated 10/10/25, indicated Staff heard R1yelling out and asked her what was wrong and the nurse, registered nurse (RN)-C, said she was going to give R1 pain medication. While trying to calm R1 down, RN-C approached R1 to give pain medication and R1 said no and kept turning her head. RN-C was yelling at the staff member and said to hold R1's hands down, then put the medication in R1's mouth. The staff member wrote, R1 called RN-C a name and said, she gave me meds [medications] I didn't want, and asked the staff why she didn't say anything.An Employee Statement Form dated 10/10/25, indicated R1 had been yelling help and seemed really upset and when asked, said I'm sick of being tied down. The staff reported RN-C walked by and said you're not tied down, ha ha ha and laughed at R1 to her face while she was distressed.During interview on 10/16/25 at 11:48 a.m., the director of nursing (DON) stated she had been contacted over the weekend by staff who were upset about the way RN-C had administered medication to R1. The DON said the on- call nurse, RN-A reported she had spoken to RN-C. RN-C told RN-A she had staff hold R1's hands to administer medication. RN-A told DON staff had been very upset. The DON stated she considered holding a resident's hands down to administer medication a restraint. The DON stated she had not spoken with RN-C following the incident and said RN-C worked the day after. The DON said the facility had other complaints about RN-C and she was no longer working at the facility. The DON said she had not had a chance to talk to any of the staff who worked the day of the incident, nor had she followed up with R1. The DON stated typically following an allegation of abuse, the facility would investigate the incident.Facility policy Abuse Prevention Plan dated 2024, indicated All residents, alleged perpetrator(s), and staff members will protected from harm and retaliation during any and all investigations. If a staff member is considered to be an alleged perpetrator in an incident that staff member will be placed on suspension pending the investigation outcome. Other interventions could include reassignment of staff, working in pairs, separation of residents, room changes, and/or supervised visitation for residents with visitors. Staff will respond immediately to protect the alleged victim, integrity of the investigation, and examine the alleged victim for any sign of injury (physical, emotional, psychological, etc.). The policy indicated staff will investigate all incidents such as falls, bruises, medication errors, resident complaints, etc. Monday through Friday during normal business hours and all incidents will be reviewed with the following disciplines via the Inter-Disciplinary Team: nursing, social services, activities, dietary, therapies, and administration. After normal business hours, the RN Supervisor will contact Social Services Director, DON, and/or Administrator regarding all potential incidents of maltreatment if unsure of further actions to take.

Based on interview and document review, the facility failed to assess smoking safety for 1 of 1 resident (R38) reviewed for smoking. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 was admitted to the facility on [DATE] and was cognitively intact. R38's diagnoses include depression, chronic pain, difficulty walking, and syncope and collapse (fainting due to a brief loss of consciousness). R38's history and physical report dated 10/3/24, identified R38 was a current everyday smoker of cigarettes. R38's care plan printed on 2/6/25, identified R38 was at risk for falls due to generalized muscle weakness, difficulty walking, pulmonary disease, and medication side effects. Care plan lacked any indication of R38's current smoking status and/or safe smoking interventions. R38's medical record lacked any smoking assessments completed prior to 2/4/25. R38's progress note dated 10/8/24, identified the facility smoking policy was reviewed and further discussed upon admission. R38's progress note dated 10/16/24, identified R38 wanted to go outside and smoke. R38's progress note dated 10/24/24, identified R38's visitor asked why R38 cannot go outside and smoke. Nurse informed R38 and visitor smoking was not allowed on property and this information was reviewed on admission. R38's progress note dated 12/4/24, identified staff witnessed R38 smoking in the facility parking lot twice. R38 confirmed had smoked after returning from outing with friends. Smoking issue and resident safety discussed. During interview on 2/5/25 at 10:21 a.m., nursing assistant (NA)-A identified R38 was a current smoker and the facility was non-smoking. Any resident who wishes to smoke must go off facility property to smoke. During interview on 2/5/25 at 12:33 p.m., registered nurse (RN)-D identified the facility as non-smoking and the smoking policy was reviewed upon admission. Residents cannot smoke on property but can leave the property with friends or family to smoke. RN-D confirmed R38 was a current smoker and explained there was one occasion were R38 was witness smoking across the street after returning from an outing with friends/family. R38 was not assessed for smoking upon admission or after this incident occurred. Due to the lack of assessment, it was uncertain if R38 was safe to smoke. During interview on 2/6/25 at 2:09 p.m., director of nursing (DON) identified all residents were informed of the facilities non-smoking policy prior to and again at the time of admission. When a resident was admitted as or later identified as a smoker, the non-smoking policy was reviewed and the resident was offered nicotine replacement therapy. Resident smoking has not been an issue until recently and the facility has not been completing smoking assessment on residents who are identified as a smoker. Effective immediate the facility will create a policy to address resident smoking safety and will complete smoking assessments on all residents who are identified as a smoker. Smoking assessments were important because the resident could be injured while smoking. Even when they are off our property, they are still our resident, and we need to make sure they are safe and can smoke safely. A policy Resident Care Polices section Smoke-Free Policy revised 10/29/19, identified no resident will be allowed to smoke in the facility or on the grounds. All residents will be notified of the smoke-free policy.

Based on interview and document review, the facility failed to ensure allegations of physical abuse were reported immediately (within two hours) to the State Agency (SA) for 3 of 5 residents (R2, R5, R1) reviewed for abuse. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and had verbal and physical behaviors towards others. On 12/17/23 at 7:18 p.m., R2's progress notes indicated R2 had grabbed another resident's arm and would not let go. R5's quarterly MDS dated [DATE], identified R5 had intact cognition and had no behaviors towards others. On 12/17/23 at 10:03 p.m., R5's progress notes indicated R5's right upper arm was grabbed by another resident at 6:00 p.m., and the director of nursing (DON) was notified. R1's quarterly MDS dated [DATE], identified R1 had intact cognition and had no behaviors towards others. On 12/18/23 at 10:29 a.m., R1's progress notes indicated R1's family was notified of the resident-to-resident altercation between R1 and R2. On 1/10/24 at 11:57 a.m., registered nurse (RN)-A stated on the evening of 12/17/23, nursing assistant (NA)-A reported that R1 was swinging her reacher at R2, but was not aware if the reacher made contact with R2. NA-B reported on in the evening on 12/17/23 R5 stated R2 had grabbed her by the right arm. R5 stated R2 was squeezing her arm tight and it hurt R5, but no staff had witnessed it. RN-A stated she reported these incidents to the DON right away. On 1/10/24 at 12:11 p.m., NA-A stated on 12/17/23 in the evening that she had seen R1 hit R2 in the arm with her reacher. NA-A stated she reported it right away to RN-A. On 1/10/24 at 1:00 p.m., NA-B stated on 12/17/23 around dinner time, she was assisting R5 who reported that R2 had grabbed her by the arm. NA-B stated she reported what R5 stated to RN-A right away. On 01/10/24 at 3:12 p.m., the DON stated she was aware of the incidents that took place on 12/17/23 and she considered both situations to be abuse. The DON stated she did tell staff that a report needed to be completed to the State Agency (SA). The DON stated she thought the report needed to be completed on 12/17/23, but it was not completed until the morning of 12/18/23. The DON stated abuse is to be reported in two hours. On 01/10/24 at 3:28 p.m., the administrator stated she was unaware that R2 was hit with a reacher. The administrator stated she felt someone being hit with a reacher or grabbing another residents arm would be abuse in this situation, and would expect it to be reported to the SA right away as it directs in the facility policy. The facility policy Abuse Prevention Plan revised 1/24 directed suspected abuse of any kind needs to be reported immediately (within 2 hours).

Based on observation, interview and document review the facility failed to ensure residents who were at risk for pressure ulcers were repositioned timely as directed by the residents care plan for 1 of 2 residents (R41), and failed to initiate facility wound documentation protocols, to re-evaluate turning and repositioning intervals, to revise care plan interventions, and to notify the dietician of a new wound for 1 of 2 (R115) residents reviewed for pressure ulcers. Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 had diagnoses which included Parkinson's disease (a progressive disease of the nervous system marked by tremor), muscular rigidity (slow imprecise movement), dementia, and cerebral infarction (stroke). In addition, R41's MDS indicated he was severely cognitively impaired, required assistance with activities of daily living (ADL's), was frequently incontinent of bladder, occasionally incontinent of bowel, and was at risk for pressure ulcers. R41's care plan dated 3/39/23, identified R41 had a healed stage two pressure ulcer to his coccyx. Interventions included pressure relief mattress, cushion in wheelchair, and the facility would establish an appropriate reposition/turn program. R41's orders dated 7/25/23, directed staff to apply Allevyn dressing to coccyx every three days and as needed for protection. On 11/8/23, R41 was continuously observed from 7:06 a.m. to 10:53 a.m. At 7:06 a.m. R41 was dressed in clean clothes wearing shoes and socks he was seated in his wheelchair in a common area near the nursing station, he had his eyes closed. -at 8:24 a.m., R41 was brought to the dining room and placed at a table. -at 8:31 a.m., R41 was observed eating his breakfast using a butter knife. -at 8:32 a.m., a staff member pulled up a chair and asked if she could help him with his food. -at 8:38 a.m., a staff member sat next to R41 and assisted him with eating. -at 8:45 a.m., R41 was brought back to the common area near the nursing station. -at 9:30 a.m., the residents in the common area were arranged into a circle R41 was in this group. -at 9:44 a.m., R41 was participating in the group activity (batting a balloon back and forth). -at 9:58 a.m., the hospice nursing assistant (NA)-I brought R41 to his room and visited with him. -at 10:05 a.m., NA-I brought him back to the common area, no cares were performed. -at 10:53 a.m., staff were asked to bring R41 to his room for a continence and skin check. Registered nurse (RN)-B and NA-I brought R41 to his room. RN-B and NA-I used a mechanical lift to move R41 from his wheelchair to the toilet, R41 was dry. -at 10:59 a.m., R41's old dressing was removed, no open areas, skin was blanchable. RN-B placed a new dressing. R41's progress notes: -10/2/23, The resident has a new area of skin breakdown to his coccyx area. During his weekly hospice shower hospice aide came to report that the resident has a new area of skin breakdown to the coccyx area under his Allevyn dressing. Hospice aide reports that the wound has a foul odor. Interview with floor nurse notes that the resident's most recent dressing change on 10/02/2023 there were no open areas, though she did note a foul odor when the dressing was changed. The entire area measures 6.5cm x 2.5cm spans both buttocks and appears to be MASD/shearing. There is an area to the lower left of the MASD that is pressure related breakdown. The wound bed is pink/purple in color, shiny area of open skin, is non-blanchable and measures 2cm x 2cm. This is a stage 2 pressure ulcer. -10/9/23 at 12:58 p.m., The resident has an area of skin breakdown to his coccyx area. The skin is pink to purple in color and the area has epithelized, all areas are fully blanchable. The entire area measures 6.5cm x 6.5cm spans both buttocks. -11/1/23 at 3:31 p.m., identified R41's open area on his coccyx was healed, interventions included to reposition frequently and have resident lay in the bed for 1-2 hours 2-3x daily. During an interview on 11/6/23 at 1:19 p.m., family member (FM)-E identified R41 had a sore on his bottom. During an interview on 11/8/23 at 10:40 a.m., trained medication aide (TMA)-A stated dependent residents should be repositioned every two hours to prevent skin breakdown. During an interview on 11/8/23 at 11:07 a.m., registered nurse (RN)-B stated she would expect staff to reposition residents according to their care plan. RN-B stated three times a shift would work out to be about every two hours. RN-B verified three hours was too long for R41 and he was at risk for skin breakdown. During an interview on 11/9/23 at 11:21 a.m., director of nursing (DON) verified residents should be repositioned based on skin assessments. The DON verified a resident who'd had a previous pressure ulcer was at risk for skin breakdown and needed to be watched closely to ensure it did not re-open. The DON verified she would expect staff to follow the resident's care plan. The policy Skin Prevention, Breakdown and Treatment dated 8/2023, indicated pressure was a primary cause of pressure ulcers. In addition, the policy identified it was important to have an effective turning and repositioning schedule to reduce the risk of developing a pressure ulcer. The policy indicated an individualized resident's turning and repositioning schedule was important to develop and follow. 48109 R115: R115's admission Minimum Data Set (MDS) dated [DATE], identified R115 was moderately cognitively intact and had diagnoses of diabetes mellitus, peripheral vascular disease, left-sided hemiparesis, and hemiplegia following a cerebral vascular accident (CVA). R115 was dependent for toileting, hygiene, bed mobility, bathing, and had a non-ambulatory status. Section M of the MDS identified R115 was at risk for pressure ulcers but had no actual pressure ulcers. The Care Area Assessment (CAA) for pressure ulcers dated 9/8/23, was triggered related to R115's risk for developing pressure ulcers. The CAA summarized risk factors as bowel and bladder incontinence, need for extensive assistance with bed mobility, toileting, and hygiene. R115's diagnoses of peripheral vascular disease, diabetes mellitus, chronic anticoagulation therapy, hemiplegia and hemiparesis all increased the risk of skin breakdown. Resident's Braden Score is 10 with risks noted in the following areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear potential. A 2-3-4-hour progressive tissue tolerance was completed and R115 had no increased redness to bony prominences. He will be repositioned three times per shift to coincide with toileting. Barrier cream is applied after each incontinent episode. Facility skin protocol will be followed. R115's care planning will be to provide interventions to ensure his daily skin care needs are met. A document, Skin Ulcer Data Collection form with a diagram for skin assessments dated 9/1/23, identified two areas on the left buttock with a notation of discoloration and pressure. The document further identified these were not open areas, skin was pink in color. No further documentation on Skin Ulcer Data Collection forms was found. A Turning and Repositioning (Tissue Tolerance) Observation form for R115 could not be located. R115's Braden scale (a tool for predicting pressure ulcer risk) scores (the lower the score, the higher the risk) with a scale from one to 23: -9/1/23 score 10 -9/8/23 score 10 -9/15/23 score 11 -9/22/23 score 15 -11/7/23 score 9 R115's care plan dated 9/22/23, identified a history of pressure ulcers with a goal of skin remaining clear through target date of 1/29/24, and interventions to: -reposition R115 three times per shift to coincide with toileting -weekly skin documentation -pressure relief for chair and bed -treatments per MD order -progressive 2-3-4-hour tissue tolerance test during assessment reference date (ARD) period to be evaluated by an RN R115's progress notes included the following: -10/4/23 identified R115 was repositioned every two hours and as needed. Skin blanches to touch, and current treatment remains effective for the resident. -10/5/23 identified new area to left lower buttock measuring 2.0 cm by 3.0 cm with an area of slough (devitalized skin tissue) in the center measuring 1.5 cm by 1.2 cm, skin is blanchable around and there is an odor. Nurse manager started calcium alginate (a type of absorbent dressing), cut to fit slough filled wound bed (leave dry), cover with an Allevyn (a type of adhesive dressing), and change every three days and as needed. -10/5/23 fax communication to Twin Cities Providers (TCP) identifying the new odorous wound with treatment initiated. -10/6/23 Alternating air pressure mattress replaced standard pressure relief mattress on resident's bed. Will assess area on weekly skin rounds. -10/9/23 (interdisciplinary team) IDT weekly skin review: Upon initial assessment peri wound was swollen and gave the appearance that the wound bed was in a crater. Peri wound is now flat and open area now measures 2.5 cm by 3 cm with a slough-filled center that measures 2 cm by 2.5 cm. Peri wound is fully blanchable right up to the edge of the slough. Continue with calcium alginate dressing covered with an Allevyn and changed every three days and as needed. Pressure relief mattress was replaced with alternating air pressure relief mattress on 10/6/23. -10/14/23 Registered nurse (RN) was requested to assess dressing on left posterior thigh where it meets the buttocks. The dressing was saturated with brown drainage and RN noted no date on the old dressing. Cleansed with normal saline and patted dry. Wound is 5 cm by 3.5cm by 0.2 cm, 100% covered with gray-yellow slough. Edges are not intact, slight maceration at 10 o ' clock position. Was tender to cleansing and causing some discomfort after sitting for two hours. Dressing replaced; MD notified via fax. R115 was placed off-loading as well, he stated better. -10/15/23 Writer changed bandage on residents bottom as it was very saturated. Large amounts of slough noted over entire wound. Resident reports it is very painful. Writer told him that he is going to have to try to stay off his bottom as much as possible, laying down after meals and he agreed. -10/15/23 fax communication to TCP indicated request to assess dressing .area tender to cleansing and is causing some discomfort after sitting for two hours. -10/16/23 indicated a new order from provider: Discontinue current dressing change to pressure ulcer to left buttock. New dressing for left buttock: cleanse area with normal saline and pat dry, apply silver alginate dressing (an antimicrobial absorbent dressing) and cover with foam dressing, change every three days, or as needed for saturation. -10/19/23 IDT weekly skin review in collaboration with certified nurse practitioner (CNP): pressure ulcer left buttock, stage two. Resident unable to respond meaningfully to pressure related discomfort due to hemiparesis of left side. Patient denies any pain or burning at site of ulcer. Unable to position himself due to mobility issues. Current off-loading plan is repositioning every two hours, a gel insert for wheelchair, and alternating air pressure relief mattress. -10/20/23 Dressing changed to wound on buttock. No improvement noted. -10/22/2023 No improvement noted to ulcer on buttocks. Resident states area is painful. Refused as needed (PRN) pain medication. -10/23/23 Resident pressure ulcer to buttocks is worsening despite current interventions in place. CNP has looked at the wound weekly and we have determined that he needs to be seen in a hospital for further treatment. Resident's guardian is aware, resident is being sent to Essentia Health emergency department for evaluation and treatment. Bed hold in place. During an interview on 11/8/23 at 10:02 a.m., RN-B confirmed neither of the areas depicted on the Skin Ulcer Data Collection diagram on 9/1/23 were the ones that was now the open area. There wasn't another Skin Ulcer Data Collection depicting and tracking the current pressure ulcer. During an interview on 11/8/23 at 12:48 p.m., nursing assistant (NA)-H reported any resident who has sores or is bed ridden would be turned and repositioned every two hours. NA-H provided there was a cheat sheet they looked at to tell them how often to reposition different residents. R115 was to be repositioned every two hours, the directions had changed for him because he was getting up in wheelchair for meals for a limit of one hour. Since R115 returned from the hospital he had been mostly in bed to keep him off the sore. During an interview on 11/8/23 at 7:46 a.m., RN-B confirmed R115 was to be repositioned three times per shift plus if he were to ask to be repositioned, so it came out to be about every two hours. During an interview on 11/8/23 at 12:55 p.m., licensed practical nurse (LPN)-H stated R115's turning and repositioning program had been the same throughout his stay. R115 had always had a lot of pain around his bottom, that had been consistent, and R115 once explained to LPN-H that once he was off the area it didn't hurt. So, they used a pillow or something under his left leg (side with above-knee amputation) R115 would say it felt better, but that intervention was not on his care plan though LPN-H had informed the nurse manager of it. During an interview on 11/8/23 at 2:00 p.m., RN-B stated she was not sure about the redistribution time the alternating pressure mattress gave but had heard it was about every ten to fifteen minutes. RN-B stated the facility reviewed wounds every week at IDT meetings. The dietician didn't attend these meetings, but the dietary department did, and RN-B wasn't aware that she should be updating the dietician when residents had a new wound. Tissue tolerance testing was done on admit, every 92 days, and with any significant changes. RN-B reported R115 didn't have redness after two hours, so she stayed with three times per shift repositioning schedule. But after R115 developed the new ulcer, they implemented an intervention for up for meals only and then lay him back down right away. RN-B confirmed the intervention was not in R115's medical record, that it had been an intervention listed on the care guide (which was a tool, not part of the care plan or medical record). During an interview on 11/8/23 at 2:45 p.m., DON stated their initial goal for the nurses was to recognize a skin change and report to the provider for further assistance with wound care orders. The facility reviewed wounds weekly on Thursdays at IDT. The dietary department was represented at these meetings, but the dietician wasn't there. The DON's expectation was that if an intervention was implemented it would be on the care plan. The care guide was a tool used by the nursing assistants and not a part of the medical record. The Skin Ulcer Data Collection and Assessment sheets should be filled out for each wound per their policy. The DON shared she had learned today that the nurse managers were no longer doing this, they used it as a guide to write a note. The DON acknowledged this practice made it difficult to follow the progress of a particular wound when a resident had multiple wounds. During an interview on 11/9/23 at 11:35 a.m., the registered dietician (RD) stated the facility didn't consistently notify her of wounds. The RD also stated she felt it was important to have a dietician assessment for residents with wounds because they assess their hydration status, whether or not they have been eating, if they are taking any supplements, whether or not they were getting enough calories. The RD stated this was important so that you could support wound healing. During an interview on 11/9/23 at 11:44 a.m., DON stated she would expect the care plan to be updated with new interventions so that they know how to care for the person. The DON confirmed it was their practice to notify the RD of any new or worsening wounds via email. Inter-Faith Care Center policy and procedure, Skin Prevention, Breakdown and Treatment dated 8/2023, identified the purpose of the policy was to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures and to provide appropriate treatment modalities for wounds according to industry standards of care. Skin Ulcer Data Collection and Assessment sheets are used for pressure ulcers. The policy identified pressure as the primary cause of pressure ulcer, and everyone's tissue tolerance (the ability of the skin and its supporting structures to endure the effects of pressure without breakdown) is different, therefore it is important to individualize each resident's turning and repositioning schedule. For those residents who are immobile, or need assistance with mobility, a Turning and Repositioning (Tissue Tolerance) Observation form will be done on admission, re-admission, with a change in condition (including the development of a pressure ulcer), annually and in both the lying and sitting positions. The care plan is to be evaluated and revised based on responses, outcomes, and the needs of the resident. The dietician will be notified: if a resident is considered nutritionally at risk; upon the discovery of a wound; when a wound declines unexpectedly, if a wound is not showing improvement after two to four weeks. The policy also indicated turning and repositioning intervals would be re-evaluated upon the development of a new pressure ulcer, as well as updating the care plan and care guides.

Based on observation, interview, and document review, the facility failed to monitor manufacturer expiration dates on medications for 1 of 5 residents (R38) reviewed for medication storage. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of primary hypertension and paroxysmal atrial fibrillation (a heart rhythm problem that causes erratic heart rates). R38's provider orders dated 4/29/21, identified nitroglycerin tablets 0.4 milligrams (mg) under the tongue every five minutes as needed for chest pain. Call medical doctor if no relief after three doses. During observation and interview with licensed practical nurse (LPN)-C on 11/9/23 at 12:39 p.m., R38's nitroglycerin tablets were found to have a manufacturer's expiration date of 8/31/23. LPN-C stated they should be going through their carts for expired medications on a regular basis because the efficacy of the expired medications could be off. During an interview on 11/9/23 at 1:06 p.m., registered nurse (RN)-C stated it was their policy to date medication bottles when they were opened. They should also be looking at expiration dates on a routine basis because it was important to not use medications that were expired because they may not work the way they should. During an interview on 11/9/23 at 1:28 p.m., the director of nursing (DON) stated the nurses should be looking at the medication carts and removing expired medications on a regular basis. It was important to not give expired medications because they may not work as expected. A policy regarding expired medications was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure the dishwasher temperatures were at the correct temperatures for proper sanitization to prevent foodborne illness. In addition, the facility failed to properly maintain the dishwasher to ensure adequate water temperatures for the wash and rinse cycle. This had the potential to affect all 57 residents who received food prepared in the kitchen. Findings include: [NAME] manufacturer's instructions for C-Line A & AW Dishwashers revised 2/2006, indicated the minimum wash temperature should be 160 F and the minimum rinse temperature should be 180 F. During an observation and interivew on 10/17/22, at 2:09 p.m. the following was noted: --The dishwasher had two temperature gauges. There was a manufacturer's sticker above the gauges which indicated the wash cycle should be 160 F and the rinse should be 180 F. --On the front of the dishwasher was a facility sign that indicated the wash cycle temperature should be 160 F and the rinse cycle 180 F. The sign directed staff to call maintenance via cell phone or the shop number when temperatures were below target temperatures. The sign further directed staff to begin using paper products immediately until they were given the okay to use the dishwasher. DM-B verified the temperatures posted on the dishwasher were correct. --The October dishwasher temperatures were posted on a clipboard near the dishwasher. The dishwasher temperatures listed for the wash were to be at 150 degrees Fahrenheit (F). The temperatures were to be recorded for breakfast, lunch, and dinner on 10/10/22, there were no temperatures recorded for the wash or rinse for breakfast or lunch. On 10/14/22, at dinner the wash temperature was recorded as 145 F. On 10/15/22, at dinner the wash temperature was recorded as 145 F. On 10/17/22, at dinner the wash temperature was recorded as 145 F. --DM-B verified the temperatures were too low and there were temperatures not recorded. DM-B stated no one had notified her of the low dishwasher temperatures over the weekend. On 10/19/22, at 1:15 p.m. dietary aide (DA)-B stated they would run a few tray racks through the dishwasher to get it up to temperature. DA-B stated when the dishwasher would break down, they would wash dishes using the three-sink method. On 10/19/22, at 1:21 p.m. DA-A stated the gauge for the wash cycle didn't work and only went up to about 150 F. DA-A stated the rinse gauge was working. On 10/19/22, at 1:28 p.m. DA-A recorded the rinse cycle temperature at 190 F. DA-A called DM-B to request a disc to measure the wash temperature. On 10/19/22, at 1:33 p.m. DM-B stated the staff did not think the wash gauge would read any higher than 150 F. DM-B verified she would expect staff to let her, or maintenance know when the dishwasher temperatures were low. DM-B verified staff were not consistently notifying maintenance of low temperatures. DM-B stated she thought the rinse cycle was the most important temperature and if that temperature was 180 F or above that it was okay. DM-B stated staff used the test strips periodically to check the dishwasher temperatures. The facility's Dishwasher Temperatures log temperature, indicated in the header that the wash temp should be 150 F and the rinse 180 F. --The August log had 24 unrecorded temperature readings. The August dishwasher wash cycle recorded temperature was below 160 F 35 times and below150 F six times. The rinse temp was below 180 F nine times. On 8/24/22, the dishwasher was listed as broken during the breakfast and lunch meals. --The September log had 20 unrecorded temperature readings. The wash temperature was recorded below 160 F 24 times and below 150 F two times. The rinse cycle was recorded below 180 F 10 times. --The October log included dates from the first to the twentieth. The log had four unrecorded temperature readings. The wash cycle was recorded below 160 F 28 times, and below 150 F four times. The rinse cycle was recorded below 180 F four times. --One dishwasher temperature test strip was affixed to the log; the strip was dated 10/18/22, by DM-B. The August and September logs did not have any test strips attached. During interview on 10/20/22, at 2:12 p.m. maintenance director (MD)-A confirmed the dishwasher was a single tank conveyor dual temperature dishwasher. MD-A stated the manufacturer guide temperatures required for the facility's dishwasher were 160 F for the wash cycle and 180 F for the rinse cycle. MD-A stated he did not keep a log for incoming calls about the dishwasher or for the maintenance of the dishwasher. MD-A stated he thought chemical vendor came in monthly to do a chemical check, and said he was not sure what else they looked at. MD-A stated his expectation was for kitchen staff to call when the dishwasher wash did not reach a minimum 160 F or the rinse to not reach a minuimum180 F. During interview on 10/20/22, at 2:44 p.m. the director of nursing (DON) she would expect staff to notify the DM or maintenance if the dishwasher was not at the proper temperatures and start using paper products. The DON stated it was important to have correct temperature to sanitize the dishes. The DON stated she did not know how often staff checked the dishwasher temperatures using test strips and had not been made aware of any problems with the dishwasher. The policy titled Dish Machine Temperature dated 8/4/99, directed staff to record temperatures at the start of each dishwasher run following each meal. The policy indicated the temperature for the wash cycle was to be above 150 F. The 5 in 150 was handwritten over the original number. The policy indicated rinse temperatures should be above 180 F. If temperatures do not reach these levels, please inform your supervisor, maintenance (sp), or call Auto Chlor as directed in dish room.

Based on interview and document review, the facility failed to ensure the resident's resuscitation status order found in the electronic medical record (EMR) matched the resident's written request of Do Not Resuscitate (DNR) found in their Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R41's Admission Record printed [DATE], indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's admission Minimum Data Set (MDS) dated [DATE], indicated R41 was cognitively intact, was able to make himself understood, and was understood by others. R41's electronic order dated [DATE], taken from the hospital discharge interagency referral, indicated R41's code status was full code (meaning staff were to initiate cardiopulmonary resuscitation [CPR]). These orders generated an EMR banner which indicated R41 was a full code. On [DATE], licensed pratcial nurse (LPN)-B signed that the POLST and EMR code status matched. On [DATE], at 4:21 p.m. R41's POLST dated [DATE], and signed by R41, located in the hardchart, indicated R41's code status was DNR. On [DATE], at approximately 5:00 p.m. R41's EMR banner indicated he was to receive CPR. R41's Temporary Care Plan dated [DATE], indicated R41 was do not intubate (DNI); neither DNR nor CPR were checked. R41's Short-Term Rehab Care Conference/Discharge Conference dated [DATE], attended by R41 indicated his current code status was DNR. The form indicated the POLST was reviewed and no changes were needed. Although R41's EMR order and banner indicated full code, R41's POLST indicated DNR. During interview on [DATE], at 6:55 p.m. R41 stated he wanted to be a full code and would want CPR started and give a few shots with the paddles, intubate, if not successful then it's meant to be. During interview on [DATE], at 7:18 p.m. registered nurse (RN)-B stated the admitting nurse would go over the POLST with the resident. RN-B stated staff should look in the EMR or the hard chart or whichever was closer to find the resident's code status. During interview on [DATE], at 7:20 p.m. licensed practical nurse (LPN)-C stated she would always go to the hard chart for the POLST. During interview [DATE], 7:22 p.m. LPN-A stated in an emergency she would look in the hard chart. During interview on [DATE], at 7:23 p.m. nursing assistant (NA)-C stated she was not certified in CPR, but she thought code status was listed in the EMR. RN-B interjected and stated the nurse would tell her where to look for the code status. During follow-up interview on [DATE], at 7:26 p.m. R41 stated I was out of it when they first brought me here. My wife probably filled out the POLST. R41 reviewed the POLST and stated, I changed my mind; he stated again that he wanted to be a full code. R41 did not recall who he talked after he changed his mind but thought it was about five or six days after being admitted . There was no documentation of this exchange in the medical record. During interview on [DATE], at 7:32 p.m. RN-B verified the POLST and the EMR did not match. RN-B stated the process was for the admitting nurse to go over the POLST with the resident on admission and enter the order into the electronic record. RN-B stated a step in the process must have been missed. During interview at [DATE], 2:27 p.m. the director of nursing (DON) stated the process was for the admitting nurse to review the POLST with the resident from the admission packet. The DON stated sometimes the resident would want a different code status than what they had in the hospital. If the code status was different the admitting nurse would notify the provider and update the code status in the EMR. When the provider signed the new POLST a nurse would check this against the order in the EMR. The DON stated the EMR would generate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON could not explain how the order was signed off, but the orders were different. On [DATE], at 12:35 p.m. attempts were made to contact LPN-B; these attempts were unsuccessful, LPN-B did not return call. During an interview on [DATE], at 8:12 a.m. advance practice registered nurse (APRN)-C, stated when she admitted a resident she would talk with them about code status. APRN-C stated her notes reflected R41 was a full code as of [DATE]. APRN-C stated the process was for the nurses to talk with the resident about their resuscitation wishes on admission. The nurse would then fax the POLST to her for a signature. The facility was responsible for reviewing and updating the EMR. The facility policy titled POLST Order Policy revised ,d+[DATE], indicated upon admission and re-admission a code status order would be on the Inter-Agency Referral (IAR). The policy indicated the POLST with the most recent date would be the legal document to follow. The policy indicated the POLST information was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and document review, the facility failed to provide a written copy of the baseline care plan following admission for 1 of 3 residents (R49) reviewed for new admissions. Findings include: R49's Admission Record printed 10/20/22, indicated R49 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/18/22, at 9:02 a.m. R49 stated she had not been to a meeting to talk about her care, and she had never received any documents about her plan of care. R49's Temporary Care Plan/Nursing Admission assessment dated [DATE], was signed by the admitting nurse There was no indication the care plan was offered to R49 in written format. R49's Short-Term Rehab Care Conference/Discharge Conference Form dated 10/5/22, indicated R49 was present for the conference. The form did not indicate if R49 was given her care plan in written format. R49's medical record had no documentation to indicate she was given a written copy of her care plan. During interview on 10/20/22, at 8:33 a.m. registered nurse (RN)-C stated the care plan was made by the admitting nurse with the resident during the admission. RN-C verified she was the admitting nurse for R-49 and she did not give R49 a copy of the temporary care plan. During interview on10/20/22, at 8:46 a.m. RN-B stated, I am not sure if the resident is offered a copy of the care plan. I have never heard of the resident being offered a care plan. During interview on 10/20/22, at 9:13 a.m. RN-A verified residents were not given a copy of the care plan. RN-A stated, It's just not part of our process. During interview on10/20/22 at 9:39 a.m. the director of nursing (DON) verified the residents were never offered a written care plan at any stage of the care plan process. During an interview on 10/20/22, at 2:12 p.m. licensed social worker (LSW)-A stated they had not given any residents a copy of the care plan. LSW-A stated the only way a resident would receive a copy of their care plan would be if they specifically asked for it. The policy titled Care Planning Process revised 10/2022, indicated the MDS Coordinator would document in the electronic medical record a progress note that the care plan was offered and accepted or declined. The policy indicated the interdisciplinary team would ask the resident and family during the care conference if they would like a copy of the care plan.

Based on observation, interview and document review the facility failed to safely store and correctly label medication in 1 of 5 medication storage areas, reviewed for medication storage. Findings included: During an observation on 10/20/22, at 11:03 a.m. the Cedar Unit nursing station refrigerator had a gallon container of distilled water in the door. The bottle had written on it in light purple sharpie/marker Acetic Acid '1:1' mixture with the date of 10/17/22; on the flip cap was written Ed H. The bottle lacked a medication label with resident information including full name, date of birth or other identifying markers. The bottle also lacked information about the compounding solution related to amount of each item mixed. The outside of the refrigerator had links on the door and frame where a padlock would go but no padlocks were observed connected to either link. On 10/20/22, at 12:14 p.m. pharmacist (PH)-A stated he was not aware of any residents having medication mixtures of any kind. PH-A stated any medications used for residents, and needed to be kept cool, should be secured in a refrigerator with a lock on it where only nurses and trained medication aides (TMA) have access. Ph-A stated when medications are left opened then anybody could take them. PH-A stated all liquid medications should have a label on it that included resident name, date of birth, medication information in bottle, mixture date and expiration date. Ph-A stated any mixtures used on residents should be considered a medication and placed on the medication administration record. On 10/20/22, at 12:37 p.m. PH-A called back and stated he had checked with the branch pharmacy, and they were not mixing the acetic acid mixture and the pharmacy did not have it on any resident's medication administration record. On 10/20/2022, at 3:01 p.m. registered nurse (RN)-A stated the unit refrigerator was the only refrigerator on the unit. RN-A stated the refrigerator did hold both resident food and drink, along with resident medications. RN-A stated all medications were in either single locked drawers or double locked drawers if the medications were controlled substances. RN-A stated all medications needed to be secure so only nurses or TMAs had access to them. RN-A stated all medications should be labeled appropriately. RN-A looked in the refrigerator and stated the acetic acid mixture was not in a secured area of the refrigerator. RN-A stated the nursing staff had mixed the solutions based on urologist instructions and had used the solution on a resident to irrigate their foley catheter. RN-A stated the liquid medication should be in a secure area because all staff had access to the refrigerator due to the food inside. RN-A stated several months ago they stopped locking the main refrigerator door so all staff could access the food and drink contents for residents. On 10/20/22, at 5:02 p.m. the director of nursing (DON) stated they utilized their consultant pharmacy's policies for medication storage and medication labels. The DON stated she expected nursing staff to follow policies to make sure medications were stored and labeled properly. The DON stated she was not aware the acetic acid mixture was in the refridgerator on Cedar unit. The DON stated all medications should be in locked areas. The consultant pharmacy's Storage of Medication policy dated 4/14, indicated all medications would be stored securely and per manufacturer's recommendations so only licensed nursing personnel, pharmacy personnel or staff members that were lawfully authorized to administer medications could have access to the medications. The pharmacy's Medication Labels policy dated 11/17, indicated medication labels would be permanently affixed to the outside of prescription container. The label would contain the residents name, the medication name, strength of medications (liquids would include strength per milliliter (ML) and the amount to be given in ML equivalents on the label. Lastly, the specific directions for use which included route of administration should be on the label.

Based on interview and document review, the facility failed to ensure a system to identify a resident's resuscitation status was accurately reflected throughout the medical record and facility documents for 2 of 17 residents (R45, R223) who had elected a do not resuscitate (DNR) status but were documented as a cardio-pulmonary resuscitation (CPR) status. This resulted in an immediate jeopardy (IJ) situation for R45 and R223 who were at risk for serious bodily injury/harm if they were given CPR when they had elected DNR. The IJ began on [DATE], when it was determined the facility failed to ensure resident resuscitation status documentation reflected each resident's current resuscitation preferences and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IJ was removed on [DATE], but non-compliance remained at a lower scope and severity of a D, which indicated no actual harm with the potential for more than minimal harm which is not an immediate jeopardy. Findings include: R45's Admission Record printed [DATE], indicated R45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's Providers Orders for Life Sustaining Treatment (POLST) signed by R45's physician and guardian dated [DATE], indicated R45's selected resuscitation status was DNR with limited interventions, and no intubation (DNI). R45's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's annual Minimum Data Set (MDS) dated [DATE], indicated R45 had a severe cognitive impairment and required extensive assistance of staff for all activities of daily living (ADLs). R45's Order Summary Report printed [DATE], indicated R45 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility resuscitation status order listing report dated [DATE], located on the wall near the chart rack behind the nurse's station on Oak unit, indicated R45's code status was DNR/DNI. R45's care guide sheet (nursing assistant care plan) updated [DATE], indicated R45's resuscitation status was Full Code (initiate CPR). On [DATE], at 7:23 am. nursing assistant (NA)-D stated she was certified to do CPR, and she would check for a resident's resuscitation status either on the POLST in the chart, the sheet hanging on the wall by the charts, and could check the care guide sheet. On [DATE], at 7:26 a.m. licensed practical nurse (LPN)-B stated she always looked for a resident's resuscitation status in the electronic medical record (EMR), but could also check the list on the wall by the charts. On [DATE], at 7:49 a.m. NA-C stated she was certified to do CPR, would check the care guide sheet to find a resident's resuscitation status, and would start CPR if indicated. NA-C stated R45's resuscitation status was Full Code, so would start CPR if she found him without respirations or a heartbeat. NA-C then said she could check the wall to make sure, but noted the care guide had just been updated so she would be able to go by that. On [DATE], at 9:34 a.m. NA-A stated she would check the care guide, check for a pulse and start CPR before the nurse arrived if the resident was full code. On [DATE], at 9:28 a.m. registered nurse (RN)-B stated she would get help, check the EMR, or the resuscitation status list on the wall by the charts. On [DATE], at 9:44 a.m. RN-A stated she made the changes on the care guide sheet. RN-A stated when the POLST was signed by the physician and returned, the nurse receiving the order would process it by entering it into the EMR, and the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A sated anyone who was certified in CPR would be able to do CPR in the facility. RN-A stated the staff should look at the POLST, but if not available, they could look at the resuscitation status list or the EMR. RN-A sated if a resident was found without respirations or heartbeat, she would call a code blue, and verify the resuscitation status by looking at the POLST or the EMR. RN-A verified each resident's resuscitation status was on the care guide, but may not be updated if there was a change over night. RN-A verified R45's care guide indicated he was Full Code (CPR), which was incorrect according to his POLST. RN-A verified if the NA had looked at R45's care guide, they would have initiated CPR, against his wishes. RN-A stated the facility policy directed staff to look at the EMR, the POLST or the list on the wall. On [DATE], at 10:01 a.m. the director of nursing (DON) verified some NAs were certified to do CPR and stated they just had a class on resuscitation status on [DATE], and they were taught to look at the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the NAs should get the nurse, and the nurse should make the determination of whether they should start CPR. The DON verified a resident could get CPR when they did not want it if the care guide was incorrect, and staff checked it for the resuscitation status and initiated CPR. The IJ which began on [DATE], was removed on [DATE], when the facility had revised the policy Code Blue (Cardiac Emergency) CPR Policy and Procedure, reviewed all resident records and educated staff. This was was verified through interview and document review. The facility policy Code Blue (Cardiac Emergency) CPR dated [DATE], directed the staff to determine the code status of the resident who was without a pulse or respirations, which could be found in the EMAR at the top of the resident record, on the POLST in the front of the chart, or on the code status list on the wall by the charts. R223's Admission Record printed [DATE], indicated R223's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R223's care guide sheet printed [DATE], indicated R223's resuscitation status was DNR. R223's POLST signed by her power of attorney (POA) on [DATE], indicated R223 did not want to be resuscitated in the event of her heart beat and breathing stopped. On [DATE], at 9:37 a.m. on the Cedar nursing unit, a list of resuscitation status for all residents was on the wall at the nurse's station. R223's resuscitation status was listed as CPR. On [DATE] at 9:41 a.m. R223's EMR was reviewed, and indicated R223's resuscitation status was DNR. On [DATE], at 9:49 a.m. NA-I was interviewed. NA-I stated she would check resuscitation status post [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], at 10:56 a.m. the DON was interviewed. The DON verified R223's code status was incorrectly posted on the wall of the Cedar nursing unit. The DON verified R223 would have received CPR against her wishes in the event she stopped breathing and her heart stopped beating.

Based on interview and document review, the facility failed to allow visitors without first making an appointment. This had the potential to affect all 74 residents who resided in the facility, and their families and friends. Findings include: On 7/26/21, at 11:45 a.m. upon entering the facility a sign was noted to be posted which had the following message: All Visits must be scheduled and confirmed through the Visitation schedule line 218-***-****. NON-scheduled visits(s) will be turned away. Another posted sign had the following message: Length of visit: All visits are no more than one hour (60 minutes), even if held outside. On 7/28/21, at 8:48 a.m. nursing assistant (NA)-G was interviewed. NA-G stated families had to call a special number to schedule visits. If no one answered the phone, there were specific instructions on what information was needed to schedule the visit. NA-G stated the visits started at 10:00 a.m., the memory care unit visitors had a special entrance to visit and stayed at the end of the hallway for visits. Visitors did not visit in resident rooms. NA-G stated other visiting areas were on the first floor. The library and dining room were used for visits. Visitors could also visit outside on the scheduled visit. The last visit of the day was scheduled for 4:30 p.m. Visits were scheduled for one hour except for the memory care unit. Visits on the memory care unit were scheduled for 30 minutes. NA-G verified there were signs on the entrance door that informed visitors could only visit by appointment. On 7/28/21, at 1:38 p.m. the ombudsman was interviewed. The ombudsman stated he received two to three calls a week about the visiting restrictions and the need to make an appointment. On 7/28/21, at 1:59 p.m. the resident council was held. R19 stated she thought the visiting rules were too restrictive. R19 stated the residents needed to be able to have visitors after business hours. An unidentified resident stated he had to visit his son outside of the front doors on one occasion. On 7/29/21, at 9:01 a.m. the activities director (AD)-A was interviewed. AD-A stated the facility had been having families make appointments prior to visiting to monitor how many families were in the building at one time. AD-A stated two to six families could visit at one time with one to three visitors. Visits were schedule for one hour. AD-A stated if families showed up without an appointment they would accommodate them. AD-A stated she did not know how many families had not tried to visit based on the front door sign. AD-A stated visiting hours were restricted from 10:00 a.m. to 11:30 a.m. and then from 1:30 p.m. to 5:00 p.m. AD-A stated they would make accommodations for evening visits if asked. AD-A stated they had complaints about the restricted visiting from families and during resident council meetings. On 7/29/21, at 11:52 a.m. the director of nursing (DON) and the administrator were interviewed. The DON stated the facility had been very liberal with compassionate care visits. The administrator stated they were trying to logistically manage who was in the building, trying to apply the rules to the letter, and not put their residents at risk. The DON stated not all of their residents were vaccinated, and they were trying to keep the residents safe. The DON stated maybe they could have opened up visiting sooner, but never to their knowledge had turned any visitors away. The DON stated they were not hearing too many complaints from families, but verified they should have lifted the visiting restrictions. The facility policy In Person Contact Allowed Visits revised 6/15/21, directed all visiting parties (resident and guest) will be eligible for visits if they were 14 days past their vaccination. Guests needed to be fully vaccinated. All visits needed to be scheduled with a time and location.

Based on observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 related to the proper utilization of personal protective equipment (PPE) for 1 of 1 resident (R273) who was reviewed for infection control practices. In addition, the facility failed to ensure proper hand hygiene and glove use was completed during toileting cares for 1 of 2 residents (R39) observed during personal cares. Findings Include: R273's Face Sheet printed dated 7/29/2, indicated R273 was admitted to the facility on [DATE], and placed in quarantine. R273's quarantine period had been identified as ending 7/28/21. On 7/30/21, signage was observed on R273's door indicating R273 was on transmission-based precautions (TBP). On 7/27/21, at 1:44 p.m. R273 was observed sitting in his wheelchair, in the entryway to his room, without a mask. On 7/27/21, at 2:13 p.m. nursing assistant (NA)-H was observed donning a yellow gown, clean gloves, a surgical mask and eye protection, and entered R273's room. NA-H was interviewed when he exited the room, and stated that no one was wearing N95 masks in the quarantine rooms. The sign outside of R273's room indicated that a surgical mask was to be used. On 7/28/21, at 7:20 a.m. registered nurse (RN)-B stated newly admitted residents were kept in isolation on droplet precautions for two weeks. RN-B further stated N95's were not required for new admission only resident who received nebulizer treatment and resident who were COVID-19 positive. On 7/28/21, at 2:00 p.m. the signage outside of R273's room indicated that R273 was on Transmission Based Droplet Precaution. The signage further indicated the specific PPE to use was gloves, gown, surgical mask and goggles. On 7/29/21, at 12:14 p.m. the director of nursing (DON) stated N95 respirators were not being used in isolation rooms for new admissions. The DON further stated she was going by the Center for Disease Control (CDC) guidelines for strategies to optimize PPE and could conserve their N95 masks in the event of a COVID-19 outbreak . The Interfaith Infection Prevention policy directed staff will use appropriate PPE when they are interacting with residents, to the extent PPE is available and per CDC guidance on conservation of PPE. R39's Admission Record printed 7/29/21, indicated R39's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's comprehensive annual Minimum Data Set (MDS) assessment dated [DATE], indicated R21 was cognitively intact, required extensive assistance with mobility, toilet use and personal hygiene, and was frequently incontinent of bladder. R39's MDS further indicated R39 had balance difficulties and required assistance to stabilize. R39's Care Guide sheet, updated 7/27/21, directed 2 staff to transfer R39 with the stand assist lift for toilet use and assist with toileting cares. On 7/27/21, at 1:49 p.m. R39 was transferred with a stand assist lift and 2 staff to the commode to have a bowel movement (BM). After having a BM, R39 was assisted to stand with the stand assist lift, nursing assistant (NA)-E, wiped the BM from R39's bottom with cleansing wipes, disposed of the wipes into the garbage, and pulled up R39's clean brief and pants with the same gloves on. R39 was lowered back down to the commode during cares and back up to complete dressing. NA-E then helped to transfer R39 with the stand aide assist into her wheelchair, helped move the stand aid assist lift. NA-E removed her gloves and then put away the cleansing wipes in a drawer, which she opened and closed. NA-E then sanitized her hands and donned clean gloves to remove the garbage and finish cleaning up supplies. On 7/27/21, at 2:05 p.m. NA-E verified she should have removed her gloves and sanitized or washed her hands before pulling up R39's clean brief and pants, and before putting the wipes away. On 7/29/21, at 11:05 a.m. registered nurse (RN)-A verified staff should complete hand hygiene before and after removing gloves, and gloves should be changed after cleansing a resident's buttocks of BM as soon as there was a safe opportunity. On 7/29/21, at 1:59 p.m. director of nursing (DON) verified the expectation was for staff to sanitize hands before and after touching something that was contaminated, and to wash hands and change gloves after wiping up BM. The facility policy and procedure for Handwashing/Hand Hygiene revised 8/15, directed staff to hand sanitize with an alcohol-based hand rub containing at least 62% alcohol, or wash hands with soap and water after contact with bodily fluids, going from a contaminated body site to a clean body site during cares, after contact with resident's intact skin, and after removing gloves.

Based on observation, interview, and document review, the facility failed to ensure difficulties with transfers using the stand-assist lift (EZ Stand) was communicated and assessed to prevent further falls for 1 of 2 residents (R39) reviewed for accidents. Findings include: R39's Admission Record printed 7/29/21, indicated R39's diagnoses included a cerebral infarction (stroke), right below the knee amputation, and Charcot's joint foot and ankle (progressive, [CONDITION(S)] condition which results in weakening of bones and soft tissues of the foot or ankle). R39's annual Minimum Data Set (MDS) dated [DATE], indicated R39 was cognitively intact, had balance deficits requiring assistance to stabilize, had range of motion deficits of both lower extremities, and required extensive assistance with transfers. R39's MDS further indicated R39 had no falls since the previous quarterly assessment. R39's care plan revised 6/22/21, indicated R39 was at risk for falls, and interventions included ensuring R39 was wearing appropriate non-slip foot wear and prosthetic leg was in place for transfers with the EZ Stand. R39's Care Guide sheet updated 7/27/21, directed staff to use two staff with transfers using the EZ stand in the bathroom, limit standing time to less than 2 minutes, and ensure the leg strap buckle was on for all transfers with the EZ Stand. R39's progress report dated 7/8/21, indicated R39 had been lowered to the floor when her right prosthetic leg slipped out of the shin pad on the EZ stand during a transfer. R39's progress report indicated the shin strap on the EZ stand was not utilized during the transfer. R39 was not injured, and her Care Guide was revised to direct the use of the shin strap during transfers with the EZ Stand. On 7/27/21, at 1:49 p.m. R39 was observed during toileting cares. Nursing assistant (NA)-B and NA-E prepared to transfer R39 with the EZ Stand. NA-E secured the shin strap around R39's lower legs, and ensured she had non-skid footwear on. R39 was lowered appropriately to limit her standing time to less than two minutes, as care planned. As R39 was transferred from the commode to the wheelchair, R39's left leg had come out the side, partially off the platform on the left, even with the shin strap appropriately secured around R39's shins. R39 was safely lowered into her wheelchair and no injury occurred. On 7/27/21, at 2:05 p.m. nursing assistant (NA)-E stated R39 only used the EZ Stand when she used the commode and could only stand for about 2 minutes. NA-E verified R39 had an incident during which she was lowered to the floor when her right leg came out of the shin pad when the shin strap was not utilized. NA-E verified during the transfer with the EZ Stand on this date, R39's left leg came out, though her legs were secured with the shin strap. On 7/29/21, at 11:05 a.m. registered nurse (RN)-A stated R39 had not been re-assessed for the use of the EZ Stand, as the shin strap had not been used, so they implemented the use of the shin strap. RN-A stated that if she had problems with the shin strap in place she would have had her re-evaluated for the safety of transfers with the EZ Stand. RN-A stated she was not aware that R39 continued to have problems with her leg sliding out of the EZ Stand shin pad and off the foot plate even with the use of the shin strap. RN-A verified none of the staff had reported this to her, but if they had she would certainly have her re-evaluated with the knowledge of continued difficulties with the EZ Stand. RN-A stated staff should be communicating any changes or difficulties, so they could be assessed. On 7/29/21, at 1:59 p.m. director of nursing (DON) verified staff should use the shin strap for transfers with the EZ stand. On 7/29/21, at 2:39 p.m. DON verified the staff should communicate change in condition or a change in transfers so they could be assessed. The facility Direct Care Expectations revised 1/24/21, directed the direct care giver to report immediately to the team leader anything that is different from the care guide, including any accidents or incidents and any changes in the physical status.

Based on interview and document review, the facility failed to ensure identification and monitoring of mood and behavior symptoms to determine efficacy of [CONDITION(S)] medications and to monitor side effects and effectiveness of [CONDITION(S)] medications for 1 of 5 residents (R26) reviewed for unnecessary medications. Findings include: R26's Admission Record printed 7/29/21, indicated R26 had diagnoses included dementia without behavior disturbances, had a problem related to social environment, was unsteady on feet, and had a history of falls. R26's Admission Minimum Data Set (MDS) dated [DATE], indicated R26 had moderately impaired cognition, had no behaviors, and was not on an antidepressant medication during the assessment period. R26's Order Summary Order Report printed 7/29/21, identified R26 started on [MEDICATION(S)] (antidepressant) 15 milligrams (mg) on 6/15/21. R26's Summary Order Report indicated R26's antidepressant side effect monitoring was not initiated until 7/28/21, and target behavior monitoring were not initiated until 7/30/21. R26's care plan initiated 6/4/21, lacked identification, goals, and interventions for R26's diagnoses of depression. R26's care plan lacked identification of target behaviors or mood symptoms, and further lacked monitoring of target behaviors and mood symptoms related to R26's [MEDICATION(S)] order. R26's physician note dated 6/15/21, indicated R26 exhibited signs and symptoms of depression and was stared on [MEDICATION(S)] 7.5 mg for appetite. R26's physician orders instructed to watch for side effects of [MEDICATION(S)] and to re-evaluate in six weeks. On 7/27/21, at 3:44 p.m. registered nurse (RN)-F verified R26's electronic medication administration record (eMAR) and electronic treatment administration record (eTAR) lacked side effect or behavior monitoring for prescribed [MEDICATION(S)]. RN-F stated he was unsure what target behaviors or side effects to monitor for R26's [MEDICATION(S)]. On 07/28/21, at 8:48 a.m. RN-E verified identification and monitoring for side effects and target behavior for [MEDICATION(S)] medication were not on R26's eMAR or care plan, and were added 7/27/21. RN-E stated R26 was started on [MEDICATION(S)] for a trial period due to a decreased appetite and sadness due to major life changes and loss. RN-A stated it was important for monitoring R26's mood and possible side effects from the medication to determine the effectiveness of the antidepressant. On 7/29/21, at 1:39 p.m. the director of nursing (DON) stated she would expect identification and monitoring of mood and behaviors along with monitoring of side effect for antipsychotic medications be identified on the residents EMR and Care Plan. The DON stated it was important as it was a way to monitor the effectiveness of the antipsychotic to ensure the resident was receiving the correct medication and dosage. A facility policy on side effect and target behavior monitoring for antipsychotropic medications was requested and not received.

Based on observation, interview, and record review, the facility failed to ensure dental concerns were followed up for 1 of 1 residents (R65) reviewed for dental services. Finding include: R65's annual Admission Data Set (MDS) dated [DATE], indicated R2 had intact cognition, and had no dental concerns. R65's care plan initiated 2/2/21, indicated R26 had no issues with chewing or oral pain. The facility assisted with scheduling dental appointments and with transportation to/from the dental office. R65 dentist was in Deerwood, MN. R65 had an upper left partial that had been made and just needed to be inserted. R65's care plan indicated R65's last appointment was in Fall 2019. R65's quarterly assessment dated [DATE], indicated R65 had her own teeth and they were in fair condition. The assessment further indicted R65 reported she used a dental clinic in Deerwood, MN. R65's last dental care services were the fall of 2019, prior to admission to the facility. R65 further reported she need to have a fixed partial inserted on the upper left jaw; and the piece had been created and was waiting placement. On 7/26/21, at 12:44 p.m. R65 stated she had upper left missing teeth and was fitted for a partial prior to COVID. R65 further stated staff from the facility were aware, and they had been working on getting her into see the dentist to get her partial. R65 states she had not been updated, so she did not know where things were at regarding her dental visit. On 7/28/21, at 9:08 a.m. RN-E stated she was not aware of any dental appointment for R65's partial, and verified R65's medical record lacked documentation a dental appoint had been scheduled. On 7/28/21, at 2:26 p.m. RN-D stated she completed annual, quarterly and change in condition MDS, and completed R65 quarterly assessment on 4/8/21. RN-D stated she did remember R65 stating she had a partial at her dentist and needed to have an appointment made to get her partial placed. RN-D stated she planned on calling the dentist to see if they still had the partial since it had been since the fall of 2019 but had not. RN-D stated R65 had her quarterly MDS due this month and planned on following up at that time. On 7/28/21, at 2:40 p.m. R65's progress note indicated a follow up telephone call was placed to R65's dental clinic, and was informed R65 had a treatment plan in place in the Fall of 2019 to have several teeth extracted and then fitted for an upper partial and R65 had not completed the treatment plan. The progress not further indicated R65 would have to be re-evaluated for a new treatment plan and the dental office would interview R65 to see how R65 would like to proceed. On 7/29/21, at 1:43 p.m. the director of nursing (DON) stated she would expect who ever completed the dental assessment to follow up on any dental concerns. The DON further stated she would expect the follow up to be timely, which would be after the assessment and the dental need was identified, and not wait for when the next assessment was due. The facility policy Resident Care revised 5/18, directed the facility will assist residents to obtain regular and emergency dental services.

Based on interview and document review, the facility failed to ensure the nurse staff posting was posted daily and was updated to reflect the current staffing. This had the potential to affect all 74 residents residing in the facility. Findings include: On 7/26/21, at 5:03 p.m. the nurse staff posting was reviewed. The staff posting included only staffing for the day shift, and lacked information for the evening or night shift. On 7/27/21, at 9:34 a.m. the staff posting included only staffing for the day shift, and lacked information for the evening or night shift. On 7/28/21, at 11:38 a.m. the staff posting included only staffing for the day shift, and lacked information for the evening or night shift. On 7/28/21, at 2:44 p.m. the director of nursing (DON) was interviewed. The DON verified the nurse staffing should be posted daily, with the amount of staff for each shift. On 7/28/21, at 2:54 p.m. registered nurse (RN)-C was interviewed. RN-C stated she filled out the nurse staff posting sometime after she arrived after 2:00 p.m. and then again before she left for the night. RN-C verified the staffing information for evening and night shifts was not on the nurse staff posting.

Based on interview, and document review, the facility failed to complete accurate and ongoing weight monitoring and nutritional assessment for 1 of 3 residents (R1) reviewed for weight loss. This resulted in actual harm to R1, who experienced a 25% weight loss in 6 weeks. Findings include: R1's admission record printed 6/9/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, and required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The MDS identified R1 required set up assist for meals and supervision for eating. The MDS identified R1 had no weight loss and had no difficulty with swallowing liquids/solids. R1's Care Area Assessment (CAA) dated 3/19/21, indicated R4 was a nutrition risk related to recent stroke that has caused dysphagia, left sided weakness/[CONDITION(S)] and left side neglect and diabetes among other disease processes. R1's care plan initiated 3/18/21, identified R1 had the potential for alteration in nutrition related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan indicated goals which included to keep R1's weight stable, maintain current weight and R1 would consume 75% of meals and fluids. The care plan further instructed staff to perform weekly weights, monitor food and fluid intakes and document after each meal, Registered Dietician (RD) to monitor weights upon admission, annually and with significant changes. Dietary Manager (DM) to monitor weights weekly with focus for weight loss/gain at interdisciplinary team (IDT) meeting. Dietary Manager to analyze weights for quarterly assessments and MDS. R1's care plan also identified R1 was at risk for changes in weight and appetite related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Nutrition assessment dated [DATE], lacked R1's current weight but had been noted to have a low caloric carbohydrate (LCC) diet with regular textures. The assessment indicated R1 had recently been progressed from tube feedings to oral nutritional intake during recent hospital stay. The assessment also indicated R1 was independent at meals but requires supervision and cues. Recorded intakes have been 75-100% with IBW (ideal body weight) 160-196 lbs. and directed staff to monitor weight and intake per protocol. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Check previous weights and reweigh if off +/- 5 pounds. Progress notes to be made noting weights, what scale used, if on wheelchair and if foot rests were in place. On 4/6/21, a Physician Visit form indicated R1 had some weight loss which was likely related both to his stroke and to the medications he had been started on recently. On 4/20/21, at 12:28 p.m. a progress note indicated R1's meal intake had been quite variable throughout stay and had been mostly inadequate. Writer reached out to dietary manager to update on this and request someone discuss with resident what his dietary preferences are and see what we can do to personalize his dining experience. On 4/21/21, at 9:26 p.m. a progress note indicated R1 had a decline in his eating, eating 25% or less most of the time. On 4/23/21, at 9:03 a.m. a progress note indicated R1 had significant weight loss of 30 pounds (lbs) since admission to the facility. R1 reported poor appetite. Fluid intake poor as well. Discussed medications that may have caused decreased appetite. Discussed a potential decrease in stimulant medication and options such as appetite stimulation medication with R1. The note indicated R1's MD was updated. On 4/23/21, at 2:41 p.m. a progress note indicated R1's MD replied back with OK to start supplement shakes 2 times daily and [MEDICATION(S)] (appetite stimulation) 2.5 milligrams (mg) 2 times daily, as well decreasing [MEDICATION(S)] (appetite stimulant) to 5 mg twice daily. The note indicated R1's insurance had not approved stimulant medication, and medication had not been started prior to readmission to the hospital on 4/25/21. On 4 /25/2021, at 8:50 a.m. a progress note indicated R1 had difficulty swallowing morning medications and swallowing water. The note indicated both water and pills ran out of R1's mouth. R1 was noted to have been weaker and having some difficulty with balance and was leaning to the left more than usual. R1 did not appear to be in pain. When asked if R1 felt he should be evaluated at the emergency room (ER), R1 replied, No, I'm not going anywhere. R1 was reevaluated 15 minutes later and was offered ER again and R1 refused. Facility continued to monitor. R1 refused breakfast. On 4/25/21, at 1:50 p.m. a progress note indicated R1 had been having increased difficulties following direction and increased weakness. R1 was requesting to go to hospital, and was transferred out. R1's weight record from the electronic health record (EHR) 3/9/21, to 4/24/21, indicated: 3/9/21, 196.4 lbs. 3/18/21, 190.2 lbs. 3/27/21, 182.4 lbs. 4/3/21, 184.4 lbs. 4/11/21, 166.4 lbs. 4/17/21, 163.8 lbs. 4/24/21, 142 lbs. indicating a 52 lbs. weight loss, or 25% since admission on 3/9/21. R1's meal intake records from the EHR from 3/9/21, to 4/25/21, and weekly total combined three daily meal (breakfast, lunch, and dinner) averages included: 3/9/21, through 3/16/21, 81% combined average meal intake for all 7 days. 3/16/21, through 3/22/21, 78% combined average meal intake for all 7 days. 3/23/21, through 3/29/21, 56% combined meal average intake for all 7 days. 3/30/21, through 4/5/21, 30% combined meal average intake for all 7 days. 4/6/21, through 4/12/21, 28% combined meal average intake for all 7 days. 4/13/21, through 4/20/21, 32% combined meal average intake for all 7 days. 4/21//21, through 4/25/21, 15% combined meal average intake for all 5 days. On 6/9/21, at 9:01 a.m. the facility MDS coordinator, registered nurse (RN)-A was interviewed and stated all resident's weights were reviewed weekly to identify weight loss and discussed at the interdisciplinary team (IDT)weekly meetings. RN-A stated she had not always attended all IDT meetings. RN-A stated if a residents would have unplanned weight loss as a team, they would discuss interventions such as maybe they needed a supplement. RN-A stated the nurse managers were responsible for collecting the information related to weight loss, and would investigate what the causes might be for the weight loss. RN-A stated the nurse managers were responsible for contacting the registered dietician, updating the physician, and notifying the dietary manager. RN-A stated she had not been made aware of R1's significant weight loss, but her expectation was that she would have been notified by the nurse managers. RN-A verified significant unplanned weight loss could contribute to changes in cognition, skin integrity and overall weakness/decline. On 6/9/21, at 9:39 a.m. dietary manger (DM)-A was interviewed and stated a resident's weight loss was reviewed and discussed at the IDT weekly meetings. DM-A stated she had attended all IDT meetings. DM-A stated she met with all residents the day of admission to complete an assessment, and find out what the residents food preferences were. DM-A stated she personally did not review residents' weights for either weight loss or weight gain. DM-A stated she also had not been reviewing intake of meal percentages. DM-A further stated she had just finished her education to become certified dietary manager and would be taking her test later that month. DM-A stated she relied on the nurses and registered dietician (RD)-A to notify her if residents were having weight loss. DM-A stated she would then initiate other food options and or a nutritional supplement. DM-A stated she had not personally revisited R1 to discuss other food options to increase his meal percentage intake. On 6/9/21, at 10:18 a.m. RD-A was interviewed and stated she had not been to the facility since the pandemic; however, she had been checking in with DM-A. RD-A stated she was always available to the facility via phone or email. RD-A stated she mainly currently had been working with the nurse managers of the facility. RD-A stated she had run a facility weight report at the end of April, and noticed R1 had a significant weight loss. RD-A stated at that time, she passed it on to registered nurse (RN)-A and the nurse managers. RD-A stated the nurse manager had responded immediately and indicated in an email they had been aware of R1's weight loss and were looking at possible medication changes with adding an appetite stimulant. RD-A stated she would expect to be notified unplanned weight loss of 5 percent or more in the past month, or 10 percent or more in less than six months. RD-A stated before she could put any interventions in place, R1 had already been admitted to the hospital. RD-A stated she had not received a weight summary report for quite some time. RD-A verified the email correspondence between herself, and the facility nurse managers had been sent out 4/27/21. On 6/9/21, at 11:16 a.m. RN-B was interviewed and stated she was the nurse manager on the unit R1 had resided while at the facility. RN-B stated IDT meetings were held weekly, and all residents' weights were being reviewed at that time. RN-A stated the nurse managers discussed weight loss and reviewed or added interventions if needed at that time. RN-A stated unplanned weight loss would be 5 percent or more in the past month, or 10 percent or more in less than six months. RN-A stated she had discussed weight loss around 4/6/21, with R1's primary physician, and medications changes had been made at that time. RN-A stated typically if they started seeing weight loss, the facility would start with a nutritional supplement. RN-A stated she had not been made aware of R1's weight loss until around 4/6/21, but she should have been made aware sooner. RN-A verified nutrition supplements had not been started for R1 until 4/23, and at that time R1 weighed 142 lbs. RN-A stated the dietician and physician should have been notified as early as 3/18/21 when R1 first had documented weight loss. On 6/9/21, at 11:39 p.m. the director of nursing (DON) stated the importance of reviewing the percentage on meal tickets would be to see what percentage of meals the residents were eating. The DON stated residents' weights are to be reviewed weekly at the IDT meetings to identify weight loss and put interventions place. The DON stated if a resident experienced unplanned weight loss of 5 percent or more in the past month, or 10 percent or more in less than a six months' timeframe she would expect the nurse managers to have notified the registered dietician, dietary manager, and primary physician. The DON stated the facility had not been sending the weekly weights to the dietician to review but should have been doing so. The DON stated it was important to identify unplanned weight loss early to prevent further decline in the residents condition. A facility policy related to Weight Monitoring and Nutrition was requested but not received.

Based on observation, interview and document review, the facility failed to provide the necessary services to maintain ambulation for 1 of 1 resident (R4) who required the use of a prosthetic leg to ambulate. This resulted in actual harm to R4, who lost the ability to ambulate when his prosthetic leg no longer fit, and the facility did not coordinate services to obtain a new prosthesis. Findings include: R4's [DIAGNOSES REDACTED]. R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 did not ambulate. R4's care plan initiated 10/16/18, indicated R4's goal was to use his prosthetic leg and walk on occasion. Interventions included: to be seen by orthotics through the Veterans Clinic to have a new prosthetic leg fit for him. Physical Therapy notes indicated R4 was last seen by the facility's physical therapy department on 6/28/17. For that visit, the therapy note indicated R4 was no longer able to ambulate or wear his left prosthetic leg due to the prosthetic leg no longer fitting. During an interview with R4 on 9/19/19 at 11:34 a.m., R4 stated his left leg prosthetic no longer fit him making it impossible for him to ambulate. R4 stated he was previously able to ambulate short distances, and wanted to ambulate again. R4 stated he had made requests to have his prosthetic leg fitted for him, or get a new one however, facility nursing staff repeatedly told him there was nothing they could do for him. On 9/19/19, at 10:11 a.m. an interview was conducted with registered nurse (RN)-[NAME] RN-A stated R4's progress notes indicated he had last ambulated back in (YEAR). RN-A stated going over two years without his prosthetic leg and without ambulation would impair R4's ability to regain mobility and ambulation status. On 9/19/19, at 10:18 a.m. an interview was conducted with the physical therapy director (PT)-[NAME] PT-A stated if a resident went two years without ambulation it would impair the ability to regain mobility. On 9/19/19, at 11:32 a.m. an interview was conducted with RN-F. RN-F acknowledged R4 required a fitting for his prosthetic leg however, verified this had not been provided. RN-F stated not providing R4 with a properly fitting prosthetic leg impacted R4's ability to regain mobility and ambulation status. RN-F verified no attempts had been made for R4 to have a prosthetic fitting or to obtain a new prosthesis. On 9/19/19, at 11:34 a.m. an interview was conducted with the director of nursing (DON). The DON stated the facility's process for ensuring the prosthetic fit was incomplete, and this error resulted in R4 not receiving services he needed for a properly fitting prosthetic. The DON also stated this error negatively impacted R4's ability to regain mobility and ambulation status. A facility policy regarding assistive devices was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure residents were free of significant medication errors for 2 of 3 residents (R6 and R8) observed who received daily dose of insulin. This deficient practice resulted in actual harm for R6, when he became dizzy, lightheaded, experienced altered level of consciousness and required administration of intravenous (IV) glucose and oral glucose to normalize his blood sugar. Findings include: R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had [DIAGNOSES REDACTED]. The MDS indicated R6 had moderate cognitive impairment and required assist with activities of daily living, and supervision for eating. Further, the MDS indicated R6 received a daily dose of insulin. R6's care plan, dated 5/7/19, indicated R6 had diabetes. R6's goals included to be free from any signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar). Interventions included to observe for signs and symptoms of altered glucose metabolism, administer anti-diabetic medication as ordered by the physician, and blood glucose checks as ordered by the physician. During interview on 8/8/19, at 9:09 a.m. R6 stated on 7/25/19, he had told facility staff he would be going out shopping with his son for a recliner for his wife. R6 stated the staff gave him insulin even though he would not be having lunch until after returning to the facility. R6 stated while at the furniture store he became tired and fell asleep in a chair and his son called the ambulance. R6's Emergency Department(ED) Note, dated 7/25/19, indicated R6 had been in a store shopping with his son, when he became faint, dizzy, lightheaded, sat down in a chair and began staring into the distance. Emergency Medical Services (EMS) was called, and upon arrival R6's blood sugar was found to be 28. EMS administered IV [MEDICATION NAME] (D50) and oral glucose in the form of lemonade. He was transferred to the ED for evaluation. In the ED his blood sugar had increased to 98, and it was reported R6 had been administered 8 units of insulin before lunch, yet accidentally forgot to eat lunch today after receiving his insulin, as his son picked him up to go shopping. R6 was discharged back to the nursing home with instructions to monitor glucose carefully, ensuring he does not miss any meals. R6's physician's orders [REDACTED]. R6's Medication Administration Record [REDACTED] A progress note dated 7/25/19, at 4:41 p.m. indicated R6's son called the facility to report he had called 911 and was waiting for an ambulance to arrive because R6 had become somnolent. The son stated the ambulance arrived and his blood sugar was found to be 28. The ambulance service transported R6 to a local hospital emergency room (ER) per the son's request. The progress note further indicated R6's medical chart was reviewed and it revealed R6's last blood glucose was done right before lunch when his blood sugar was 188, he received his scheduled 8 units of [MEDICATION NAME]. This AM at breakfast he was 169 (blood sugar) and received [MEDICATION NAME] 8 units along with his [MEDICATION NAME] 15 units. Computer documentation revealed that he ate 100% at both meals. However, the son had arrived to pick the resident up before he'd eaten. On 8/8/19, at 1:27 p.m. an interview was conducted with the director of nursing (DON). The DON stated she was made aware of the medication administration error at the time it occurred. DON indicated when she reviewed R6's record, she found the facility staff had also inaccurately documented R6 had eaten 100% of the noon meal, even though he was not in the facility for lunch. DON confirmed she considered the medication error for R6 a significant medication error. Further, DON stated if the facility had followed the physician's orders [REDACTED]. R8's quarterly MDS dated [DATE], included he was cognitively intact, had a [DIAGNOSES REDACTED]. R8's physician orders [REDACTED]. [MEDICATION NAME] (fast acting insulin) 12 units with meals and [MEDICATION NAME] daily. There was an order to hold the [MEDICATION NAME]if blood glucose was less than 130. R8's insulin administration and blood glucose records indicated on 7/29/19, at 7:00 a.m. R8's blood sugar reading was 108, and R8's [MEDICATION NAME]was administered despite the order to hold the insulin if blood sugar under 130. R8's blood sugar result on 7/29/19, at 11:00 a.m. was 174 and R8's progress notes did not show any adverse effects of receiving the insulin in error. On 8/7/19, at 2:15 p.m. R8 was sitting in his room in a wheelchair. R8 stated his blood sugars have been in the 100's recently and have been stable. R8 stated his blood sugars were running high, but they adjusted his insulin and stated he had no low blood sugars. R8 stated he eats regularly, but not too much. On 8/7/19, at 3:49 p.m. DON verified the Medication administration notes and Medication Administration Record [REDACTED]. On 8/8/19, at 8:58 a.m. R8 was eating breakfast and stated he has eaten the same breakfast every day for the past 5 years. R8 ate all his breakfast and drank all his liquids. On 8/8/19, registered nurse (RN)-B stated R8's blood sugar was 154 that morning and received his insulin. RN-B stated she gives insulin 15 minutes before eating or within 15 minutes after eating. RN-B stated R8 showed symptoms of [DIAGNOSES REDACTED] at times, and then she checks his blood sugar. RN-B stated if it is a resident who does not always eat well, she will make sure they eat before giving the insulin. RN-B stated R8 has parameters to hold insulin if it is under 130, so would hold it if it were below 130. The facility's 7/2018 policy, Medication and Treatment Errors, directed staff to recognize errors as any variation in administration of medication from the physician's orders [REDACTED]. The facility 8/8/19 training, Insulin Administration, directed nursing staff, NOT to administer short/fast acting insulin to a resident until you know they are going to eat. The direction further accentuated the importance of fully understanding and implementing each insulin order.

Based on observation, interview, and document review the facility failed to ensure timely identification, notification of physician, and implementation of appropriate treatment for 1 of 3 residents (R5) reviewed for non-pressure related skin conditions. This failure resulted in actual harm for R5 when the wound deteriorated and became infected. The facility had immediately implemented corrective action 7/29/19, as a result the deficient practice is being issued at past non-compliance. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE], included severe cognitive impairment with a [DIAGNOSES REDACTED]. R5's care plan revised 8/8/19, indicated R5 was at risk for pressure related skin breakdown, required assistance with ADLs, and directed staff to inspect skin daily with routine cares and observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. In addition, staff were to conduct weekly skin inspections by the nurse on bath days. R5's care plan further directed nursing staff to follow facility protocols for the prevention and treatment of [REDACTED]. R5's facility incident report dated 7/29/19, included, On 7/29/19, resident was noted to have an Allevyn gentle border dressing (a type of dressing with a gel adhesive which maintains a moist environment) on rt (right) shin with redness and warmth of skin below dressing. Allevyn was removed and a 2.6 cm (centimeter) x (by) 1.7 cm abrasion was present on rt shin. Wound was 75% moist, pink dermal tissue and 25% slough (dead tissue) tissue with moderate purulent (pus) drainage, foul odor noted. Wound bed flush with surrounding skin. Area of redness surrounding wound 15.3 cm x 4.9 cm, skin slightly warm. RN (registered nurse) cleansed wound with NS (normal saline), applied gauze and wrapped with kerlix (gauze wrap). Resident reported mild pain to area. There was no treatment order in residents TAR (treatment administration record) for the abrasion. RN updated MD (medical doctor) and requested treatment orders. Family updated along with Nurse manager, administrator and DON (director of nursing). A follow up report dated 8/5/19, included, Abrasion originally discovered 7/17/19, Skin event/risk management report was not completed and MD not updated within 24 hrs (hours) of discovery. Treatment initiated 7/17/19 was not a part of facility skin care protocol. Treatment orders were not implemented in TAR. The report went on to identify a dressing change completed after R5's shower on 7/20/19, and the nurse who changed the dressing had not added to the TAR, nor contacted the MD. The report indicated another nurse changed the dressing on 7/26/19, and also did not update MD or add to TAR. It was added to a 24 hour report book. Then on 7/29/19, the wound appeared infected with foul odor, slough and purulent drainage. The physician was notified, the wound was cultured, it was added to the TAR, and an antibiotic was initiated. The wound culture [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus- an antibiotic resistant bacteria). Nurses were educated, the policy was reviewed, and the facility placed intervention of the nurse manager reviewing the 24 hour book every day to ensure skin incidences would be documented properly, proper treatments initiated and appropriate personnel/contacts updated. R5's progress notes dated 7/17/19, lacked documentation of a skin abrasion on the right shin. R5's progress note dated 7/19/19, indicated R5's dressing was clean, dry and intact (CDI), and R5 offered no complaints of pain of the right shin. R5's progress note dated 7/20/19, indicated R5 had no signs of pain or infection of the right shin and the dressing was CDI, and a new Allevyn was applied after her shower. There were no progress notes regarding assessment of the wound again until 7/26/19. R5's progress notes lacked further documentation regarding the right shin abrasion, until 7/26/19, when R5's right shin abrasion was observed to be red and painful. R5's abrasion was cleaned and a new Allevyn dressing was applied. R5's progress note dated 7/27/19, indicated R5's dressing was intact and R5 had no complaints of pain. R5's progress note dated 7/29/19, at 8:25 p.m. documented the right shin abrasion (originally identified on 7/18/19), measured 1.5 cm x 2 cm when identified, and on 7/26/19, an Allevyn dressing was applied over the area. R5's progress note indicated on 7/29/19, a nursing assistant (NA) alerted a nurse of redness located below the dressing that had not been present a few days prior. The dressing was removed and revealed R5's wound measured 2.6 centimeters (cm) x 1.7 cm with a moderate amount of foul smelling, purulent drainage. R5 had slightly warm, redness around the wound measuring 15.3 cm x 4.9 cm and extended down the leg toward R5's foot. R5 complained of some increased pain to the area. R5's physician was sent a fax notification and treatment orders requested. R5's progress notes dated 8/1/19, indicated R5's redness around the right shin wound had not increased in size, but had not improved, remained slightly warm and tender to touch with a minimal amount of tan, bloody drainage, but was no longer foul smelling. R5's physician was faxed an update and orders for a culture were requested. R5's progress note dated 8/2/19, indicated a culture had been obtained from R5's right shin wound, and new treatment orders were obtained. R5's progress note dated 8/4/19, indicated the physician was notified of R5's wound culture results [MEDICAL CONDITION] positive, and an order was received Bactrim DS. R5's progress note indicated R5 was on, precautions (to prevent the spread [MEDICAL CONDITION] to other residents and staff). R5's right shin remained reddened and painful with a scant amount of drainage. R5's progress note dated 8/6/19, indicated R5's right shin wound was improving. R5's interdisciplinary team (IDT) progress note dated 8/7/19, indicated the IDT had met on 8/2/19, to review R5's skin incident discovered on 7/29/19. The notes indicated on 7/29/19, a NA noted R5 to have an Allevyn dressing on right shin, with red and warm skin below the dressing. The NA informed the supervisor who assessed, cleansed and dressed R5's right shin wound, and updated the physician and R5's resident representative. The IDT reviewed the physician orders [REDACTED]. The IDT reviewed the investigation which revealed an abrasion on R5's right shin was identified on 7/17/19, and R5 had no pain or concerns at that time, but was unable to identify the cause of the abrasion at that time. The registered nurse (RN) had added R5's wound to the 24 hour report to be monitored for 9 shifts, but did not document in R5's progress notes, initiate a skin event or risk management report. R5's right shin wound was monitored until the p.m. on 7/20/19, when a new Allevyn dressing was applied. The investigation indicated there was no treatment in the treatment administration record for the Allevyn dressing. On 7/26/19, R5 was added back on the 24 hour report book, and progress notes indicated R5's right shin abrasion was red and painful, and a new Allevyn dressing was applied after cleansing the wound. The physician and resident representative were not updated. On 7/29/19, R5's right shin wound had worsened, and at that time the RN followed the facility protocol for initiating treatment and change of condition reporting. The physician and family representative were notified and R5 was then started on an appropriate treatment, and R5's right shin wound improved. R5's IDT notes indicated the facility had educated the nurses. On 8/7/19, at 2:10 p.m. R5 was sitting in the day area by the bird aviary with a dressing on her right leg. R5's room doorway had a sign posted for precautions. On 8/8/19, at 11:22 a.m. RN-B performed a dressing change according to physician orders [REDACTED]. R5's dressing had a small amount of green purulent drainage without odor. RN-C stated R5's skin surrounding the open area was reddened and said it was slightly warm. RN-B stated R5's wound was improving. On 8/8/19, at 12:09 p.m. RN-A stated R5's wound had not been reported to the physician, and it was put on the 24 hours report for 3 days and then fell off report. R5's wound was not identified as a concern until 7/29/19, though a dressing had been put on R5's right shin wound on 7/26/19. RN-A stated a skin event report and risk management report should have been done and the treatment put on the TAR, when it was identified. RN-A stated the nurses involved were re-educated, and a unit education is planned, as well. RN-A stated R5 had developed [MEDICAL CONDITION] infection in the wound and stated the infection most likely would not have happened if it had been treated and followed up on appropriately. On 8/8/19, at 1:28 p.m. director of nursing, DON stated two nurses put dressings on R5's right shin wound, didn't identify it, and didn't follow protocol, and didn't have orders for the Allevyn dressing. The DON stated they had developed a new employee checklist which included the wound care protocol on the checklist. The facility policy and procedure for Addendum to Change of Condition/Incident Report Policy dated 8/16, directed staff to follow the incident report procedure for all skin tears, investigate the incident and staff statements, follow 24 hour change of condition policy, notify family, physician, administrator, DON, nurse manager, complete the white skin sheet, document in the electronic medical record (EMR) until healed. The facility Skin Procedure dated 5/15, directed staff to assess skin daily with ADLs and report to floor nurse any area of concern. The nurse was directed to assess skin weekly on bath day, and update skin sheets. The facility policy and procedure for Change in condition revised 4/15, directed staff to put all changes in condition on the 24-hour report for follow up, including any change in skin integrity, which was to be assessed and reported to physician in a timely manner either verbally or written, and family. Although the facility failed to ensure R5's wound was identified and care implemented in a timely manner. On 7/29/19, when the infected wound was identified, the facility immediately sought medical care for the resident, initiated an error report and met with nurses involved. Education for all nurses involved was provided. Facility policies for treatment, condition change and risk management were reviewed. The facility initiated nurse manager review of the 24 hour book every day to ensure skin incidences were documented properly, proper treatments initiated and appropriate personnel/contacts updated. The facility's corrective action was verified during the onsite survey on 8/8/19 as having been implemented 7/29/19 therefore, this deficient practice is being cited at Past Non-compliance.

Based on observation, interview, record review and policy review, the facility failed to provide assessment, interventions and monitoring to treat and/or prevent the development of pressure ulcers for 1 of 2 residents (R60) reviewed for pressure ulcers. R60 sustained actual harm with the development of multiple recurrent pressure ulcers. Findings included: R60 was not assessed, provided interventions or monitoring related to the development of recurrent stage 2 pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) on the buttocks that were first noted during the survey. R60's [DIAGNOSES REDACTED]. The significant change and readmission minimum data set ((MDS) dated [DATE], indicated R60 had moderate cognitive impairment, was independent with bed mobility, required supervision with transfers, and limited assistance with toilet use and ambulation in the room. R60 had an indwelling urinary catheter and was continent of bowel. The MDS identified R60 was at risk for developing pressure ulcers and did not have pressure ulcers at the time of the assessment. The Skin assessment dated [DATE], indicated R60 was independent with bed mobility, independent with offloading and slept in a recliner chair instead of a bed due to shortness of breath and oxygen dependency. The assessment indicated R60 sat in the recliner chair during the day and spent less than one hour per day in a wheelchair for transports to showers or for weights. The narrative summary, also dated 5/16/2011, indicated R60 did not have any friction or shearing concerns, as R60 was "able to stand from the recliner chair without sliding against the surface." and "did not require a scheduled repositioning program due to (R60's) ability to reposition independently." The pressure ulcer Care Area Assessment (CAA) dated 5/20/2011, indicated R60 was at risk for development of pressure ulcers due to DMII, ongoing steroid dependency, his refusal to ambulate and spending the majority of the time in a recliner chair, although there was no physical reason for being chair-fast. The tissue tolerance (a test used to determine repositioning needs) indicated R60 was able to independently offload (remove pressure) adequately enough to prevent pressure ulcers. The CAA indicated R60 had a Braden score (a tool used to predict potential for skin break down from pressure) of 19 which indicated a low risk for development of pressure ulcers. R60's skin care plan dated 5/20/2011, identified R60's history of skin breakdown due to [MEDICAL CONDITION] on the legs and increased risk of skin breakdown. An undated hand written note further indicated, "I have been having shearing to my buttocks. I am not compliant with my ambulation program always or I will not stand & sit back in my recliner but push myself back & my skin then slides against the surface causing my skin to open. I am not always easy to redirect." The hand written approach dated 8/16/11 directed, "Stand q (every) 2 hours for 2 minutes at a time. Document refusals." and "Butt Paste (the name of a topical barrier medication consisting of [MEDICATION NAME] paste, [MEDICATION NAME] cream and [MEDICATION NAME] ointment) daily to buttocks." R60's nursing progress notes at 10:00 a.m. on 5/31/2011, indicated "stage III ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) to the right buttocks, lateral from his sacrum-shearing effect." The ulcer measured 0.5 cm x 1 cm, the center was described as red with 75% yellow tissue present, the depth was superficial, the skin surrounding the ulcer was described as intact and pink, but chafed and peeling. The note indicated Zinc Oxide was applied, R60 refused ambulation "on a constant basis." Routine pressure ulcer monitoring was not initiated. There was no evidence of assessment (or tissue tolerance evaluation) to determine appropriate interventions and the care plan was not revised to address refusals of care or to indicate interventions for treatment of [REDACTED]. A nursing summary dated 7/20/2011, indicated R60's buttocks ulcers (specific location not indicated) were reopened and the plan included the following: 1. Continue to encourage ambulation. 2. Continue to encourage standing for 2 minutes instead of 3 minutes (hoping to get more compliance with program). 3. Continue to review with MD (medical doctor) wound status. 4. Educate on skin risks PRN (as needed). 5. MD will continue to review medications and treatment and labs for appropriateness. 6. Monitor pain and treat as indicated. There was no evidence of monitoring the pressure ulcer and no indication of when the pressure ulcer was healed. In addendum dated 8/5/2011, indicated a Tissue Tolerance was completed for the recliner and revealed R60 did not stand or move from a sitting position often enough, there was no functional decline but R60 did not always comply. There was no indication that pressure reduction interventions were attempted. The quarterly MDS dated [DATE], indicated R60's cognition had improved, but still had moderate impairment; he remained functionally unchanged with activities of daily living (ADL's); he remained at risk for skin breakdown and had developed one stage 2 pressure ulcer (location not indicated) on 7/20/2011. He continued to use an indwelling Foley catheter and was continent of bowel. The Braden dated 8/5/2011, indicated R60's score was 17 indicating increased risk for development of pressure ulcers. The Quarterly Skin Assessment narrative summary dated 8/5/2011, identified R60 had a change in the Braden score and identified a decrease in R60's friction and shearing as "a problem," even though the previous assessment identified friction and shearing was not a problem. The narrative summary indicated R60 only walked to the bathroom and refused to walk in the hall. The summary revealed R60 had an open area to the buttocks (specific location undocumented) due to friction and shearing noted on 5/29/2011, (thirteen days after the skin assessment on 5/16/2011)." The summary indicated the open area was treated with Zinc, an assessment was completed on 5/31/2011, and the care plan was revised. The summary indicated that shortness of breath, anxiety and shoulder pain "may have contributed to the increased friction and shearing." There was no evidence of routine monitoring related to healing and/or effective treatment of [REDACTED]. On 6/29/2011, the open area was documented as resolved. The summary further indicated that R60's greatest risk factors were related to noncompliance with repositioning/standing program. There was no evidence of tissue tolerance evaluation and no documented interventions related to pressure reduction in the recliner. The undated Resident Status Sheet (a form used to direct nursing assistant (NA) staff on resident care needs) indicated the direction to "Change by self " crossed out and an undated hand written note directed "While awake PC (position change) by standing for 2 min (minutes) to decrease (downward pointing arrow) pressure." On 9/28/2011, at 8:51 a.m., R60 was observed asleep in the recliner chair in the room. A brown blanket was observed over the lap and the door to the room was open. A check of the rounding sheets indicated a position change (PC) and a check mark at 8:00 a.m.. From 8:51 a.m. through 9:36 a.m., R60 remained seated in the recliner chair unmoved. At 9:36 a.m. two nursing assistants (NA-B and NA-C) entered the room and helped R60 with a rolling walker in front of the recliner chair. A piece of dycem ( nonskid material used to prevent sliding) and a soaker pad were observed in the recliner chair. R60 was pleasant, conversational and tolerated standing until he sat in the recliner chair at 9:39 a.m. At 11:10 a.m. on 9/28/2011, the registered nurse MDS Coordinator (RN-B) stated there had been a change in R60's skin condition. During observation with RN-B at11:47 a.m., R60's buttocks area had a white [MEDICATION NAME] dressing loosely covering the buttocks with scant amounts of sanguineous (bloody) drainage on the dressing. The skin was purple in color with two pressure ulcers on the left buttock. The first pressure ulcer was near the center of the buttock, near the gluteal fold and was approximately 1-2 cm wide and circular. The second pressure ulcer was approximately 1 cm, circular in shape and distal to the first ulcer. The ulcer was denuded with first layer of skin folded back and loose. RN-B stated the ulcers were from shearing and pressure. RN-B stated the ulcer measurements were "already in the computer." RN-B stated that R60 had a history ulcers opening and closing "usually right there" pointing at the larger pressure ulcer on the right buttock. The nursing progress note at 3:41 a.m. on 9/28/2011, indicated, "Coccyx discolored 20 cm long x 23 cm wide across buttocks. Minute cracks noted with scant amount of sanguineous drainage. 100% granulation tissue, 90 % beefy red/pink. Butt paste applied and covered with [MEDICATION NAME]. Continue to offload and stand every 2 hours while awake." The note lacked measurements or identification of the exact location of the open areas. Review of the "Skin to buttocks" nursing progress note at 12:54 p.m. on 9/28/2011, indicated, "Upon cleansing buttocks it was noted that there were open areas to (R60's) buttocks (shearing in nature) that were measurable. One is located closest to the gluteal crease on mid right buttocks. Measures 1x1 (there was no unit of measurement) without depth. Bleeds with cleansing. No actual drainage from area. Wound bed is 50% pink and 50% red. The open slit directly parallel to the previous wound measures: 0.2 x 0.1 (there was no unit of measurement) with no depth. Area will be cleansing also. No actual drainage from wound. Buttocks are purple red in color which appears to the norm for (R60) and blanches throughout entire area of discoloration. Measurements of the discolored area remain unchanged 20 x 23 cm as noted in weekly skin completed last night. Buttocks have several skin cracks that have no depth and are located sporadically to mid and lower buttocks." The note further indicated the MD was updated on 8/19/2011, and Butt Paste was implemented to decrease shearing. The note identified R60 was noncompliant with the Tempurpedic cushion in the recliner and recapitulated comorbidities potentially contributory to pressure ulcer development. The " Plan" section of the note indicated the MD was updated on the new pressure ulcers and "Will continue to encourage the repositioning/standing program Q2 (every two) hours. Continue with butt paste. Continue with ROM (range of motion) program. Continue to monitor diabetes. Check skin daily with cares and report changes. Care plan reviewed and updated if needed." There was no evidence of information provided to R60 related to the risks of non compliance with repositioning or of increased pressure to the buttocks area while sitting in the recliner for most of the day/night. RN-B, interviewed at 2:26 p.m. on 9/28/2011, stated there was no indication that the second pressure ulcer was present at the time of the night shift skin assessment. RN-B stated there were minute cracks noted with scant amounts of drainage at the time of the night shift skin check. Regarding pressure relief devices, RN-B stated, "We have attempted to get a Tempurpedic cushion in there. We've tried a lot of things to get (R60's) bottom better." RN-B stated she had attempted to re-approach R60 with no success on 9/27/2011. RN-B stated R60 had been educated at the care conference on 8/25/2011, about the risks of non-compliance including the possibility of death. A copy of the risk versus benefit was provided and appropriate. At 4:00 p.m. on 9/28/2011, RN-B stated the interdisciplinary team (IDT) decided to continue the every two hour repositioning schedule because R60 had "such a history of noncompliance." RN-B stated that more frequent repositioning was not attempted and the care plan had not been changed for R60. RN-B confirmed the clinical record lacked evidence of attempted pressure relief interventions or of interventions to improve compliance with repositioning. RN-B further confirmed R60 second stage 2 pressure ulcer was not noted prior to the observation with the surveyor on 9/28/2011. RN-B confirmed the assessment was not updated to address recurrent pressure ulcers. At 12:48 p.m. on 9/29/2011, the director of nursing (DON) stated, " Typically we would change things on the assessment, try something different." The DON confirmed the clinical record lacked documentation of previously attempted interventions for R60. The DON also confirmed R60 needed to be re-approached to determine individual compliance with new interventions. Review of the "Pressure Ulcer Prevention and Treatment Policy & Procedure" dated as revised on 9/2011 indicated the following: "Purpose Inter-Faith Care Center will prevent pressure ulcers unless they are clinically unavoidable and will provide all the necessary treatments and services to help the ulcers heal if they occur. Interventions The RN will ensure all risk factors have appropriate individualized interventions or are modified whenever possible (or documented valid reasons why such interventions were not appropriate or feasible) When a pressure ulcer develops, a new Comprehensive Risk Assessment will be done and appropriate individualized interventions should be put in place. Prevention Interventions Provide appropriate pressure reduction and relief, when in bed, sitting, and lying An individualized turning and repositioning schedule (in bed and in a chair) The RN will formulate a care plan based on the Comprehensive Risk Assessment findings."

Based on observation, interview, record and policy review, the facility did not ensure 1 of 3 residents (R101) in the sample received comprehensive services for pain management. R101 was identified to have severe breakthrough pain at bedtime and was not provided preventative management for the pain. This resulted in actual harm to R101. In addition, the facility did not ensure interventions were implemented to address abnormal blood glucose levels for diabetics in 6 of 14 residents (R33, R107, R66, R60, R18, R40) in the sample reviewed for diabetic management. Findings included: R101 experienced severe pain during the night on a consistent basis. Facility staff was aware of R101's nighttime significant pain, but interventions were not implemented to address/prevent severe pain. This resulted in actual harm for R101. R101 had multiple [DIAGNOSES REDACTED]. On 8/1/11 at 12:30 pm, during the entrance tour, R101 indicated she had severe pain " I'd rather be dead than have this pain every day." R101 acknowledged her pain was better during the day; however it was "horrible" at night and caused her difficulty with sleeping. The quarterly MDS (Minimum Data Set) dated 5/13/11 identified R101 experienced pain "almost constantly" and has made it "hard to sleep at night" and rated her pain as 9 out of 10 in severity. R101's most current pain assessment dated [DATE] identified her to have "pain almost constantly" and the "pain made it hard for her to sleep at night and that it limited her day to day activities." The assessment further indicated her pain level to be 9 out of 10 in the past five days and indicated that pain medications were effective. The interventions included a topical [MEDICATION NAME] cream; however, there was no indication as to the effectiveness of the cream. The assessment indicated the physician had discontinued an HS (bedtime) dose of pain medication ([MEDICATION NAME] 10/500mg) on 6/30/11, and increased the [MEDICATION NAME] (pain medication) dosing. Although the medication change was identified, the assessment did not indicate if the current medication plan was effective. R101's Biofreeze (topical [MEDICATION NAME]) was discontinued on 6/30/11, but it was not addressed in the assessment. The ADL (Activities of Daily Living) Functional Status/Rehabilitation Potential CAA (Care Area Assessment) dated 3/4/11, indicated R101 had difficulty "with pain control which could be contributing to more physical assist with ADL's." The Psychosocial Well Being CAA dated 3/1/11, stated "when she is in severe pain she feels down, depressed and has passing thoughts of being better off dead. These thoughts pass when her pain is controlled. Her trouble sleeping is also pain related. If pain can be controlled sufficiently, her overall mood is likely to improve." Current physician orders for pain management include: [MEDICATION NAME] (immediate release narcotic [MEDICATION NAME]) 7.5mg TID (administered at 6:00 am, 2:00 pm, and 8:00 pm), [MEDICATION NAME] 2-5 mg po every 2 hours PRN for pain, and ES (extra strength) Tylenol 1000mg TID at 6:30 am, 11:00 am, and 5:30 pm. Nursing notes consistently identified significant levels of pain at bedtime that was effectively relieved with the use of PRN [MEDICATION NAME]. However; R101 had to experience significant pain and request [MEDICATION NAME] rather than using a scheduled dose or longer acting [MEDICATION NAME] to manage pain. Review of tne July 2011, MAR indicated that [MEDICATION NAME] 5 mg PRN was administered 24 times, primarily between midnight and 2:00 am, for pain rated from 6 to 10 on a scale of 1 to 10. Nursing notes on 7/24/11, at 9:21 pm indicated "Resident has requested PRN [MEDICATION NAME] 5x's in the past 7 days. Requests are during the noc (night). Rated pain at 8 1x. Does not usually rate pain but is sleeping when checked on later." On 7/17/11, at 9:16 pm, notes indicated "Resident has complained of pain less of late. [MEDICATION NAME] was increased on 6/30. Resident has also received PRN [MEDICATION NAME] 5x's this past week. Rated pain at 6-9. Resident was sleeping when checked on later." On 7/10/11 at 6:00 pm the note indicated "Upon assessment resident c/o (complained of) pain all over #7. Resident receives scheduled [MEDICATION NAME] 7.5mg TID (three times a day) and Tylenol 1000 mg TID. She has received PRN [MEDICATION NAME] four times in the past week for pain all over ranging from a #7-10/10. Resident typically found asleep upon reassessment." On 7/3/11 at 5:50 pm "Reports of frequent pain that is "everywhere" with a rating of a 10 at worst this week. Receives [MEDICATION NAME] 7.5mg TID and Tylenol 1000 mg TID. PRN [MEDICATION NAME] received 6 times this past week. Expresses anxiety over anticipating pain and when she will receive pain medication. Asked writer for HS (bedtime) pills to be given immediately after PM pills given as she wants to prevent the pain she gets at night. Reassured with 1:1 that HS pills will be given at the correct time." Physician's orders dated 6/30/11 discontinued Biofreeze (topical [MEDICATION NAME]) for R101 with no explanation. There was a note on the cupboard in R101's bathroom reminding her to ask staff for Biofreeze. R101, interviewed 8/4/11 at 1:00 pm, stated "I ask for the Biofreeze - I like it. It's always worked so well for me. I used to have it in here and now they tell me to ask for it. But I ask for it and they never bring it. That's mine, I want it." When asked on 8/4/11 at 2:00 pm, LPN B stated "Yes she has pain. Some days are worse than others. It's the arthritis pain and her aching all over. She's got generic Bengay too but that's not always effective. She likes ours better than the Biofreeze." Review of the facility "Pain Assessment Policy and Procedure" revised 6/08 indicated "non-medicinal measures " would be used for comfort and the "nurse will notify the nurse manager if pain medication is not effective." Interview on 8/4/11 at 1:30 pm with NAR-H revealed "she has pain in the morning like when she's getting up her legs bother her. I ask her if she wants to have something for pain and tell the nurse and I put a pillow between her knees - that helps." On 8/4/11 at 2:00 pm LPN-B stated "Yes she has pain. Some days are worse than others. We kind of have it figured out now the [MEDICATION NAME] helps her rest. It's the arthritis pain and her aching all over." Clinical Manager A stated on 8/4/11 at 3:00 pm "My understanding is she has some chronic pain and [MEDICAL CONDITION]. Her doctor is aware and has been trying to adjust her meds. She has pain more so at night but gets relief with her PRN pain medication she has available. She also has an [MEDICATION NAME] balm she uses. Nurses do a weekly pain summary. The expectation is to review the effectiveness with the PRN pain medication then our nurse manager reviews the pain management program with the physician on rounds." On 8/5/11 at 8:50 am Clinical Manager A clarified "If the pain appears not to be managed the MD can be updated between rounds via fax or phone. My understanding is she is getting relief with the PRN [MEDICATION NAME]. I think it would be appropriate to update the MD about her pain. She gets her TID [MEDICATION NAME] at 0600-1400-2000. I need to review this care plan." On 8/5/11 at 10:15 am, the DON stated "I can see the physician needs to be updated on that. Looks like that one slipped through and that should have been caught." R33 was not provided management of low blood glucose in accordance with physician's protocols. The physician signed policy and procedure on extreme [MEDICAL CONDITION] and [DIAGNOSES REDACTED], dated 4/2005, described [MEDICAL CONDITION] as blood glucose >300 mg/dl for >48 hours, with or without symptoms or [MEDICATION NAME]; and any instance of blood glucose >450 mg/dl, with or without [MEDICATION NAME]. Management of [MEDICAL CONDITION] included the following interventions: call MD for further orders if: blood glucose >300 mg/dl for 48 hrs, unless otherwise ordered, and for blood glucose >450 mg/dl. The policy described [DIAGNOSES REDACTED] as blood glucose readings <60 mg/dl at any one time. Management of [DIAGNOSES REDACTED] included the following: hold all insulin/diabetic medication if blood glucose reading <60, repeat BS (a device to check blood glucose levels) in one hour, and if [DIAGNOSES REDACTED] occurs within the same timeframe 2 days in a row, call the MD for notification and possible medication adjustments. R33 was admitted [DATE] with multiple [DIAGNOSES REDACTED]. The care plan dated 7/11/11 identified R33 had cognitive loss, short term memory loss. The care plan also identified diabetes managed with insulin, blood sugar checks and a diet low in carbohydrates. The care plan directed staff "Blood sugar checks per MD orders. Medications as ordered by MD - see MAR. MD to review regularly and order labs as needed." Initial review of R33's medical record review a progress note dated 4/28/11 at 6:15 pm which stated "Res (resident) has low BS (blood sugar) of 56 at 4PM. Resident was fed juice and sandwich. BS rechecked in one hour = 62. Extra food offered. Was feeling better and did eat supper." At 7:30 pm the BS was documented to be 106. R33 did not have individualized physician orders to manage [DIAGNOSES REDACTED] (low BS). In the absence of resident specific orders, the facility protocol would be followed. Nursing notes on 6/18/11 at 6:00 am, indicated R33's BS was 60. Sliding scale insulin was held as ordered and routine dose of [MEDICATION NAME] was provided. There was no further follow up or documentation regarding follow up BS testing or food intake untils 11:20 am when the BS was 271. R33's physician's order for sliding scale insulin based on accu-check (blood sugar) results. Review of the MAR's (Medication Administration Records) for implementation of the sliding scale from May 2011 through July 2011 revealed 14 documented instances of the wrong dose of insulin being administered. Further review of BS results following these medication errors revealed no negative outcome for R33. On 8/3/11 at 1:15 pm Clinical Managers A and B and the DON (Director of Nursing) reviewed the blood sugar and insulin administration concerns. They had no further information. R107 was not provided management of low blood glucose as directed by facility protocol. R107 experienced no negative outcome from these incidents. R107 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. It further indicated R107 "would not be able to ...ask for assistance or remember recent instructions." The care plan dated 5/3/11 identified R107 as diabetic and "staff to take blood sugars and monitor my diabetes for me." The goal was to "reduce risk of endocrine disease exacerbation" with the approach of "Medications as ordered by MD-see MAR. MD to review regularly and order labs as needed." The care plan reviewed 7/11 indicated "I am diabetic and have dementia. I don't always make good food choices or drink enough fluids and this affects my health." The identified goal was "My blood sugars will be in range." The approaches were "Staff will offer and encourage diabetic snacks, in the appropriate portion sizes. If family brings in snacks for me, I will be allowed to eat a portion if my blood sugars are within range." At 4:00 pm on 4/21/11, R107's BS was 42 (normal is 80-120). Nursing notes at 10:00 pm indicated "[DIAGNOSES REDACTED] present with accu-check 42 at 4 pm. Confusion present otherwise no other symptoms. Ate 100% of supper meal. Blood sugar 104 following. Insulin held per [DIAGNOSES REDACTED] policy." Based on this documentation, R107's BS was not rechecked after one hour as directed but the facility [DIAGNOSES REDACTED] protocol. On 4/22/11 the MAR (Medication Administration Record) indicated R107's BS was 56 at 4:30 pm with no follow up documented. The electric record identified a BS on 4/22/11 at 6:30 pm of 143. There was no further documentation related to the episode of low BS. There were no BS documented at HS (bedtime) on 4/27, 4/28, 4/29 or 4/30/11 On 5/6/11 at 5:00 pm, R107 had a BS of 58. There was no follow up accu-check and no nursing note related to the incident. R107's HS BS was 219. Nursing notes on 5/27/11 at 11:00 pm stated "Resident had a low blood sugar. Gave 120 cc Ensure. No signs or symptoms noted. Noc (night) nurse will follow up with a recheck." Per the MAR the HS BS was 53. There was no evidence of a follow-up BS by the night nurse. Interview with Clinical Managers A and B and the DON on 8/3/11 at 1:15 pm indicated they had no additional information at that time. On 8/4/11 at 8:30 am, the DON stated her expectation would be to follow the facility protocol in place as well as any MD orders in place. R66 was not provided diabetic management as directed by physician/facility policly. R66 was admitted on [DATE]. In May, 2011, R66 was not provided sliding scale insulin based on BS results on 8 occasions. R66's CAA dated 4/29/11 identified "severe memory loss" and "difficulty with problem solving". The care plan dated 5/2/11 identified an endocrine problem "I also have diabetes I have this managed with insulin, my diet and my blood sugar is checked routinely. I will need staff to remember this for me." Identified approach was "Medications as ordered by MD -- see MAR. MD to review regularly and order labs as needed." Physician's orders 4/22/11, included [MEDICATION NAME] 2 units sub-q TID (three times a day) PRN (as needed) for blood sugars above 250 and 2 extra units TID with meals for blood sugars above 250. " The sliding scale was discontinued on 5/17/11. The MARs indicated the following: On 5/4/11 at 11:00 am indicated R66's BS was 262; however, the sliding scale insulin was not administered. On 5/6/11 at 11:00 am R66's BS was 313 but she was not provided the sliding scale insulin. On 5/711 at 11:00 am, R66's BS was 354 and no sliding scale insulin was administered. R66 did not receive sliding scale insulin on 5/7/11 at 5:00 pm, when the BS was 260. On 5/14/11 at 11:00 am, the MAR indicated a BS of 356 and the EMR indicated the BS was 256. Regardless, R66 should have received the 2 units of [MEDICATION NAME]for coverage and she did not. On 5/15/11 at 11:00 am, the MAR indicated a BS of 348 and the EMR indicated a BS of 248; however, there was no sliding scale insulin administered. On 5/16/11 at 11:00 am, R66's BS was 390 but no sliding scale insulin was administered. In addition, there was no documentation on the MAR to indicate why the insulin was not administered and the physician was not updated. On 5/15/11 at 1:30 pm a nursing note indicated BS "past 2 am shifts above 300. Will notify nurse manager." There was no follow up note by the nurse manager and no update to the physician. There was no evidence that the physicain was updated regarding R66's elevated BS readings on 5/17/11 during a clinic visit. The sliding scale insulin was discontinued on 5/17/11, but there was no documentation to indicate why that was an appropriate intervention. On 8/3/11 at 9:20 am, physician D stated "I'm m not going to say the nurses didn't notify me. They may have left me information I don' t recall and I don't keep the communication slips. I'm not sure." On 8/3/11 at 1:15 pm the DON and Clinical Managers A and B reviewed the above accu-check and insulin concerns. They had no additional information at this time. R60 was not provided interventions to address low and high BS readings. R60's [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE], indicated R60 was cognitively impaired and required physical assistance from staff for activities of daily living (ADL's). The Care Area Assessment (CAA) for cognition dated 5/20/2011, indicated R60 was resistive to cognitive testing and this was "not new." The CAA for ADL's Functional Status/Rehabilitation Potential indicated R60 required limited assistance with most ADL's. Review of the Endocrine care plan dated for 5/20/2011, indicated that R60 was diabetic and required insulin to "assist with managing it," and required routine BS testing. The care plan goal identified, "Will reduce risk of endocrine disease exacerbation." The care plan directed to complete BSs (blood sugar checks) as ordered by the physician and to see the MAR for current orders. The current physician's orders for 3/4/2011 thru 6/7/2011, included TID BS testing and sliding scale (SS) [MEDICATION NAME] Insulin 17 U subcutaneous (SQ) three times daily (TID) as needed (PRN) for the following blood sugar ranges: 150 to 199 = 2 Units (U) 200 to 249 = 4 U 250 to 299 = 7 U 300 to 349 = 10 U 350 OR GREATER = 12 U The March 2011 through June 2011, R60's MARs indicated blood sugars were obtained TID at 6:00 a.m., 11:30 a.m. and 5:00 p.m. The MAR had an extra space for additional BS documentatation. On a separate page of the MAR, the SS was documented to correspond with the BSs at 7:00 a.m., 11:30 a.m. and 5:00 p.m. At 6:00 a.m. on 3/31/2011, R60's BS was 58 and a recheck at 7:30 am was 157. There were no documented interventions to address low blood sugar. At 11:30 a.m., the BS was 328 but the MAR was blank for a nurse's signature or dosage of SS insulin administered. The 11:30 a.m. dose of scheduled 17 U of [MEDICATION NAME]was also blank. At 11:30 a.m. on 4/8/2011, R60's BS 349, the MAR indicated 4 U of insulin was administered, when according the the physician's orders, the correct dose would have been 10U. At 11:30 a.m. on 4/27/2011, the BS was 387 and the MAR indicated 7 U of insulin was administered when 12 U of insulin was the correct dose. At 7:08 a.m. on 5/12/2011, R60's BS was 410 and the MAR indicated 12 U of insulin was administered. The clinical record lacked documentation or the signs and symptoms of [MEDICAL CONDITION] and/or if urine testing was completed for the presence of [MEDICATION NAME]. At 6:00 a.m. on 5/28/2011, R60's BS was 49. There was no documentation related to signs/sypmtoms of [DIAGNOSES REDACTED], interventions provided or a recheck in one hour. R60's Physician's Orders for June 2011, changed the insulin SS order to: "TID - 120-140 = 1 unit, additional 1 unit for each 20 over 140 up to 10 units." The June 2011, MAR included the following sliding scale for [MEDICATION NAME] insulin. 120 to 140 = 1 U 140 to 160 = 2 U 161 to 180 = 3 U 181 to 200 = 4 U 201 to 220 = 5 U 221 to 240 = 6 U 241 to 260 = 7 U 261 to 280 = 8 U 281 to 300 = 9 U The documented SS was incorrect for the dosage when BS was 140 and did not include the dosage for BS between 301 and 320. There was no order for a SS if the BS was greater then 320. At 6:00 a.m. on 6/16/2011, R60's BS was 354. The MAR indicated 12 U of SS insulin were administered although there was no corresponding physician's order and no evidence that the physician was contacted. At 11:30 a.m. on 7/2/2011, R60's BS was 329; and on 7/10/2011, the BS was 360. On both occasions the MAR indicated 10 U of SS insulin were administered although the physician's order did not specify the dosage when BS was greater than 300. At 6:00 a.m. on 7/11/2011, the BS was 53. Although the insulin was held, the clinical record lacked evidence of interventions to address low blood sugar and a recheck was not documented. At 5:00 p.m. on 7/15/2011, the BS was 54. The recheck at 6:00 p.m. was 137 and the MAR indicated the scheduled insulin was held; howver, there was no documentation related to administration or not of the SS insulin At 5:00 p.m. on 7/24/2011, the BS was 374; at 11:30 a.m., on 7/27/2011, the BS was 403; and at 5:30 p.m. on 7/28/2011. On all three occasions the MAR indicated 10 U of SS insulin was administered despite the lack of physician's orders for BS greater than 300. At 10:13 a.m. on 8/3/2011, the DON verified the SS errors for R60 and that the SS range for BS beteeen 301 to 320=10 U was not documented on the MAR. The DON stated the MD should have been contacted regarding the blood sugar being out of range for the ordered SS insulin. At 4:22 p.m. on 8/2/2011, LPN-F stated that if the BS was less than 60, "We give glucose gel and recheck in 15 minutes (BS). The procedure instructs to recheck the BS in 1 hour, I usually check it sooner, it makes more sense. We usually document the BS in the computer under the vitals, there is a place for blood sugars, and also write a note about it and notify the next shift." At 8:38 a.m. on 8/3/2011, LPN-C stated that for blood sugars below 60, she would check for responsiveness and address the blood sugar with either glucose gel or orange juice depending on what the resident's preference was. LPN-C stated she would recheck the blood sugar in 1 hour. She further stated, per policy, she would recheck the blood sugar at the next meal, if the blood sugar was consecutively low for the 2nd time, the policy directs to then notify the MD. If the resident was unconscious, she stated she would administer Glucogon IM and notify the MD when the IM injection was administerd. At 11:27 a.m. on 8/4/2011, the DON stated that nursing staff should be calling the physician if there were symptoms of hyper/[DIAGNOSES REDACTED] or if the blood sugar was 450, and if "checking for [MEDICATION NAME]." The DON stated there should be documentation of interventions related to hypo/[MEDICAL CONDITION]. R18 was not provided interventions to address low BS during the months of April and June 2011. R18 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated R18 had severe cognitive losses and required some physical assistance with ADLs. The quarterly MDS 4/29/2011, indicated no changes in his cognitive status or ADL needs. Review of the Care Area Assessment (CAA) for pressure ulcers dated 7/25/2011, identified R18 as having stable diabetes per the last medical doctor (MD) visit. The care plan for endocrine dated as reviewed 5/2011; indicated R18 had diabetes mellitus (DM) and the goal was to reduce the risk of exacerbation of DM. The care plan directed licensed staff to monitor BS and administer medications as ordered by the MD. R18's June 2011 Physician's Orders included [MEDICATION NAME] 22 U SQ daily at HS and to check BS twice daily (BID). R18's MAR and clinical record revealed the following: At 6:00 a.m. on 4/4/2011, the BS was 43; at 6:00 a.m. on 4/16/2011, the BS was 60; and at 6:00 a.m. on 6/12/2011, the BS was 57. There was no documentation of interventions or recheck of BS related to the hypoglycimic episodes. R40's blood sugar checks were ordered three times each day and were scheduled at 6:00 a.m., 11:30 a.m. and 5:00 p.m. R40's BS record revealed the following: on 5/24/2011 at 11:04 a.m. the BS was 59; on 5/25/2011 at 3:17 p.m. the BS was 42; on 6/21/2011 at 10:49 a.m. the BS was 51; on 7/18/2011 at 3:50 p.m. the BS was 53 and on 7/31/2011 at 11:09 p.m. the blood sugar was 54. The BS was not checked an hour after any of the episodes and there was no documentation of interventions for treatment of [REDACTED]. The DON, interviewed at 5:00 p.m. on 8/4/2011, stated there was no further information regarding rechecking the blood sugar within an hour or any interventions done.

Based on observation, interview, record and policy review, the facility did not ensure the necessary care and services were provided to prevent the development of avoidable pressure ulcers for 2 of 3 residents (R112, F109). This resulted in actual harm for R112. Findings included: R112, identified as having intact skin and a low risk for development of pressure ulcers, developed a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). R112's [DIAGNOSES REDACTED]. The care plan dated [DATE], and updated [DATE], indicated R112 had a Brief Interview for Mental Status (BIMS) score of 15 (indicates a person is cognitively intact) and was independent with transfers. The care plan did not address the pressure ulcer or treatment. Observations throughout the survey showed R112 was able to ambulate independently with a walker. A Braden Scale (a tool used to predict pressure ulcer risk) was completed on [DATE], [DATE], and [DATE], and indicated respective scores of 17, 18 and 18 (a score of 17 or higher indicates low risk). A skin assessment completed [DATE], indicated R112 was at risk for skin breakdown, and was provided a Tempurpedic mattress for her bed, and a pressure reduction cushion for her wheelchair. R112 refused the Tempurpedic mattress, and her family brought in a foam overlay mattress. A review of the progress notes included inconsistent and conflicting descriptions of R112's skin condition. On [DATE], R112 had a red area measuring 2x2 cm on the left inner buttocks, and zinc was applied; on [DATE], the MD was informed of a pressure ulcer to left buttocks; on [DATE], the area was documented as two Stage III pressure/shearing ulcers, one located on upper left buttocks measuring 1 cm x 0.3 cm with a depth of 0.1 cm, the second ulcer on the sacrum measuring 1 cm x 0.4 cm with a depth of 0.2 cm; on [DATE], the area was documented as sacral area red and chaffed, total area measures 10 cm x 10.5 cm with two small open areas measuring less than 1 cm around each; on [DATE], the area is documented as two open areas on left side of buttocks which measure 0.3 cm each; on [DATE], the area is documented as a Stage III to left side of sacrum measuring 0.3 cm x 0.2 cm, with a depth of 0.1 cm; on [DATE], the area is documented as 0.2 cm in diameter, pimple like opening; on [DATE], the area is documented as 1 cm x 0.4 cm with deep center; on [DATE], the area is documented as 0.2 cm in diameter, 0.4 cm in depth. R112's dressing change was observed at approximately 1:00 p.m. on [DATE]. LPN-D stated the area was measured every time the dressing was changed, and the measurements should be documented in the progress notes. During the observation, the area was measured to be 0.2 cm in diameter and 0.4 cm deep. The director of nurses, interviewed at 10:05 a.m. on [DATE], stated pressure ulcers should be measured and documented in the progress notes when the dressing change is done, and the care plan should be updated to reflect pressure ulcer interventions. The facility's pressure ulcer prevention and treatment policy and procedure revised ,[DATE], indicated all residents will be individually assessed based on their risk factors, and their plan of care will be formulated accordingly, when a pressure ulcer develops, a new comprehensive risk assessment will be done and individualized interventions would be put in place, and the RN will form a care plan based on the comprehensive risk assessment findings. R109 was not provided a comprehensive assessment upon admission to implement interventions to address a red coccyx and prevent the development of an avoidable pressure ulcer . R109 was admitted on [DATE] and expired on [DATE]. R109 was admitted to the skilled nursing facility (SNF) on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], indicated he had some cognitive impairments and he required physical assistance for all activities of daily living (ADL's). The Care Area Assessment (CAA) for Pressure Ulcers dated dated [DATE], indicated the CAA was triggered due to the "resident required extensive assist with mobility, was occasionally incontinent of bowl, has current pressure ulcer and was at risk for developing pressure ulcers. Resident receives (ends and was not complete)." Care plan in the closed record dated for [DATE], identified R109 had problems with nutrition, hydration and vulnerability. No further care plan was observed in the clinical record. Review of the "Progress Notes" revealed the following: At 10:05 p.m. on [DATE] (admission), a progress note labeled "Skin Assessment" and written by a licensed practical nurse (LPN), indicated R109 had "4++ [MEDICAL CONDITION]" and was identified as having, "A red coccyx and surrounding skin. Area measures from anus to end of redness 12 cm and 8 cm wide. Zinc applied. Anus remains open about 3 cm. Scrotum and penis are [MEDICAL CONDITION]." Although the progress note identified a red coccyx upon admission, the clinical record lacked evidence interventions to prevent further breakdown of the red coccyx were implemented. At 10:37 p.m. on [DATE], "Zinc applied to pink skin on coccyx." The "Braden Scale for Predicting Pressure Ulcer Risk" (a tool used to calculate potential risk for pressure ulcer development) dated [DATE], was 16, placing R109 at risk for pressure ulcer development. The "Skin Assessment" for R109 dated [DATE], identified comorbidities, impaired circulation, and identified no history of pressure ulcers. The Tissue Tolerance (a tool used to determine repositioning needs) results for the bed, chair and recliner indicated R109 required "Q (every) 2 Hour repositioning." The "Admission Skin Assessment" narrative note dated [DATE], reviewed risk factors and identified R109 "does not make often movements to reposition self at this time." The note further indicated, "Tissue Tolerance indicated the resident had redness noted to coccyx and upper buttocks on admission. There is an open area on the coccyx which appears to be friction related. Zinc is applied daily and prn. Buttocks crease and anal area are excoriated. Will place resident on a reposition q 2 hours through day and night d/t the risk for pressure ulcers, shearing and friction. Had tempurpedic cushion in w/c and recliner. Temperpedic mattress was placed on the bed. Resident had been repositioned q 2 hours during the night. Had a catheter. and does use the bathroom for bowel movements." Although the clinical record indicated comorbidities and risk factors were identified in the skin assessment on [DATE], the clinical record did not reflect timely assessment of R109's skin risk factors upon admission. Further review of the Progress notes revealed the following. At 9:14 p.m. on [DATE], "Skin assessment reveals...Res continues to have reddened coccyx measuring 5 cm. Skin intact. Area treated with zinc." At 1:42 a.m. on [DATE], "Resident continues to have zinc applied to coccyx." At 9:46 p.m. on [DATE], "Resident continues to have a 5 cm reddened area on coccyx. There is a 1.5 cm open area as well. Zinc applied. No redness noted to bony prominences." At 3:24 p.m. on [DATE], the Nurse Manager reviewed documentation in the electronic medical record (EMR). The Nurse Manager stated she did not know what the "open anus" meant. Confirmed the documentation findings in the computer. Stated she was unclear if the the skin was open upon admission based on the documentation available and confirmed the hospital records do not identify an open area to the coccyx. The Nurse Manager stated the care plan for R109 would be a "temporary care plan which was normally placed in the closet." The Nurse Manager reviewed the closed paper record and was unable to locate the care plan. The Nurse Manger further stated "based on the documentation from the skin assessment," she "believed" the resident's skin was intact upon admission. "I believe it was pink on admission." The Nurse Manager further confirmed the documentation of the 1.5 cm open area lacked detailed description of where the open area was located on R109. At 4:00 p.m. on [DATE], the registered nurse (RN-B) stated the temporary care plan should have been completed on admission, but they were "unable to locate it." At 4:11 p.m., the licensed practical nurse (LPN-E) confirmed the admission skin assessment was completed by her. LPN-E stated she did not recall why she wrote the "anus remained open 3 cm." Stated if the coccyx area had been open, she would have measured the open area and documented it. At approximately 5:00 p.m. on [DATE], the Nursing Assistant Manager provided the "Resident Status Sheet" and stated the Status Sheet was the temporary care plan for R109. Review of the Resident Status Sheet indicated R109's skin was to be checked daily with cares and the resident had a "decubitus (pressure ulcer)" on the coccyx. The care plan directed to elevate the head of bed (HOB) up for 60 minutes after meals, to apply [MEDICAL CONDITION] gloves bilaterally, R109 had a Foley catheter, and the resident was occasionally incontinent of bowel.. The care plan lacked interventions to prevent the development of pressure ulcers including: repositioning of the resident, pressure reduction devices in the bed and wheelchair. At 10:20 a.m. on [DATE], the director of nursing (DON) was contacted via telephone. When queried what she would expect to be documented and implemented for a pressure ulcer identified on the admission skin assessment, she stated she would expect documentation of measurements and interventions implemented to address the pressure ulcer. The DON further stated she expected the nurse manager to be notified of the pressure ulcer so the MD could be updated.