Every finding on record at Karlstad Healthcare Center Inc

Based on interview and document review, the facility failed to provide restorative ambulation services and respond to a decline in ambulation status for 1 of 3 residents (R26) reviewed for ADLs. Findings include:R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had mild cognitive impairment and required set up/clean up assistance for eating, substantial/maximal assistance for bathing and upper body dressing and was dependent on staff for all other care areas. Diagnoses included dementia, hypertension, diabetes, weakness, and chronic pain. R26's care plan revised [DATE], identified R26 had an ADL Self Care Performance Deficit related to weakness and malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify). Interventions included: Ambulate R26 with front wheeled walker (FWW) and staff assistance of 1 once daily as desired/as tolerated. R26 was able to ambulate short distances. [NAME] used for transfer in room as able. The care plan also identified R26 had limited physical mobility and was at risk for falls due to weakness, chronic pain, and unsteadied gait/balance. Interventions included: NURSING REHAB: Ambulate daily with 1 staff and FWW- distances as able.R26's Functional Abilities Care Area Assessment (CAA) dated [DATE], identified R26 required staff assistance with ADLs. Staff offered morning and evening cares as well as toileting around the clock. R26 was able to alert staff as needed using call lights. R26 was working with therapy to regain independence where she was able. Goal was for R26 to not have any falls. The facility document Daily Rehab Responsibilities updated [DATE], identified R26 was to ambulate with 1 staff and forward wheeled walker (FWW)- distances as able.R26's undated, untitled nurse aide care sheet identified staff were to encourage the activity well fit program and R26 was to ambulate with staff and FWW daily.R26's Nursing Rehab Point of Care documentation dated [DATE] - [DATE], identified the following:[DATE] R26's ambulation was not applicableXXX[DATE] R26's ambulation was not applicableXXX[DATE] R26's ambulation was not applicableXXX[DATE] R26 refused ambulationXXX[DATE] R26's ambulation was not applicableXXX[DATE] R26's ambulation was not applicableXXX[DATE] R26's ambulation was not applicableXXX[DATE] R26 ambulated for 15 minutesXXX[DATE] R26's ambulation was not applicable.During an interview on [DATE] at 2:41 p.m., R26 stated R26 couldn't walk anymore. The staff needed to help R26 to get in my bed and wheelchair.During an interview on [DATE] at 2:41 p.m. R26 stated she did exercises for an hour every week for an activity but doesn't do any exercises with the aides anymore. R26 shook her head and stated no, I don't do that. I can't do that anymore.During an interview on [DATE] at 7:39 a.m., nursing assistant (NA)-A stated the nursing assistants were responsible for resident ambulation. The aides were not completing the task, and the director of nursing (DON) had talked to NA-A about restarting a formal nursing rehab program with an assigned restorative aide. NA-A stated she did not know how that was going to work because the residents who needed those services were in bed when NA-A was working. During an interview on [DATE] at 9:17 a.m., NA-B stated the nursing assistants were supposed to do the resident ambulation but I'm not going to lie, that's not very often. When staff did not complete the task, they documented it as not applicable because it just didn't get done. NA-B stated R26 did not walk at all and used a sit to stand lift with assist of two staff for all transfers. R26 needed this type of assistance for at least several weeks because it just wasn't safe to ambulate R26 with a walker.During an interview on [DATE] at 9:22 a.m., registered nurse (RN)-A stated the nursing assistants were responsible to complete the resident ambulation, but it just didn't get done. Nursing did have a meeting not that long ago to discuss ideas or to come up with a plan to fix this, but there was no plan created. Staff were expected to complete these tasks because not doing so could lead to contractures or a decline in the residents' ability to perform activities of daily living (ADLs). R26's medical record lacked an assessment for ADL decline including any revision to the ambulation care plan.During an interview on [DATE] at 11:52 a.m., the DON stated therapy made recommendations regarding resident restorative needs and the facility had a Well Fit program where the residents performed exercises as able in the activity room. Assignments were listed on the nurse aide care sheet directing staff who had resident ambulation and what that consisted of. The DON stated R26 was care planned to walk daily as tolerated but the care plan needed to be revised because the DON wouldn't transfer R26 with an assist of 1. The care plan stated that exercises were to be done as desired or tolerated, but staff should notify the DON if R26 was not able to perform the task. R26's condition had changed, and a therapy evaluation should have been requested to evaluated R26. On [DATE] at 1:25 p.m., attempted to observe R26's ambulation but R26 declined. That's just not my thing. Although R26's care plan and restorative program directed daily ambulation with a front wheeled walker and assist of one, staff interviews on [DATE] confirmed R26 had not ambulated for several weeks and required a sit-to-stand lift with assist of two for transfers.An ADL or resident ambulation policy was requested but not received.

Based on interview and document review, the facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to prevent the loss of mobility for 1 of 3 residents (R3) reviewed for restorative nursing services. Findings include:R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had mild cognitive impairment and was dependent on staff for all care areas. Diagnoses included diabetes, hemiplegia (paralysis affecting one side of the body) and hemiparesis (partial weakness affecting one side of the body). R3's Functional Abilities Care Area Assessment (CAA) dated 10/9/25, identified staff assisted R3 every 2-3 hours with toileting and repositioning. Staff anticipated R3's needs and R3 was able to ask for assistance as needed by using the call light. Goal was for R3 to continue at current level of functioning and avoid complications of immobility.R3's care plan revised 1/19/22, identified R3 had limited physical mobility and a fall risk related to weakness, hemiplegia, hemiparesis, involuntary movements, contractures, and limited range of motion. Intervention included:Nursing Rehab: 3 times per week. Bilateral lower extremity passive range of motion (PROn to active range of motion (AROM) See instructions in room, passive hamstring stretch: hold 30 seconds, repeat 3 times and passive Heel Cord Stretch: hold 30 seconds, repeat 3 times. R3 frequently refused stretching exercises. NURSING REHAB: PROM to both hands for finger flexion and extension. The following were to be completed 10 times, being held for 3 seconds, 5 times per week: Hip flexion/extension, Abduction/Adduction, Rotation, and Foot Pronation/Supination- Ankle Inversion/Eversion R3 frequently refused stretching exercises. NURSING REHAB: Assistance with splint or brace at least 3 times per day for 1 hour and overnight as tolerated. Nursing to apply: RIGHT HAND: foam anti-spasticity splint with finger separator. LEFT HAND: Cone splintR3's untitled nurse aide care sheet undated, identified R3 had a restorative program and to encourage the Well Fit program in the activity room. R3's Nursing Rehab Point of Care documentation dated 4/20/26-5/19/26, identified R3 wore the hand splints 41 times and was documented as not applicable 20 times out of the 90 opportunities. The documentation failed to identify R3 refused to wear the hand splints. R3's leg stretches were performed 3 times out of the 30 opportunities. The documentation failed to identify why no further leg were or were not performed.During an interview on 5/19/26 at 8:00 a.m., nursing assistant (NA)-B stated staff were to encourage residents to participate in the Well Fit program and R3 only wore his splints when he wanted to. R3 sometimes went to the Well Fit program and other times R3 would just rather watch tv. It just depended on the day. Staff were supposed to do R3's PROM and AROM but it didn't get done very often. Most of the time, staff just documented it as not applicable because it wasn't offered.During an interview on 5/19/26 at 9:22 a.m., registered nurse (RN)-A stated the nursing assistants were responsible to complete the resident restorative programs, but it just didn't get done. Nursing did have a meeting not that long ago to discuss ideas or to come up with a plan to fix this, but there was no plan created. Staff were expected to complete these tasks because not doing so could lead to contractures or a decline in the residents' ability to perform activities of daily living (ADLs). During an interview on 5/19/26 at 11:52 a.m., the director of nursing (DON) stated we have therapy make recommendations and we have a well fit program where they do exercises there as able. Assignments were posted on the NA care sheet. R3 was care planned to apply splints to his hands. He had one that he would wear at night when R3 allowed it. R3 was alert and oriented and decided that. R3 was to have ROM to hand and fingers as he allowed, and he hated it. R3 was to also have leg stretches and R3 hated that too. The DON stated staff should have offered the tasks and documented R3's refusals but the DON supposed when a resident repeatedly refused staff stopped offering. The DON stated R3's restorative program needed to be updated because it should have been based off what R3 wanted to do. The DON stated she was unaware staff were documenting R3s nursing rehab tasks as not applicable, and staff would be educated regarding that.Although R3 intermittently refused ROM and splinting interventions, staff interviews confirmed restorative tasks frequently were not offered and were documented as 'not applicable' rather than refused.The facility policy Restorative Program Process updated 10/26/21, the facility would ensure our resident(s) achieve and maintain their highest level of function. Process: a) Upon admission, quarterly, and with significant change the resident's level of function will be assessed by the licensed nurse or in collaboration with therapy. b) Based on the results of the assessment the licensed nurse will develop a care plan showing the resident's individual problems, determine approaches/interventions and set goals. c) The licensed nurse will develop a restorative nursing program with individualized interventions and goals which may include recommendations for strategy and adaptive equipment from therapy. d) The licensed nurse will educate all direct care staff assigned to the resident(s) on their restorative nursing program. e) The licensed nurse will monitor staff and resident(s) to ensure compliance with the restorative nurse program. f) The licensed nurse will monitor the daily restorative nursing program documentation in POC and follow-up with staff as needed. g) The licensed nurse will write a monthly restorative nursing summary to track the resident(s) progress. h) The licensed nurse will update the care plan and the restorative nursing program to reflect the resident(s) specific goals and interventions as needed. i) The licensed nurse will make referrals to therapy as needed. j) The licensed nurse will develop a discharge plan for the resident(s) who no longer need a restorative nursing program.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 2 residents (R8) reviewed for weight loss and 1 of 1 resident (R18) reviewed for falls. Findings include: R8: R8's significant change MDS dated [DATE], identified R8 had diagnoses of malnutrition and cancer. The MDS did not identify if there was a significant weight loss or gain. R8's recorded weights identified on 3/7/25, the resident weighed 132 lbs. On 3/28/25, the resident weighed 124 pounds which was a -6.06 % loss of weight. The MDS Resident Assessment Instrument (RAI) Manual dated 4/1/25 identified a loss of weight of 5% or more in the last month was a significant weight loss. R18: R18's annual MDS dated [DATE], identified severe cognitive impairment with wandering and required substantial/maximal assist with ambulation. R18's MDS did not identify any falls since last MDS assessment dated [DATE]. R18's progress notes identified: -12/8/24, R18 had a witnessed fall with no injury. -12/12/24, R18 had an unwitnessed fall with no injury. -12/18/24, R18 had an unwitnessed fall with injury. During an interview on 4/16/25 at 2:15 p.m., registered nurse (RN)-B stated she had prepared the MDS's for R8 and R18. In R8's weights, an algorithm was used to identify percent of weight loss or gain. RN-B entered the weights in the algorithm, and it identified a significant weight loss, and stated it should have been recorded as such on R8's significant change MDS dated [DATE]. R18's falls should have been pulled in the electronic medical record for review and was not sure why they did not. R18's annual MDS dated [DATE] should have captured the falls but did not. During an interview on 4/16/25 at 3:10 p.m., the director of nursing (DON) stated it was important for MDS data to be entered correctly as it directly correlates with the development and the quality of the resident's care plans. A policy on coding the MDS was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were consistently implemented in accordance with Centers for Disease Control (CDC) recommendations to reduce the risk of infection for 1 of 4 residents (R16) reviewed for EBP; and failed to ensure cross contamination to reduce the spread of infection for 1 of 1 residents (R4) observed who was transferred with a potentially contaminated lift sheet. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had a severe cognitive impairment and had diagnoses that included type 2 diabetes, legal blindness and dementia. R16's care plan revised 8/7/24, identified R16 had an activities of daily living (ADL) self-care deficit related to poor vision, impaired cognition and weakness. R16 required 1-2 staff to assist with personal cares and hygiene. However, the care plan failed to identify R16 required EBP due to having methicillin-resistant staphylococcus aureus (MRSA) (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections. Most methicillin-resistant staphylococcus aureus (MRSA) infections occur in people who've been in hospitals or other health care settings, such as nursing homes and dialysis centers. When it occurs in these settings, it's known as health care-associated MRSA (HA-MRSA). health care-associated methicillin-resistant Staphylococcus aureus (HA-MRSA) infections usually are associated with invasive procedures or devices, such as surgeries, intravenous tubing or artificial joints. HA-MRSA can spread by health care workers touching people with unclean hands or people touching unclean surfaces.) in a left second toe wound. R16's wound culture dated 2/12/25, identified R16 had MRSA. R4's quarterly MDS dated [DATE], identified R4 had moderate cognitive impairment and diagnoses included type 2 diabetes. R4 was dependent on staff for hygiene and grooming. R4's care plan revised 1/4/23, identified R4 had an activities of daily living (ADL) self-care performance deficit related to need for staff assistance with care due to a history of schizophrenia, depression, anxiety and developmental delay and limited physical mobility. Staff were directed to provide grooming and hygiene daily and as needed. During an observation on 4/16/25 at 7:12 a.m., nursing assistant (NA)-D and NA-C transferred R16 from R16's bed to R16's wheelchair using the full body mechanical lift. NA-D nor NA-C were wearing gowns or gloves. - At 7:15 a.m., NA-D made R16's bed. NA-D was not wearing a gown, or gloves and NA-D's uniform brushed up against R16's bed and linens. During an interview on 4/16/25 at 7:55 a.m., an enhanced barrier precautions sign on the room door with a post it with a handwritten note that stated R16 only. NA-D stated she wore a gown and gloves to assist R16's morning cares but took them off to leave the room to get the full body mechanical lift. I just spaced it out. R16 had a sore on his toe but was unable to say why it was important to wear personal protective equipment (PPE). During an observation on 4/16/25 at 7:39 a.m., an enhanced barrier precautions sign on the room door with a post it with a handwritten note that stated R16 only. NA-E entered R4's room with the shower chair and stated R4 was going to have a shower. NA-E gathered R4's clothing, a clean brief and bath supplies. NA-E laid a bath fully body mechanical lift sling on R16's bed. - At 7:41 a.m., NA-F entered R4's room with the full body mechanical lift and picked up the full body mechanical lift sling from R16's bed. NA-E removed R16's incontinent brief. R4 had a small bowel movement (BM), and NA-E cleaned R4's skin with a disposable wipe. - 7:43 a.m., NA-E removed the soiled gloves but did not use hand sanitizer before putting on clean gloves. - 7:43 a.m., NA-E put the full body mechanical lift sling under R4. NA-E and NA-F assisted R4 to the shower chair using the full body mechanical lift. During an interview on 4/16/25 at 7:52 a.m., NA-E stated only R16 required staff to wear personal protective equipment (PPE) during direct resident care because R16 had a wound on his toe. Staff needed to do that with any resident who had a catheter, a wound, tracheostomy, or anything like that. Staff were expected to put on a gown or gloves before entering the room because staff never knew what was going to happen and staff might need it. NA-E stated R4's full body mechanical lift sling should not have been lying on R16's bed and used for R4 because it can spread bacteria between the residents. Also, NA-E stated she should have used hand sanitizer before putting on clean gloves. During an interview on 4/16/25 at 12:45 p.m., the director of nursing (DON) stated staff should follow EBP for a resident with a catheter, feeding tube, tracheostomy, open wounds that are draining, and chronic wounds. Staff were also expected to use hand sanitizer or wash their hands when their hands were visibly soiled. The DON stated she had educated and re-educated staff regarding the use of gowns and gloves. The DON worked closely with staff on the floor and followed EBP as an example to staff. The door sign stated exactly when and which type of PPE was expected. Additionally, staff should not put one resident's things on another resident's bed, especially when either resident had an MDRO. The DON stated she was unaware of R16's lab culture showing MRSA but would immediately notify and educate staff on expectations to protect other residents and themselves. A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The feature identified several examples of high-contact resident care activities including dressing, bathing, providing hygiene, transferring, changing linens or briefs, and wound care. The facility policy Enhanced Barrier Precautions dated 11/13/24, identified Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. High-contact resident care activities include: - Dressing - Bathing - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy /ventilator tubes - Wound care: any skin opening requiring a dressing (excluding shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing). - Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/ common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. EBP applies to the MDRO's that are resistant organisms targeted by CDC. Examples of MDROs targeted by CDC include the following (residents must be in EBP if they currently have these MDRO's or have a history): 1) Pan-resistant organisms 2) Carbapenemase-producing carbapenem-resistant Enterobacterales 3) Carbapenemase-producing carbapenem-resistant Pseudomonas spp. 4) Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii 5) Candida auris Additional epidemiologically important MDROs may include, but are not limited to (residents must be in EBP if they have a current diagnosis of these additional MDROs but EBP is not required if they only have a history): 1) Methicillin-resistant Staphylococcus aureus (MRSA) 2) ESBL-producing Enterobacterales 3) Vancomycin-resistant Enterococci (VRE) 4) Multidrug-resistant Pseudomonas aeruginosa 5) Drug-resistant Streptococcus pneumoniae h) Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. A policy regarding hand hygiene was requested but not received.

Based on observation, interview and document review, the facility failed to ensure pillows were not used in a manner to restrain residents while in bed for 1 of 1 residents (R17) reviewed for restraints. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 had severe cognitive impairment and diagnoses of dementia and legal blindness. R17 used no restraints. R17's care plan reviewed 5/31/24, identified R17 had limited physical mobility and was a fall risk related to poor vision and weakness. R17 used a grab bar on the exiting side of R17's bed to enable R17 to go from lying to sitting, to aid in turning/repositioning and to get in and out of bed. Staff were directed to assess R17's grab bars routinely and with changes in condition to assure appropriateness of use, safety/security of the bar to the bed frame and potential for entrapment. R17 used a landing pad next to his bed as R17 liked to purposefully crawl out of bed onto the floor. R17's care plan did not identifiy the use of pillows under his fitted sheet to prevent R17 from crawling out of bed. R17's Physical Device Evaluation dated 5/16/24, identified R17 used a right and left grab bar, hi-low bed, and floor mats by his bed. However, the assessment did not identify the use of pillows to prevent R17 from rolling out of bed. R17's Morse Fall Scale 6-16 V3 dated 5/16/24, identified R17 was at high risk for falls. During an observation on 7/23/24 at 8:34 a.m., R17 was lying on his back in the middle of his bed with his blankets covering to his chest. On R17's right side two pillows were tucked under the fitted sheet and ran along R17's body from his shoulders to his knees. R17's bed was in low position with a fall mat next to his bed. - At 8:40 a.m., nursing assistant (NA)-A entered R17's room and greeted R17. R17 declined getting up for the day. NA-A exited R17's room and did not remove the pillows. - At 8:56 a.m., the director of nursing (DON) entered R17's room and turned-on music for R17. The DON did offer to assist R17 with morning cares, but R17 declined. The DON then removed the pillows from underneath R17's fitted sheet and placed them on the unused bed in the room before exiting R17's room. During an interview on 7/23/24 at 8:57 a.m., the DON stated R17 could have significant behaviors. NA-A was a new nursing assistant who had been working day shift for approximately a month and was extremely nervous to be observed. DON stated she was guessing the pillows were put underneath the fitted sheet by night shift. R17 could wiggle and move around in the bed and the night shift staff were probably worried R17 was going to fall out of bed. R17 had a mat, and the bed was 6 inches off the floor. R17 was not going to get hurt if there was a fall. The DON stated the pillows should never be placed under the fitted sheet because that was a restraint. The DON removed the pillows and planned to speak to staff and explain why the staff could not do that. NA-A should have removed the pillows and immediately reported the pillows to nursing. During an interview on 7/23/24 at 9:08 a.m., NA-A stated R17's pillows were underneath the fitted sheet so R17 could not roll out of bed, we do it all the time. R17 can put his legs over the side of the bed and roll out onto the mat. NA-A stated she did not know if R17 could remove the pillows if R17 wanted to and would have to ask the nurse. During an interview on 7/23/24 at 9:20 a.m., NA-B stated Yea, we put pillows underneath the fitted sheet all the time because R17 rolled out of bed. R17 could remove the pillows if the pillows were not underneath the fitted sheet. A facility policy related to restraints was requested but not received.

Based on observation, interview and document review, the facility failed to test and implement transmission based precautions (TBP) for residents symptomatic for COVID-19 according to Centers for Disease Control and Prevention (CDC) for 3 of 3 residents reviewed for infections; failed to ensure hand hygiene was completed for 1 of 3 residents (R10) observed during personal cares. This had the potential to affect all residents currently residing in the facility. Findings include: COVID-19 Testing and TBP R10's annual Minimum Data Set (MDS) dated [DATE], identified R10 had moderate cognitive impairment and diagnoses of atrial fibrillation, coronary artery disease and hypertension. R10's nursing progress notes identified the following: - On 7/19/23 at 9:25 a.m., R10 was very agitated and irritable that morning. Oxygen was put back on at 2 liters (L) at 8:30 a.m., gesturing he wished it was back on. Staff were unable to understand much of what R10 was saying. - On 7/19/23 at 12:10 p.m., R10 was evaluated by the physician's assistant (PA). R10 was started on an antibiotic and oral steriods. - On 7/19/23 at 1:00 p.m., R10's COVID test was negative. The test was done due to upper respiratory symptoms, temperature, cough and respiratory distress. The note did not identfiy the type of COVID-19 test obtained. - On 7/19/23 at 4:50 p.m., R10's temperature was 101.2 temporal. Respirations wheezy at 36 per minute. R10 spit up a large amount of thick gray phlegm. Oxygen saturations 93% on 2L. - On 7/20/23 at 6:02 p.m., R10 coughed up a large amount of stringy gray phelgm. R10's medical record lacked evidence R10 had a confirmation COVID-19 test and/or was placed into transmission based precautions until a confirmatory negative test could be obtained. R26's significant change MDS dated [DATE], identified R26 had intact cognition and diagnoses of coronoary artery disease, hypertension and diabetes. R26's nursing progress notes identified the following: - On 7/26/23 at 1:09 p.m., R26 compliained of not feeling well. R26 stated he felt weak and had been using his call light to request assistance with transfers. - On 7/27/23 at 6:00 a.m., R26 was noted to be coughing a lot on night shift. R26 was afebrile. - On 7/28/23 at 5:08 a.m., R26 was noted to cough again during the night. R26 remained afebrile. - On 7/28/23 at 1:35 p.m., R26 complained of not feeling well and had been needing more assistance from staff the last couple of days. - On 7/28/23 at 1:42 p.m., R26 was evaluated by the physician's assistant. R26 had not been feeling well. R26 was weak with a productive cough, congested and lethargic. R26 was started on an antibiotic. R26's medical record lacked evidence R26 was tested for COVID-19 test and/or was placed into transmission based precautions until a confirmatory negative test could be obtained. R22's quarterly MDS dated [DATE], identified R22 had a moderate cognitive impairment and diagnoses pulmonary hypertension, emphysema, history of transient ischemic attack (TIA) and hypertension. R22's nursing progress notes identified the following: - On 8/24/23 at 12:00 a.m., R22's temperature was 99.5 - On 8/24/233 at 1:00 a.m., R22 had a congested cough. - On 8/24/23 at 5:28 a.m., a COVID test was performed for R22 due to low oxygen saturations, cough and elevated temperature. Results were negative. The note did not identfiy the type of COVID-19 test obtained. - On 8/24/23 at 6:09 a.m., R22 was noted to have a congested cough. Oxygen saturations on room air were 85-88%. R22 was weepy. As needed Tylenol and cough medicine were given at 1:00 a.m. and oxygen applied at 2 liters (L) per nasal canula (nc) and saturations rose to 90%. R22 rested throughout the night. R22's current temperature was 97.5. - On 8/24/23 at 3:09 p.m., R22 continued to have low oxygen saturations. - On 8/24/23 at 4:07 p.m., R22 was evaluated by the physician's assistant due to cold symptoms, low grade fever and low oxygen saturations. R22 was started on an antibiotic. - On 8/26/23 at 4:24 p.m., R22 continued to not feel well. - On 8/27/23 at 5:35 a.m., R22's oxygen saturations were 94% on 2L/nc. Temperature was 97.6. R22 was very tearful at times. R22's medical record lacked evidence R22 had a confirmatory test for COVID-19 test and/or was placed into transmission based precautions until a confirmatory negative test could be obtained. During an observation on 8/28/23 at 1:34 p.m. R22 was wheeling her self in her wheelchair in the hallway outside her room. R22 repeatedly stated help. Nursing assistant (NA)-A and activities (AA)-A attempted to console R22. However, R22 was unmasked, there was no signage identifying R22 was in TBP and staff did not wear PPE. During an interview with the licensed social worker (LSW) and registered nurse (RN)-A on 8/28/23 at 2:26 p.m., RN-A stated the director of nursing (DON) mentioned R22 was tested for COVID-19 just to make sure but it was negative. R22 was being treated for a cold. RN-A stated the facility used COVID-19 antigen test kits and only collected one test. R22 was evaluated by a medical provider who did not direct for further testing either. R22 was not placed on TBP due to her COVID-19 test being negative. During an interview on 8/28/23 at 4:31 p.m., the DON stated the facility used COVID-19 antigen test kits. Residents who exhibit signs/symtpoms of COVID-19 such as cough, fever and low oxygen saturations were tested for COVID-19. The staff did not collect confirmatory tests for residents who tested negative with an antigen test. The DON stated she did not think that was their policy to do so or at least she did not remember being told that. R10 nor R22 were placed into TBP because their tests were negative, but the staff did follow standard precautions. The DON confirmed standard precautions did not direct staff to wear a gown and/or mask during direct resident care. If any resident tested positive for COVID-19, they would immediately placed into TBP to prevent the transmission of COVID-19. - At 5:01 p.m., the DON stated R26 began showing signs/symptoms of a respiratory infection on 7/28/23 with a new cough; however, R26 was never tested for COVID-19 nor placed into TBP. - At 6:24 p.m., the DON stated she reviewed the facility COVID testing policy. The policy identified a repeat antigen test would be collected 48 hours after a negative antigen test for residents who were symptomatic. The DON stated she created staff education to remind staff and also collected a repeat test for R22 which was negative. The Interim Infection Prevention and Control (IPC) Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, identified anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for COVID-19 as soon as possible and be placed in Transmission Based Precautions. Mild illness is defined as any various signs and symptoms of COVID-19 such as fever, cough, sore throat, malaise, headache, muscle pain, without shortness of breath, dyspnea or abnormal chest imaging. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. The facility policy Infection Control Manual 10/19/22, was provided by the facility, however, the page regarding COVID-19 testing was missing. Hand Hygiene R12's significant change MDS dated [DATE], identified R12 had severe cognitive impairment and included diagnoses of dementia, seizures, urine retention and weakness. R12's care plan revised 12/6/18, identified R12 required assistance with personal hygiene and toileting. During an observation on 8/29/23 at 3:24 p.m., RN-A and NA-E assisted R12 with personal cares. R12 was transferred into bed with the full body mechanical lift, RN-A and NA-E both put on gloves. NA-E assisted R12 to roll onto his right side. RN-A removed R12's soiled brief and cleaned feces from R12's skin with a disposable wipe. R12 was assisted to roll to his left side. RN-A continued to wear her soiled gloves. RN-A and NA-E fastened R12's clean brief. RN-A then picked up R12's pillows and and instructed NA-E to roll R12 onto his left side. RN-A then tucked the pillow behind R12 for positioning. RN-A continued to wear her soiled gloves while attaching R12's call light to his shirt and turned off his lights. RN-A removed her soiled gloves but did not perform hand hygiene. RN-A reapplied gloves and wiped R12's nose with a tissue, applied lotion to his arms and legs and covered R12 with a blanket. RN-A removed her soiled gloves and used hand sanitizer. During an interview on 8/29/23 at 3:35 p.m., RN-A stated she did not use hand sanitizer or wash her hands after removing soiled gloves. RN-A continued to wear soiled gloves while touching items in R12's room and this was unwanted because it soiled anything you touched and should not be done to prevent infection. The facility policy Hand Hygiene dated 10/19/22, identified staff were directed to use alcohol based hand sanitizer immediately before putting on gloves and after glove removal and between resident care sites, if indicated.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R5, R10, R22, R26) reviewed for immunizations. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identfied R5 was [AGE] years old and included diagnoses of diabetes and hypertension. R5's Immunization Report dated 8/30/23, identified R5 received pneumovax (type unknown) on 4/28/14, and a pneumococcal conjugate vaccine (Prevnar 13) on 9/8/16. R5's medical record did not include evidence R5 or R5's representative received education regarding pneumococcal vaccine booster and there was no indication R5 was offered the pneumococcal vaccine per CDC guidance. R10's annual MDS dated [DATE], identified R10 was [AGE] years old and included diagnoses of atrial fibrilation, coronary artery disease, hypertension, renal failure, and diabetes. R10's Immunization Report dated 8/30/23, identified R10 received a pneumovax (type unknown) on 9/16/10, and a Prevnar 13 on 10/8/15. R10's medical record did not include evidence R10 or R10's representative received education regarding pneumococcal vaccine booster and there was no indication R10 was offered the pneumococcal vaccine per CDC guidance. R22's quarterly MDS dated [DATE], identified R22 was [AGE] years old and included diagnoses of pulmonary hypertension, emphysema, and hypertension. R22's Immunization Report dated 8/30/23, lacked evidence R22 reveived a pneumococcal vaccine. R22's medical record did not include evidence R22 or R22's representative received education regarding pneumococcal vaccine booster and there was no indication R22 was offered the pneumococcal vaccine per CDC guidance. R26's significant change in status MDS dated [DATE], identified R26 was [AGE] years old and included diagnoses of coronary artery disease, hypertension, and diabetes. R26's Minnesota Immunization Information Connection (MIIC) dated 8/30/23, identified R26 received a Prevnar 13 on 9/10/15, and a pneumococcal polysaccharide vaccine (PPSV23) on 8/21/17. R26's medical record did not include evidence R26 or R26's representative received education regarding pneumococcal vaccine booster and there was no indication R26 was offered the pneumococcal vaccine per CDC guidance. During interview on 8/30/23 at 9:27 a.m., the director of nursing (DON) stated R5 and R10 received a dose of pneumovax prior to admission; however, their record did not identify what type of vaccine they received. The DON reviewed resident immunizations upon admission. A MIIC report would be printed and data would be entered into the resident's medical record. The DON was not aware of changes in pneumococcal vaccine recommendations and had not reviewed any resident for eligibility. Additionally, resident or resident representative education were not previously documented but the facility used the CDC's Vaccine Information Sheet (VIS) that was available online. The facility provided Vaccine Information Statement (VIS) Pneumococcal Conjugate Vaccine dated 5/12/23, and Pneumococcal Conjugate Vaccine (PCV13) dated 2/4/22, identified education regarding the need for PCV 15, PCV 20, PPSV23 and Prevnar 13. The facility policy Pneumococcal Vaccinations dated 10/19/22, identified all resident's would be provided the opportunity and encouraged to receive the pneumococcal vaccinations. On admission, each resident would be questions regarding history of receiving pneumococcal vaccinations (offered year round). Each resident would be educated and offered the pneumococcal vaccine if they have never had the vaccine. The DON/designee would be responsible for following up with the Physician's office when questions arose, as to whether a resident had had vaccines in the past.

Based on observation, interview and document review, the facility failed to minimize body exposure during the provision of morning cares for 1 of 4 residents (R23) observed during personal cares. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and diagnoses of history of traumatic brain injury, dysphagia and seizures. R23 required extensive assistance to total dependence for all activities of daily living. R23's care plan revised 4/3/23, identified R23 had a communication problem with difficulty expressing ideas/wants, understanding verbal content related to cognitive impairment and R23 used minimal words. R23 could answer yes/no questions at most time. Staff were directed to anticipate need and to cue/supervise as needed. On 8/29/23 at 10:32 a.m., nursing assistant (NA)-C and NA-D were observed to assist R23 to lie down in bed using a full mechanical lift. R23's window blinds remained open with a view of the facility's back lawn. NA-D exited the room and NA-C continued to assist R23 with personal cares removing his towels so R23 was unclothed on his bed. R23's blinds continued to be open. R23 was dressed and NA-C prepared to transfer R23 to his wheelchair using the full mechanical lift. NA-C requested staff assistance over the walkie and trained medication aide (TMA)-A entered the room. Neither TMA-A nor NA-C acknowledge R23's blinds were open, or attempted to close them. TMA-A pushed R23 in his wheelchair out of the room. NA-C stated she completely forgot about closing R23's blinds for privacy. On 8/30/23 at 12:55 p.m. TMA-A refused interview stating no, my shift is over. I'm done. During an interview on 8/30/23 at 9:49 a.m., the director of nursing (DON) stated R23's blinds remaining open during personal cares was a privacy issue and should never have happened. The blinds should always be closed during personal cares. If a resident did not want the blinds closed, for whatever reason, the privacy curtain should be closed to provide privacy to ensure no person walking by the building could see the resident. A facility policy regarding privacy was requested by not received.

Based on observation, interview and document review, the facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for 2 of 2 residents (R17, R22) reviewed for MDS accuracy. Findings include: R17's quarterly MDS dated [DATE], identified R17 had moderate cognitive impairment and diagnoses of anemia, hypertension, and diabetes. R17 used anticoagulant ( blood thinners, interfere with proteins in your blood that are involved with clotting) medication. R17's Order Summary Report dated 8/30/23, identified R17 received clopidogrel bisulfate (an antiplatelet medication used to prevent heart attacks and strokes in persons with heart disease, recent stroke, or blood circulation disease, to prevent clots from forming) 75 milligram (mg) by mouth (po) in the morning related to a stroke. R22's quarterly MDS dated [DATE], identified R22 had moderate cognitive impairment and diagnoses of pulmonary hypertension, emphysema, history of transient ischemic attack (TIA) and hypertension. R22 used anticoagulant medication. R22's Order Summary Report dated 8/30/23, identified R22 received clopidogrel bisulfate 75 mg po one time a day related to history of TIA. During an interview on 8/30/23 at 1:50 p.m., the director of nursing (DON) called and placed registered nurse (RN)-A on speaker phone. RN-A stated she coded R17's and R22's clopidogrel bisulfate as an anticoagulant because it was. The DON completed an internet search for clopidogrel bisulfate's drug class which identified the drug as an antiplatelet. However, the DON stated it also described clopidogrel bisulfate as a blood thinner. RN-A stated she believed the CMS Resident Assessment Instrument (RAI) Manual instructed to code clopidogrel bisulfate as an anticoagulant. The DON opened the RAI manual and read aloud Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. At that time, the DON and RN-A stated the MDS's for R17 and R22 were coded incorrectly and would need correction. The DON stated resident MDS entries needed to be accurate to allow for reimbursement, accurate care planning and to provide proper resident care. A policy/procedure regarding MDS was requested but not received.

Based on observation and interview the facility failed to ensure walls were repaired for 1 of 1 resident (R8) whose walls were in disrepair; the facility failed to ensure call bell pads were in good repair for 2 of 2 residents (R8, R12) whose call bell pads were in disrepair. Findings include: WALLS: During observation on 8/28/23 at 1:57 p.m., R8's bed was against the wall, there was a large area of chipped paint across the area where the head of the bed met the wall. The chipped area was the length of the headboard measuring approximately 3 feet. On 8/30/23 at 1:00 p.m., a joint interview was conducted with nursing assistant (NA)-B and NA-C. NA-B and NA-C stated R8's wall had chipped paint for at least the past year. NA-B and NA-C stated maintenance was aware of it but had not completed any repairs to the wall. During interview on 8/30/23 at 1:12 p.m., the administrator was unaware R8's wall needed repair and the room was not on the work order list. A work order should have been entered into the system, so the repairs could be completed. CALL BELL PAD: During observation on 8/28/23 at 1:57 p.m., R8's call bell pad was cracked. During observation on 8/30/23 at 8:50 a.m., the rubber around R12's call pad was gone exposing the plastic call pad. During interview on 8/30/23 at 8:39 a.m., registered nurse (RN)-B stated if she were made aware of a call bell pad that was cracked she would take one from an empty room because she doesn't have access to extra call bell pads while working on the evening shift. RN-B stated she was not aware of any rooms that had cracked call bell pads and all the call lights were working correctly. During interview on 8/30/23 at 8:46 a.m., NA-B stated if she noticed the rubber on a call light/call light pad was cracked or broken she would report to the charge nurse and/or the director of nursing (DON) right away. NA-B stated a couple of days ago she noticed the rubber on R12's call pad was ripped off exposing the plastic call bell pad as well as the coated wires. Also, the rubber on R8's call bell pad was cracked and the coated wires were exposed. NA-B stated she had not yet reported the issues. During interview with the DON on 8/30/23 at 8:50 a.m., the DON stated there was not a formal process for changing out call bells and as long as they were working no-one checked them. If staff reported that a call bell pad was cracked or not working she would replace it right away. The DON was not aware of any call bell pads that were cracked or broken until today when it was brought up by the state agency. During interview on 8/30/23 at 8:30 a.m., the administrator stated he was not aware of any call bell pads that needed to be repaired although, if he had, they would need to be replaced right away. A policy for maintenance of resident care areas was requested but not received. A policy for call light maintenance was requested but not received.

Based on interview and document review the facility failed to report an allegation of physical abuse to the administrator and state agency (SA) with in two hours for 1 of 1 residents (R1) reviewed for abuse. Findings include: A facility Feedback Form, Grievances/Comments/Suggestions dated 8/24/22, indicated on the evening of 8/24/22, family member (FM)-A had R1 at home for dinner and was visiting when R1 began telling FM-A that a nursing assistant (NA) had been giving her orders and became irritated and slapped R1 across the face. A report to the SA dated 8/25/22, indicated on the morning of 8/25/22, an envelope was found in the administrators mail box with a grievance form. The form stated it had been reported the previous day that a NA had slapped R1 the previous week. During interview on 8/29/22, at 2:34 p.m. registered nurse (RN)-A stated on 8/24/22, R1's family told her they were going to file a grievance and had reported one of the facility staff had slapped R1. RN-A stated she told the family member to take the form and put it in writing. RN-A stated she did notify the administrator. RN-A further stated she believed a report had to be made to the SA within 24 hours. On 8/29/22, at 2:56 p.m. the administrator stated the report to the SA should have been made immediately but no later than 24 hours after the allegation. The administrator stated she was notified on 8/24/22, by RN-A that family had alleged physical abuse by a staff member. The administrator stated she was advised by the facility nurse consultant to wait until morning and see what was reported. A facility policy Vulnerable Adult, dated 11/2/21, indicated all allegations of abuse will be reported immediately but no later than two hours if the alleged violation involves abuse.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19. The facility failed to ensure gowns were used in a manner to prevent potential cross contamination when providing personal care and treatment to 7 of 7 residents (R1, R2, R3, R4, R5, R6, R7) residing on the quarantine unit and 4 of 4 residents (R8, R9, R10, R11) residing of the well unit. This deficient practice resulted in an immediate jeopardy (IJ) situation for the 11 out of 26 residents identified by facility as residents who had not tested positive for COVID-19; and resided in the facility during the COVID-19 Focused Infection Control Survey. The IJ began on 11/9/20, when the facility established a quarantine unit and started reusing one disposable gown per employee, per shift, while providing direct resident care with multiple COVID-19 negative residents who were exposed to confirmed positive COVID-19 residents. The administrator and director of nursing (DON) were notified of the IJ on 11/18/20, at 4:06 p.m. The IJ was removed on 11/19/20, at 3:45 p.m. when the facility implemented actions to reduce/ prevent the spread of COVID-19 within the facility. However, noncompliance remained at the lower scope and severity, pattern, which indicated no actual harm with potential for more than minimal harm that was not IJ (Level E). Findings include: The CDC guidance Coronavirus Disease 2019 (COVID-19) People at Increased Risk dated 9/11/20, identified the risk for severe illness from COVID-19 increased with age, with older adults at the highest risk. Severe illness means a person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. On 11/17/20, at 11:44 a.m. while being escorted to the conference room by acting administrator, a disposable gown was observed hanging on a hook on the wall. The acting administrator stated the activities person re-used the same disposable gown with all the residents on the quarantine unit and would change the disposable gown out daily. During the facility entrance conference on 11/17/20, at 11:55 a.m. the acting administrator stated there were fifteen residents diagnosed with [REDACTED]. There were seven residents the facility identified who were exposed to the COVID-19 positive residents and they were all residing on the quarantine unit. In addition, the facility had identified four residents who were not exposed to COVID-19 and they were residing on a separate well unit. The acting administrator stated when staff entered the quarantine unit for the day they were to put on a new clean disposable gown and could wear it throughout the unit and when performing personal cares with residents. They did not need to change the disposable gown between each direct resident care interaction as all the residents were on quarantine. When staff left the unit to care for the four residents on the well unit, they would take off the used disposable gown and hang it up on a hook in the staging room on the unit. When staff come back onto the unit, they were to reuse the same disposable gown they had hung up. The CDC Responding to Coronavirus (COVID)-19 in Nursing Homes updated 4/30/20, identified a facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. All recommended personal protective equipment (PPE) should be worn during care of residents under observation and should include a facemask/respirator, eye protection, gloves and gown. The CDC Using Personal Protective Equipment (PPE) updated 8/19/20, identified gowns should be donned (put on) prior to entering the resident's room. The gown should be doffed (removed) while standing in the resident's room, if disposable it should be thrown away and if it was washable it should be bagged for laundry. On 11/17/20, at 12:10 p.m. the quarantine unit was observed. The unit included two short halls consisting of 5 rooms each with an activity room combining the halls into one unit. Both hallways had closed double doors with a a sign posted on the door indicating PPE would need to be worn beyond that point. On the 101-105 quarantine hallway, room [ROOM NUMBER] was set up as a staging room for donning and doffing PPE. There were five hooks on the wall to the left of the room. There were disposable gowns hanging on two of the hooks. One hook with a gown was labeled with a name and the other hook with a gown was unlabeled. The room had gowns, gloves, masks and hand sanitizer to be used throughout both halls. On the 106-110 quarantine hallway, there was a window on the left side of the hall and it had three hooks attached to the window with a disposable gown hanging on one of the hooks. The hook the gown was on was not labeled. There was also an isolation cart next to the window holding disposable gowns, gloves, masks and hand sanitizer to be used. During interview on 11/17/20, at 12:17 p.m. the community life director (CLD) stated when entering the quarantine unit for the first time on her shift, she would obtain a new disposable gown and wore that same gown into each residents' rooms on the unit. If CLD left the unit, she would untie the disposable gown and hang it up for when she next entered the unit again. The CLD stated they would get a new disposable gown every day or if visibly soiled or dirty; otherwise the wore the same gown with all resident interactions on the quarantine unit. During interview on 11/17/20, at 12:26 p.m. housekeeper (H)-A stated when cleaning rooms on the quarantine unit she would use one disposable gown throughout the day and if they needed to leave the unit, she would hang it up and then put it back on when coming back onto the unit. H-A stated they received a new disposable gown every day. The facility provided resident list identified R1, R2, R3, R4, R5, R6 and R7 resided on the quarantine unit. R8, R9, R10 and R11 resided on the well unit. R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 was [AGE] years old with severe cognitive impairment. R1 required extensive assist with bed mobility, transfers, toileting, dressing and personal hygiene. R1's [DIAGNOSES REDACTED]. R2's quarterly MDS dated [DATE], identified R2 was [AGE] years old and had severe cognitive impairment. R2 required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene. R2's [DIAGNOSES REDACTED]. R3's quarterly MDS dated [DATE], identified R3 was [AGE] years old and had moderate cognitive impairment. R3 required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene. R3's [DIAGNOSES REDACTED]. R4's quarterly MDS dated [DATE], identified R4 was [AGE] years old and had intact cognition. R4 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. R4's [DIAGNOSES REDACTED]. R5's annual MDS dated [DATE], identified R5 was [AGE] years old and had moderate cognitive impairment. R5 required extensive assistance with transfers, dressing, toileting and personal hygiene. R5's [DIAGNOSES REDACTED]. R6's quarterly MDS dated [DATE], identified R6 was [AGE] years old and had moderate cognitive impairment. R6 required extensive assistance with bed mobility, transfers, walking, toileting, dressing and personal hygiene. The MDS included a [DIAGNOSES REDACTED]. R7's annual MDS dated [DATE], identified R7 was [AGE] years old and had intact cognitive cognition. R7 required extensive assistance for dressing, toileting and personal hygiene. [DIAGNOSES REDACTED]. R8's quarterly MDS dated [DATE], identified R8 was [AGE] years old and had severe cognitive impairment. R8 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS identified a [DIAGNOSES REDACTED]. R9's admission MDS dated [DATE], identified R9 was [AGE] years old and had severe cognitive impairment. R9 required extensive assistance with bed mobility, transfers, walking,dressing, toileting and personal hygiene. R9's [DIAGNOSES REDACTED]. R10's quarterly MDS dated [DATE], identified R10 was [AGE] years old and had intact cognition. R10 was independent with all personal cares. R10's [DIAGNOSES REDACTED]. R11's annual MDS dated [DATE], identified R11 was [AGE] years old and had severe cognitive impairment. R11 required extensive assistance with bed mobility, transfers, toileting, walking,dressing and personal hygiene. The MDS included a include [MEDICAL CONDITION]. During observation on 11/17/20, at 1:01 p.m. nursing assistant (NA)-B come out of R6's room with a disposable gown on and then walk up to R5 and began talking to them. NA-B was within 3 feet (ft) of R5; however, did not have any direct contact. Another staff, NA-A, came out of R6's room with a disposable gown on, carrying garbage, and entered a soiled utility room. Upon exit NA-A was still wearing the same disposable gown. NA-A stood next to NA-B, who was talking to R5. Neither NA-A nor NA-B were providing direct care to R5. During interview on 11/17/20, at 1:08 p.m. with NA-A and NA-B, NA-A stated when NA-A entered the quarantine unit for the day, she would put on a clean disposable gown and wear it throughout the unit while providing hands on care to residents. NA-B also stated this was the facility practice. Further, when staff needed to leave the quarantine unit to provide direct resident care to the residents on the well unit the contaminated disposable gown was removed and hung up on a hook. When NA-B returned to the quarantine unit, she would put on the same contaminated disposable gown she had removed and hung up earlier. During observation on 11/17/20, at 2:16 p.m. NA-B then entered R2's room wearing the same disposable gown and NA-C entered room to assist with transferring R2. Using a gait belt, NA-B and NA-C both assisted with transferring R2 to their chair. After assisting with transfer, NA-C removed her disposable gown, hung it up on a hook, and left the unit. NA-B finished her shift on the quarantine unit wearing the same contaminated gown. When NA-B's shift was over she removed the gown, and disposed of it in the garbage. During observation on 11/17/20, at 2:37 p.m. NA-C entered the quarantine unit, took the previously used (contaminated) disposable gown, and put it on. NA-C then entered R1's room and helped her adjust her wheelchair. NA-C leaned over R1 and removed food debris from R1's shirt she was wearing. During this interaction NA-C's gown was touching R1 at the knees and legs. NA-C then their changed gloves, sanitized their hands, and did not removed their contaminated disposable gown. NA-C then entered R6's room and straightened up his bed, adjusted R6 in the chair and attached his call light to his shirt. NA-C gown came in direct contact with R6 and or R6's items during the interaction. When NA-C left the room she removed her gloves, sanitized her hands, then untied the contaminated disposable gown she was wearing , hung it up on a hook on the window , sanitized their hands and exited the quarantine unit. During interview on 11/17/20, at 2:56 p.m. NA-C stated staff were to wear the same disposable gown on the quarantine unit for the entire shift, unless it became visibly soiled or dirty. Upon exiting the unit to help residents on the well unit, they needed to take the disposable gown off and hang it up to reuse later, when they returned to the quarantine unit to continue caring for residents. NA-C stated the same gown was used for all residents on the quarantine unit regardless if they were providing direct care or not. During interview on 11/17/20, at 3:32 p.m. the administrator stated the facility originally had a combined quarantine and COVID-19 unit, with changing disposable gowns between each resident interaction. As the number of COVID-19 cases and residents on quarantine increased, they separated residents into separate areas on 11/9/20, then they started using the same disposable gown throughout the quarantine unit. During observation on 11/18/20, at 7:19 a.m. NA-D was in R1's room finishing NA-D's personal cares. NA-D was wearing a disposable gown, gloves, facemask and goggles. Upon exiting R1's room, NA-D removed their gloves and sanitized her hands. NA-D then removed her disposable gown, hung it on a hook next to her name, sanitized her hands, and exited the unit. - At 7:25 a.m. NA-D came back onto the unit and put on the contaminated disposable gown they previously hung on the hook. NA-D entered R2's room and assisted R2 to sit up on the side of her bed. NA-D the placed a gait belt on R2 and assisted R2 to stand and pivot transfer to the wheelchair. NA-D wheeled R2 to the bathroom and assisted R2 to stand and pivot transfer to the toilet, and before R2 sat down, NA-D removed R2's wet incontinent brief and assisted her onto the toilet. NA-D changed her gloves, sanitized her hands and continued to assist R2 to wash their face, back, chest, stomach, and under R2's arms and peri area. When cares were completed NA-D assisted R2 to stand and transfer to the wheelchair. - At 7:44 a.m. NA-D came out of R2's room and disposed of dirty linens and garbage. She washed her hands, removed the contaminated disposable gown, re-hung it on hook next to her name, and exited the unit. During observation on 11/18/20, at 7:51 a.m. LPN-A wore a disposable gown, gloves, mask and goggles. Upon entering R2's room, she administered R2's medications and then assisted R2 to the bathroom. LPN-A used a gait belt to assist with transferring to the toilet and removing their incontinence product. LPN-A removed her gloves and sanitized her hands and exited R2's room. LPN donned new gloves. LPN-A did not remove and dispose of her gown and continued wearing same contaminated disposable gown. - At 7:57 a.m. LPN-A returned to assist R2 after using the bathroom. LPN-A assisted R2 to stand, completed peri care and transferred R2 to the wheelchair. Upon exiting R2's room, LPN-A removed their gloves, sanitized their hands, and put on new gloves. LPN-A did not remove and dispose of her gown and continued wearing same contaminated disposable gown. - At 8:20 a.m. LPN-A entered R3's room wearing the contaminated disposable gown and gave R3 an insulin injection in their abdomen. When exiting the room LPN-A went to the med cart, removed her gloves and sanitized their hands. LPN-A then removed her contaminated disposable gown and hung it on an unlabeled hook on the wall and exited the quarantine unit. - At 9:00 a.m. LPN-A returned to the quarantine unit and took the contaminated disposable gown she had hung on the wall earlier and put it back on. LPN-A then answered R2's call light and removed R2's breakfast tray. Upon exit of the room, LPN-A removed their gloves and sanitized their hands. LPN-A then removed her contaminated disposable gown and hung it back on a hook on the wall and exited the unit. During observation on 11/18/20, at 9:15 a.m. LPN-A and NA-D wore the contaminated disposable gowns, gloves, mask and goggles and entered R6's room. LPN-A and NA-D assisted R6 to sit on the edge of the bed. LPN-A and NA-D assisted R6 to walk across his room using a gait belt with LPN-A and NA-D on each side of R6 assisting them to walk across their room. Upon exiting the room LPN-A and NA-D removed their gloves and sanitized their hands. LPN-A removed her contaminated disposable gown and hung it on hook on wall and went out to break. NA-D continued to wear the same contaminated disposable gown. - At 9:23 a.m. NA-D put on new gloves and answered R2's call light. R2 wanted to go to bed. NA-D assisted R2 to stand and transfer to their bed using a gait belt. Upon exiting the room, NA-D removed their gloves and sanitized their hands. NA-D then removed their contaminated disposable gown and hung it on hook on wall next to LPN-A's contaminated disposable gown. - At 9:30 a.m. LPN-A and NA-D both re-entered the quarantine unit and put on the contaminated disposable gowns they had previously took off and hung up. - At 9:32 a.m. NA-D and LPN-A answered R1's call light and assisted R1 to transfer to the commode using a gait belt with one staff on each side of R1. NA-D was assisting R1 to stand and LPN-A pulled down R1's pants and removed their incontinent brief. NA-D remained in room with R1 and LPN-A exited R1's room. Upon exit LPN-A removed their gloves, sanitized their hands, put new gloves on, and continued to wear the contaminated disposable gown. -At 9:40 a.m. LPN-A went in to R1's room and helped NA-D assist R1 off the commode. LPN-A assisted R1 to stand as NA-D cleaned up R1's peri-area and put on a new brief. LPN-A then removed their gloves, sanitized their hands, took her contaminated disposable gown off, hung it up and exited the unit. NA-D continued to assist in R1's room and upon exit; she disposed of garbage in the dirty utility room, removed their gloves, washed their hands, and put on new gloves and continued to wear the same contaminated disposable gown. NA-D then went to R5's room and shut the door as R5 did not want their cares observed. -At 9:52 a.m. NA-D came out of R5's room and sanitized their hands. NA-D then removed her contaminated disposable gown, hung it on hook on the wall, and exited the quarantine unit. During interview on 11/18/20, at 11:02 a.m. NA-D stated the facility policy was to use the same disposable gown all shift while on the quarantine unit. They would use the same disposable gown between all the residents, even during direct personal cares. When they had to leave the quarantine unit, they would remove the used disposable gown and hang it up to reuse when the staff returned to the quarantine unit. Gloves were changed and hands were sanitized between each resident, but they used the same disposable gown all day. Further, NA-D stated the disposable gown she was wearing was the one she received when she came to work that day and was using the same disposable gown all day, even while providing direct resident care to multiple residents. During interview on 11/18/20, at 11:13 a.m. LPN-A stated on the quarantine unit staff received one disposable gown to use each day and were to use it with all the residents on the quarantine unit. When exiting the unit, they must take the disposable gown off, hang it up, and put it back on again when coming back on the unit. They would get a new disposable gown each day and could change the gown if it became visibly soiled or torn. LPN-A stated she was using the same disposable gown all shift between the residents on the quarantine unit, while providing direct resident care. During interview on 11/18/20, at 12:21 a.m. the DON stated the facility was following the corporate policy for gown use and they are using one disposable gown per day, between residents who reside on the quarantine unit. When staff left the unit they were to hang up the disposable gown. When the staff reentered the unit they were to grab the gown they had hung and continue using it between all the residents on the quarantine unit. They were to dispose of the disposable gown at the end of their shift. The DON stated residents on quarantine unit did not have a [DIAGNOSES REDACTED]. The DON did not take the time to review updated CDC guidance to ensure there were no changes missed in the guidance. The DON relied on the corporate office to update policies and ensure the facilities were knowledgeable to the current guidance. The DON stated using the same contaminated disposable gown throughout the shift on the quarantine unit could spread COVID-19 to all the residents who reside on the quarantine unit. Staff could contaminate themselves when donning and doffing the same contaminated gown multiple times and could potential transfer COVID-19 to the four residents that resided on the well unit. The best practice was to use new gown with each resident encounter when residents were under quarantine. The corporate policy dated 3/23/20, identified; Considerations can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same staff member when interacting with more than one patient to be known to be infected with the same infectious disease when these patients are housed in the same location (example; COVID-19 patients or presumptive positive residing in an isolation cohort). The CDC Strategies for Optimizing the Supply of Isolation Gowns updated 10/9/20, identified the facility could prioritize gown use for those under observation. Gowns should be prioritized for the following activities: During care activities where splashes and sprays are anticipated, which typically includes aerosol generating procedures; During the following high-contact patient care activities that provide opportunities for transfer of pathogens to other patients and staff via the soiled clothing of healthcare providers, such as: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care. Re-use of isolation gowns indicated, The risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. The IJ was removed on 11/19/20, at 3:45 p.m. when the facility implemented actions to reduce/ prevent the spread of COVID-19 within the facility. This was verified by observation, interview and document review. It showed the facility within current guidance with usage of PPE in relationship to quarantine for the observation for COVID-19. The interventions included educating staff on taking a new gown when having direct interactions with resident, placing PPE throughout the quarantine unit to make it accessible along with updating the policy to reflect the current CDC guidance.

Based on observation, interview, and document review, the facility failed to ensure professional standards of practice were followed during medication set-up for 1 of 1 resident (R30) whose [MED] was drawn out of an [MED] pen and into an [MED] syringe for administration. Findings include: During medication administration observation on 2/26/20, at 11:40 a.m., licensed practical nurse (LPN)-B was observed to set-up R30's medications. LPN-B retrieved an [MED] pen from the top drawer of medication cart, inspected the pen, noted there was air in the pen and stated someone must have drawn [MED] out of the pen in order for air to be in there. LPN-B proceeded to clean the rubber seal of the [MED] pen, inserted an [MED] syringe needle into it, and drew the prescribed amount of [MED] into the syringe, and administered the medicaiton to R30. Following the observation, LPN-B stated R30 did not have a vial of [MED] and she though the pen had too much air in it to safely use, therefore she did not use the [MED] pen to inject the medication so she drew up the needed [MED] from the [MED] pen into another syringe. -At 12:28 p.m. the director of nursing (DON) stated the staff had not been directed to draw [MED] from an [MED] pen and into another syringe to be administered to residents. The DON stated [MED] pens were always to be primed prior to use which would remove the air. Package insert from Lilly corporation regarding [MED] [MED] directed to prime the [MED] pen every time it was to be used. The pen must be primed to a stream of [MED] before each injection to make sure the pen is ready to dose. priming removes air that may collect in the needle or the [MED] cartridge during normal use. Policy for [MED] administration using [MED]'s was requested although not provided.

Based on observation, interview, and document review, the facility failed to identify weight fluctuations and assess for signs and symptoms of exacerbation of [MEDICAL CONDITIONS] for 1 of 1 resident (R30) who experienced multiple excessive weight gains and was diagnosed with [REDACTED]. Findings include: R30's significant Change Minimum Data Set ((MDS) dated [DATE], indicated R30's [DIAGNOSES REDACTED]. The MDS further indicated R30 had moderate cognitive impairment and required supervision of eating, extensive assistance of one staff person for locomotion, dressing, and personal hygiene and extensive assistance of two staff persons for all other ADLs. R30's Nutritional Status Care Area Assessment (CAA) dated [DATE], indicated R30 had a high body mass index (BMI), and received a low [MED] diet. The CAA also indicated R30 had difficulty swallowing at times and would cough when eating. R1 was evaluated by speech therapy with a recommendation made for thickened liquids however, R30 opted not to follow the recommendation therefore a regular diet/liquids was ordered. R30 was provided a risk agreement acknowledging the risks of not adhering to the speech therapist recommendation for thickened liquids to ensure safe swallowing. The CAA did not address R30's [MEDICAL CONDITION] or [MEDICAL CONDITION]. R30's Care Plan dated [DATE], indicated R30 had fluid overload related to kidney failure and directed staff to provide diet/fluids as ordered, encourage activities that promoted exercise, encouraged rest periods as needed, and apply size E [MEDICATION NAME] on each leg from toes to knees with overlapping dorsum of feet. However, the care plan did not direct the staff to obtain daily weights nor how to monitor for signs or symptoms of [MEDICAL CONDITION]. R30's physician progress notes [REDACTED]. The physician also indicated R30's [MEDICAL CONDITION] was likely due to [MEDICAL CONDITION] and directed to increase R30's [MEDICATION NAME] (water pill) medication to 40 milligrams (mg) twice a day and to carefully monitor R30's weights and vitals, oral intake/output, lung sounds, and renal function. R30's Hospital Discharge Additional Information form dated 1/3/20, directed the staff to obtain R30's daily weights. Review of R30's clinical record from 1/3/20 to 2/25/20, revealed the following weights: - 1/8/20, 1[AGE] - 1/9/20, 1[AGE] a weight gain of 3 pound (lbs.) - 1/12/20, 178 - 1/13/20, 171 a weight loss of 7 lbs. - 1/15/20, 170 - 1/16/20, 1[AGE] a weight gain of 14 lbs. - 1/17/20, 1[AGE] - 1/18/20, 170 a weight loss of 14 lbs. - [DATE], 174 - 1/24/20, 1[AGE] a weight gain of 3 lbs. - 1/28/20, 174 - 1/29/20, 178 a weight gain of 4 lbs. - 2/3/20, 181 - 2/4/20, 1[AGE] a weight gain of 4 lbs. - 2/4/20, 1[AGE] - 2/5/20, 1[AGE] a weight loss of 8 lbs. R30's progress note (PN) dated 1/8/20, indicated R30 had [MEDICAL CONDITION] and had not voiced concerns regarding her chronic illness. However, the note further indicated R30 had been having issues with retaining fluid, coughing, and it had been harder for her to breathe. The PN did not indicate the healthcare provider had been notified of the increased retention, coughing or breathing concerns. R30's PN dated 1/13/20, indicated R30 was noted to have shortness of breath (SOB) and verbalizing that she felt dizzy. However, the PN did not indicate the healthcare provider had been notified of these symptoms. R30's PN dated 1/13/20, indicated a body skin audit had been conducted for R30. The note further indicated R30's skin was very dry, [MEDICAL CONDITION] was present, and fluid had been fluctuating as [MEDICATION NAME] was decreased due to [DIAGNOSES REDACTED]. The healthcare provider recommended using a dressing to protect R30's skin. However, the note did not indicate R30's lung sounds, breathing or amount of [MEDICAL CONDITION] had been noted. R30's PN dated 1/28/20, indicated R30 continued to have fluids shifts, daily weights were being done related to excess fluids and CKD. R30 continued to scratch herself on all extremities and buttocks related to CKD and [MEDICAL CONDITION]. R30's skin was lotioned frequently, and fluids encouraged. R30 continued to refuse to lay in bed and would only sit in her recliner or wheelchair. The note did not identify R30's lung sounds, breathing or amount of [MEDICAL CONDITION] noted. R30's clinical record lacked PNs related to the weight fluorinations noted on 1/16/20, 1/18/20. 2/4/20, and 2/5/20. On 2/27/20, at 8:53 a.m. the licensed practical nurse (LPN)-B stated R30 was weighed daily and the weight was documented onto the paper Medication Administration Record [REDACTED]. However, LPN-B was unable to state what weight parameters were to be followed regarding as to when to contact R30's provider when a weight gain or loss was noted. -At 9:00 a.m. LPN-A stated R30's daily weights were started on 1/7/20, four days later than the physician had ordered on [DATE]. LPN-B stated R30 had [MEDICAL CONDITION], CKD and her condition varied day to day. Because of this, LPN-B stated the healthcare provider frequently changed R30's medications and nursing had spoken with the nurse practitioner every day. However, LPN-B confirmed nursing would only document this communication if the health care provider had made a change to R30's medication orders, and would not document R30's condition such as lung sounds or level of [MEDICAL CONDITION]. LPN-B further stated R30 could have a 10 pound weight loss or gain in a less than a week or 14 pounds overnight, but again repeated no note would be entered unless the healthcare provider had made medication changes. On 2/27/20, 10:11 a.m. R30 was observed in the dining room, seated at a table. R30 was wearing [MEDICATION NAME] to both legs and also slipper socks. LPN-B stated the [MEDICAL CONDITION] was minimal per R30's norm. - At 10:52 a.m. R30 stated she felt fine, but was tired. R30 denied feeling SOB and was not observed to have a cough. On 2/27/20, at 11:16 a.m. the director of nursing (DON) stated nursing was aware to monitor for signs and symptoms of [MEDICAL CONDITION] and fluid overload, and R30's healthcare provider had not provided parameters for when to be notified of R30's weight changes. The DON verified nursing should have requested daily weight parameters and stated nursing was expected to document actions taken when R30's weights had significantly fluctuated. On 2/27/20, at 1:10 p.m. the Physician Assistant (PA) stated R30's daily weight order was given upon discharge on 1/3/20 from the hospital. However, the PA stated she would have expected nursing to notify her whenever R30 had a weight loss or gain of 2 pounds as it could indicated an exacerbation or complication of [MEDICAL CONDITION] which may lead to an adjustment of medications to prevent hospitalization . However, the PA stated she had evaluated R30 earlier in the week and felt R30's condition had improved and her [MEDICAL CONDITION] was stable at that time. The facility policy titled Weight All Scales revised 11/02, directed staff to weight residents monthly, at time of admission, and as per doctor order.

Based on interview and document review, the facility failed to ensure resident resuscitation wishes were correctly identified in the electronic health record (EHR) based on signed advanced directives for 2 of 16 residents (R22, R1) reviewed for advanced directive. Findings include: R22's EHR Admission Record dated [DATE], indicated R22's advance directive was to resuscitate (CPR-cardiopulmonary resuscitation) or Full Code. However, R22's signed Directives to Define Scope of Medical Care dated [DATE], indicated in the event of acute or impending respiratory arrest, no CPR shall be initiated or endotracheal to provide sustained assisted ventilation shall be provided to R22. There was no code status sticker note on the outside of R22's chart. On [DATE], at 7:09 a.m. licensed practical nurse (LPN)-A stated in the event of an emergency, he would refer to his report sheet to check the code status of an individual resident. LPN-A confirmed the report sheet indicated R22 had a DNR status indicated and the EHR indicated R22 had a Full Code status entered. LPN-A could not locate R22's signed physician order [REDACTED]. On [DATE], at 8:54 a.m. the director of nursing (DON) stated R22 had physician orders [REDACTED]. The DON stated in the event of an emergency, she would have expected the staff to refer to the code status sticker located on the outside of the chart or the report sheet. The Advanced Care Planning and Provider Orders for Life Sustaining Treatment (POLST) policy dated ,[DATE], indicated a signed physician order [REDACTED]. The CPR (cardio [MEDICAL CONDITION] resuscitation) policy dated ,[DATE], indicated if a resident experiences [MEDICAL CONDITION], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -in accordance with the resident's advance directives -in the absence of advanced directives or a DNR order The facility follows the resident/family/guardian's wishes or intentions as directed on the POLST document. R1's Directives to Define Scope of Medical Care form dated [DATE], indicated R1's son chose DNR/DNI. This directed staff that in the event of acute or impending respiratory arrest, no resuscitation or sustained ventilation would be initiated. R1's EHR Admission Record dated [DATE], did not identify a code status. The facility nurse report sheet undated, indicated R1 was a full code which directed staff to initiate resuscitation and ventilation. R1's Physician order [REDACTED]. R1's Care Plan last reviewed [DATE], indicated R1 was DNR/DNI. On [DATE], at 7:10 a.m. LPN-A stated in the event of a resident emergency, he would refer to his report sheet for the resident's code status. LPN-A verified the nurse report sheet indicated R1 was a full code and that R1's code status had not been entered into R1's electronic health record. LPN-A further verified R1's paper record indicated R1 was DNR/DNI. At that time, the DON interrupted and stated that's a problem. The DON verified if R1 had an emergency and the nurse referred to the report sheet for R1's code status, the nurse would begin CPR. However, the DON stated once the error was identified, the nurse would stop CPR because the resident had chosen to be DNR/DNI and performing CPR would have been against R1's wishes. The DON stated if the resident was resuscitated during that time, we would pray they forgave us. On [DATE], at 11:12 a.m. the DON stated the Directives to Define Scope of Medical Care form was reviewed when a new code status order was received and quarterly during the resident care conference. The DON further stated nursing staff were expected to always check the resident paper chart prior to initiating CPR.

Based on observation, interview and document review, the facility failed to ensure interventions were implemented to reduce the fall risk for 3 of 3 residents (R22, R1, R30) reviewed for accidents. Finding include: R22's admission Minimum Data Set ((MDS) dated [DATE], indicated R22's cognition was moderately impaired and R22 required extensive assistance with all activities of daily living (ADL's) including transferring. R22's Care Plan dated 2/4/20, indicated R22 had limited physical mobility due to [MEDICAL CONDITION] and required two staff members with all transfers. If unable to transfer with two attempts, use sit to stand mechanical lift. The Nursing Assistant Care Plan dated 2/18/20, indicated staff to use a transfer belt for assisting with transfer and ambulation. On 2/26/20, at 8:12 a.m. R22 was observed in bed as nursing assistant (NA)-A and NA-B were providing morning cares. Following the care, NA-A assisted R22 to a sitting position on the side of the bed and a wheelchair was positioned next to bed. While pulling on the back of R22's pants, NA-A and NA-B assisted R22 to stand and pivot into the wheelchair. A gait belt was observed to be hanging on the inside of the room door and was not used during the transfer. -At 11:33 a.m. licensed practical nurse (LPN)-C stated if a resident required extensive assistance for transfers, a gait belt was expected to be used by staff. -At 11:40 a.m. NA-B verified a gait belt was not used for R22's transfer and it should have been. -At 12:34 p.m. the director of nursing (DON) confirmed R22 was to be transferred with two staff and she would expect a gait belt to be used. R1's admission MDS dated [DATE], indicated R1 had moderate cognitive impairment and required assist of 1-2 staff persons for all ADLs. R1's Care Plan last reviewed [DATE], indicated R1 had limited physical mobility and was at risk for falls due to weakness. The Care Plan also indicated required AO1 for all transfers. On 2/26/20, at 9:07 a.m. NA-A was observed while she assisted R1 to the toilet. NA-A proceeded to assist R1 to stand by pulling up on the back of R1's pants and transferred R1 onto the toilet. A transfer belt was not used. R1 was able to bear weight during the transfer, however, required the use of the safety bar for balance. - At 9:14 a.m. R1's personal hygiene was completed and NA-A proceeded to assist R1 to stand up from the toilet. NA-A again pulled up on the back of R1's pants and transferred R1 back into the wheelchair. A transfer belt had not been applied. When asked, NA-A stated the staff only needed to use the transfer belts on some people who had trouble standing and R1 could stand right up therefore R1 did not need a transfer belt applied. On 2/27/20, at 11:12 a.m. the DON verified staff were expected to use a transfer belt on all residents to prevent falls and injuries. R30's Significant Change MDS dated [DATE], indicated R30 had a moderate cognitive impairment and required extensive assist of two staff for transfers. R30's Care Plan dated [DATE], directed staff to provide assist of one for transfers. On 2/26/20, at 8:52 a.m. NA-B was observed to assist R30 to stand from her wheelchair by pulling up on the back of R30's pants. Once standing, and holding onto the back of R30's pants, NA-B gave R30 verbal cues to pivot and position in front of recliner but R30 did not lift either foot and did not pivot. - 8:55 a.m. R30 continued to stand in place as NA-B continued to provide verbal cues to pivot turn. However, R30 complained of feeling weak and was unable to perform the task. At that time, NA-B requested assistance from another staff person via the walkie talkie and positioned her foot in front of R30's feet and stated it was to prevent R30's feet from sliding. - 8:57 a.m. LPN-C entered R30's room at which time NA-B asked LPN-C to obtain a transfer belt. LPN-C obtained the belt from a hook on the wall near the door of the room. LPN-C instructed NA-B to lower R30's recliner and proceeded to assist NA-B to seat R30 into the chair. - 9:00 a.m. NA-B and LPN-C both stated R30 did not normally need a transfer belt as R30 normally could just transfer. NA-B stated R30 was weaker this morning and required the transfer belt and more assistance. On 2/27/20, at 11:16 a.m. the DON confirmed R30's Care Plan directed staff to provide assist of one for transfers and R30's MDS stated extensive assist of two. The DON further stated the nursing assistant care sheet stated assist of 1-2, but then stated 1-2 did not correspond to facility policy to promote safety. At that time, the DON stated she would update R30's Care Plan and the nursing assistant care sheet to indicate R30 required assist of two staff. In addition, the DON verified a transfer belt should have been utilized per facility policy. Transfer Belt policy/procedure dated 11/2002, indicated to provide a method of safely assisting and stabilizing residents during movement transfer belts will be used for standing pivot transfers.

Based on observation, interview and document review, the facility failed to provide range of motion (ROM) services in order to maintain and/or prevent further decline in ROM abilities for 4 of 5 residents (R16, R20, R29, R9) reviewed who had limitations in ROM and had not received ROM services according to their individualized assessed need. Findings include: R16's annual Minimum Data Set ((MDS) dated [DATE], indicated R16 had moderate cognitive impairment, was independent with bed mobility and transfer, required limited assistance to ambulate and had no functional limitations in upper or lower extremities. R16's Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/30/18, indicated R16 required supervision/assistance with some ADL's. R18 had arthritic hands and fingers were stiff/sore. R16's [DIAGNOSES REDACTED]. R16's Care Plan reviewed 12/4/18, indicated R16 had limited physical mobility related to history of falls with a goal that R16 would remain free of complications to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review period. The interventions included functional maintenance nursing program 3 x per week. Nursing rehab was to perform biodex: (seat level 12, resistance 1) x 10 minutes and arms: green band active range of motion (AROM) for arms/shoulder. Do 10x each and a total of 3 sets. R16's Nursing Assistant Care Plan directed staff to provide restorative services 3-5x per week. R16's monthly Task documentation forms revealed R16 received nursing rehab as follows: November (YEAR): 0 times out of 13 opportunities December (YEAR): 0 times out of 13 opportunities January (1st - 24th) 2019: 1 time out of 9 opportunities R20's quarterly MDS dated [DATE], indicated R20 had moderate cognitive impairment, required extensive assistance with most ADL's, and had no functional limitations in upper or lower extremities. R20's ADL Functional/Rehabilitation Potential CAA dated 6/27/18, indicated R20 had weakness and disorientation that impacted ability to care for herself and staff provided assistance to complete ADL's. R20's [DIAGNOSES REDACTED]. R20's Care Plan reviewed 12/21/18, indicated R20 had an ADL self care deficient/limited physical mobility and was a fall risk related to weakness status [REDACTED]. The care plan directed nursing rehab to provide AROM to legs- seated bilateral leg exercise with 2# and green Thera-band / 10 reps x 2 sets and AROM to arms with pulley for 1-2 minutes, using yellow Thera-band 10 times x 2, and 1# free weight - bilateral chest press 10 times and repeat x 3. These exercises were scheduled to be completed 3 x per week. R20's Nursing Assistant Care Plan directed staff to provide restorative services 3 x per week. R20's monthly Task documentation forms revealed R20 had received restorative services as follows: November (YEAR): Arms/Legs: 4 times out of 12 opportunities December (YEAR): Arms/Legs: - 5 times out of 13 opportunities January (1st - 24th 2019): Arms/Legs: 3 times out of 11 opportunities R29's annual MDS dated [DATE], indicated that R29 required extensive assistance with all ADL's and there was no identified impairment of upper or lower extremities. R29's Falls CAA dated 1/7/19, indicated R29 was at risk for falls and has a history of falls. Staff to assist with all transfers and functional maintenance is provided 3 x per week with staff. R29's Care Plan dated 1/14/19, indicated R29 had limited physical mobility related to history of being found on floor, weakness, incontinence, cognitive status and impulsiveness. Nursing rehab was directed to provide passive ROM to arms, fingers, feet and legs with cares. R29's Nursing Assistant Care Plan directed staff to provide restorative services 3 x per week. R29's monthly Task documentation forms indicated the staff were to provide PROM to the arms and legs 3 x per week. The forms revealed restorative services had been provided as follows: November (YEAR): 2 times out of 12 opportunities December (YEAR): 2 times out of 13 opportunities January (1st - 24th 2019): 4 times out of 10 opportunities R29's monthly Task documentation also indicated PROM to the arms/fingers/feet/legs daily with cares was to be provided starting 1/14/19. However, the forms revealed the service was provided two times out of nine opportunities during the period of (MONTH) 15th - 24th 2019. On 1/24/19, at 10:58 a.m. nursing assistant (NA)-C stated restorative services had very much changed since the restorative aide position was eliminated last spring. NA-C stated now the staff assigned to provide daily cares to each resident, was responsible to provide the restorative services for those residents which was probably never being provided. NA-C indicated that the other NA's do not want to do the exercises because they do not know how to provide them. The staff felt they had not been trained properly and the only training available was the on-line computer training, not hands on training. NA-C stated the residents ROM abilities are declining terribly. NA-C stated the staff had never been directed to inform the nurse if a resident refused restorative exercise. NA-C also stated the list of residents who required restorative services has become shorter since the director of nursing (DON) would just take the residents off the list if they refused. -At 11:13 a.m. NA-A stated she has not received training on how to perform the restorative programs rather, the staff are expected to follow the directions which are on papers hanging in the exercise room in order to provide the exercises. NA-A stated the residents were lucky if they received restorative services once per week as there was usually not enough time to complete with only two aides working. On 1/25/19 at 8:24 a.m. registered nurse (RN)-A stated the NA's should be performing restorative exercises with cares. -At 8:31 a.m. the DON stated staff received training for restorative services by computer, face to face and there were also many posters to view. The DON confirmed the residents' restorative documentation did not reflect restorative services having been provided as recommended and verified if the documentation was blank the task did not occur. The DON provided the Restorative Nursing Policy and Procedure which indicated a purpose to provide a mechanism to assure that those residents requiring restorative nursing care would receive services in a timely manner. The policy/procedure indicated that therapists would train restorative nursing staff on context of Restorative Care Program. The DON stated the policy needed to be updated since there was no longer a designated restorative staff person and the documentation was now in point click care and not in a binder as the procedure reflected. R9's annual MDS dated [DATE], indicated R9 was cognitively intact and had [DIAGNOSES REDACTED]. contract uncontrollably). The MDS indicated R9 required limited to extensive assist of one for all activities of daily living, was able to ambulate with assist of one and was independent with operation of an electric scooter. The MDS also indicated R9 had limited ROM of the left upper extremity and chronic pain. R9's ADL Functional/Rehabilitation potential CAA dated 1/11/19, indicated R9's goal was to continue at his current level of assistance. R9 had spasmodic [DIAGNOSES REDACTED] (a condition in which the neck muscles cause the head to turn or rotate to the side) and [DIAGNOSES REDACTED]. The CAA indicated R9 required extensive assist of one staff for most ADLs, R9 asked for assistance as needed. The CAA also indicated R9 walked and exercised with staff for the functional maintenance program, as he was able. R9's Care Plan dated 1/17/19, indicated R9 had limited physical mobility and directed staff to assist R9 to ambulate 120 feet with a front wheeled walker, use the biostep bicycle for 10 minutes and to obtain a physical therapy (PT)/occupational therapy (OT) evaluation and treat as per medical practitioners orders. R9's most recent OT evaluation dated 6/28/18, directed staff to provide R9 with AAROM, PROM, and the biostep bicycle for 10 minutes 6-7 times per week. The staff were directed to: - Legs (Tuesday, Thursday and Saturday): 1. While sitting: hip flex with 3 pound weight, knee extension with 3 pound weight, hip abduction and knee flexion with green band. Bilateral heel cords and hamstring stretches for 30 seconds, do twice for each. 2. Bike (Monday, Wednesday and Friday): biostep bicycle (seat level 3, resistance level 1) for 10 minutes. 3. Walk daily/twice a day if R9 agreed as able with front wheeled walker. - Arms (every day): 4. Right shoulder flexion to extension, abduction, internal and external rotation. Hold count of 10, rest 5 seconds, repeat for 10 reps. 5. Left arm: supination/pronation, wrist flex/extend, finger flexion/extension. Hold count of 10, rest 5 seconds, repeat for 10 reps. 6. Stretching = long arm hang: Right with 4 pound weight, left with 3 pound weight (each for 20-30 seconds per R9's comfort, do not do at the same time). 7. Strengthening: 2 pound weight right elbow flexion/extension, supination/pronation, wrist flex/extend 10 reps twice. 1 pound weight left arm supination/pronation, wrist flex/extend 10 reps twice. R9's Documentation Survey Report dated 1/25/19, indicated R9 received restorative nursing services as follows: -January 2019: R9 used the biostep bicycle one time out of 24 opportunities. R9 ambulated three times out of the 24-48 opportunities. R9 refused to ambulate once. However, the report lacked documentation of AAROM and/or PROM. -December (YEAR): R9 used the biostep bicycle once out of the 31 opportunities. R9 ambulated 7 times out of 31-62 opportunities. The document also indicated R9 refused to use the biostep bicycle once and refused to ambulate 5 times. However, the report lacked documentation of AAROM and/or PROM. -November (YEAR): R9 used the biostep bicycle once out of the 30 opportunities. R9 ambulated 10 times out of the 30-60 opportunities. The document also indicated R9 refused to use the biostep bicycle 4 times and refused to ambulate once. However, the report lacked documentation of AAROM or PROM. -October (YEAR): R9 used the biostep bicycle 4 times out of the 31 opportunities, AAROM was completed 8 times out of the 31 opportunities, and PROM was completed 11 times out of the 31 opportunities. The document also indicated R9 refused ROM twice. On 1/22/19, at 4:48 p.m. R9 was observed seated in his electric chair. R9 stated he should have been receiving exercises daily, but they were only occasionally provided. On 1/23/19, at 2:57 p.m. NA-F stated he did not know if the facility had a restorative program, but some of the nursing assistants did ROM exercises while providing daily cares. When asked what the ROM exercises entailed, NA-F stated to speak with the director of nursing. On 1/23/19, at 3:05 p.m. licensed practical nurse (LPN)-A confirmed the facility did have a restorative program and the nursing assistants would do this during off times, but exercises were not completed during daily cares. On 1/24/19, at 10:59 a.m. NA-C confirmed all nursing assistants were responsible for providing the restorative nursing program and instructions for the identified residents were on the wall in the exercise room. NA-C stated the exercises could be completed anywhere, but most of the nursing assistants needed the directions to perform the tasks. NA-C verified R9 had a decline in ROM and was scheduled for his restorative services seven days a week with three of those days being the whole program, which took approximately one hour to complete. NA-C further stated the nursing assistants were to document in the electronic medical record what R9 was able to do and for how long. On 1/24/19, at 11:13 a.m. NA-A stated the residents had not received restorative services as ordered, rather, maybe received it once a week. On 1/24/19, at 3:15 p.m. registered nurse (RN)-B confirmed R9 should have received ROM through the restorative program and further stated R9's program was pretty extensive. RN-B confirmed there was a list in the exercise room that directed the nursing assistants which residents had a restorative program and what the program entailed. RN-B stated R9's ROM had greatly worsened over the last year, but R9's neurologist had stated it was a progression of his disease. On 1/25/19, at 823 a.m. NA-E was observed to assist R9 to dress for breakfast. NA-E put R9's very loose T-shirt over R9's head, stretched the shirt out in order to allow R9 to slip his hands into the sleeve pockets without raising his arms. Once the shirt was on, R9 independently stood up while NA-E pulled up R9's pants. NA-E stated she had worked at the facility for three years and confirmed she had not assisted any resident with ROM exercises during daily cares, but would assist R9 to perform his restorative program later in the day, when R9 wanted to. At 8:35 a.m., R9 stated he was unable to do his exercises at that time due to increased pain and wanted to attempt later. On 1/25/19, at 11:28 a.m. the DON confirmed R9's restorative nursing program had not been completed as expected. The DON further confirmed R9 had chronic pain and occasionally refused to perform his restorative exercises however, the DON confirmed she would have expected staff to document such refusals and report to the nurse. The DON stated a new occupational therapy evaluation would be requested and his restorative program evaluated.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R5) was provided the necessary social services to ensure individualized needs were met for identified mental health needs, issues with non-compliance with necessary care and services, and increased inappropriate behavior symptoms. R5 experienced actual psychosocial harm related to the ongoing worry of being displaced from her home, a decline in physical functioning, and the onset of increased mood and behavioral problems that had not been systematically addressed by the facility. Findings include: R5's cumulative [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 had no cognitive or memory deficits, R5 had inappropriate behavior symptoms identified as inattention (trouble focusing attention, being easily distractible, or had difficulty keeping track of what was being said). The MDS also indicated R5 had the following mood symptoms present 2-6 days a week: feeling down, depressed, or hopeless, feeling tired or having to little energy, and feeling bad about self-or that you are a failure or have let yourself or a family member down. The MDS indicated R5 did not have any symptoms of psychosis (hallucinations or delusions), however, R5 did have verbal behavior symptoms directed at others (threatening others, screaming or cursing at others) 1-3 days a week. The MDS indicated R5 required extensive assistance of two persons for bed mobility and toilet use, and required extensive assistance of one person for dressing, personal hygiene and locomotion on and off the unit using a wheelchair. R5 was unable to ambulate, and was totally dependent on two staff during transfers. R5 was interviewed on 10/17/17, at 2:00 p.m. and stated she was extremely upset because the director of nursing (DON) had told her the previous week that she had one month to drastically improve her behavior or else she would be discharged to a facility over 300 miles south from where she was currently living in the nursing home. R5 began to cry and stated the facility had tried sending her to a nut house last week and would not allow her to come back to the facility. R5 stated she had been sent to the emergency room at(NAME)Medical Center in Fargo, ND from dialysis, and because the nursing home refused to allow R5 to come back to the nursing home, she ended up going all the way to a hospital in Rochester Minnesota (322 miles). R5 stated a social worker from the hospital in Rochester had called the DON at Karlstad Healthcare Center and made the nursing home allow R5 to come back to the facility. R5 stated she was frustrated, anxious, and felt panicked that she may be discharged from the facility if her behavior did not improve in the next 30 days. R5 continued crying throughout the interview and stated, I make a big goof of myself like a retard so people laugh at me, instead being mad at me. R5 explained she had increased anxiety throughout every day and cried daily with worry that she would become homeless or have to leave to another facility since being told by the DON she had to drastically improve her behavior in order to stay in the facility. R5 stated that since returning to the facility she had felt isolated because facility staff no longer seemed to want to talk with her or visit. When R5 was asked what type of behavior needed to improve over the next 30 days, R5 stated she had been screaming loudly when she needed something or needed assistance. When R5 was asked why she screamed loudly, she stated she screamed because she was anxious and frustrated and could get assistance in a timelier manner. Registered nurse (RN)-A was interviewed on 10/18/17, at 8:35 a.m. and stated R5 screamed many times a day, if it was a bad day. RN-A stated she could not quantify how many times R5 screamed every day because the facility had not tracked how often the behavior occurred or the antecedent to the behavior. RN-A stated R5 screamed loudly when she wanted something immediately, and had anxiety about not getting care and assistance timely. The DON was interviewed on 10/19/17, at 10:14 a.m. during which she stated the reason R5 was told she had 30 days to change her behavior in order to keep living at Karlstad Healthcare Center was because the transport company which transported R5 to dialysis three times a week had verbally notified the facility that they would no longer transport R5 due to behavior of yelling, screaming, and making false allegations of the driver's driving ability, behavior, and conduct. The DON stated because there was only one transport company available in the Karlstad area the facility had no choice but to attempt to find R5 a different nursing home to live at where R5 had transportation to dialysis. When the DON was asked to provide evidence the transportation service had refused ongoing transportation services to R5, the DON stated the transport company had not provided any documentation which identified R5 was denied transportation services. R5's medical record included a document identified as Order Appointing Guardian dated and signed by a judge on 5/26/16, which indicated R5 was incapacitated from mental impairment to the extent lacking sufficient understanding or capacity to make or communicate responsible decisions concerning personal needs for medical care, nutrition, clothing, shelter or safety. The judge appointed R5 two guardians. The progress notes for R5 were reviewed from 10/1/17 - 10/18/17, during which the following was learned regarding R5's transportation issues, emergency room visits, and hospitalization s: -On 10/4/17, R5 returned to the facility via R&L transport service and stated the transport driver tried to kill her. The progress note indicated R5 was too upset to eat supper, and wanted to report the van driver to the owner of the transport service because R5 indicated the van driver had driven onto the shoulder of the road for many feet. -On 10/5/17, R&L transport reported to the nursing home staff that R5's behavior was escalating and R&L doesn't know how long they could continue to transport R5 to dialysis. -On 10/6/17, R5 was sent to the emergency room at(NAME)Fargo, ND after having dialysis at(NAME)Thief River Falls, MN. R5 was evaluated in the emergency room and was not admitted for inpatient stay. The emergency room at(NAME)Fargo, ND attempted to discharge R5 back to Karlstad Healthcare Center, however, they refused to allow R5 back into the facility. -On 10/8/17, R5 was sent to the emergency room at Mayo Medical Center for psychiatric evaluation. -On 10/9/17, R&L transport refused to provide any further transportation services. -On 10/9/17, indicated the DON refused to allow R5 to return to the facility because R&L transportation refused to provide further transport to dialysis. -On 10/11/17, indicated the licensed social worker (LSW) at the Mayo Medical Center contacted R5's insurance provider to assist with dialysis transportation needs for R5. R5's insurance provider got R&L to agree to provide transport services for the month of October. -On 10/12/17, indicated R5 finally returned back to Karlstad Healthcare Center on 10/12/17, at 5:30 p.m. (six days after R5 had initially went to the(NAME)Fargo, ND ER for evaluation). Review of R5's behavior progress notes from 4/1/17, through 8/24/17, revealed three behavior progress notes had been documented on dated 4/1/17, and 5/9/17, and 8/24/17 which indicated R5 had inappropriate screaming behavior. A General progress note dated 8/7/17, indicated, Behaviors are not a problem right now. However, the behavior progress note dated 8/24/17, indicated R5 had had an increase in behaviors over the past month which included hollering, screaming, and demanding staff to clean her glasses 15-20 times per shift, requesting oxygen tubing re-arranged 10-15 times per shift, and wanting wheelchair adjusted 1-2 millimeters (mm) to the right or left 10-20 times per shift. The behavior progress note identified possible causal factors included declining physical health. Interventions identified included staff attempt to meet needs as quickly as possible. From 8/24/17 - 10/16/17, there were seven behavior progress notes which identified R5 had increased inappropriate behaviors which included screaming, yelling, and demanding repetitive assistance with cares. Despite the aforementioned increase in behavioral progress notes that identified R5 had increased inappropriate behaviors, there was no evidence R5 had been comprehensively assessed to determine causal factors for the increased behaviors, and interventions to minimize ongoing inappropriate behaviors had not been developed or implemented. R5 was observed on 10/17/17, from 1:15 p.m. to 4:00 p.m., 10/18/17, from 7:00 a.m. to 9:30 p.m., 10/19/17, from 8:30 a.m. to 3:30 p.m. and again on 10/20/17, from 8:30 a.m.-9:30 a.m. during which R5 was not heard yelling, screaming, or cursing. It was noted when R5 was observed being dropped off by R&L transportation on 10/17/17, at 1:15 p.m. R5 gave the van driver a hug and expressed words of thanks for the transportation provided. The van driver returned the hug to R5 and told R5 he would be at the facility the following day for transport to dialysis. Review of the Mayo Clinic Medicine 9 Hospital dismissal summary dated 10/12/17, indicated R5 was assessed in the emergency department and was found not in need of hospital admission for psychiatric services because R5's outbursts were more behaviorally based. The dismissal summary indicated the Karlstad Healthcare Center would not agree to accept R5 back into the facility, therefore R5 had to be admitted to the hospital so that she could receive dialysis treatments. The dismissal summary indicated while in the hospital, psychiatry was consulted and a behavior plan was employed to outline expected respectful behaviors and R5 did very well with this. R5's care plan dated 10/13/17, indicated the following: R5's [DIAGNOSES REDACTED]. R5 has no cognitive impairment. Care planned interventions included the following: -Administer medications as ordered. Observe/document for side effects and effectiveness. Alert medical practitioner to side effects or ineffectiveness of medication. Pharmacy review monthly or as needed. No medications are to be sent with R5 when out of building for appointments. -Allow opportunity for R5 to express her feelings/concerns. -Remove from common areas and leave in safe manner and explain you will return when unable to redirect. -R5 needs as much encouragement, assistance, and support to maintain as much independence and control over her environment as possible. -Crying: interventions included diversion with talking about church/hymns, country music and 1:1 visits. -Verbal Aggression: interventions included remove from common areas, leave in a safe manner and explain you will return when unable to redirect. Invite to activities of choice. Offer to escort her to activities, if desired. Non-pharmacological interventions included to leave alone in safe environment and reapproach, remove from common areas, discuss hymn or country music, offer coloring books, take outside weather permitting, spiritual support. -Observe/document/report to Nurse/MD signs and symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. -Observe/record target behaviors/symptoms and document per facility protocol. Two staff at all times when doing any personal cares with R5. Staff may go in alone to answer call light but if personal cares are needed wait till another staff is there to assist. The care plan dated 10/13/17, failed to identify R5's screaming/yelling behavior or behavior of repeatedly asking for assistance with tasks that had already been recently completed (i.e. washing glasses, adjusting fan, putting on the call light repeatedly and when answered denying that she had put it on). The care plan had not included any therapeutic conversation interventions with the licensed social worker (LSW) to work through inappropriate behavior symptoms and the frequency of those LSW services would be offered in an attempt to calm R5's anxiety and frustration before behavior escalated to repeatedly yelling and screaming. R5's care plan had not identified the issues with R&L transportation providing transport for R5 only on a trial basis for the month of October due to R5's inappropriate behavior during transport. The care plan did not identify behavioral interventions developed to assist R5 with being successful with maintaining appropriate behavior during transportation to and from dialysis. Additionally, the behavioral plan used while at Mayo Medical Center and found to be successful while R5 was hospitalized there, was not added to R5's nursing home care plan, nor were the behavioral interventions implemented. On 10/18/17 at 8:43 a.m. the facility LSW was interviewed and asked if she had any residents in the facility that had high psychosocial needs, and also had a care plan developed with appropriate interventions and goals which addressed mood and behavior symptoms. The LSW stated she did not have any residents with high psychosocial needs with mood and inappropriate behavior symptom's. The LSW confirmed R5's mood and behavior symptom's had not been comprehensively assessed and care plan interventions and goals to address the mood symptom's and inappropriate behavior had not been developed or implemented. The LSW indicated she was not aware a successful behavioral plan had been developed for R5 while hospitalized at Mayo Medical Center. The LSW confirmed the behavioral plan developed by Mayo Medical Center had not been implemented after R5 returned to Karlstad Healthcare Center 10/12/17.

Based on observation, interview, and document review, the facility failed to ensure [MEDICAL TREATMENT] fluid restriction was monitored to minimize hospitalization s for fluid overload for 1 of 1 resident (R5) reviewed for [MEDICAL TREATMENT]. Actual harm occurred as a result of the facility's lack of monitoring R5's fluid intake despite repeated hospitalization s for fluid overload. In addition, based on observation, interview, and document review the facility failed to identify and monitor impaired skin integrity for 1 of 1 resident (R37) observed who was at risk for developing serious complications from impaired skin integrity. Findings include: R5's cumulative [DIAGNOSES REDACTED]. R5's medical record included a document identified as Order Appointing Guardian dated and signed by a judge on 5/26/16, which indicated R5 was incapacitated from mental impairment to the extent lacking sufficient understanding or capacity to make or communicate responsible decisions concerning personal needs for medical care, nutrition, clothing, shelter or safety. The judge appointed R5 two guardians. R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 had no cognitive or memory deficits, R5 had inappropriate behavior symptoms identified as inattention (trouble focusing attention, being easily distractible, or had difficulty keeping track of what was being said). The MDS also indicated R5 had the following mood symptoms present 2-6 days a week: Feeling down, depressed, or hopeless, feeling tired or having to little energy, and feeling bad about self-or that you are a failure or have let yourself or a family member down. The MDS indicated R5 did not have any symptoms of [MEDICAL CONDITION] (hallucinations or delusions), however, R5 did have verbal behavior symptoms directed at others (threatening others, screaming or cursing at others) 1-3 days a week. The MDS indicated R5 required extensive assistance of two persons for bed mobility and toilet use, and required extensive assistance of one person for dressing, personal hygiene and locomotion on and off the unit using a wheelchair. R5 was unable to ambulate, and was totally dependent on two staff during transfers. On 10/20/17, at 9:22 a.m. R5 was observed at the end of the breakfast meal and was noted to have four cups of fluid each which held 240 cubic centimeters (cc) per cup for a total of 960 cc of fluid on her breakfast tray. R5 drank all of the fluids provided. R5 stated the facility did not serve her the correct amount of fluids according to her [MEDICAL TREATMENT] diet. R5 stated she herself tracked how much fluid she consumed each day and showed the surveyor a notebook with numbers written down for each day. However, there were no totals which identified how much fluid was consumed in a day and many of the days did not look complete. R5 also stated the fluid calculation was not correct and she did not know if her fluid restriction was 32 or 36 ounces per day. R5 stated the [MEDICAL TREATMENT] unit had not even looked at her personal fluid intake log because they did not believe her recordings. R5 stated she was trying to do better with fluid management because she did not want to keep going into the hospital for fluid overload. Review of R5's undated physician orders [REDACTED]. Review of R5's care plan for [MEDICAL TREATMENT] last revised on 10/13/17, revealed no fluid restriction was identified, and the care plan stated R5 monitors her own fluid restrictions. The care plan directed total intake to be distributed between dietary and nursing and to document non-compliance. The care plan had not identified a plan for how many cc's of fluid was to be allotted for each meal and medication pass and R5's noncompliance with fluid restrictions. The care plan had not included interventions to minimize fluid consumption like offering ice chips instead of water, offering a popsicle rather than juice, offering hard candy or lemon drops for symptoms of dry mouth. Further review of R5's medical record revealed intake monitoring and R5's fluid balance had not been documented and monitored. Licensed practical nurse (LPN)-A was interviewed on 10/20/17, 9:50 a.m. and stated R5's fluid intake was not monitored by the facility, and there was no way to tell where R5 was in regards to fluid balance. On 10/20/17, at 9:59 a.m. the [MEDICAL TREATMENT] registered nurse manager was interviewed regarding R5's fluid intake and monitoring. The [MEDICAL TREATMENT] nurse manager stated R5's fluid restriction was 1000 cc of fluid daily, and R5 was fluid overloaded. The [MEDICAL TREATMENT] nurse stated R5 was 8-12 kilograms over her dry weight, and was gaining large amounts of fluids between [MEDICAL TREATMENT] treatments (3-5 kg). The [MEDICAL TREATMENT] nurse stated she expected the facility to record and monitor R5's fluid intake so when R5 got close to daily total of fluid intake, R5 could be educated regarding the risks and benefits of non-compliance with fluid restrictions, and make choices after being provided the education. The [MEDICAL TREATMENT] nurse stated R5 could be non-compliant with the fluid restriction, however, in the last month R5 had been really trying to decrease fluid intake amounts. The [MEDICAL TREATMENT] registered nurse manager stated R5 had been hospitalized at least twice in the previous 6 months for fluid volume overload on 6/24/17, and 9/6/17. Review of R5's hospitalization records revealed R5 had been hospitalized with fluid overload twice in the last six months on 6/24/17, and 9/6/17. The Altru hospital dismissal summary dated 9/8/17, indicated R5 was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. The dismissal summary indicated R5 had not been compliant with fluid intake restrictions, and required hospitalization where daily [MEDICAL TREATMENT] runs were implemented to remove the excess fluid. The dismissal summary indicated R5 had also been hospitalized on R5 discharged from Altru hospital on [DATE]. The hospitalization records for R5's hospitalization [DATE]- 6/28/17, were requested from the facility but not provided. Review of R5's [MEDICAL TREATMENT] run sheets from 10/1/17 - 10/16/17, revealed R5 was routinely 5-10 kg (11-22 pounds) over her target weight (dry weight), and had not reached her dry weight goal during any [MEDICAL TREATMENT] treatments in October 2017. The director of nursing (DON) was interviewed on 10/20/17, at 10:32 a.m. regarding R5's fluid restrictions during which she confirmed the facility was still not monitoring her fluid intake despite the fact R5 had been hospitalized for [REDACTED]. The DON stated R5 was non-compliant with fluid restrictions, however, she wanted to monitor her own fluid restrictions and intake. The DON confirmed a judge appointed R5 a guardian because R5 was incapacitated from mental impairment to the extent lacking sufficient understanding or capacity to make or communicate responsible decisions concerning personal needs for medical care, nutrition, clothing, shelter or safety. In addition, The DON did not respond when asked if R5 had the mental capacity to make responsible and reasonable decisions concerning medical care. R37 was at risk for impaired skin integrity complication and the facility failed to identify, report, and treat a current wound. R37's [DIAGNOSES REDACTED]. R37's quarterly MDS dated [DATE], indicated R37 had no cognitive impairment and was independent with activities of daily living except he required supervision with eating. R37's cognition care plan last revised on 8/15/16, indicated R37 had cognitive loss/dementia or alteration in thought process evidenced by deficits in memory, judgement, and decision making. The CKD care plan revised on 8/17/16, directed staff to check body for breaks in skin and treat promptly as ordered by medical practitioner. The anticoagulant therapy care plan dated 11/1/16, directed daily skin inspections and to report abnormalities to the nurse/medical practitioner. The skin care plan dated 11/1/16, directed staff to use caution during bed mobility and transfers to prevent striking arms, legs, and hands against surfaces that may cause injury. R37's undated Nursing Assistant Care Plan indicated R37's bath day was on Mondays. R37's Comprehensive Skin assessment dated [DATE], indicated R37's ability to walk was severely limited or non-existent or could not bear own weight and/or must be assisted in/out of chair or wheelchair. R37 had a potential problem with friction and shear injuries, his lower extremities showed signs and symptoms of [MEDICAL CONDITION], and had loss of sensation to lower extremities. The assessment indicated staff would inspect skin daily. R37's medical record did not reflect any current skin impairment or evidence of daily skin monitoring as directed by the care plan. On 10/18/17, at 7:54 a.m. R37 was observed seated in wheelchair, and the lower extremities were not covered. The right leg was amputated just below the knee and the left leg had a dime sized light yellow/reddish thin scab on the outside of the upper calf just below the knee. The skin around the wound was not red. Nursing assistant (NA)-D entered the room first and NA-E shortly after. The surveyor reported to both NAs and to R37 the wound on the outside of the leg. NAs were not previously aware of the wound. R37 stated he got the injury a week ago when he transferred into the wheelchair. The NAs failed to report the wound to the nurse, as directed. -at 12:58 p.m. NA-B stated the resident's skin was looked at during daily cares or with each resident contact and areas of concern were reported to the nurse as soon as possible. On 10/19/17, at 3:45 p.m. the assistant director of nursing (ADON) stated she was not informed of R37's left leg wound. The ADON assisted R37 in his wheelchair back to his room to assess the wound. The wound periphery was now red and the scab had changed to a darker red and appeared to be thicker. The ADON cleansed, measured, and dressed the wound. R37 stated he had received the wound over a week ago when he bumped it on his wheelchair when transferring. R37 stated he had not told anybody about the wound because he figured it would just heal. The ADON stated the NAs should have reported the change in skin condition to the nurse. Following this assessment, a comprehensive skin assessment was completed for R37's wound. R37's Comprehensive Skin assessment dated [DATE], indicated R37 was found to have an area of concern to left leg, near the knee which was dry with no drainage. Area measured 1.5 centimeters (cm) x 1.0 cm and surrounding skin was 0.5 cm around scab like area. R37 reported he bumped it on the wheelchair. After investigating the area and wheelchair, the area on the wheelchair where R37 had bumped his leg was identified. R37's Incident Progress Note dated 10/20/17, indicated maintenance would pad the wheelchair part which caused the wound, dietary was informed and protein powder was added to the diet plan, and the wound would be monitored on the 24 hour clipboard and Medication Administration Record, [REDACTED]. On 10/20/2017, at 9:51 a.m. ADON explained she had put the new wound interventions into place and provided education to the NAs about reporting skin concerns to the nurse timely. The ADON stated, NA-E reported she had forgotten to report R37's wound to the nurse. The facility Person Centered Care Plan Guideline, revised 11/2016, indicated the facility must develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care and the care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable, mental and psychosocial well-being. A skin care policy was requested and not received.

Based on observation, interview, and document review, the facility failed to develop an ongoing surveillance program to analyze patterns and trends of resident infections not treated with an antibiotic. This had the potential to affect all 36 residents residing in the facility. Findings include: On 10/19/17, at 1:10 p.m. the facility infection control logs were reviewed with the director of nursing (DON). The logs were a tracking form which identified the date symptoms were identified, name of the resident, room number in which the resident resided, if the identified symptoms were new or ongoing, type of infection, if a culture was completed, the name of the organisms, and the type of antibiotic or treatment prescribed by the physician. However, the logs did not contain the tracking or trending of any illnesses which were not being treated with an antibiotic. On 10/19/17, at 1:30 p.m. the DON, also the infection control preventionist, confirmed only infections with prescribed antibiotics were tracked. She stated the facilty had not established a system to track infections which were not treated with antibiotics and verified the facility failed to follow their surveillance policy. The facility's Surveillance policy, revised 11/16, indicated surveillance was implemented to identify and report evidence of infection. Collecting, documenting, and analyzing data would be done by the infection preventionist or designated staff member.

Based on observation, interview, and document review, the facility failed to implement interventions to minimize the risk of injuries and accidents related to independent wheelchair mobility out of the facility for 1 of 1 resident (R33) observed traveling in the lane of traffic. The findings rose to the level of immediate jeopardy (IJ) for R33. The facility was notified of the IJ on 4/9/13, at 4:00 p.m.. The IJ was removed on 4/10/13, at 3:20 p.m., with noncompliance remaining at the isolated scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy). In addition, wheelchair positioning was not addressed for 1 of 1 residents (R29) in the sample whose feet were observed dragging on the floor during wheelchair transport inside the facility. Findings include: R33 had [DIAGNOSES REDACTED]. On 4/9/13, at 12:08 p.m., surveyors were in cars traveling from facility when R33 was observed in the other lane independently propelling his wheelchair backwards, against traffic, down Washington Street. R33 was near the middle of the traffic lane with his back toward the oncoming traffic. R33 was propelling backwards using his left leg. He would not have been able to see any oncoming traffic and due to amount of snow traffic turning on side streets may not have been able to see him on the street. Washington street was not observed to have any sidewalks. R33 was then observed on United States (US) Highway 59 and continued to propel the wheelchair backwards near the middle of the lane going backwards into oncoming traffic. Surveyor returned to facility to notify staff of observation. The nursing home administrator, interviewed on 4/9/13, at 12:14 p.m., stated she knew (R33) often signed himself out of the facility and independently traveled to different destinations in town. She knew that R33 propelled the wheelchair backwards and against oncoming traffic. The administrator stated R33 was cognitively intact and had a care plan for going out into the community. On 4/9/13, at 12:15 p.m., R33 was observed on Highway 59 in downtown Karlstad (approximately 0.5 mile from the facility), still traveling backwards into oncoming traffic. R33 did not have a slow moving vehicle sign or flag on his wheelchair. The most recent annual Minimum Data Set ((MDS) dated [DATE], and quarterly MDS dated [DATE], identified R33 with cognitive independence and no signs/symptoms of delirium. The MDS also indicated R33 had mood disorder symptoms present, had impaired motor function/range of motion in upper and lower extremities on one side, was non-ambulatory, and was independent with transfers and wheelchair mobility. The visual function Care Area Assessment summary (CAA) dated 12/20/12, indicated R33 had glaucoma, macular degeneration, visual field deficit and decreased visual acuity. The summary statement noted use of medications for glaucoma and reading glasses for reading and doing puzzles. There was no assessment of R33's vision loss related to the ability to travel safely in the community. The activities of daily living (ADLs) CAA dated 12/20/12, indicated vision problems, contractures and locomotion by wheelchair. The summary statement included a goal to maintain independence and staff supervised R33's efforts. The CAAs did not address R33's ability to travel safely outside the facility. The most recent fall risk assessment check list dated 3/19/13, identified R33 with falls prior to admission, wheelchair use, vision impairment, standing balance problems and impaired upper extremity strength. The team review of risk factors for falls and injury did not address independent wheelchair use in the community or safety of interactions with other vehicular traffic. Physician orders [REDACTED]. The orders did not address independent travel by wheelchair in the community. The physician indicated R33 required stand by to contact guard assistance for stand pivot transfers--never by himself. R33's care plan dated 6/24/11, identified the risk of falls and potential for injury related to unsteady gait, history of falls, hemiparesis and physical limitations. The care plan indicated R33 was independent with wheelchair level transfers. The focus area for impaired physical mobility indicated R33 propelled the wheelchair with the left arm and foot and was independent in the wheelchair for distance mobility, as well as for stand-pivot transfers and wheelchair mobility inside and outside the facility. The activity care plan included wheeling uptown during the summer months. A note indicated R33 chose to sign himself out and venture uptown in his wheelchair. The care plan also identified R33 was a vulnerable adult secondary to age, placement and diagnoses, and required staff assistance to avoid potentially dangerous situations. R33's record included a negotiated risk agreement dated 7/29/10, to address independent standing transfers. There was no evidence of a risk versus benefit assessment of independent wheelchair mobility in the community. The director of nursing (DON) was interviewed on 4/9/13, at 2:30 p.m.. The DON stated facility staff were aware of R33's independent wheelchair travel to the uptown area located several city blocks (1/2 mile) away from the facility. The uptown area was situated on both sides of US Highway 59 with four lanes of traffic/parking. The DON stated R33 was required to notify staff and sign a sign-out sheet that functioned as a waiver of liability for injuries sustained during the outing, the same as any other resident leaving the building. The DON stated R33 was not cognitively impaired, was his own consentor and should have the right to travel about town independently by wheelchair if he wished. The DON verified there had never been a comprehensive assessment of R33's vision, mobility or safety with independent wheelchair mobility in the community. The DON stated she did not know that R33 propelled the chair backwards in the roadway, or that he traveled against the traffic. The DON stated R33 had been allowed to travel by wheelchair independently in the community for approximately the last year, and that he didn't go out much in the winter. The sign out sheets for the past year indicated R33 had signed out to go uptown alone forty-seven (47) times, including eleven (11) times during the period of November 2012 to April 2013 (winter months). The DON verified there had been no negotiated risk agreement with R33 traveling uptown, and if R33 had a problem, he had no way to communicate with the facility for assistance. The occupational therapist (OT), interviewed at 11:00 a.m. on 4/9/13, stated, "Wheelchairs are meant to go forward, not to say it couldn't go backwards if they could turn the head to visually see where they were going." The physical therapist (PT) was interviewed at 3:10 p.m. on 4/9/13, she stated she would not recommend propelling the wheelchair backwards. The PT also stated there had been no PT assessment of R33's wheelchair mobility. R33 was interviewed on 4/9/13, at 3:15 p.m., and stated he went uptown that day to buy lottery tickets at the gas station. R33 stated he propelled the wheelchair both forward and backwards and stated, "Backwards is easier to do and better if it's windy." R33 stated he could see where he was going by turning his head, but when asked to demonstrate, he could only rotate about 90 degrees to the left and right. R33 verified there was no way to communicate with the facility if he had a problem. He stated that if he fell out of the chair he would, "Just lay there and try to flag down a car." The administrator and DON were notified of the IJ related to the lack of safety assessment and interventions for R33's independent wheelchair travel in the community on 4/9/13, at 4:00 p.m.. The administrator stated R33 didn't go out much in the winter and had not considered the risk. The DON knew R33 went backwards in the wheelchair sometimes. The IJ was removed on 4/10/13, at 3:20 p.m., after development of a safety plan for R33 and determination that no other residents were unsafe in the community. The safety plan indicated that R33 would be supervised when leaving the facility until a risk/benefit analysis and appropriate comprehensive assessment and plan could be established. The interdisciplinary team assessed R33 for wheelchair handling skills and safety with traffic as well as street and weather conditions for outdoor use of the wheelchair. Interventions were developed and care planned to minimize the risk for injuries and accidents with independent wheelchair mobility during outings within the community and on community streets. R33's care plan was reviewed and revised to include all safety interventions. Facility policy was developed to ensure the safety of all residents unattended outside the facility. Education was provided to staff that included the procedure for staff to accompany R33 on all independent wheelchair trips until appropriate safety interventions were offered/implemented to minimize the risk of injuries and accidents. R29 was not provided foot rests for wheelchair positioning and safety. R29 was observed being pushed forward in the wheelchair with his feet dragging on the surface of the floor. The resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 4/8/13, at 5:43 p.m. nursing assistant (NA)-A was observed to push R29 in his wheelchair down the hall with his feet skimming the floor. When NA-A rounded the corner of the hallway the resident's feet caught the carpet, pushing the feet back under the chair. R29 said, "Ugh!" and pulled the feet a bit higher to keep them from dragging under the chair. NA-A, interviewed at the time of the observation, stated that R29 did not need foot rests on the wheelchair during transport. A physical therapy (PT) assessment dated [DATE], addressed R29's transfer ability but not wheelchair positioning or the need for footrests. The mobility care plan, dated as last reviewed on 1/4/13, indicated R29 required assistance of one person and a wheel chair for mobility. The care plan did not include direction for the use of foot rests during transport of the resident. The assistant director of nursing (ADON) was interviewed on 4/11/13, at 10:01 a.m. and stated that NA-A should have reported R29 having difficulty holding his feet up during transport. The ADON confirmed that NA-A had not reported that R29 had difficulty adequately holding his feet up during transport on 4/8/13 at 5:43 p.m.