Every finding on record at Kittson Healthcare

Based on observation, interview, and document review, the facility failed to maintain a safe environment by ensuring appropriate precautions remained in place while a freshly mopped floor was wet for 1 of 2 residents (R25) reviewed for falls and failed to provide transfer assistance in accordance with the resident's care-planned interventions for 1 of 1 resident (R9) reviewed for transfer assistance. This resulted in actual harm for R25 when she slipped and fell on the freshly mopped, wet floor, struck her head on the concrete floor, and sustained a head laceration that required emergency medical evaluation and staples.Findings include: R25 R25's annual Minimum Data Set (MDS) dated [DATE], identified R25 had intact cognition, was independent with activities of daily living (ADLs), transfers and ambulation. R25 had not experienced any falls since admission and/or the previous assessment. Diagnoses included repeated falls, dysthymic disorder, unspecified intracranial injury, osteoporosis, essential tremor, paroxysmal vertigo, gait and mobility abnormalities, weakness, urinary incontinence, seizures and disorientation. R25's care plan dated 5/5/26, identified an activity of daily living status. R25 believed herself capable of increased independence with bed mobility, transfers, walking in room and hall, dressing, eating, toilet use and personal hygiene. A goal was identified R25 would accept limitations of unsteady gait and function at her maximum capacity as evidenced by walking with staff when out of her room. Approaches included that R25's usual performance was substantial assist with bathing, supervision with shower transfer and setup with eating. R25 was independent with all other abilities. During interview on 7/27/26, at 6:49 p.m. R25 stated she had fallen in her room a few weeks prior, when she trying to go to the bathroom. The housekeeper had just mopped the floor, and she had slipped on the wet floor and fell. R25 stated she hit the back of her head on the floor during the fall and had to go to the emergency room where she received stitches to the back of her head. R25 stated a wet floor sign had not been placed, and she was not aware her floor was wet when she tried to ambulate to the bathroom. R25' The Patient/Resident Event Report Form dated 6/7/26, at 11:30 a.m. identified R25 had an unwitnessed fall in her room. The report identified R25 was coming out of the bathroom and the floor was wet and she slipped and hit the back of her head on the concrete floor. A one-to-two-centimeter laceration and egg like bruise was observed on the back of R25's head and she was sent to the emergency room to evaluate. Listed actions taken included assist of one in room and a physical therapy evaluation. The floor was confirmed to be wet. R25's CT Spine Cervical Without Contrast Results dated 6/8/26, identified R25 had a CT of the brain and cervical spine was performed. There were no acute intracranial process and no acute fracture; however, the CT results did identify R25 did have a head laceration. No further hospital documentation was received from the facility. R25's progress note(s) identified the following:6/7/26, R25 was found on her bedroom floor with a moderate amount of blood on the floor and the back of her head. R25 had stated she was up to use the restroom, but the floor had just been mopped and was slippery. R25 had slipped and fell and hit the posterior right side of her head. Area of head was cleansed and there was a one-to-two-centimeter laceration and a five-centimeter egg lump on the back of her head. R25 denied pain and pupils were equal and reactive to light. Range of motion and hand grasps were within normal range. R25 was sent to the emergency room for further assessment. 6/7/26, R25 returned from the hospital at 1:30 p.m. and had received 8 staples to the back of her head.6/13/26, identified the staples were present and the wound was dry, intact and had no signs of infection.During interview on 7/28/26, at 9:11 a.m. the director of nursing (DON) stated the event report was the only information on the fall and did not have evidence of an internal investigation into the events that lead to the missing wet floor sign or what corrective measures were taken by the facility following the fall. During interview on 7/29/26, at 7:03 a.m. housekeeper (HK)-A stated she usually waited to clean and mop resident rooms when the resident went out for meals or activities. If HK-A had to clean a room when the resident was there, she reminded the resident the floor was wet and to be careful and she always dry mopped the floor after mopping to ensure the floor was not to wet. HK-A stated she always placed a wet floor sign in the resident's doorway as well. The housekeeping staff had been told a resident had fallen on a wet floor and were given reminders to be sure to wring out their mops better, so the floor would not be too wet, as well as to use a dry mop over it. The housekeeping staff had also been told to inform the resident the floor was wet and to place a wet floor sign in their room. During observation on 7/29/26, at 11:36 a.m. HK-A was observed mopping a resident's room. The resident had exited the room to go to lunch and HK-A had wet mopped the floor and then used a dry mop to go over the entire floor. When she was finished, HK-A placed a wet floor sign in the doorway to the room. During interview on 7/30/26, at 9:35 a.m. HK-B stated she had mopped R25's floor on 6/7/26. HK-B did not know R25 was in the room when she cleaned, as she must have been in her bathroom at the time. Mopping was the last thing HK-B did before she finished the room. When HK-B heard R25 had fallen, the staff had told her there was no wet floor sign in the resident's room. HK-B was sure she had used one, but she may have taken it down to soon, before the floor was fully dry. A few of the facility nursing assistants had told her about it the next time she returned to work, however, no one else had talked to her about it or provided education. She did not think anyone else knew it was her that had cleaned the room that day. During an interview on 7/30/26, at 10:06 a.m., the DON stated that following R25's fall, she met with staff who had been working that day. Staff confirmed R25's floor had been wet at the time of the fall. The housekeeper had recently mopped R25's floor and reported reminding R25 that the floor was wet; however, a wet-floor sign had not been placed. The DON stated she spoke with the housekeeping supervisor (HS)-C regarding the incident and understood that HS-C had spoken with the involved housekeeper and provided education. The DON was not able to provide evidence of staff education following the fall. During interview on 7/30/26, at 11:04 a.m. HS-C stated she had been notified a resident had fallen because of a freshly mopped floor about a week after the fall had occurred. HS-C had been told that a resident had gotten up to go to the bathroom, and the floor was wet from the housekeeper mopping and the resident had slipped and fell; however, was not aware of the injury. She had talked with the housekeepers and HK-B stated she had cleaned the room and then mopped the floor. HK-B said she had put a wet floor sign up and told the resident to be careful the floor was wet, but that she may have removed the wet floor sign to soon, before the floor was dry. HS-C reminded all her staff frequently about using the wet floor signs as they were there to protect the housekeeper as well as to alert others the floor was wet. The housekeepers did put the wet floor signs in the resident doorways and not in the resident's room as they did not want the residents tripping over the sign and also to alert staff coming in the room that the floor was wet. Most of the time the resident was not in the room during cleaning. That day the weather was very hot, and the facility air conditioner was not working, which may have contributed to delay drying of the mopped floor. HS-C had not done any formal audits of compliance using the wet floor signs or documented the actions and education that was provided to the housekeeper and the rest of the housekeeping staff. R9R9's annual MDS dated [DATE], identified R9 had severe cognitive impairment and required maximal assistance with dressing, grooming and toileting hygiene. R9 was dependent with transfers and bed mobility and was unable to ambulate. R9 did not have behaviors of rejection of care. Diagnoses included Alzheimer's disease, abnormal gait and mobility, history of transient ischemic attack (TIA) and stroke, heart disease and dementia. R9's care plan date dated 4/30/26, identified an ADL functional status with a goal R9 would not deteriorate as evidenced by maintaining her ability to be independent with bed mobility, transfers, walking and eating after setup. Approaches were listed and included R9's usual performance was substantial assistance with toileting hygiene, bathing, dressing, partial assist with eating, and dependent with all other functional abilities. R9 was unable to ambulate and was switched to a two person stand and pivot transfer. During observation on 7/29/26, at 12:07 p.m. nursing assistant (NA)-C was assisting R9 from the bed to the wheelchair. NA-C assisted R9 to sit on the side of the bed and placed a gait belt around R9's waist. NA-C assisted R9 to stand and pivot transfer to her wheelchair. NA-C noted a need to check for incontinence care and proceeded to assist R9 back into bed for incontinence care. R9 had difficulty coming to a standing position, so NA-C called on his walkie talkie for assistance. NA-D entered the room and assisted NA-C to help R9 into a standing position and pivot transfer back into bed. NA-D exited the room and NA-C provided incontinence care to R9. NA-C assisted R9 back to a seated position on the edge of the bed and placed a gait belt around R9's waist. NA-C assisted R9 to stand and then pivot back into her wheelchair without another staff's assistance. NA-C then wheeled R9 to the dining room for lunch.During interview on 7/29/26, at 12:15 p.m. NA-C stated R9's ability to stand varied day to day and R9 was mainly an assist of one with transfers. Sometimes R9 was an assist of two for transfers and had to call for help when she had trouble with standing. R9 stood fine most of the time. When interviewed on 7/29/26, at 12:34 p.m. registered nurse (RN)-C stated R9 was an assist of two to transfer per the care plan. NA-C should have had two persons assist when assisting R9 to transfer in case something happened, like if she fell. During interview on 7/29/26, at 2:12 p.m. RN-A stated R9 was assist of two to transfer and was not able to ambulate. The nursing assistants were trained for what type of care each resident needed during their orientation. There was also a list on the nursing assistant clip board that listed all the changes with the residents, including any therapy changes. The nursing assistants also had access to the resident's care plans. During interview on 7/30/26, at 10:30 a.m. the DON stated R9's ability fluctuated from day to day and had recently had an increase in staff support for assistance. When changes were made to a resident's plan of care for increase assistance, it was passed on in shift reports and discussed in daily huddles. Staff should follow the resident plan of care. The DON was sure it had been passed on in huddle and shift report but was not able to find the notes. The facility's Fall Prevention Program dated 3/20/26, identified goals that included to provide a comprehensive fall preventions program aimed at promoting patient safety with participation by the entire organization. Patients, residents, families and staff would be educated as appropriate on measures to prevent falls and implement interdisciplinary fall prevention interventions tailored to the resident. The plan identified universal fall precautions were to be implemented for all residents, as they were aimed at keeping the care environment safe. Universal fall precautions identified several approaches, which included to keep floor surfaces clean and dry and clean up all spills promptly.

Based on observation, interview, and document review, the facility failed to implement Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact resident care activities, f1 of 1 resident (R18) reviewed for catheters and 1 of 1 resident (R29) reviewed who was receiving wound care. In addition, the facility failed to conduct ongoing infection surveillance to identify and track residents with signs and symptoms of potential infection for 1 of 1 resident (R1) reviewed for infection surveillance. Findings include: R18 R18's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and was incontinent of bowel and bladder. R18's diagnoses include chronic kidney disease stage 3 and retention of urine-chronic (long term). R18's Health Service Referral Form discharging hospital dated 6/17/26, identified R18 was admitted back to the facility following hospitalization with a discharge plan of maintaining Foley (indwelling) catheter related to urine retention. R18's provider orders dated 6/26/26, identified R18 had a Foley catheter. During observation on 7/29/26 at 7:09 a.m., registered nurse (RN)-A had just completed a dressing change and assisted R18 to get comfortable in bed by placing pillows under his head and behind his back and then covered him with a blanket while waiting for the nursing assistant (NA)s to come in and assist R18 with getting dressed. RN-A was not wearing a gown while assisting R18 with bed mobility. During observation on 7/29/26 at 7:11 a.m., NA-A and NA-D entered the room and assisted R18 in getting dressed. Both NAs sanitized their hands and put on gloves prior to assisting R18. The NAs assisted R18 to roll from side to side, placed an incontinent brief, shirt and socks on. NA-A unwrapped the Foley catheter tubing from around R18 leg before threading it through R18's pants leg. NA-A then washed hands with soap and water in the bathroom. In the bathroom there were gowns and gloves on the door with a sign identifying enhanced respiratory precautions. NA-A came back out of bathroom and placed gloves on and NA-A and NA-D placed transfer sling under resident and used a total lift to transfer him to the wheelchair. During observation on 7/29/26 at 7:29 a.m., the hospital lab tech (HLT) entered R18's room to draw blood from R18. The HLT sanitized his hands and prepared his supplies, then sanitized his hands again and put on gloves and drew 2 vials of blood from R18. HLT was only wearing gloves when in direct contact with resident. During an interview on 7/29/26 at 7:29 a.m., the HLT stated he did not know R18 was on EBP and pointed out there was no signage to indicate EBP and did not get an update from staff. If I had known, I would have worn a gown and gloves. During an interview on 7/29/26 at 8:29 a.m., NA-A stated their understanding was they would only need to wear a gown and gloves while providing catheter care and did not do it with other direct resident contact. There were PPE supplies in the R18's bathroom for use with catheter cares. During an interview on 7/29/26 at 9:53 a.m., NA-D stated they had only been working at the facility for a couple of weeks and got three days of orientation. During the time it was explained they would need to wear a gown and gloves when doing catheter care for R18, or if the nurse was doing a dressing change. She stated she had not realized R18 was on EBP and stated it was not on the Kardex (a quick reference for care plan). During an interview on 7/29/26 at 2:10 p.m., the director of nursing (DON) stated staff were expected to use EBP with residents when they provided any catheter cares or wound dressings. The DON also touched base with infection preventionist when any precautions are instituted. Staff were also expected to follow the policy if there are any questions. R29 R29's quarterly MDS dated [DATE], identified R29 had moderate cognitive impairment and diagnoses that included chronic heart failure, pressure ulcer, peripheral vascular disease and chronic kidney disease. R29 was at risk for developing pressure ulcer/injury and had no unhealed pressure ulcer/injuries. R29 used a pressure reducing device for her bed and chair and had an application of a nonsurgical dressing. R29's care plan revised 7/12/26, failed to identify R29's need for enhanced barrier precautions due to having a pressure ulcer. During an observation on 7/29/26 at 7:33 a.m., NA-A and NA-B entered R29's room but did not put on a disposable gown. Both walked past the personal protective equipment cart hanging on the backside of R29's bathroom door. There were disposable gowns and gloves available with signage indicating R29 required contact precautions. At 7:34 a.m., R29's foam border dressing was loose and no longer covered R29's pressure ulcer wound. NA-A and NA-B assisted R29 to use the bedpan, then transferred R29 from her bed to the wheelchair using a fully body mechanical lift. At 7:43 a.m., NA-A and NA-B removed their soiled gloves and assisted R29 to the shower room. At 8:16 a.m., NA-A and NA-B returned to R29's room with R29 and transferred R29 back into bed using a full body mechanical lift to finish dressing. R29's foam border dressing had been removed and R29's wound was exposed. Neither NA-A nor NA-B were wearing disposable gowns. At 8:47 a.m., registered nurse (RN)-A entered to assist R29 with her stockinette and to assess R29's wound. RN-A did not put on a disposable gown. During an interview on 7/29/26 at 8:59 a.m., NA-A and NA-B Earnistine stated R29 has a wound, so staff always had to wear gloves but pointed to the sign and stated if there's any drainage then they had to wear a gown. Only then. During an interview on 7/29/26 at 9:05 a.m., RN-A stated staff only needed to wear a gown and gloves when doing the dressing for the wound and it was not needed at any other time. During an interview on 7/29/26 at 12:25 p.m., DON and RN-B stated staff were expected to wear a gown and gloves during wound care and when R29 needed to use the bed pan, potentially. The DON stated she was unaware that a contact precautions sign was hanging on R29's PPE cart and it should have been enhanced barrier precautions because R29 had a pressure ulcer. Staff were expected to follow Centers for Disease Control and Prevention (CDC) guidelines and wear a disposable gown and gloves whenever providing care for R29 to prevent the potential transmission of infection to R29. A facility policy related to Enhanced Barrier Precautions was requested but not received. The Centers for Disease Control and Prevention guidance dated 6/28/24, identified Enhanced Barrier Precautions were an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). SURVEILLANCE R1 R1's quarterly MDS dated [DATE], identified R1 had a moderate cognitive impairment and diagnoses that included Post Traumatic Stress Disorder (PTSD) and anxiety. R1 was independent with eating, toileting, hygiene, transfers and walking. R1's care plan revised 5/30/26, identified R1 experienced differences in ability to perform activities of daily living (ADLs) related to dementia. Staff were directed R1 was independent with eating, toileting, hygiene, dressing/footwear, bed mobilities, transfers and walking. Supervision of 1 with personal hygiene and substantial assist of 1 with bathing. R1's nursing note dated 7/25/26 at 5:34 p.m., identified R1 refused to eat breakfast, said she was not hungry. Did take 240 milliliter (ml) chocolate ensure (nutritional shake) with her medications. R1 said she had been sick with diarrhea. The facility Nursing Home Infection Control Log dated May 2026, identified the resident name, date, onset date, site, infection related diagnosis, culture yes/no, organism, antibiotic, isolation yes/no, nosocomial (did the infection originate in the facility) yes/no and follow up. The log identified 1 cellulitis (a common, potentially dangerous skin infection), 3 urinary tract infections (UTI), 1 leg wound and 1 paronychia (an infection or inflammation of the skin fold around a fingernail or toenail). Only 1 culture was identified, and 1 UTI provided no further information. Additionally, the log failed to identify any infectious symptoms not treated with an antibiotic. The facility Nursing Home Infection Control Log dated June 2026, identified the resident name, date, onset date, site, infection related diagnosis, culture yes/no, organism, antibiotic, isolation yes/no, nosocomial (did the infection originate in the facility) yes/no and follow up. The log identified 2 cellulitis, 1 vaginal infection, 2 pneumonia, 1 great toenail removal, and 3 UTI. No cultures were identified and 1 UTI was identified as none. Additionally, the log failed to identify any infectious symptoms not treated with an antibiotic. The facility Nursing Home Infection Control Log dated July 2026, identified the resident name, date, onset date, site, infection related diagnosis, culture yes/no, organism, antibiotic, isolation yes/no, nosocomial (did the infection originate in the facility) yes/no and follow up. The log identified 4 UTI, 1 g-tube infection, 1 eye infection, a leg infection, 1 lung infection, 2 cellulitis and 1 resident treated with an antibiotic with no other information provided. Additionally, the log failed to identify any infectious symptoms not treated with an antibiotic and failed to identify R1's diarrheal symptoms on 7/25/26. During an interview on 7/28/26 at 1:58 p.m., the facility infection preventionist (IP)-A stated she was responsible for the facility's education coordination and gathering surveillance data to report for IP during the QAPI meeting. Once per month, IP-A received the Nursing Home Infection Control Log from the director of nursing (DON), usually at the beginning of the following month. If something were to come up during the month, it would be discussed during the interdisciplinary team (IDT) meeting. IP-A also collected data for the Risk meeting as well, but it was basic information such as numbers of infections and the number of line days for the facility. During an interview on 7/30/26 at 2:51 p.m., the DON stated nursing was responsible for entering a nursing note and the DON would review the notes to add the infections to the Nursing Home Infection Control Log. Then, at the end of the month, she provided the log to IP-A to review the information. However, viral infections were not added to the log. The DON stated she used to try to keep track of everything, but she had so much on her plate she just wasn't able to get it all done. However, all signs/symptoms of infection should have been tracked to prevent the potential spread of infection. The facility policy Infection Surveillance revised 5/2025, identified infection prevention began with routine and ongoing surveillance to identify possible communicable diseases or infections before they could spread to other persons in the facility or have the potential to cause an outbreak. The policy directed the following: The unit charge nurses will identify residents with symptoms or identified infections and complete the Criteria for Infection Report Forms for the respective type of infection and report to the IP: UTI, respiratory tract infection; gastrointestinal tract infection; skin, soft tissue and mucosal infections. The IP will ensure data collection to complete a comprehensive monthly infection control log for the surveillance activities on: Site Pathogen Signs and symptoms Resident location Summary and analysis of number of residents and/or staff with infections Observations of staff adherence to policies and procedures. identification of outcomes that were unusual or unexpected that could potentially lead to patterns, trends or outbreaks. The IP or designee would be alerted to identify any necessary interventions in or to identify trends or clusters for action. The IP would keep an updated map of infections to identify any clusters or trends. Data obtained from process surveillance audits would be collected to analyze the compliance of staff with facility policies and procedures.

Based on interview and document review, the facility failed to ensure an as-needed (PRN) antipsychotic medication order was limited to 14 days and failed to ensure the resident was evaluated by the prescribing practitioner before the PRN antipsychotic medication was renewed. In addition, the facility failed to ensure there was adequate clinical justification for the use of the PRN antipsychotic medication when it was restarted at the request of the resident's family for 1 of 5 residents (R19) reviewed for unnecessary medications.Findings include; R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had moderately impaired cognition. and exhibited behaviors symptoms not directed at others such as rummaging, pacing, disrobing or disruptive sounds one to three days per week. R19 also displayed rejection of care and wandering four to six days per week. R19 had not exhibited physical or verbal symptoms toward others during the observation period. R19 had taken antipsychotic medications. Diagnoses included Parkinson's disease, Alzheimer's disease, dementia with agitation, and mild neurocognitive disorder with behavioral disturbances. R19's care plan with revision date 6/10/26, identified behavioral symptoms of verbal and physical behavioral symptoms directed toward others such as screaming, cursing and hitting others with a goal to accept assistance with activities of daily living (ADL) without threatening behaviors. Approaches included to avoid power struggles, maintain calm, slow approach and provide a comfortable private environment for care. R19 was seen by neurology and family hoped they could get her medications straightened out for her Parkinson's and dementia, so behaviors would not continue. R19's Physician Order Report(s) identified the following:5/1/26 to 6/30/26, included olanzapine 2.5 mg by mouth as needed prn daily for severe agitation, with a start date 3/31/26, the end date was listed as open ended.6/30/26 to 7/30/26, included olanzapine 2.5 milligrams (mg) by mouth as needed (prn) daily for severe agitation, with a start date 7/23/26, the end date was listed as open ended. R19's provider notes identified the following:Physician Order Report 5/1/26 to 6/30/26, listed several medication orders which included olanzapine 2.5 mg by mouth as needed prn daily for severe agitation, with a start date 3/31/26, the end date was listed as open ended.Physician Progress Note dated 4/11/26, identified R19 was seen by her primary care provider (PCP) and medications reviewed. Assessment and Plan identified psychiatry was managing R19's medications for her agitation with violent behaviors and R19 was on scheduled Seroquel (antipsychotic medication) daily as well as prn olanzapine daily as needed for agitation or violent behavior. The PCP identified R19's behaviors had improved with the drug regimen.Psychiatric provider note dated 4/13/26, identified R19 presented with ongoing improvement in agitation and psychosis on her current medication regimen and had not required prn olanzapine since her last visit one week prior.Psychiatric provider note dated 4/23/26, identified R19 had been stable and had not required any prn medications.Psychiatric provider notes dated 5/27/26, identified R19 had minimal behavioral incidents and had used prn olanzapine one time on 4/30/26 for agitation related to refusing care. R19 had not required the prn olanzapine since that episode and family reported R19 was doing well overall.Physician Progress Note dated 6/11/26, identified R19 was seen by her primary care provider (PCP) and medications reviewed. Plan identified psychiatry was managing R19's psychotropic medications including her olanzapine, which was on board as needed. R19's behavior had improved with no verbal or physical aggression recently.Psychiatric provider notes dated 6/12/26, identified R19's hallucinations had been well controlled with no recent auditory or visual hallucinations reported. Medications were reviewed, including olanzapine with notation the medication had not been used in nearly four weeks and was going to be discontinued due to the lack of use.Psychiatric provider notes dated 6/18/26, identified R19 had been stable over the past two months with minimal behavioral or psychological disturbances and her olanzapine was previously discontinued due nonuse.Psychiatric provider notes dated 7/16/26, identified R19 was being seen for follow up for medication management and agitation in Alzheimer's dementia. Staff had noted R19 was getting out more frequently with family. A behavioral concern had been noted that R19 had refused to return indoors on at least one occasion following an outing. Family requested prn olanzapine be restarted for agitation. R19 had not had anger outbursts similar to prior episodes, but family would like the medication available. The prn medication had been stopped due to it had not been utilized. The plan identified to add olanzapine 2.5 mg tablet prn for severe agitation, once daily as needed for 30 days.Physician Progress Note dated 7/22/26, identified R19 was seen by her primary care provider (PCP) and medications reviewed. Plan identified psychiatry was managing R19's psychotropic medications and to continue olanzapine 2.5 mg as needed. Review of R19's medical record from 4/11/26 through 7/22/26 identified R19 was seen by medical providers on 4/11/26, 4/13/26, 4/23/26, 5/27/26, 6/11/26, and 6/12/26. The medical record identified R19's PRN olanzapine remained available for use beyond 14 days. The medical record did not identify R19 was directly examined and evaluated by the prescribing practitioner every 14 days to determine whether a new PRN antipsychotic medication order remained appropriate. The PRN olanzapine was discontinued on 6/12/26 due to nonuse. Further, The medical record did not identify adequate clinical justification for restarting PRN olanzapine for severe agitation after the medication had been discontinued due to nonuse. The 7/16/26 psychiatric provider note identified R19 had not experienced anger outbursts similar to her previous episodes and identified the medication was restarted following the family's request to have the medication available. During interview on 7/30/26, at 10:45 a.m. the director of nursing (DON) stated R19 had prn olanzapine ordered 4/26/26 through 6/23/26, by her psychiatric provider. The psychiatric provider reviewed her medications and had chosen to keep continuing the prn medication when she did. The pharmacist had made the recommendation to the provider about the need to do a face-to-face evaluation with R19 for the continued use of the prn olanzapine, or it needed to be discontinued. The DON did not know why the physician had not done so. The facility's consultant pharmacist was not available; they did have a backup pharmacist that filled in for medication questions. During interview on 7/30/26, at 10:54 a.m. registered nurse (RN)-B stated there had been situations when R19 would refuse to get out of the car and go into the facility after outings with the family but not as severe as the behaviors had been when R19 was first admitted . The family was fearful if she did react that badly again at the end of these outings, there would be something to give R19 to calm her down. There should be more justification for the use of the prn medication, and the facility would request a better narrative from the prescriber. RN-B had reminded the prescriber there needed to be a fourteen-day assessment. An attempt to contact R19's psychiatric provider by telephone was made on 7/30/26, at 2:40 p.m. with message left. During telephone interview on 7/30/26, at 3:36 p.m. pharmacist (PH)-F stated she was not familiar with nursing home regulations in regard to prn psychotropic medications. The facility policy Psychotropic Medication and Monitoring dated 10/17/23, identified prn psychotropic medications would be prescribed on a prn basis to address acute or intermittent symptoms, or in an emergency. In order for a resident to have a prn order for a psychotropic medication, the physician must document the diagnosed specific condition and indication for the medication. An order may be extended beyond fourteen days if the physician believed it was appropriate to extend the order. The provider should document the rationale for the extended time period in the medical record and indicate the specific duration. Prn orders for antipsychotic medications were for fourteen days with no exceptions. If the provider wished to write a new order for a prn antipsychotic, the provider must first evaluate the resident to determine if the new order was appropriate and document the findings in the resident's medical record.

Based on observation, interview, and document review, the facility failed to revise the comprehensive care plan to accurately reflect that a resident was independent with toileting, transfers, and ambulation for 1 of 4 residents (R15) whose care plans were reviewed. Findings Include:R15's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R15 needed supervision to touch assist with toileting, transfers, and walking. Diagnosis included Alzheimer's disease-late onset. No falls from the last assessment (3 months). R15's care plan dated 5/21/26, identified R15 had a history of fallsAn intervention dated 5/21/26, identified per therapy R15 was observed with an unsteady balance and was not able to stabilize without human assistance for on and off the toilet and surface-to-surface transfers; independent with standing, walking, turning around while walking. A second intervention dated 5/21/26, identified per therapy R15 was observed with unsteady balance but able to stabilize without human assistance for on and off the toilet and surface-to-surface transfers, standing, walking, turning around while walking. During observations on 7/29/26 and 7/30/26, R15 was observed to stand up, ambulate, use the bathroom and go to the dining room without assistance, and was stable on their feet. During an interview on 7/30/26 at 10:21 a.m., nursing assistant (NA)-G stated R15 was vastly independent and only needed slight help getting up and washed up in the morning. Otherwise, he was independent with all transfers, toileting, and ambulation. During an interview on 7/30/26 at 11:16 a.m., registered nurse (RN)-B, a clinical care coordinator, stated care plans are reviewed regularly during inter-disciplinary team meetings (IDT). R15's care plan should only have the second intervention due to R15 being identified as independent by therapy. During an interview on 7/30/26 at 11:20 a.m., the director of nursing (DON) stated it should have been updated to identify the R15's current status so all staff are aware of the care R15 needs. The RN who normally addresses care plans was not available and noted there was a mistake with updating R15's care plan. It should have stated R15 was independent. A care plan policy was requested, but none received.

Based on observation, interview, and document review, the facility failed to assess ability to independently activate the call light and provide a reasonable accommodation for 1 of 1 resident (R29), such as an adaptive call light, after staff became aware of ongoing difficulty using the standard call system, resulting in the potential for delayed access to assistance for toileting and other care needs.Findings include:R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 had a moderate cognitive impairment and diagnoses that included chronic kidney disease, a pressure ulcer of the sacral region, atrial fibrillation (irregular heartbeat) and hypertension. R29 required set up/clean up assistance with eating and oral hygiene, substantial/maximal assistance with bathing, and was dependent on staff for all other care areas.R29's care plan revised 7/12/26, identified R29 had occasional urinary incontinence and preference for a bedpan related to impaired mobility. Staff were directed to Respond promptly to toileting requests and provide the bedpan according to resident preference whenever safely possible. Provide prompt incontinence care following episodes of urinary incontinence, monitor for constipation, urinary tract infection, and skin breakdown, educate regarding safe toileting options, and notify the provider of significant changes in bowel or bladder status. Keep call light in reach.During an interview on 7/29/26 at 10:48 a.m., R29 stated she could push her call button, and the staff didn't come for over two hours. Family member (FM)-A stated R29's understanding of time had changed, and two hours was an exaggeration, however, R29 had difficulty pushing the call light at times. R29 had believed the call light had been turned on and the call light did not. R29 and FM-A had not suggested a different type of call light that might be easier for R29 to use. They just don't come. You can wait and wait. They just don't.R29's electronic medical record lacked any assessment for R29's call light ability. During an interview on 7/29/26 at 2:17 p.m., nursing assistant (NA)-A stated R29 complained that she had turned on her call light and staff do not answer probably every day. NA-A had reported this to nursing but there's been no changes.During an interview on 7/29/26 at approximately 3:00 p.m., the director of nursing (DON) stated R29 had complained of long call wait times, but after reviewing the call light logs, R29 had not turned on her call light. R29 was able to push the call light button and did not like a pancake call light (a flat, pressure-sensitive call light). However, R29 did not have a formal call light assessment, nor did the facility try a different type of adaptive call light for R29. A facility call light policy was requested but not received.

Based on interview and document review, the facility failed to identify and report an alleged violation of neglect to the State Agency (SA) for 1 of 1 resident (R25) reviewed for accident reporting. R25 slipped and fell on a freshly mopped, wet floor after facility staff failed to place a wet-floor warning sign and sustained a head laceration that required six sutures at the emergency department.R25's annual Minimum Data Set (MDS) dated [DATE], identified R25 had intact cognition, was independent with activities of daily living (ADLs), transfers and ambulation. R25 had not experienced any falls since admission or the previous assessment. Diagnoses included repeated falls, dysthymic disorder, unspecified intracranial injury, osteoporosis, essential tremor, paroxysmal vertigo, gait and mobility abnormalities, weakness, urinary incontinence, seizures and disorientation. During interview on 7/27/26, at 6:49 p.m. R25 stated she had fallen in her room a few weeks prior, when she trying to go to the bathroom. The housekeeper had just mopped the floor, and she had slipped on the wet floor and fell. She hit the back of her head on the floor during the fall and had to go to the emergency room where she received six stitches to the back of her head. R25 stated a wet floor sign had not been placed, and she was not aware her floor was wet when she tried to ambulate to the bathroom. R25' The Patient/Resident Event Report Form dated 6/7/26, at 11:30 a.m. identified R25 had an unwitnessed fall in her room. The report identified R25 was coming out of the bathroom and the floor was wet and she slipped and hit the back of her head on the concrete floor. A one-to-two-centimeter laceration and egg like bruise was observed on the back of R25's head and she was sent to the emergency room to evaluate. Listed actions taken included assist of one in room and a physical therapy evaluation. The floor was confirmed to be wet. R25's CT Spine Cervical Without Contract Results dated 6/8/26, identified R25 had a CT of the brain and cervical spine was performed. There were no acute intracranial process and no acute fracture; however, the CT results did identify R25 did have a head laceration. No further hospital documentation was received from the facility. R25's progress note(s) identified the following:6/7/26, R25 was found on her bedroom floor with a moderate amount of blood on the floor and the back of her head. R25 had stated she was up to use the restroom, but the floor had just been mopped and was slippery. R25 had slipped and fell and hit the posterior right side of her head. Area of head was cleansed and there was a one-to-two-centimeter laceration and a five-centimeter egg lump on the back of her head. R25 denied pain and pupils were equal and reactive to light. Range of motion and hand grasps were within normal range. R25 was sent to the emergency room for further assessment. 6/7/26, R25 returned from the hospital at 1:30 p.m. and had received 8 staples to the back of her head.6/13/26, identified the staples were present and the wound was dry, intact and had no signs of infection.There was no report made to the SA.During an interview on 7/30/26, at 10:06 a.m., the director of nursing (DON) stated she began investigating R25's fall when she was notified of the incident. At that time, the DON had not been aware the floor was wet when R25 fell. Because of staff scheduling, it took a couple of days to identify and interview the staff who had been working at the time of the fall. The DON stated it also took time to identify the housekeeper involved because housekeeping staff worked campus-wide and were not assigned only to the nursing home.During the investigation, the DON met with staff who had been working that day and verified the floor was wet at the time of R25's fall. The housekeeper had recently been in R25's room and reported she had reminded R25 the floor was wet; however, a wet floor sign had not been placed. The DON stated she spoke with the housekeeping supervisor (HS)-C, who then spoke directly with the housekeeper and provided education.The DON stated the facility's fall committee met every Wednesday. The committee discussed R25's fall, including what could have been done differently. The DON recalled the team also discussed whether the incident was reportable but could not remember why the team ultimately determined it was not a reportable incident. The DON stated that in the past she had reported many incidents and had subsequently been questioned about why an incident was reported or whether it was actually reportable. The DON was unable to provide any supporting documentation regarding the discussion and education. The facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with review date 6/25/24, identified if there was caregiver neglect (i.e., the care plan not being followed that resulted in a resident injury), a report must be made to the Minnesota Department of Health within 24 hours of the initial findings.

Based on observation, interview and document review, the facility failed to provide timely assistance with incontinence care for 1 of 1 resident (R9) reviewed for activities of daily living and who were dependent on staff for their care. Findings include: R9's annual Minimum Data Set (MDS) dated [DATE], identified R9 had severe cognitive impairment and required maximal assistance with dressing, grooming and toileting hygiene. R9 was dependent with transfers and bed mobility and was unable to ambulate. R9 did not have behaviors of rejection of care. Diagnoses included Alzheimer's disease, abnormal gait and mobility, history of transient ischemic attack (TIA) and stroke, heart disease and dementia. R9's care plan date with revision date 4/30/26, identified an activity of daily living (ADLs) functional status with a goal R9 would not deteriorate as evidenced by maintaining her ability to be independent with bed mobility, transfers, walking and eating after setup. Approaches were listed and included R9's usual performance was substantial assistance with toileting hygiene, bathing, and dressing. During observation on 7/29/26, at 12:07 p.m. nursing assistant (NA)-C entered R9's room and notified R9 he would assist her up to go to lunch. NA-C put on disposable gloves and assisted resident to sit on the edge of the bed. NA-C placed a gait belt around R9's waist and assisted her into her wheelchair using a stand and pivot to transfer. When R9 stood up, her jeans were visibly wet along each outer buttock and hip area. After assisting R9 into her wheelchair, NA-C removed the gait belt and his gloves and wheeled her out to the hall. When asked if R9 used the toilet prior to meals, NA-C stated R9 did not and was check and change only, as R9 was incontinent. NA-C assisted R9 back into bed. NA-C confirmed R9's jeans were wet and put on gloves and removed her pants. R9's brief was saturated and R9 had been incontinent of bowel. NA-C removed the soiled brief and washed R9's peri area with disposable wipes. NA-C changed his gloves and put on a clean brief and clean pants. NA-C transferred R9 back into her wheelchair and assisted her to the dining room for her lunch meal. During interview on 7/29/26, at 12:10 p.m. NA-C stated he had not been in to check or change R9 since she was assisted to lie down after breakfast. NA-C stated he had not turned or checked for incontinence before transferring R9 to her wheelchair to go to lunch. NA-C thanked surveyor for noting R9 jeans were wet as he would not have liked for her to be in a soiled brief and he had forgotten to check her. During interview on 7/29/26, at 2:12 p.m. registered nurse (RN)-A stated R9 was incontinent of both bowel and bladder and should be checked every two hours and changed when needed. During interview on 7/30/26, at 10:30 a.m. the director of nursing (DON) stated R9 had been fluctuating back and forth with her care needs but with the hot weather it was especially important to push fluids and keep residents clean and dry. The DON knew residents were not left in soiled briefs and felt the staff was too nervous about being watched and went to quickly, anxious about getting the resident to the dining room and forgot steps. The facility's undated policy Activities of Daily Living (ADL) identified several purposes which included to provide assistance to residents as necessary.

Based on observation, interview, and document review, the facility failed to reposition a resident in accordance with the resident's established every two-hour turn and reposition schedule for 1 of 1 resident (R9) reviewed for pressure ulcer prevention and was at risk for developing pressure ulcers. Findings include; R9's annual Minimum Data Set (MDS) dated [DATE], identified R9 had severe cognitive impairment and required maximal assistance with dressing, grooming and toileting hygiene. R9 was dependent with transfers and bed mobility and was unable to ambulate. R9 did not have behaviors of rejection of care. Diagnoses included Alzheimer's disease, abnormal gait and mobility, history of transient ischemic attack (TIA) and stroke and dementia. R9's care plan dated 4/30/26, identified an activity of daily living (ADLs) functional status with a goal R9 would not deteriorate as evidenced by maintaining her ability to be independent with bed mobility, transfers, walking and eating after setup. Approaches were listed and included R9's usual performance was substantial assistance with toileting hygiene, bathing, dressing, partial assist with eating, and dependent with all other functional abilities. R9 was unable to ambulate and was switched to a two person stand and pivot transfer. The care plan also identified a risk for pressure ulcers with a goal R9's skin would remain intact. Approaches included staff to observe skin daily with care and nursing to complete a head-to-toe assessment weekly. R9 had a standard pressure reduction mattress.R9's Progress Note dated 7/26/26, identified R9 continued to be assist of two with transfer and assist of one with ADLs. R9 had a turn and reposition schedule when in bed and heels were to be off-loaded with a pillow. During continuous observation on 7/29/26, from 9:30 a.m. to 12:06 p.m. R9 was observed lying on her back with her arms extended down on either side. R9 was fully dressed and covered with a pink quilt. R9's bed was positioned in its lowest position, the lights to the room were off and the room was quiet. The door to her room was wide open. R9 was observed sleeping during the observation period and did not move on their own. No nursing staff entered the room during the observation period to offer repositioning.On 7/29/26, at 12:07 p.m. nursing assistant (NA)-C entered R9's room, put on gloves, and explained to R9 he was there to get her up for lunch. NA-C sat R9 on edge of bed and placed a gait belt around her waist. NA-C pivot transferred R9 to her wheelchair. NA-C stated sometimes R9 was able to turn herself, unless she was tired, and then she needed help. NA-C stated he had not been in R9's room since he assisted her to lie down after breakfast. NA-C stated R9 did not currently have any open skin areas and could not identify if R9 should have been repositioned after two hours lying in bed, as he thought she was able to do so herself. During interview on 7/29/26, at 2:12 p.m. registered nurse (RN)-A stated the nursing assistants had a list of residents that required turning and repositioning every two hours on their clipboard. RN-A stated R9 was on the turn and reposition schedule, which included all residents that could not reposition themselves and all the residents on the list were to be repositioned every two hours. When interviewed on 7/30/26, at 10:30 a.m. the director of nursing (DON) stated R9's functional ability had been fluctuating back and forth. It was communicated during shift report and huddle when her care needs had increased. She was on a turn and reposition scheduled and the DON felt staff had not performed due to being nervous over being watched during survey. The facility's undated policy Activities of Daily living identified staff would provide assistance to residents as necessary.

Based on observation, interview, and document review, the facility failed to ensure a comprehensive assessment was completed related to a diagnosis of Post Traumatic Stress Disorder (PTSD) to identify and mitigate potential triggers for 1 of 2 residents (R1) reviewed for trauma-informed care.Findings include:R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/29/25, identified R1 opened up about her history of abuse from her past boyfriends/husbands. This was confirmed to be true. R1 discussed how it went on for many years. She explained that she has dyslexia (lifelong learning difference that affects how the brain processes written and spoken language), and her family often saw her as being less than due to her learning disability. She started experiencing a lot of emotional abuse from her own parents. She stated she had gone to counseling for this, and it helped her learning to see her self-worth and be more assertive. She also stated wanting to get in contact with a previous friend from her childhood who currently lives in Mexico City. She stated things have been going well for her and she had no other concerns.R1's CAM/PHQ-2 to 9/PHQ-9-OV/Trauma observation dated 5/18/26, identified the trauma symptoms and triggers were not completed.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had a moderate cognitive impairment and diagnoses that included PTSD.R1's care plan revised 5/30/26, failed to identify R1's diagnosis of PTSD and/or interventions to address known triggers for R1.R1's nursing note dated 7/25/26 at 5:34 p.m., identified R1 refused to eat breakfast, said she was not hungry. Did take 240 milliliter (ml) chocolate ensure (nutritional shake) with her medications. R1 said she had been sick with diarrhea. Writer told R1 that she should let nurse/staff know if she gets diarrhea again so R1 could get medicine for it. R1 answered no one cares about me. Writer told R1 she needed to be aware of what was going on with R1 or if R1 needed anything. A lunch tray was delivered to R1's room since R1 refused to go to the dining room for lunch. R1 had been eating chocolates and snacks in her room. Writer went to R1's room at supper time to encourage her to eat supper in the dining room. R1 asked why? Writer told R1 she had been laying down in her bed all day and if she could at least eat supper in the dining room. R1 may not feel good if she didn't get up at all. R1 then agreed and put on socks and shoes, but before entering dining room R1 stated she did not want to be told what to do.On 7/27/26 at 6:32 p.m., R1 was sitting in her room with her door shut. R1 stated she had a history of PTSD because she had been abused by her spouse and a boyfriend in her past. R1 stated she liked to stay in her room and preferred when staff knocked on the door and introduced themselves. R1 also preferred when staff suggested things to her, to go to the dining room for supper for example but did not like when staff told R1 what to do. I don't like being bossed.During an interview on 7/28/26 at 2:36 p.m., nursing assistant (NA)-E and NA-F stated R1 liked to keep to herself. R1 likes to stay in her room with the door shut and R1 could be selective with staff as well. R1 could be very upfront and tell staff, I don't want you in my room. NA-F stated R1 did have a history of abuse, but NA-F did not know what R1's triggers were. NA-E stated it was how staff approached R1 that mattered and, for some unknown reason, R1 would get put off by a staff member.During an interview on 7/28/26 at 3:33 p.m., registered nurse (RN)-A stated she worked the weekend on R1's hallway. It was either Saturday or Sunday and RN-A brought R1 her morning meds and asked R1 if she was going to the dining room for her breakfast meal. R1 didn't like to come out of her room, but we encourage her to. R1 stated she had been sick the whole day prior so I asked if R1 was throwing up or if she had diarrhea. RN-A explained RN-A might be able to give R1 medicine that might make R1 feel better. R1 was ok with that and wanted to stay in her room. RN-A didn't check on R1 at lunch, but another staff did and they brought R1 a tray because R1 didn't want to come out of her room. So around 5 or so, RN-A checked on R1 and asked how R1 was feeling. R1 said she had had diarrhea one time that day. RN-A asked if R1 was going to go to the dining room for supper. Why? Why do you keep asking that? RN-A explained R1 had been in her room all day and maybe getting out would make R1 feel better. It was calm and R1 put on her gripper socks and went to the dining room. RN-A and the other cart nurse then parked our carts down at the dining room. R1 often has a serious face expression but says things when R1 was actually joking so at first that's what RN-A thought was happening but R1 said she didn't want to be pestered anymore. Then next day during report, it was reported R1 no longer wanted RN-A in her room.During an interview on 7/30/26 at 12:04 p.m., the director of nursing (DON) stated R1's PTSD diagnosis was fairly new for R1 and had been seeing a mental health provider for that. However, the facility social work designee (SWD) was responsible for conducting the trauma informed care assessment and to care plan those things. During an interview on 7/30/26 at 12:05 p.m., SWD-A stated the trauma informed care assessments were conducted annually and R1 did not have a PTSD when she was admitted to the facility on [DATE]. Because of this, SWD-A did not complete the trauma symptoms and triggers section of the CAM/PHQ-2 to 9/PHQ-9-OV/Trauma observation for R1 on 5/18/26 because it had not been a year. SWD-A stated, because R1 had been diagnosed with PTSD, the section should have been completed. A trauma informed care facility policy was requested but not received.

Based on interview and document review, the facility failed to obtain laboratory services as ordered for 1 of 1 resident (R9) reviewed for laboratory services when staff failed to arrange a white blood count (WBC) laboratory draw ordered for 7/10/26 following R9's return from the emergency department (ED).Findings include:R9's annual Minimum Data Set (MDS) dated [DATE], identified R9 had severe cognitive impairment and required maximal assistance with activities of daily living (ADLs). Diagnoses included Alzheimer's disease, history of transient ischemic attack (TIA) and stroke, heart disease and dementia. R9's care plan date dated 4/30/26, identified an alteration in health care status related to dementia, unstable gait, hypertension, chronic lymphocytic leukemia, osteoarthritis and history of TIA. A goal was listed to have vital signs in acceptable range. have pain controlled to mild range and have ordered labs in acceptable range. R9's ED Provider Notes dated 7/9/26, identified R9's plan of care was to return to the facility and to recheck R9s white blood count (WBC) the next day (7/10/26). R9's progress notes identified the following:7/13/26, identified the after-visit summary (AVS) from R9's ED visit on 7/9/26, had been reviewed. Instructions on the AVS included to check a WBC on 7/10/26. When telephoned, the laboratory department indicated they had not performed a lab draw for R9 on 7/10/26. R9's primary care provider (PCP) was notified. 7/15/26, identified R9's PCP had responded to the facility's update with orders to draw a complete blood count with differential on 7/13/26 and 7/14/26. When interviewed on 7/29/26, at 2:12 p.m. registered nurse (RN)-A stated the charge nurse working on the resident's unit was responsible for checking orders when a resident returned from an appointment, hospital or emergency department. That nurse was also responsible to follow up if any changes or new orders were received. When completed the orders were to be rechecked by another nurse. During interview on 7/30/26, at 11:52 a.m. RN-B stated the nurse that had reviewed R9's AVS from her ED visit had missed the orders for the lab work. RN-B reviewed the orders and noticed the orders had not been called into the lab. RN-B placed the order with lab and notified the PCP of the error. The lab work was completed the next day after the error was discovered. A policy on physician orders was requested; however, none were received.

Based on interview and document review, the facility failed to implement its antibiotic stewardship protocols for the assessment and monitoring of antibiotic use for 1 of 2 residents (R9) reviewed for antibiotic use. R9 received repeated courses of antibiotics for suspected urinary tract infections (UTIs); however, the facility failed to use its established UTI assessment process and failed to complete, and document required 72-hour antibiotic reassessments to evaluate the continued need, duration, and selection of antibiotic therapy. Findings include:R9's annual Minimum Data Set (MDS) dated [DATE], identified R9 had severe cognitive impairment and required maximal assistance with dressing, grooming and toileting hygiene. R9 was frequently incontinent of bowel and bladder. R9 did not have behaviors of rejection of care. Diagnoses included Alzheimer's disease, abnormal gait and mobility, history of transient ischemic attack (TIA) and stroke, heart disease and dementia. R9's care plan dated 4/30/26, identified an activity of daily living (ADLs) functional status with a goal R9 would not deteriorate as evidenced by maintaining her ability to be independent with bed mobility, transfers, walking and eating after setup. Approaches were listed and included R9's usual performance was substantial assistance with toileting hygiene, bathing, dressing, partial assist with eating, and dependent with all other functional abilities. R9 was frequently incontinent of bowel and bladder and required assistance with peri care.R9's Physician Order Report dated 6/29/26 to 7/29/26, identified several medications, including cephalexin 500 milligrams (MG) three times per day 7/10/26 to 7/16/26. Cephalexin was again ordered 500 mg two times per day 7/21/26 to 7/29/26. R9's Progress Notes identified the following:7/9/26, R9 was lethargic and had a temp of 99. and elevated pulse of 113. Rhonchi (rattling) was noted throughout lungs. R9 had been seen in the emergency department (ED) and returned with a diagnosis which included acute cystitis. A new order was received for cephalexin 500 mg three times per day for seven days.7/17/26, R19 had completed antibiotic treatment with no complaints of pain or discomfort. She was noted to have bilateral edema (swelling) in her lower extremities, and her primary care provider (PCP) was updated. 7/20/26, R19 returned from a clinic appointment and Rocephin 1 gram had been administered intramuscularly (IM) at the appointment. New orders were received for Nitrofurantoin 100 mg two times per day for cystitis/urinary tract infection. 7/21/26, R19's antibiotic was changed from Nitrofurantoin to cephalexin due to resident required medications to be crushed and unable to crush Nitrofurantoin. 7/28/26, R19 completed her last dose of cephalexin and denied pain or burning. R19's lab results were reviewed 6/8/26 through and identified the following: 6/8/26, a urinalysis was obtained and cephalexin 500 mg two times per day for five days was ordered. A urine culture was in process, however R19's medical record lacked the results of the culture.7/13/26, identified R19 had Escherichia coli (e. coli, a bacteria) was present in her urine noted from the urinalysis obtained 7/9/26, and was sensitive to the cephalexin antibiotic treatment that was ordered. R9's medical record was reviewed from 6/1/26 through 7/28/26, lacked any further urinalysis or culture results, despite having received three courses of antibiotic treatment during the time frame. During interview on 7/30/26, at 10:30 a.m. the director of nursing (DON) stated the facility's consultant pharmacist was in charge of the facility's antibiotic stewardship program, however, was not available during survey and could not be reached via phone. The DON stated she had recently provided education to the facility staff on ways to prevent resident urinary tract infections, such as increasing fluids and frequent peri care and assistance with toileting. R19 was declining in health and did not drink a lot of fluids. The facility had recently increased R19's fluids with meals and throughout the day and educated the staff on the new interventions. The facility used Situation, Background, Assessment and Recommendation (SBAR) forms specific for urinary tract infections (UTI) to communicate with resident's primary care providers. The UTI SBAR required the nurse to note the resident vital signs, and if symptoms of pain or burning with urination, temperature, or two or more symptoms such as urgency, blood in urine, incontinence of frequency was noted. The provider could respond with suggested orders as indicated on the bottom of the form. The DON was not able to provide the SBAR communication forms that were communicated the R19's PCP. The DON stated the staff do try to push fluids first for a suspected UTI, but they also wanted to notify the physician quickly because they had some residents that would show delayed symptoms and were very sick by the time they demonstrated symptoms. When interviewed on 7/30/26, at 11:52 a.m. registered nurse (RN)-B stated she had accompanied R9 to her provider appointment on 7/20/26, when she was given an injection of Rocephin and an antibiotic had been ordered. The provider did not feel more labs were needed and did not want to obtain a urinalysis or culture. The physician felt R9 still had cystitis and so just treated her with the Rocephin and oral Nitrofurantoin which then was changed to cephalexin. The consultant pharmacist did the facility antibiotic stewardship. Typically, when staff suspected a resident had a UTI, they pushed fluids, monitored, noted the urine, but it was an informal process. The SBAR was just to notify the provider of the resident's symptoms at the time of notification and was not a formal three-day type of process to ensure the staff have monitored and tracked symptoms before physician contact. The facility policy Antibiotic Stewardship with revision date 5/25, identified patients who needed antimicrobial therapy would get optimal drug selection, dose, duration and route to maximize patient outcomes, minimize side effects and decrease the emergence of resistance. Providers would utilize the Loeb criteria when considering the initiation of antibiotics. Consistent with the criteria, the UTI SBAR form would be used for all residents suspected of having a UTI. At 72 hours after antibiotic initiation the resident would be reassessed for consideration of antibiotic need, duration, selection and escalation potential. Laboratory testing results, response to therapy, resident condition and facility needs would be considered. Completion of antibiotic time-out must be recorded in the resident record. The facility would monitor antibiotic use, stewardship actions, and outcomes related to antibiotics in order to guide practice change and impact.

Based on interview and document review, the facility failed to provide timely toileting assistance for 1 of 1 resident (R13) reviewed who had complaints of not receiving timely toileting assistance.Findings include:R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 was cognitively intact and needed substantial/maximal assistance for transfers and toileting. R13 was continent of bowel and bladder. R13's diagnoses included stroke and irritable bowel syndrome (a condition which affects the large intestine) with diarrhea. R13's care plan dated 7/9/26 identified R13 needed assistance with toileting related to impaired mobility following a stroke. The care plan identified staff would respond promptly to requests for toileting assistance, provide one-person pivot transfers as indicated, and assist with toileting hygiene.R13's call light log from 7/10/26-7/23/26, identified four times R13 had waited from 24-35 minutes prior to their call light being answered.During an interview on 7/27/26 at 6:39 p.m., R13 stated I sometimes had to wait 30 minutes for assistance to the bathroom. Due to having to wait I soiled myself numerous times and became embarrassed. During an interview on 7/30/26 at 10:53 a.m., nursing assistant (NA)-B stated R13 had soiled their brief after having to wait more than 30 minutes. When we get busy, residents may have to wait longer than 30 minutes to getting assistance. During an interview on 7/30/26 at 11:50 a.m., registered nurse (RN)-A stated at times they do not have enough staff to help all the residents quickly. Nursing will assist the NAs in answering call lights at this time. I was not aware if a resident waited longer than 30 minutes, but they should not have waited that long. During an interview on 7/30/26 at 12:00 p.m., the director of nursing (DON) stated the facility policy is to have all call lights answered within 10 minutes and that is the expectation for staff. It would be unacceptable for residents to have to wait longer than 20 minutes before receiving help. The facility's undated Use of Call Light policy identified all call lights are to be answered promptly.The facility's undated policy Activities of Daily Living (ADL) identified several purposes which included to provide assistance to residents as necessary.

Based on observation, interview and document review the facility failed to ensure a transfer belt was used during a transfer for 1 of 2 residents (R30) reviewed for falls. This resulted in actual harm to R30 who sustained a left arm fracture. The facility implemented corrective action prior to the survey; therefore, the deficient practice was issued at past non-compliance. Findings include: R30's Fall Risk (Acuity) observation dated 7/16/24, identified R30 was at risk for falls. R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 was cognitively aware and had diagnoses that included blindness, type 2 diabetes, and hypertension (high blood pressure). R30 required partial/moderate assistance (helper did less than half the effort. Helper lifted, held or supported trunk or limbs, but provided less than half the effort) to walk 50 feet with two turns. R30's Physical Therapy (PT) Caregiver Education dated 3/11/25, identified R30 was able to complete sit to stand transfers from recliner in room to participate in lower extremity strengthening program but R30 would continue to require stand by assist (SBA) (refers to a caregiving approach where a caregiver remains close to a patient to ensure safety without providing physical assistance. This means the caregiver is ready to intervene if the patient loses balance or needs help during a task.) of one staff to contact guard assist (CGA) (a technique used in occupational and physical therapy where the therapist maintains light physical contact with the patient, typically at the hips or trunk, to provide safety without offering direct support. This method helps with body stabilization and balance, acting as a safety net to prevent falls while allowing the patient to perform movements independently.) of one staff for all mobility in the facility. R30's care plan revised 4/25/25, identified R30 is at risk for deterioration in transfer, walking in room, and walking in corridor, related to being a new resident and being blind. R30 was supervision/part assist with walking. R30 did not do steps due to her blindness. Sit to stand, transfers CGA/partial/moderate with one for safety depending on weakness and risk for unsteady gait. R30's untitled nurse aide care sheet undated, identified R30 used a cane with a gait belt for walk to dine. R30's resident progress note dated 6/4/25 at 2:48 p.m., identified R30 had a witnessed fall at 1:50 p.m. in day area hall. R30 was ambulating with cane and SBA. R30 lost balance and landed on her left side on floor. Stated hope I didn't break my left arm again. Large protrusion (bump) with a skin tear noted on left elbow. Stated moderate pain in area. At first R30 was very anxious about fall and with staff offered calm approach and encouraged deep breathing. R30 calmed down. R30 was sent to the emergency room with staff assist for evaluation. R30's resident progress note dated 6/9/25 at 2:27 p.m., R30 had a new diagnosis of left open ulnar (the ulna is a long bone found in the forearm that stretches from the elbow to the smallest finger, and when in anatomical position, is found on the medial side of the forearm. It runs parallel to the radius, the other long bone in the forearm, and is the larger and longer of the two) shaft fracture below elbow fusion hardware - due to fall last week - surgery completed on R30's left arm, R30 was not to remove dressing before follow up visit on 6/23/25. R30 was to be non-weight bearing with left upper extremity. Resident did not have any complications with surgery. During an interview on 6/9/25 at 2:02 p.m., R30 was sitting in her room recliner with her feet elevated. R30's left arm was wrapped in ace bandages, was in a sling and rested on a pillow. R30 stated she was walking in the hallway with a nursing assistant (NA) behind her and R30 really didn't know what happened but R30 and the NA could not catch her. R30 stated she broke her left arm and pointed to her forearm with her right hand. During an observation on 6/11/25 at 8:00 a.m., NA-B assisted R30 to walk to the dining room while NA-C followed behind with a wheelchair. R30 wore a gait belt around her waist and NA-B held onto the gait belt and remained close to R30. During an interview on 6/11/25 at 8:03 a.m., NA-B stated she was not at the facility when R30 fell but heard about it. R30 was walking with a nursing assistant, R30 stumbled and fell. NA-B stated she didn't know if R30 was wearing a gait belt or if the nursing assistant was holding the gait belt, but stated staff were expected to always use a gait belt when moving a resident to make it safe. During an interview on 6/11/25 at 8:04 a.m., NA-C stated she wasn't working when R30 fell and didn't know what happened. You always use a gait belt when you're walking someone. It just helps keep them steady in case the resident tripped. It was better to be safe than sorry. During an interview on 6/11/25 at 8:06 a.m., NA-D stated she was working the day R30 fell. NA-D was coming out of a room and heard a scream. R30 was walking with a nursing assistant and stumbled. You know how sometimes your feet stick to the floor? It was like that. NA-D stated she did not know if R30 was wearing a gait belt, but staff were always expected to use a gait belt when walking with a resident. During a phone interview on 6/11/25 at 8:18 a.m., registered nurse (RN)-B stated she was the nurse on duty the day R30 fell. RN-B was in the charting room when it happened. A nursing assistant was walking with R30 when it happened. RN-B stated she couldn't say if R30 was wearing a gait belt and/or if the nursing assistant was in close contact with R30 because she didn't see it happen. During an interview on 6/11/25 at 8:45 a.m., the director of nursing (DON) stated R30 was blind and was care planned to have CGA with walking. There was confusion to what CGA meant and the nursing assistant did not use a gait belt nor were they in close contact with R30. Since R30's fall, the DON had instructed staff to always use a gait belt for safety and had given education what SBA and CGA meant. On 6/11/25 at 10:00 a.m., a review of a surveillance video dated 6/4/25 at 1:54 p.m. to 1:55 p.m. was conducted with the DON. R30 was observed walking with a cane in her right hand with NA-A walking slightly behind her right side. R30 was not wearing a gait belt nor was NA-A in close proximity to R30. R30's stumbled and R30 fell forward, twisting on to her left side, landing on her left elbow/arm. The DON stated staff were expected to use gait belts and to follow care planned interventions to prevent/lessen the risk of falls. During an interview on 6/11/25 at 1:42 p.m., NA-A stated she was walking with R30 to the dining room for bingo and R30 lost her balance and fell. NA-A stated she tried to catch R30, but she just couldn't and R30 fell onto her left side. NA-A stated she didn't use a gait belt because R30 was steady and had never needed one. After R30's fall, the DON told staff they always had to use a gait belt when walking or moving residents for safety. The facility' corrective actions were confirmed through observation of staff using transfer belts along with staff interviews that identified staff knew to utilize a transfer belt for all transfers. The facility policy Fall Prevention Program revised 11/21, identified all staff members were responsible for implementing the intent and directives contained within this policy and creating a safe environment of care. Falls Prevention Plan: l. Universal fall precautions are to be implemented for all patients/residents admitted to Kittson Healthcare as they are aimed at keeping the care environment safe. Universal fall precautions include: a. Familiarize the patient with the environment. b. Have the patient demonstrate call light use. c. Maintain call light within reach. d. Keep the patient's personal possessions within patient safe reach. e. Have sturdy handrails in patient bathrooms, room, and hallway. f. Place the bed in a safe position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. g. Keep bed brakes locked. h. Keep wheelchair wheel locks in locked position when stationary. i. Keep nonslip, comfortable, well-fitting footwear on the patient. j. Use night lights or supplemental lighting. k. Keep floor surfaces clean and dry. Clean up all spills promptly. l. Keep patient care areas uncluttered. m. Follow safe patient handling practices. II. An individualized care plan utilizing a multidisciplinary approach is to be created and implemented for each patient/resident identified as a fall risk. a. Members of the multidisciplinary team may include the attending physician, nursing, therapy, pharmacy, family, patient/resident or other members of the care team. b. The multidisciplinary team members will collaborate to address modifiable fall risk factors and implement interventions to try to minimize the consequences of risk that are not modifiable c. Interventions are to be patient/resident centered However, the policy failed to direct staff to use a gait belt with all resident transfers and/or ambulation.

Based on interview and document review, the facility failed to ensure there was a signed copy an advanced directive (identifying whether to do cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR)) for 1 of 16 resident (R31) reviewed for advanced directives. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had no cognitive impairment. R31's undated face sheet, care plan dated [DATE], and the undated admission care plan checklist identified R31 was a DNR. R31's medical record did not have an advanced directive identifying a DNR status signed by R31or representative and the provider. During an interview on [DATE] at 2:36 p.m., R31 stated they wanted a DNR status. During an interview on [DATE] at 10:30 a.m., the director of nursing (DON) stated the process for when residents were admitted was a copy of signed provider orders and advanced directive were to be received upon admit. Residents who wanted CPR were identified on a list at the nurse's station and R31 was not on the list and would be treated as a DNR. The DON could not locate the advanced directive for R31 and stated it should have been completed and placed in the advanced directive book to be easily accessible. A policy related to advanced directives was requested but not received.

Based on observation, interview and document review, the facility failed to ensure residents with attached bed rails were comprehensively assessed for use on the bed for 1 of 1 resident (R4) who had bed rails. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had no cognitive impairment and was independent with bed mobility and transfers. The MDS identified resident did not use bed rails. R4's Restraint/Adaptive Equipment assessment dated [DATE], did not identfiy bed rails or adaptive equipment was used. R4's medical record lacked an assessment to to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. During observation on 6/9/25 at 2:53 p.m., R4 had half bed rails up and locked into position on both side of the upper half of the bed. On 6/11/25 at 1:22 p.m., R4's half side rails were observed were locked in the upright position on R4's bed. R4 stated they used the rails to reposition and assist with getting out of bed. The bed rails did not restrain R4's movement. During an interview on 6/11/25 at 3:06 p.m., registered nurse (RN)-A, who was MDS coordinator, stated restraint/adaptive equipment assessments were done when using bed rails. Since they were half bed rails or less, they did not do an assessment because resident was using them to reposition in bed and transfer out of bed. They did not do an assessment identifying if it was used as a bed rail or adaptive equipment. During an interview on 6/11/25 at 3:32 p.m., the director of nursing (DON) stated it was restraint free facility. When bed rails were used as restraints, a provider's order is required, and an assessment would be done and restraint policy followed but was not sure of what was done when bed rails for use for bed mobility and transfers. The facility's Physical Restraint Policy dated 6/18/24, identified bed rails should only be used when necessary for safety and with the consideration of the resident's ability to use them independently. Document how the restraint will address the medical need, enhance safety, and maintain the resident's physical and psychological well-being.

Based on observation, interview and document review the facility failed to ensure medications were administered according to manufacturers instructions for 1 of 1 residents (R31) observed during medication administration. Findings include: R31's quarterly Minimum Data Set, dated [DATE], identified R31 was cognitively intact and had a diagnosis of diabetes. R31's physician orders report dated 5/11/25 through 6/11/25, identified R31 received Lantus insulin 34 units every morning, Novolog insulin 7 units every morning, 14 units every lunch time and 7 units every evening. R31's care plan dated 3/5/25, identified R31 received insulin related to diabetes. The goal identified R31 would safely receive insulin injections per doctors orders. The nursing approaches included monitoring R31 for signs and symptoms of hypo/hyperglycemia. On 6/10/25 at 6:46 p.m., licensed practical nurse (LPN)-B was observed to prepare insulin for R31. LPN-B scrub the hub of the Novolog FlexPen with alcohol pad and then attach a sterile needle to the hub. LPN-B dialed 7 units of insulin and started to enter R31's room. Upon surveyor intervention and questioning, LPN-B stated she was instructed that she did not need to prime the insulin pen after the initial use. LPN-B stated she always placed a new needle on the insulin pens prior to use and had never primed the new needle prior to administering the insulin. LPN-B reviewed the manufacturer's instructions for Patient Information Insulin Aspart which included a section titled Preparing your Insulin Aspart FlexPen with picture diagrams and written explanations. The instructions identified giving an airshot of 2 units insulin before each injection. LPN-B stated she had not primed the pen with 2 units prior to administering the insulin to R31. On 6/10/25 at 7:04 p.m., RN-C stated when preparing to give insulin to a resident, she wasted 2 units prior to drawing up the residents ordered dose of insulin. RN-C stated she wasted 2 units to ensure the needle was full with medication to ensure the resident received the correct dose of insulin. On 6/11/25 at 8:38 a.m., director of nursing (DON) stated per facility policy staff are instructed to always prime an insulin pen prior to administering insulin to a resident. The facility Insulin Pen Administration Policy reviewed 4/28/24, identified the policy purpose was to ensure the safe, accurate, and hygienic administration of insulin using insulin pens for patients requiring insulin therapy. The policy applied to all licensed nursing staff and other healthcare professionals authorized to administer medications at the facility. The Insulin Aspart manufacturers instructions included the following instructions to prepare the insulin pen: - Turn the dose selector 2 units - Hold the insulin pen with the needle pointing up. Tap the cartridge gently with your finger a few time to make any air bubls collect at the top of the cartridge - Keep the needle pointing upwards, prss the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. Inyou do not see a drop of insuling after 6 times, do not use the Insulin pen and contact Novo Nordisk. A small air bubble may remain at the needle tip, but it will not be injected - select the dose of insulin

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 for vaccinations being offered along with offering the most recent pneumococcal vaccine for 3 of 5 residents (R24, R28, R31) reviewed for immunizations. Findings include: R24: R24's quarterly Minimum Data Set, dated [DATE], identified R24 was [AGE] years old and admitted on [DATE]. R24 was cognitively intact, and diagnoses included dementia and atrial fibrillation. R24's immunization record dated 6/11/25, identified R24 received Pneumo-poly (PPSV-23) on 2/3/2015, and Pneumo-conjugate (PVC-13) on 6/24/20. R24's vaccination consent form dated 9/7/24, included consent for influenza and COVID-19, however, the form failed to identify if R24 received Vaccine Information Statements (VIS), risk/benefits of the pneumococcal vaccine. R24's medical record failed to identify if R24 was offered, or given/declined the PCV20 or PCV21 vaccine. R28: R28's admission MDS dated [DATE], identified R28 was [AGE] years old and admitted on [DATE]. The assessment identified R28 was cognitively intact, and diagnoses included seizure disorder and traumatic brain injury. R28's immunization record dated 6/11/25, identified R28 received PPSV23 vaccine on 2/12/13, and PCV-13 vaccine on 1/12/15. R28's vaccination consent form dated 2/10/25, identified R28 previously received pneumococcal vaccine, however, the form failed to identify which pneumococcal vaccine was administered and what education was provided and discussed. R28's medical record failed to identify if R28 was offered, or given/declined the PCV20 or PCV21 vaccine. R31: R31's quarterly MDS dated [DATE], identified R31 was [AGE] years old and admitted on [DATE]. The assessment identified R31 was cognitively intact, and diagnoses included heart disease, kidney failure, and diabetes. R31's immunization record dated 6/11/25, identified R31 received the PPSV23 vaccine on 1/16/13. R31 preventative health care report dated 2/27/25 through 6/11/25, identified R31 received PCV13 vaccine on 10/26/15. R31's vaccination consent form dated 2/7/25, identified R31 declined the COVID-19 vaccine, although the form failed to identify if R31 received the VIS or risk/benefits of the pneumococcal vaccine. R31's medical record failed to identify if R31 was offered, or given/declined the PCV20 or PCV21 vaccine. The facility standing orders dated 8/8/24, included orders to administer pneumococcal vaccine (Prevnar 13) if not previously given and upon consent from resident or surrogate. On 6/11/25 at 10:48 a.m., registered nurse (RN)-A stated upon admission the residents Minnesota Immunization Information Connection (MIIC) report was reviewed and the admitting nurses were notified which vaccines the resident would need. RN-A stated vaccines, including pneumococcal, influenza and COVID-19, were offered on admission and annually. On 6/11/25 at 3:52 p.m., RN-D stated prior to admission, the provider reviews and recommends vaccines for the resident. The admitting nurse is notified which vaccines should be discussed with the resident and/or family and administered to the resident upon admission. RN-D stated there was a policy in place for vaccinations upon admission, although, the facility is lacking a process to re-evaluate current residents' pneumococcal vaccination status. On 6/11/25 at 4:17 p.m., the director of nursing (DON) stated staff review and offer vaccinations to the resident and/or families upon admission. The facility standing orders include orders to administer pneumococcal vaccine Prevnar 13 if not previously given and upon consent from the resident and/or family. The DON stated current residents' vaccination status was reviewed and vaccines are offered annually during their care conferences, although, there was not a procedure in place to catch the current residents for the new pneumococcal vaccines prior to their annual care conference. The facility Pneumococcal Vaccine Program reviewed 5/25, identified it was the policy of the facility that residents would be offered immunization/s against pneumococcal disease in accordance with Advisory Committee on Immunizations Practices (ACIP) recommendation. Pneumococcal disease is a serious illness that can cause sickness and even death. The purpose of the policy was to reduce the incidence of pneumococcal disease, and the morbidity and mortality attributed to the infection. The policy identified residents would be offered vaccinations based on the CDC and ACIP recommendations and physician orders. The policy further identified the facility would utilize the Adult Immunization Schedule, prepared by the CDC, to ensure residents were offered and encouraged to adept the appropriate vaccinations, and the determination to vaccinate or not would be documented in the residents electronic medical record.

Based on observation, interview and document review, the facility failed to ensure the daily census was on the nurse staff posting. This had the potential to affect all 31 residents residing in the facility and/or visitors who may wish to view the information. Findings include: On 6/9/25 at 4:25 p.m., 6/10/25 at 1:03 p.m. and 6/11/25 at 7:17 a.m., the facility staff posting was observed hanging on the wall across from the nurse's station. The nurse staff posting included the date; the hours of shifts for day, evening and night shifts, the number of registered nurse (RN), licensed practical nurse (LPN) and nursing assistants (NA) with total and actual hours worked; however, the postings were missing the daily census. The nurse staff postings were reviewed from 5/1/25 through 6/8/25. The facility census was not recorded on 37 of 38 days reviewed. On 6/11/25 at 1:53 p.m., health unit coordinator (HUC)-A stated she reviewed the nurse schedule and documented the information on the daily nurse staff posting and the director of nursing (DON) signed off on the form. HUC-A stated she was trained from the previous person but was not trained to document the census on the form. HUC-A stated the census is documented on a white board in the nurse's area, although it was not in a place visible by the residents and/or families. On 6/11/25 at 2:12 p.m., the DON stated she approved the nurse staff posting after the HUC completed the form. The form identified what staff were working, how many RN, LPN, and NA hours per shift, and hours per shift/day. The DON stated although the form should include the resident census, the previous staff had not filled in the census number and therefore, she or HUC-A had not documented the census number on the form. The DON stated the census was not written anywhere within the facility that was visible to the residents and/or visitors. A nurse staff posting policy was requested but not received.

Based on observation, interview and document review, the facility failed to implement timely transmission-based precautions (TBP) and testing for COVID-19 according to the Centers for Disease Control (CDC) for 4 of 4 residents (R31, R1, R12, R30) who were displaying COVID-19 symptoms; and failed to ensure enhanced barrier precautions (EBP) were implemented for an indwelling catheter for 1 of 1 resident (R38) reviewed for catheter care. Findings include: The Nursing Home Infection Control Log (Respiratory Only) updated 4/5/22, identified 8 (R1, R6, R12, R18, R28, R30, R31) residents who exhibited congested cough, chest congestion, shortness of breath, fever, aches, malaise and/or tiredness in the month of May 2024. The log identified all had tested negative for COVID-19. However, the log failed to identify the COVID-19 test type, if a confirmatory test was obtained and/or if isolation had been implemented. R31's undated Resident Face sheet, identified R31 was [AGE] years old, had hypertension, Type 2 diabetes and chronic kidney disease. R31's Resident Progress Notes identified the following: - On 5/19/24 at 2:17 p.m., R31's cough had worsened since yesterday and R31 had clear sputum production. Afebrile (without a fever). Covid test was negative. R31 was requesting to be seen in the clinic on 5/20/24. - On 5/19/24 at 4:29 p.m., despite not feeling well, R31 was still in a pleasant mood. R31 requested as needed cough medicine twice. R31 stated this did help with his cough. R31 rested in bed between meals. R31 was afebrile. - On 5/20/24 at 12:32 p.m., as needed cough syrup given per R31's request for cough. - On 5/21/24 at 9:56 a.m., as needed cough syrup given per R31's request for cough. R31 was to be seen by the provider during rounds. - On 5/21/24 at 1:29 p.m., as needed cough syrup given per R31's request for cough. R31 was to be seen by the provider during rounds. - On 5/22/24 at 4:14 a.m., R31 had a good night. Now on azithromycin (antibiotic) and gabapentin (a medicine used to treat partial seizures, nerve pain from shingles and restless leg syndrome). As needed cough syrup was administered once and was effective. R31's medical record failed to identify if R31 had a confirmatory COVID-19 test and/or if/when R31 had been placed in isolation. On 5/21/24 at 9:45 a.m., R31 was sitting in the common area with 11 other residents in the room which was approximately 12 feet x 20 feet. R31 was unmasked and was observed coughing. R31 stated he reported his cough to nursing and had a COVID-19 test, which was negative. R31 stated he was going to be seen by the doctor to see what was going on. R1's Resident Face Sheet undated, identified R1 was [AGE] years old and diagnoses that included chronic kidney disease, chronic heart failure and Type 2 diabetes. R1's Resident Progress Notes identified the following: - On 5/4//24 at 3:216 p.m., R1 complained of shortness of breath (SOB) earlier today. Oxygen levels, respirations, and temperature were within normal limits. Slight wheezing heard to upper lobes when auscultated. Offered nebulizer treatment and R1 declined at that time. R1 ambulated throughout the facility and did well with her seated walker. No SOB was stated at those times. Will continue to monitor. Did not eat lunch today. R31 stated she felt well, just was not hungry for lunch. - At 3:31 p.m., COVID test completed and was negative. - On 5/14/24 at 11:06 a.m., R1 requested as needed cough syrup this morning, which was effective. No SOB. No signs or symptoms of infection. R1's medical record failed to identify if R1 had a confirmatory COVID-19 test and/or if/ when R1 had been placed in isolation. R12's Resident Face Sheet undated, identified R12 was [AGE] years old and had diagnoses that included atrial fibrillation (irregular heartbeat), and seizure disorder. R12's Resident Progress Notes identified the following: - On 5/2/24 at 11:37 a.m., R12 requested an as needed albuterol nebulizer treatment (relieves muscle tightening in the airways to help a person breathe) after R12 got dressed this morning. Nebulizer was given and effective. - On 5/3/24 at 3:22 p.m., R12 displayed signs/symptoms of COVID-19, was given a test and was negative. - On 5/4/24 at 1:49 p.m., R12's medical provider was contacted and an order for albuterol nebulizer was sent to the pharmacy. However, R12's medical record failed to identify if R12 had a confirmatory COVID-19 test and/or if he had been placed in isolation. R30's Resident Face sheet undated, identified R30 was [AGE] years old and had diagnoses that included dementia and hypertension. R30's Resident Progress Notes identified the following: - On 5/16/24 at 1:22 p.m., R30's husband requested R30 to be seen in the clinic for her cough that she has had for five to six days. Communication form faxed to clinic. R30 had been in a good mood today. Ate 75% at breakfast. As needed cough syrup given twice. - On 5/17/24 at 3:48 p.m., R30 had an appointment this morning with her physician to address the cough she has been having. R30's husband accompanied R30 to the appointment. R30 was prescribed azithromycin (an antibiotic), (500 milligrams (mg) first day, 250 mg daily for 4 more days) and titrated doses of methylprednisolone (a steroid) for 6 days. R30s medical record failed to identify if R12 had a confirmatory COVID-19 test and/or if/when R30 had been placed in isolation. During an interview on 5/21/24 at 11:19 a.m., the director of nursing stated as the month progresses, she would add residents to the log, but the campus-wide infection preventionist (IP) was ultimately responsible for tracking and trending of infections in the facility. The DON was responsible to ensure staff implemented transmission-based precautions when warranted. The DON stated there was no current COVID-19 positive residents or staff in the facility. The DON confirmed the residents listed on respiratory infection log were tested for COVID-19. Three residents (R6, R18 and R28) had a SARS-COV-2, Influenza A+B and/or RSV Nucleic Acid Testing Panel (multitarget molecular test that aids in simultaneous qualitative detection and differentiation of SARS-CoV-2 (COVID-19), influenza A, influenza B, and respiratory syncytial virus (RSV) viral RNA) completed in the emergency department but R31, R1, R12, R27, R30 were tested using the facility's antigen tests. The DON stated some residents may have stayed in their rooms by choice if not feeling well but this was not implemented by nursing because they did not want to isolate the residents. The DON stated was unaware of guidance to place a symptomatic resident into isolation until a confirmatory test could be obtained. The DON confirmed no symptomatic resident was placed into isolation. During an interview on 5/21/24 at 11:29 a.m., licensed practical nurse (LPN)-A stated if a resident was coughing, congested and/or had a fever or was sick, the first thing they did at the facility was to get a COVID test, then get a set of vitals. If the symptoms had just started, LPN-A would probably fill out a form and send it to the medical provider to see if the resident should be evaluated. If the COVID-19 was positive, the resident would be placed into isolation but, if negative, the resident would not be placed into isolation. No further testing would be done. The facility policy Management of Respiratory Illness updated 10/19/23, identified the use of well-fitting masks in healthcare settings are an important strategy to prevent the spread of respiratory viruses. Well-fitting masks can help block virus particles from reaching the nose and mouth of the wearer (wearer protection) and, if someone is ill, help block virus particles coming out of their nose and mouth from reaching others (source control). However, even when masking is not required by the facility, individuals should continue using a mask or respirator based on personal preference, informed by their perceived level of risk for infection based on their recent activities (e.g., attending crowded indoor gatherings with poor ventilation) and their potential for developing severe disease if they are exposed. Evaluating Healthcare Personnel with Symptoms of SARS-CoV-2 Infection HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays. When testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. - If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT. - If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. - Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. For HCP who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. However, the policy failed to provide direction for symptomatic residents who have a negative antigen test. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 3/18/24, identified 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 NAAT (molecular) (A Nucleic Acid Amplification Test is a type of viral diagnostic test for SARS-CoV-2, the virus that causes COVID-19. NAATs detect genetic material (nucleic acids). NAATs for SARS-CoV-2 specifically identify the RNA (ribonucleic acid) sequences that comprise the genetic material of the virus), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT. - If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. - If a patient suspected of having SARS-CoV-2 infection is never tested , the decision to discontinue Transmission-Based Precautions can be made based on time from symptom onset as described in the Isolation section below. Ultimately, clinical judgment and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions. 41575 R38's admission Minimum Data Set (MDS) dated [DATE], identified R38 had intact cognition. Diagnoses included malignant neoplasm of male genital organs, benign prostate hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. R38 had an indwelling urinary catheter and required moderate assistance to transfer to and from the toilet and maximal assistance with toileting hygiene. R38's care plan dated 4/17/24, identified R38 had an indwelling catheter due to history of cancer. The goal was for R38 to have his catheter care managed appropriately evidenced by not exhibiting signs of infection or trauma. The care plan did not identify enhanced barrier precautions or when to use personal protective equipment (PPE) when performing catheter care. On 5/21/24, at 11:58 a.m. nursing assistant (NA)-B entered R38's room to assist R38 to the dining room for lunch. NA-B gathered a urinal and alcohol pads and put on gloves in preparation to empty R38's leg bag. NA-B did not put on a gown. After wiping the leg bags port with alcohol swab, NA-B emptied the urine from the leg bag into the urinal and re-secured the tubing. NA-B emptied the urine into R38's toilet carried the urinal from the room to the soiled utility room. NA-B rinsed the urinal in the dirty utility room hopper, sprayed with a cleaning agent and then rinsed the urinal again. NA-B then dried the urinal with paper towels removed gloves performed hand hygeine, and returned it to R38's bathroom . When interviewed on 5/21/24 at 12:05 p.m. NA-B stated she had never put on a gown to perform catheter care. NA-B had been instructed to put on gloves and to wash their hands after removing gloves. NA-B was not instructed on using enhanced barrier precautions with R38. During interview on 5/21/24, at 12:45 p.m. the director of nursing (DON) stated staff had not been instructed on any enhanced barrier precautions related to catheter care. The DON had not heard of the new guidelines as they had been focusing on other areas and so enhanced barrier precautions was not on the facility radar. The Centers of Disease and Control Implementation of Personal Protective Equipment (PPE). Use in Nursing Homes to Prevent Spread of Multi-drug-resistant Organisms (MDROs) dated 4/2/24, identified residents in nursing homes were at increased risk of becoming colonized and developing infection with multiple drug resistant organisms. Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who by definition have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) which contributes to the silent spread of MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The facility's undated policy Catheter Care identified staff were to follow general infection control guidelines which directed staff to observe standard universal precautions or other infection control standards as approved by appropriate facility committee. Wash hands before and after all procedures and wear gloves when appropriate.

Based on interview and document review the facility failed to ensure unlicensed personnel did not administer injectable medications consistent with state requirements for 4 of 4 residents (R25, R28, R31, R35 ) who received insulin injections; and the facility failed to ensure medications were administered as ordered for 3 of 3 (R3, R16, R21) residents whose medications were omitted during medication pass and medication remained in the pharmacy return medication. Findings include: R25's significant Minimum Data Set (MDS) dated [DATE], identified R25 had severely impaired cognition. Diagnosis included diabetes mellitus and R25 received injectable medication seven days of the week. R25's Medication Administration Record (MAR) dated 5/1/24 through 5/21/24, included insulin glargine solution 100 units per milliliter (ml) administer 32 units subcutaneously (SQ) at bedtime. Novolog Flexpen 100 units per ml, administer 18 units SQ two times per day. The MAR identified certified clinical medical assistant (CCMA)-C administered the glargine insulin on 5/10/24 and the Novolog insulin on 5/6/24, 5/7/24, 5/8/24, 5/20/24 and 5/21/24. R28's quarertly MDS dated [DATE], identified R25 had intact cognition. Diagnosis included diabetes mellitus and R28 received injectable medication seven days of the week. R28's MAR dated 5/1/24 through 5/21/24, included insulin glargine solution 100 units per milliliter (ml), administer 15 units SQ at bedtime. The MAR identified CCMA-C administered the glargine insulin on 5/10/24. R31's annual MDS dated [DATE], identified R31 had intact cognition. Diagnosis included diabetes mellitus and R31 received injectable medication seven days of the week. R31's MAR dated 5/1/24 through 5/21/24, included insulin glargine solution 100 units per milliliter (ml), administer 10 units SQ at bedtime. The MAR identified CCMA-C administered the glargine insulin on 5/10/24. R35's quarterly MDS dated [DATE], identified R35 had moderately impaired cognition. Diagnosis included diabetes mellitus and R35 received injectable medication seven days of the week. R35's MAR dated 5/1/24 through 5/21/24, included insulin glargine solution 100 units per milliliter (ml), administer 33 units SQ at bedtime. Lispro insulin 100 unit per ml, administer 12 units in the evening. The MAR identified CCMA-C administered both the glargine and lispro insulins on 5/11/24 and 5/12/24. During interview on 5/21/24, at 11:00 a.m. CCMA-C stated she passed her exams as a certified clinical medical assistant in February 2024 and started working for the nursing facility in April 2024. Each state was different in what a CCMA could or could not do. CCMA's work was performed according to established rules and procedures with day to day supervision by a registered nurse (RN). Things like new assessments and neurological checks had to be performed with a nurse, as CCMA could not do assessments independently. CCMA did not have to have supervision of a nurse in the room in order to administer injections, blood sugar checks, blood draws or immunizations. An RN just needed to be in the building and available if CCMA needed them. Insulin and injections were within her scope of practice and she saw no reason not to continue to administer the medications as ordered. The administrator had told her to continue to administer medications as ordered as well. On 5/21/24, at 1:15 p.m. a joint interview with the director of nursing (DON) and administrator was conducted. The administrator stated she reviewed the literature regarding the allowed duties of the CCMA, which included medication administration and the administration of injectable medications. CCMA-C had received extensive training on both oral and injectable medication administration and CCMA always worked under RN supervision. National guidelines for nursing delegation indicated certified medical assistants could be taught to give injections. If the state statute does not allow her to administer injectable medications she would have to correct the CCMA job description The undated facility policy Injection (subcutaneous) identified basic responsibility as the licensed nurse for the purpose to inject a small quantity of medication under the skin. Minnesota State Statute 1570 4658.1325 subp. 5 Medications administered by injection may be given only by a physician, physician's assistant, registered nurse, nurse practitioner or licensed practical nurse or may be self administered by a resident. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had moderate cognitive impairment and diagnoses included depression, anxiety, chronic atrial fibrillation, hypertension, chronic obstructive pulmonary disease (COPD) and hypothyroidism. R3's Medication Administration Record (MAR) dated 5/1/24 through 5/21/24, identified medications and treatments prescribed by his primary MD. Medications included levothyroxine 175 micrograms (mcg) by mouth once in the morning. On 5/20/24, at 6:30 p.m. observation of medication cart revealed R3's Levothyroxine tablets remained in the morning medication card for the 5/12/24 and 5/15/24 morning medication pass. The medications were signed off as administered by licensed practical nurse (LPN)-A however, remained in the medication card, and not administered. During interview on 5/20/24, at 6:00 p.m. registered nurse (RN)-A stated all morning medications were setup by pharmacy in individual medication cards for each medication to be administered for each shifts. All medications in the am medication cards had been dispensed and were awaiting refill cards from the pharmacy, as it was the end of the two week fill cycle. New medication cards were to arrive that evening for the next two week cycle to begin the next day. R16's quarterly MDS dated [DATE], identified R16 had moderate cognitive impairment and diagnoses included Alzheimer's disease, dementia, anxiety, hypothyroidism, and history of transient ischemic attack and cerebral infarction. R16's MAR dated 5/1/24 through 5/21/24, identified medications and treatments prescribed by his primary MD. Medications included levothyroxine 50 mcg by mouth once in the morning. On 5/20/24, at 6:30 p.m. observation of medication cart revealed R16's levothyroxine tablets was missing a tablet and the card was completely empty and should not have been. During interview on 5/20/24, at 6:00 p.m. registered nurse (RN)-A stated if a tablet was missing out of the card, the nurse was suppose to indicate on the bubble pack that the pill had been wasted. There was no initial or explanation noted on the medication card to account for the missing tablet and there should have been. RN-A stated the pharmacy would have to be contacted to send out an extra tablet so R16 does not miss a dose. R21's quarterly MDS dated [DATE], identified R21 had intact cognition and diagnoses included heart failure, atrial fibrillation, hypertension, diabetes and hypothyroidism. R21's MAR dated 5/1/24 through 5/21/24, identified medications and treatments prescribed by her primary MD. Medications included levothyroxine 112 mcg by mouth once in the morning. On 5/20/24, at 6:30 p.m. observation of the medication cart revealed R21's levothyroxine tablets remained in the morning medication card for the 5/16/24 morning medication pass. The medication was signed off as administered by clinical certified medication assistant (CCMA)-C, however, remained in the medication card and not administered. When interviewed on 5/21/24, at 1:50 p.m. pharmacist (PharmD)-E stated they filled the pills at the nursing home on a two week cycle. When they deliver the new medication cards, they pull the old cards and return them to the pharmacy. When there are pills remaining in the cards they keep them for about six months incase they can recycle them to that resident and if unable to recycle them they get destroyed after the six months. She has been logging the pills remaining in the cards and sending the director of nursing (DON) the list but has not updated the log lately. If there are pills remaining in a residents medication card and there had been no medication changes, then that would be a missed medication administration. The pharmacy had only recently started taking the old cards back because they had a lot of medication cards with medications remaining in them and it was a big concern, so the pharmacy started taking the cards back. She had raised her concerns with the DON with not only the remaining medications in the medication cards but also having to replace missing medications for residents because the nursing home would run out of a residents medication before they should have and not able to find the missing medications. They were working on the problems, had just recently changed to a two week fill cycle and that had helped some. During interview on 5/22/24, at 11:30 p.m. the DON stated the extra medications or missing medications from resident medication cards would be medication errors. The facility was aware of the issues with the medications and were trying to do better at tracking resident medications. She had implemented the policy for the nurses to initial and date each bubble on the bubble pack when administering each medication and was trying to get consistency on what order they were popping the pills out of the cards. She had identified the staff that were not consistently doing this and educated them. She has hired an RN resident care coordinator who would be helping her track medications as she knows the facility needs much improvement with medication administration. Missing medications or extra medications in resident medication cards were medication errors. We have a lot of new staff and that is part of the issue. She or RN-D has been going through the medication carts to try to figure out why there would be an extra or a missing pill for a resident and try to narrow down each incident to which nurse was responsible. She has the pharmacy letting he know when a resident is short medications and needs an extra fill. She felt some of the problems is it was to easy for the nurses to just call the pharmacy and get an extra fill when a resident had missing pills, so now they are instructed they can only order extra medications for a resident if it is a vital medication and it would need two nurses to sign off when a medication was short or could not be found and needed to order a short fill. The facility policy Medication Pass Delivery Policy identified the staff must follow the six rights of medication administration. Right medication, right dose, right route, right time, right resident and right documentation. The facility policy Medication Errors dated 4/19, identified medication errors included wrong drug, dose, route or time, omission,and unordered dose. The facility had a process to respond to actual or potential medication errors. All medication errors would be reviewed by the medical staff. The nurse who identified an error would document on an incident report form. all medication error reports would be reviewed by the DON and pharmacist and categorized according to severity.

Based on observation, interview, and record review, the facility failed to ensure residents were monitored for target behaviors, monitored for side effects, and educated on the risks/benefits of psychotropic use prior to initiation for 1 of 3 residents (R1) reviewed for unnecessary medications. This deficient practice caused actual harm when R1 experienced a decline in condition following the initiation and continued increase of a psychotropic medication. Findings include: R1's admission Minimum data set (MDS) dated [DATE], identified R1 was admitted on [DATE]. R1 had minimal difficulty in some environments with hearing, clear speech, and impaired vision, could see large print only. R1 sometimes understood others and responded adequately to simple, direct communication. R1's cognition was severely impaired with no behaviors. R1 required extensive assistance of two for toileting and extensive assistance of one for transfers, mobility, dressing, personal hygiene and supervision (oversight, encouragement, or cueing) for eating. R1's mobility devices included cane, walker, and wheelchair. R1 was frequently incontinent of bowel and bladder and was not on a toileting program. R1's diagnoses included non-brain traumatic syndrome, arthritis, and dementia. During the seven-day look-back period R1 received antidepressants five out of seven days and opioids (narcotics managed moderate to serve pain) six out of the seven days, and no antipsychotic medications were received. R1's psychiatric evaluation with nurse practitioner (NP) dated 7/3/23, identified concerns included anxiety and agitation secondary to Alzheimer's disease. R1 was identified as disoriented times four, sleepy throughout the appointment, fair eye contact, and does not answer questions coherently. R1 was disoriented to time, place, and situation and can be paranoid with delusional thinking at times. R1's insight and judgement were poor and deficits in both short- and long-term memory. NP recommended a trial of Rexulti 0.5 milligrams (mg) tablets orally daily times seven days then increase to 1 mg daily to target Alzheimer's dementia with agitation. Discussed risks and benefits with R1. R1's psychiatric medication management follow up with NP dated 7/17/23, identified R1 was last seen on 7/3/23, at that appointment was started on Rexulti for agitation secondary to Alzheimer's dementia. R1 remained disoriented times four, poor judgment, and deficits in both short- and long-term memory. Discussed typical course of treatment, treatment options, risks, and benefits discussed. Also discussed current/potential medications, their indications, and worst/most common side effects reviewed. Healthy lifestyle choices and coping skills reviewed and recommended. No indication a family representative attended the psychiatric appointments on 7/3/23, and 7/17/23, or the MD visit on 8/31/23. R1's quarterly MDS dated [DATE], identified R1's cognition remained severely impaired, and no behaviors identified in the seven-day look back period. R1's functional status had changed and R1 required extensive physical assistance of two staff for bed mobility, dressing, transfers, toilet assistance, and one-person physical assistance with eating. R1 was always incontinent of urine and no toileting plan used. R1's new diagnoses included Alzheimer's disease and anxiety disorder. R1 received antipsychotic, antidepressant, diuretic (reduced fluid buildup in the body), and opioid seven out of the seven days of the look back period. R1 had two falls with minor injuries. R1's care plan, last reviewed/revised 9/26/23, identified on 9/24/23, the use of Rexulti, psychotropic medication, was added along with possible side effects staff were directed to monitor for: drowsiness, dizziness, lightheadedness, shaking, increased appetite, weight gain, restlessness, and inability to keep still may occur. R1 was followed by medical doctor/director (MD) and pharmacy consultants, and the staff will dose change as ordered. Staff were directed to redirect daily, introduce self as necessary, offer cues as needed to maintain orientation level, allow R1 to make decisions as able, POA (power of attorney) to be contacted for financial decisions and family included on medical decisions. Additionally, staff were directed to have R1 included preferences in rendering care and services, encouraged and escorted to all group activities, praise involvement, informed R1 of upcoming activities and provided setting in which activities were preferred such as commons area and dining room, and varied the physical environment, when possible, outdoors on the Whitetail Square patio. Care plan lacked direction for frequency of side effect monitoring. R1's care sheet dated 9/25/23, identified R1 transferred independently, extensive assist of one partial bath and toileting. R1 very forgetful, fall risk, and may wander. Ambulation used a cane and assist of one and wheelchair for long distances. R1 may wander and needed redirection. Wander guard and hard of hearing (HOH) had hearing aids, did not wear them. Poor peripheral vision, look directly facing R1 when talking (had glasses did not wear them). R1 had arthritis in hand and ate a pureed diet. R1's Abnormal Involuntary Movement Scale (AIMS) dated 8/29/23, identified no involuntary movements noted after completion of the AIMS. Due to increase dose of Rexulti this a.m. R1 had some stiffness and reached out to things not there. Staff will monitor and notify provider if noted to worsen. R1's primary provider medical doctor (MD) visit dated 8/31/23, identified Plan: staff will notify psychiatry of R1's possible side effects from Rexulti were managing his psychotropic medications. R1 had dementia with behavioral issues can be combative and anxious. Rexulti was recently started, and staff notice he had some odd movements and posterior. They will notify NP who managed this. R1's physician's order dated 6/28/23, through 9/29/23, identified: -Start date 7/3/23, end date 7/9/23, Rexulti tablet 0.5 mg. Start 0.5 mg daily times seven days then increase to 1 mg daily one a day. Order written by psychiatric nurse practitioner (NP). -Start date 7/3/23, end date 7/19/23, Nurses please chart follow up on Rexulti effectiveness. Chart on effect on behaviors, and on side effects (e.g., drowsiness, dizziness, light headedness, hypotension, shaking, increased appetite, weight gain, restlessness, and inability to keep still. Provider will need notes from charting for follow up appointment on how to proceed with doses. Every shift; shift one, shift two, and shift three. -Start date 7/10/23, end date 7/17/23, increase Rexulti tablet 1 mg orally daily. Follow up appointment 7/17/23, at noon. Order written by medical doctor (MD). -Start date 7/17/23, through 8/25/23, Rexulti 1 mg daily with follow up appointment on 7/17/23, noon. Order written by NP-A. -Start date 8/25/23, through 9/28/23, Rexulti 2 mg orally once a day. Order written by NP. - 9/28/23, Rexulti take 1 mg tablet along with 0.5 mg tablet to equal 1.5 mg daily. (decrease) Ordered by MD. R1's monthly pharmacy review dated 9/6/23, included the following recommendations: NP please reassess the effectiveness of Rexulti on R1's behaviors versus risks and recent development of odd movements and posture. Could consider trying Divalproex (Depakote) (used to treat manic episodes associated with bipolar disorder and seizures). Although pharmacist consultant (PC) recommended a trial of Divalproex on 9/6/23, R1's medical record lacked documentation of a response to the request and side effect monitoring. R1's progress notes from 6/6/23, through 7/2/23, identified: -6/6/23, resident admitted to facility. -6/8/23-6/18/23 progress notes identified R1 had two falls, attempted to self transfer, was observed urinating behind door and attempted to inappropriately touch staff. -6/20/23, resident needs frequent one to one, up and down from wheelchair and interventions were mostly ineffective. -6/24/23, ambulated with walker and staff assist, played harmonica, and sang. Resident needed multiple reminders today to not self-transfer. -6/26/23 at 5:21 p.m., self-transferring, striking and hollering out. -6/28/23, Care Conference for resident - no real concerns noted, resident enjoys walking. -7/1/23, resident combative, hollering out in hallway, yelled someone help me', very angry and irritable. Resident was swinging at staff, spit in their faces, and tried to bite them. Resident got a hold of a gait belt and was flinging it into the air trying to hit staff with it. Tried to remove it from his hands but unable. Called MD on call and ordered 1 mg of Ativan. -7/2/23 at 1:30 a.m. Resident appeared calm. -7/2/23, hollering back and forth with other resident, calling him names, making threats, kicked and spit on staff. R1's records lacked assessments or behavioral notes addressing concerns related to R1's incidents on 6/26/23, 7/1/23 or 7/2/23, additionally, no new interventions were identified to assist in managing the behaviors. R1's progress notes from 7/3/23, through 9/29/23, identified: -7/3/23 at 3:33 p.m. provider phone orders follow up diagnosis agitation in Alzheimer's disease: start Rexulti 0.5 mg daily times seven days, then increase to 1 mg orally daily. Take at noon. Follow up appointment 7/17/23, at noon. Nurses, please chart follow up on medication effectiveness. Chart on effect on behaviors, and also side effects (e.g. drowsiness, dizziness, lightheadedness, hypotension, shaking, increased appetite, weight gain, restlessness, and inability to keep still. Provider will need notes from charting for follow up appointment on how to proceed with doses. R1's progress notes from 7/3/23-7/9/23 included a total of 8 total entries 3 of which indicated no adverse effects, 3 identifying no aggressive behaviors, and 3 identifying sexual or aggressive behavior or both. Progress notes from 7/10/23-8/21/23 indicated: -R1's medical record lacked evidence of progress notes on 7/14/23, 7/16/23, 7/19/23, 7/20/23, 7/22/23, 7/23/23, 7/25/23, 7/26/23, 7/28/23, 7/30/23, 8/10/23, 8/11/23, 8/13/23, 8/14/23, 8/16/23, 8/18/23, and 8/19/23. -7/10/23 at 4:14 p.m. started on first dose of 1 mg today. R1 does not exhibit increased drowsiness or lethargy. No complaints from staff regarding inappropriate behaviors this shift, although he attempted self-transfer from his wheelchair about two times. No concerns regarding hypotension as his gait appeared to be steady during attempt. Cooperative during cares, takes him medications without protest without spitting out medications. No observations of delusional conversations. No other observations to note. -7/11/23 at 7:28 a.m. R1 had been lethargic for most of the shift. Hard to arouse, but irritable when woken up and cried out as if in pain. Very confused and hard to re-direct -7/12/23 at 10:51 p.m. agitated and defensive this evening -7/13/23 at 10:16 p.m. confused -7/15/23 at 4:27 a.m. slept in bed all night without behaviors. -7/17/23 at 3:18 p.m. NP-A here for follow up visit of Rexulti. This was started at 0.5 mg for seven days and then increased to 1 mg orally daily for seven days. Today it was decided by NP-A after reading the progress notes since start date through the 14 days to stay with the 1 mg orally daily. Follow up with NP in six weeks. -7/21/23 at 4:55 p.m. Alert and oriented, assist of one for ADLS, and transferred with wheelchair and assist of one. Incontinent of bladder and continent of bowel. Behaviors had improved since taking new medication but still could be sexually inappropriate with staff at times. R1 was walked in hallways when restless and seemed to help. R1 played harmonica for staff. -7/24/23 at 6:30 p.m. Inappropriate comment made to female staff. -7/24/23 at 9:02 p.m. R1 very restless, kept getting up form wheelchair to walk, redirected and close supervision at nurse's station to prevent falls. -7/27/23 at 3:17 p.m. R1 had been sleepy often in past couple days. Today R1 was wide awake at 7:00 a.m. Staff provided 1:1, walked R1, and played his harmonica. These approaches were somewhat effective and R1 needed frequent redirection throughout the shift. -8/3/23 at 8:10 p.m. R1 required extensive assistance of one to two for ADLS, propels self in wheelchair, and stand by assist for transfers and walks. R1 was set up only for meals and consumed 100%. R1 needed supervision at times, liked to joke with staff and enjoyed playing harmonica. R1 usually in a fair mood and able to make needs known. -8/5/23 at 6:44 p.m. R1 had inappropriate behavior and restlessness, redirected but short lived due to his dementia level. R1 needed frequent redirection. Offered snacks and fluids, liked to play harmonica and go for walks. All of these combined helped with his inappropriate behavior and restlessness. -8/17/23 at 1:44 p.m. Extensive assistance of one with transfers and stand by assist with locomotion on the unit. Gait appeared to be more unsteady. Some inappropriate behavior, confused behavior, speech observed but easily redirected. -8/20/23 at 6:25 p.m. Witnessed self-transferring fall. Gait more unsteady. -8/21/23 at 4:46 p.m. urinalysis to rule out UTI (urinary tract infection) for increase confusion prior to recent fall. UA results are negative, Rexulti ordered to be increased to 2 mg orally daily. -8/25/23, 11:05 a.m. Rexulti increased to 2 mg daily per NP-A for Alzheimer's dementia with agitation. Follow upon 9/25/23, at 10 a.m. -R1 records lacked evidence of progress notes from 8/26/23--8/29/23. -8/30/23 at 2:25 p.m. R1 slept until 11:30 a.m. Staff went to assist from bed, buckled knees and refused to stand. Staff stated it was like he did not understand direction. Two assist to transfer to chair. Required extensive with all cares. Extensive assist with meal intake. Staff reported he was experiencing twitches and reaching out into midair. -8/31/23 at 10:48 a.m. R1 seen by MD today on rounds. R1 answered questions about sleeping and eating, not always answering appropriately. MD indicated he would notify NP about increase of reaching for things in the air, and jerky movements when sitting up in wheelchair. No new orders currently. -9/1/23 at 2:13 p.m. FM-A requested to discontinue Rexulti, provider was contacted to reach out to family to discuss concerns. -9/4/23 at 4:40 p.m. R1 slept all weekend. R1 placed hand over forehead, possible headache, given Tylenol which seemed to be effective. R1 was unable to say or rate pain to tell where his discomfort was due to his dementia. R1 was awake today but not happy mood like normal when awake. R1 would not sing, placed hand over mouth when writer tried to administer medications, not drinking fluid like his normal self, just maintained a frown and closed his eyes. Noted staff had to feed him at meals and does not pick- up silverware. When silverware placed in R1's hand unable to hold onto it to get his food onto it. -9/5/23 at 1:30 p.m. R1's daughter, son, and wife visiting. Family had asked for a copy of medications R1 had taken. Requested and talked to assistant director of nursing (ADON) and ask how R1 was doing and questions about Rexulti. Explained to family started on Rexulti due to negative behaviors displayed, hitting, spitting, attempted to bite. They talked about negative things said about Rexulti on television and it was explained that R1 was followed by NP and was the one that prescribed the medication, was willing to talk to family and planned on contacting them to discuss the medication. -9/6/23 at 1:19 p.m. Therapy comments: staff report transfers primarily assist of one. If fatigued, they may use assist of two. No therapy needs currently. -9/6/23 at 10:04 a.m. R1 was extensive assist of one for activities of daily living (ADLS) and transfers. Incontinent of bowel and bladder at times. Was out for all meals, took all medications without difficulty, drank all supplements this evening, and no behaviors noted. -9/7/23 at 1:18 p.m. Extensive assistance with ADLS. Staff now feeds resident all meals. Transfers are assist of one and mobility was extensive assistance of one. R1 incontinent of bladder and continent of bowel. No mood changes or behaviors noted at this time. -9/8/23 at 3:13 p.m. Incontinent of bowel and bladder most of the time. No behaviors noted today. R1 now required feeding resident at all meals. -9/9/23 at 5:14 a.m. R1 required extensive assistance of one to two for ADLS and transfers. Incontinent of bowel and bladder. -9/9/23 at 3:21 p.m. R1 very tired today. No behaviors noted and wanted to rest at breakfast time, ate lunch and supper. Incontinent of bowel and bladder wore incontinent products. Unable to ambulate today due to issues with balance despite staff assisting him. -9/9/23 at 6:55 p.m. R1 pocketed food (ground meat) in cheeks at lunch today. Spit it all out on his napkin. Smooth food textures ate really well. Needs assistance with feeding at meals. -9/10/23 at 6:03 a.m. Incontinent of bowel and bladder. -9/10/23 at 3:28 p.m. More alert today. Incontinent of bowel and bladder. Unable to ambulate today could not follow direction to take steps and grab walker in front of him. -9/11/23 at 1:27 p.m. and 9:10 p.m. No behaviors. R1 required to be fed at all meals. Appetite fair. -9/12/23 at 4:07 a.m. No behaviors extensive assistance of two for ADLS and transfers. Incontinent of urine. -9/12/23 at 11:16 a.m. Quarterly assessment completed. R1 severely impaired cognition. No signs or symptoms of depression. R1 pleasant and spends a majority of his time sitting in the commons room. R1 liked to visit but most of the time will not visit with appropriate responses and was very confused but pleasant. Family was good support and visits often. -9/14/23 at 3:43 p.m. R1 required extensive assistance of two for ADLS and transfers. Incontinent of bowel and bladder most of the time. No behaviors noted today. R1 now required to be fed all meals and more verbal queuing. Appetite was fair most of the time, pleasant and smiled. -9/14/23 at 5:29 p.m. Offered to walk R1 three times so far since 7:00 a.m. and had not been active or strong enough to ambulate. -9/14/23 at 9:14 p.m. Mobility was in wheelchair and if awake enough can move around. Most of time staff needed to push R1 to destination. Appetite was poor and liquid intake fair. R1 has slept the evening shift in his wheelchair, refused to eat supper, drank three to four ounces of ensure. R1 did not ambulate this evening was too sleepy. R1 was incontinent of bladder, not able to feed self, does not talk, reaches out in the air looking for something, does not attempt to self-transfer from his wheelchair. May need a reduction in his medications. -R1 records lacked evidence of progress notes from 9/15/22, 9/16/23, and 9/17/23, 9/18/23 9/19/23, 9/20/23, and 9/21/23. -9/22/23 at 10:46 a.m., Screen form sent to therapy to assess safe transfers. Staff reported R1 needed one to three staff at times. Also assessing transfers into bath chair. Reported had been lowered to floor when getting up into the bath chair. R1 records lacked evidence of progress notes on 9/23/23. -9/24/23 at 4:37 p.m., R1 very sleepy. Attempted to get R1 up for meal, used sternum tub with no effect, will same meal and attempt later. -9/24/23 at 7:58 p.m., Able to get medication in and had four ounces of ensure. R1 records lacked evidence of progress notes for 9/25/23, and 9/26/23. -9/27/23 at 12:53 p.m. MD signed orders to decrease Rexulti to 1.5 mg daily. New order will be sent to drug store. -9/27/23 at 2:28 p.m. Activity staff played music for R1 and he clapped hands and legs started moving with activity staff. Activity staff will continue to visit and take R1 on walks in the halls or go on the patio as weather permits. No concerns. -9/28/23 at 12:31 p.m. in response to the decrease in Rexulti form 2 mg to 1.5 mg was signed by MD. Hoped medication would be delivered by courier today in early afternoon. The 2 mg has been discontinued. The facility failed to document side effects or target behaviors as ordered by the NP each day, evening, and night shifts on: 7/5/23, 7/6/23, 7/17/23, 7/18/23, 7/19/23, 7/20/23, 7/27/23, 7/28/23, 7/30/23, 7/31/23, 8/1/23, 8/2/23, 8/3/23, 8/4/23, 8/7/23, 8/8/23, 8/9/23, 8/10/23, 8/11/23, 8/13/23, 8/14/23, 8/15/23, 8/16/23, 8/18/23, 8/19/23, 8/20/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 8/27/23, 8/28/23, 8/29/23, 9/6/23, 9/13/23, 9/15/23. 9/16/23. 9/17/23, 9/18/23, 9/19/23, 9/20/23, 9/21/23, 9/22/23, 9/23/23, 9/25/23, 9/26/23, and 9/27/23. The facility failed to document side effects or target behaviors as ordered by the NP each day and night shifts on: 7/8/23, 7/9/23, 7/10/23, 7/12/23, 7/13/23, 7/16/23, 7/25/23, 7/26/23, 8/5/23, 8/21/23, 8/30/23, 9/4/23, 9/7/23, 9/24/23, 9/28/23, and 9/29/23. No side effects assessment documented days, evening shift, and night shifts: 7/21/23, 7/25/23, 7/26/23, 7/27/23, 7/28/23, 7/29/23, 7/30/23, 7/31/23, 8/6/23, 9/1/23, 9/5/23, 9/9/23, 9/10/23. 9/11/23, and 9/14/23. The facility failed to document side effects or target behaviors as ordered by the NP each day and evening shifts on: 7/15/23, and 8/21/23. The facility failed to documented side effects as ordered by the NP on day and night shifts on 7/11/23. Progress notes lacked evidence from 7/3/23, though 9/28/34, a responsible party was contacted and informed in advance of the risks/benefits and receive informed consent prior to the start, increased doses, and decreased doses of the Rexulti. Additionally, R1's medical record lacked side effect and behavioral monitoring for the antipsychotic medication administered. During an observation on 9/27/23 at 1:07 p.m., R1 sat in wheelchair with gripper socks on both feet without footrests on in commons area. R1 was hunched over, eyes were open and was observed to reach out into mid-air and attempt to grab something (that was not there) then flung his left hang/arm out wards numerous times. At 1:10 p.m. R1 reached out, leaned forward down to floor hunched over, and tried to touch and pick up something (that was not there) on the floor. At 1:15 p.m. a staff member came over to R1 and asked him to be her helper with colored pens, placed a pack of pencils in R1's hands and pushed him down the hallway. R1 did not respond to the staff member with words. During an observation on 9/27/23 at 3:30 p.m. R1 sat in wheelchair with eyes open looking around in commons area. R1 reached out into midair with his right hand and tried to grab something not there twice during this observation. During an observation on 9/28/23 at 9:00 a.m., R1 was pushed into the dining room in wheelchair by nursing assistant (NA-E) and placed at a table. NA-E placed a cloth protector on R1's chest and offered bites of hot cereal with a spoon. R1 was unable to open his mouth for the spoon to be placed. NA-E poured the hot cereal into a plastic cup and R1 was able to drink/swallow 50 % of the hot cereal and water offered. R1 appeared sleepy during this observation and given many cues by NA-E. At 9:30 a.m. NA-E removed R1's cloth protector from chest and pushed R1 down the hallway to the commons area. NA-E placed R1 in front of the television and put brakes on wheelchair. R1's head hung down and eyes were closed, and NA-E walked away. No verbal conversation was heard by R1 or behaviors noted. During an observation on 9/29/23 at 10:41 a.m., NA-C and NA-B located in tub room with R1 with door closed. R1 sat on tub chair awake without clothes on. NA-C placed lotion on R1's legs and R1 stated you got lotion and smiled. RN-B entered the tub room and stated R1 seemed more awake today which may be because he had not received Rexulti medication yesterday and had been placed on a new decreased dose that the pharmacy had not yet delivered. R1 conversed with NA-E and NA-B, appeared confused, and pointed at things that were not there. NA-C placed a gait belt around R1's waist. Together NA-C and NA-B stood on each side of R1, placed their hand underneath the gait belt and instructed R1 to stand up. R1 leaned forward but was unable to follow directions and could not stand up. NA-C reminded R1 he needed to stand up so that he could be transferred from tub chair to his wheelchair and placed R1's right hand on wheelchair arm rest and R1 was unable to follow directions and hands slide off arm rest. NA-C positioned himself in front of R1 with his legs touching his knees, took hold of the transfer belt from both sides, and instructed R1 to stand up. NA-C lifted R1 off the wheelchair with the gait belt and supported R1's knees so he stood up and then pivoted R1 into his wheelchair. No behaviors were noted during observation. During interview on 9/28/23, at 11:40 a.m., family member (FM)-A stated R1 walked with assist of one and was unstable on his feet when admitted on [DATE]. FM-A stated about a month after R1 was admitted to the facility he was unable to recognize family and we noticed a change in his cognitive abilities. FM-A stated he reminded R1 who they were, during visits and noted he had short fleeting ability to recognize family and was gone in an instant. FM-A stated R1 was agitated when he could not see a familiar face, but the facility placed him on Rexulti so quickly and without their knowledge or consent. FM-A also stated when they visited R1 started to ramble, and they were unable to understand what he was talking about. FM-A stated the Rexulti may have had some calming affects but in their opinion, it had deterred good parts of R1 while on it. FM-A indicated the facility had jumped the gun prior to him being placed on the Rexulti and really needed to get to know him better. FM-A stated they found out R1 was on a new medication over one week after he had started the medication and were informed by a nurse during a visit. They had never been given information about drug, risk and benefits and never provided the facility consent to start administrating the medication. Additionally, FM-A was not given the possible side effects and R1's daughter-in-law, a retired nurse looked upside effects. FM-A indicated family had informed staff nurse on 9/1/23, they wanted R1's Rexulti discontinued, and a staff nurse indicated they were unable to take R1 off until a doctor was contacted. FM-A stated on 9/5/23, a copy of R1's medication list was requested and received. FM-A stated family was contacted two weeks ago on 9/18/23 (18 days later), informed NP would meet with them on 9/25/23, at 10:00 a.m. FM-A stated he had received a phone call from the facility the morning of 9/25/23, indicated the meeting with NP had been canceled, and rescheduled for 10/6/23, at 10:00 a.m. FM-A stated as of today 9/28/23, a doctor had not visited with the family and had been almost three months R1 had been on Rexulti (28 days since the family asked for the medication to be discontinued). FM-A stated the family was very concerned about R1's change in behavior since starting the medication such as his unsteady gait, required more assistance with cares and eating, increased weakness, and cognitive decline. During an interview on 9/27/23 at 1:23 p.m., nursing assistant (NA)-A stated R1 was admitted [DATE], walked with a cane with stand by assist (SBA) of one, alert and oriented, played harmonica and sang. NA-A stated R1 was able to carry on a conversation, used a wheelchair to get around, and sometimes became restless, and unsteady when he tried to get up by himself. NA-A indicted R1 was started on a medication called Rexulti approximately three months ago. NA-A stated noted changes in R1 quickly after the medication was started and the nurse told me it was his body adjusting to it, then the dose was increased. NA-A stated R1 displayed jerking movements, suddenly, his entire body jerked, jumped in his chair, and arms and legs would go. NA-A the jerking movements started approximately 1 1/2 months ago. NA-A indicated families walked by him and asked if he was ok when they saw the jerking movements that occurred randomly and quite often and lasted only a short time. NA-A stated nursing was aware of these jerking movements many staff talked about it especially during report. NA-A stated R1's personality has diminished, does not laugh, poor eye contact, and seemed like R1 looked right through her. NA-A also stated had been difficult to get R1 to eat and drink fluids, had to be fed by staff, and once the food was placed in his mouth, he was unsure what to do with it. NA-A stated R1 was toileted with assist of staff but had changed to a check and change and off load every three hours. NA-A stated R1 was unable to reposition himself in the wheelchair. During an interview on 9/28/23 at 10:00 a.m. medical doctor (MD) stated R1 was seen last 8/21/23, and staff reported R1 was having side effects (reaching for things in midair and jerky movements). MD confirmed those are possible side effects of Rexulti and was concerning. MD stated the staff planned on contacting NP the following day as she was the primary prescriber. MD indicated when staff were concerned about side effects from Rexulti medication they would be expected to have notified NP. During a telephone interview on 9/29/23 at 10:46 a.m. PC stated R1's chart was reviewed last on 9/6/23, a progress note identified increased jerky movements and reached for things in the air. PC stated she recommended NP reassess the effectiveness of Rexulti on R1's behaviors versus risks and decent development of odd movements and posture. PC stated she suggested considering trying Depakote instead of Rexulti. PC stated she just visited with RN-B during a meeting on 9/27/23 and noted R1 also had drowsiness and so the MD decreased R1's Rexulti as the NP was gone. PC confirmed she was unaware if NP had assessed the recommendations from 9/6/23 yet or not. PC stated once the facility received the recommendations, she expected them to give them to the provider and then it would be up to the provider to follow through. During an interview on 9/28/23 at 2:20 p.m., NA-D stated R1 can no longer stand up, walk or have a conversation like he did when first admitted to the facility. NA-D indicated R1 was slumped over in the wheelchair most of the time, had a lot less energy, no longer tried to get up on his own, and was more resistant to cares. NA-D stated when R1 was admitted to the facility he used a cane and SBA (stand by assist) of one to ambulate, fed himself, played harmonica, sang songs, cracked jokes, then a few months ago his condition started to change and decline. NA-D stated R1 was unable to converse, speech did not make sense, mumbled, hard to understand, and poor eye contact started. NA-D stated the NAs were expected to document on behaviors, not sure it had been done though. NA-D also stated there was a spot in R1's medical record behaviors should have been documented every shift but had to know when to chart those behaviors and were they normal or not, was not clear. NA-D indicated was not informed as to what side effects NAs were expected to watch for. NA-D confirmed R1 tried to touch staff and intervention such as redirection and staff placed body in a position R1 was unable to be reached helped and R1 no longer did that anymore, but no other strategies or interventions were implemented. NA-D stated R1 currently became combative with cares and did not seem to understand fully what staff wanted to do with him. NA-D indicated they used redirection and when staff felt unsafe, had two staff when cares were completed. During an interview on 9/28/23 at 2:35 p.m. NA-B indicated they had seen changes in R1 especially the last two months. NA-B stated R1 use to feed himself with set up but now staff had to feed him and place his hot cereal in a cup so that he drank it. R1 was now unable to figure out how to eat with spoon, which is a significant decline. NA-B noted R1 to be drowsy and experienced unexpected body jerking movements while he sat in a wheelchair along with grabbing in the air with his hands and tow [TRUNCATED]

Based on interview and document review, the facility failed to initiate cardio-pulmonary resuscitation (CPR) for 1 of 3 residents (R1) who was found unresponsive, no respirations or heartbeat with a full code status who wished to receive CPR. The IJ began on [DATE], at approximately 2:15 a.m. when R1 had no respirations or pulse, and CPR was not initiated. The IJ was identified on [DATE], and the interim administrator and assistant director of nursing (ADON) were notified of the IJ on [DATE], at 4:30 p.m. The immediate jeopardy was removed on [DATE], and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's Orders For admitted d [DATE] and Temporary Plan of Care dated [DATE], both indicated code status as Full Code. R1's Resident Progress Notes indicated the following: -[DATE] (admission) R1 arrived from the hospital and commented she was very tired and did not feel real good. The note indicated R1 received therapy and following therapy staff entered the room to find R1 asleep. A second note dated [DATE], indicated R1 planned to work with therapy to improve strength and mobility and return home. -[DATE], at 3:54 a.m. R1 was found expired at 2:15 a.m. R1 had mottling (occurs when blood flow to tiny vessels under your skin is disrupted, this results in a fine, bluish-red, lace-like pattern) to her legs and hands, no heartbeat and no pulse. Family was notified and physician was notified via facsimile. -[DATE], a second note written at 4:05 a.m. indicated upon entering R1's room, she was found lying in bed on her back with her eyes closed. Oxygen running at 3 liters. Upon assessment no radial pulse was found. Auscultation (the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope) was done and no heartbeat was heard. R1's ears, nose, face, hands, legs and feet were completely blue due to mottling, R1's abdomen was distended and rigid, Rigor Mortis (stiffening of the joints and muscles of a body a few hours after death) had already set in as writer was not able to move extremities easily. During interview on [DATE], at 2:39 p.m. licensed practical nurse (LPN)-A stated a nursing assistant (NA) came and alerted her of R1's condition so she went to R1's room, LPN-A stated R1's arms and legs were blue and R1 displayed no signs of life. LPN-A said she went back out into the hallway and called for the other NA to come to the room. LPN-A stated they all went back into R1's room. LPN-A stated she was in shock as she had never seen anyone like that before. LPN-A stated she remembered seeing R1's code status at the start of her shift but did not process it, and said I guess I didn't realize. LPN-A stated if she had realized it she would have called for a crash cart and initiated CPR even though R1 looked like she did not have any chance of survival. LPN-A further stated no call was made to emergency services and said she should have paged the hospital (connected to the facility) to bring the cart, initiated CPR and continued CPR until the physician arrived. During interview on 2:51 p.m. with facility leadership that included registered nurse (RN)-A, assistant director of nursing (ADON) and interim administrator, RN-A stated following the incident, the policy was reviewed and it was determined it had not been followed. RN-A added during the investigation they determined not all of the nurses knew where to find the resident code status and updated the policy to include posting the code status on the inside of the resident's closet doors and immediately educated staff about the existing policy and the change. The ADON stated a full review of all resident charts was conducted to verify the code status was accurate. The ADON stated the immediate education provided included initiating CPR immediately for all residents with a full code status. The interim administrator stated they had consulted with the medical director who agreed CPR should have been started. During interview on [DATE], at 1:51 p.m. RN-B stated if a resident was found unresponsive she would check the code status either on the care sheet or the back of the closet door and if full code she would page over the intercom and initiate CPR. RN-B stated she had recently received education that included adding the code status to the door and review of the policy that indicated initiating CPR for a full code status both verbally and during a staff meeting. On [DATE], at 1:58 p.m. LPN-B stated if she found a resident unresponsive she would check the closet door or the medication administration record for the code status. If the resident was full code LPN-A said she would immediately initiate CPR. On [DATE], at 2:12 p.m. the ADON stated if a resident was full code and unresponsive she would call for help and initiate CPR. The ADON said a nurse from the hospital would arrive with a crash cart and CPR would continue until the physician assessed the resident and directed otherwise. On [DATE], at 2:20 p.m. RN-C stated if he found a resident unresponsive with a full code status he would call a code over the intercom and initiate CPR. RN-C stated CPR would continue until he received further instruction from the provider. On [DATE], at 2:27 p.m. LPN-C stated the residents code status could be found on the back of the closet door, in the computer and on the report sheet. LPN-C stated if a resident was found unresponsive and was full code she would initiate CPR, have another staff call a code over the intercom and continue CPR until further instructed by the physician. LPN-C stated she had received education immediately following the incident with R1. Facility policy titled Cardiopulmonary Resuscitation (CPR) undated, directed staff to determine unresponsiveness, call out for help, delegate an individual to check care plan for code status. The policy directed staff to initiate CPR and continue CPR until qualified help arrived or a physician pronounced the resident dead and gave orders to discontinue CPR. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: -Reviewed their policy and system to ensure no system issue. -Reviewed all residents' POLST to ensure they were consistent with residents' wishes. -Immediate education was provided to facility staff on CPR policy and adhering to advanced directives/POLST with a plan to continue to educate staff prior to staff working their shifts. -Interviews with staff on [DATE] confirmed the facility's policies will be followed.

Based on observation, interview and document review, the facility failed to ensure the Centers for Disease Control (CDC) guidance to prevent/or minimize the transmission of COVID-19 was fully implemented. The facility failed to establish a system to identify which residents were on quarantine to ensure appropriate gown use was used for 3 of 20 residents (R1, R2, R3) identified to be on quarantine precautions; immediately quarantine residents who had symptoms of COVID-19 for 6 of 6 residents (R1, R2, R3, R4, R5, R7) who were displaying signs and symptoms of COVID-19; utilize available rooms to cohort like residents for 1 of 1 residents (R5) who was transferred to a non COVID-19 wing following exposure to COVID-19 residents. In addition, the facility allowed 12 of 15 nursing staff (LPN-A, NA-K, NA-L, RN-B, NA-M, NA-O, LPN-D, LPN-E, NA-P, LPN-F, NA-J, NA-F ) who displayed COVID-19 symptoms to work without confirming negative [MEDICATION NAME] tests with a RT-PCR test. These deficient practices resulted in an immediate jeopardy (IJ) situation which placed 43 out of 50 residents at risk for contracting COVID-19, which had the potential to cause serious illness or death. The IJ began on 10/29/20, when the facility identified the first COVID-19 positive resident and failed to ensure residents who were potentially exposed to COVID-19 positive residents were immediately quarantined and staff were aware of when to utilize gowns for quarantined residents. Residents presenting with COVID-19 symptoms were not quarantined and provided a follow up RT-PCR test to ensure the rapid [MEDICATION NAME] test results were accurate. In addition, the facility did not utilize their empty rooms to cohort residents with potential COVID-19 exposures to one wing to reduce the chances for residents without exposure from contracting COVID-19. Staff presenting with symptoms of COVID-19 were provided a rapid [MEDICATION NAME] test and allowed to work without being provided a RT-PCR test to confirm the negative COVID-19 test. The administrator, director of nursing (DON) and the infection preventionist (IP) were notified of the IJ on 11/20/20, at 5:10 p.m. The IJ was removed on 11/24/20, at 1:05 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 11/19/20, at 12:45 p.m. upon entrance to the facility, the administrator stated the facility had five residents and four employees who had tested positive for COVID-19. The administrator stated the county positivity rate was 4.3% and the facility was testing staff and residents two times per week. The administrator identified the facility's first COVID-19 positive case occurred on 10/19/20, when two employees tested positive for COVID-19. On 10/29/20, two residents tested positive for COVID-19. On 11/19/20, at 1:00 p.m. a brief facility tour was conducted with the DON. The west wing of the facility had been turned into a COVID-19 wing and housed COVID-19 positive residents, who were on isolation precautions along with residents with potential exposures to COVID-19 positive residents and were on quarantine. One non-COVID-19 positive resident resided on the west COVID-19 wing, however she stayed in her room and was not on any COVID-19 transmission based precautions. During the tour, room doors of isolated residents who were COVID-19 positive were not closed, as recommended by the CDC. Both the west COVID-19 wing and the east wing of the facility were located on the ground level of the facility and were opposite of each other, separated by a small lobby area and the nurses station. The second floor of the facility was identified as a dementia unit that housed 18 residents, all of whom were non-COVID-19 positive and had not had previous exposures to COVID-19 positive staff or residents. On 11/20/20 at 4:30 p.m. the administrator and DON were interviewed. The administrator stated 14 residents resided on the west COVID-19 wing. Five residents (R9, R10, R11, R18 and R19) were diagnosed with [REDACTED]. The administrator stated eighteen residents resided on the east wing. Six residents on the east wing were under quarantine due to an exposure to the COVID-19 positive residents, however were not moved to the west COVID-19 wing. The DON stated the facility had seven open beds on the west COVID-19 wing and two open beds on the east wing. RESIDENT QUARANTINE/ GOWN USE /COHORTING: The CDC's Symptoms of Coronavirus, updated 5/13/20, people with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 11/4/2020, directed facility's to implement mechanisms and policies that promoted situational awareness for facility staff. The guidance indicated to the extent possible, patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should be housed in the same room for the duration of their stay in the facility. HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to standard precautions and use an approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. HCP must receive training on and demonstrate an understanding of: when to use PPE, what PPE is necessary, how to properly don, use, and doff PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE and the limitations of PPE. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 was [AGE] years of age and had severe cognitive impairment. R1 was unable to ambulate and required extensive assistance with all activities of daily living (ADL's). R1's [DIAGNOSES REDACTED]. R1's mandatory Resident Temperature/Heart Rate and Oxygen Saturation (O2) Tracking Log from 11/1/20 - 11/19/20, identified R1's temperature, pulse and O2 were monitored two times per day. R1's temperature ranged from 97 degrees Fahrenheit (F) to 98.8 degrees (F) on a.m. and p.m. checks 11/1/20 through 11/28/20. On 11/19/20, a.m. R1's temperature was recorded at 99.9 degrees (F). R1's progress note(s) from 11/1/20 through 11/20/20, identified the following: -11/7/20, R1 was in her wheelchair and was spending time in the hallways or common areas within the unit most of the day. -11/19/20, R1 was placed in quarantine due to contact exposure to a COVID-19 positive resident. During observation on 11/19/20, at 2:20 p.m. R1 was seated in her wheelchair in the doorway of her room on the COVID-19 unit. R1 was not wearing a face mask. Licensed practical nurse (LPN)-A was seated on the floor in front of R1 to change a dressing to her right leg. Nursing assistants (NA)-F and NA-G stood in the hallway directly behind LPN-A and were handing LPN-A dressing packages and gloves. All three staff members wore goggles, face masks and gloves, however, the three staff members were not wearing isolation gowns. LPN-A stated R1 was on the unit due to a possible exposure to a COVID-19 positive resident and had been running a fever that morning but stated a rapid [MEDICATION NAME] test was done that morning and was negative. During interview on 11/19/20, at 2:31 p.m. LPN-A stated five residents had recently tested positive for COVID-19 and those residents had PPE stations hanging on their doors because gowns were required to be worn for their care. LPN-A stated three residents had displayed elevated temperatures, including R1, that morning but they had done rapid [MEDICATION NAME] tests on them and all three tests were negative. The other nine residents on the COVID-19 unit, including R1, were under quarantine because of a potential exposure to a COVID-19 positive resident. LPN-A stated the staff did not wear gowns when they provided care for these residents, because they were not positive for COVID-19. On 11/20/20, at 9:07 a.m. NA-K had on a N95 facemask, faceshield, goggles, and an isolation gown. NA-K removed her isolation gown inside R11's room, who was COVID-19 positive, and performed hand hygiene prior to exiting R11's room. NA-K entered R1's room and shut the door to assist R1 with care. NA-K did not put on an isolation gown prior to entering the room. R1's room had a purple flower sign hanging on the outside of her door, however did not have a PPE cart or drape near/on her door, nor CDC signage to direct staff to what type of PPE was needed for R1's care. NA-K began to gather supplies in R1's room and then stated, Oh, wait a minute. NA-K stated she was unsure if staff were required to wear an isolation gown to provide care to R1 or not. NA-K stated there was no PPE setup in R1's room, but stated she was going to leave the room to obtain an isolation gown to put on, just to be safe. NA-K exited R1's room and went to another resident's PPE cart and obtained a clean isolation gown. NA-K put on the isolation gown and asked LPN-C if she was to wear a gown when providing care to R1. LPN-C stated she was supposed to wear a gown with R1 . NA-K again entered R1's room to provide care, wearing an isolation gown and finished providing care to R1. During interview on 11/20/20, at 9:15 a.m. NA-K stated R1 was under quarantine but was not positive for COVID-19, therefore it was hard to tell if she needed to wear a gown when providing care to R1. NA-K indicated there was no PPE cart or station setup outside R1's room and there was nothing to identify R1 was under quarantine and what, if any PPE was supposed to be used. NA-K stated she was told who was on quarantine through shift report. NA-K stated she could usually tell if a gown was needed if the resident had a PPE drape on their door. NA-K stated there was not a PPE cart or drape on/in R1's room to identify she was on quarantine and a gown was supposed to be worn when providing direct resident care. R7's quarterly MDS dated [DATE], identified R7 was [AGE] years of age and had minimal cognitive impairment. R7 required extensive assistance with all ADL's. R7's [DIAGNOSES REDACTED]. R7's progress note dated 11/16/20, indicated R7's COVID-19 test was negative. During observation on 11/19/20, at 3:37 p.m. NA-H entered R7's room on the west COVID-19 wing, to assist with toileting. NA-H wore a N95 facemask, goggles and a faceshield. NA-H did not put on an isolation gown prior to entering R7's room. NA-H removed the cloth gait belt from around her neck and placed it around R7's waist. NA-H donned (put on) gloves and leaned over R7, while on the toilet to assist R7 with placing her hands on the toilet seat grab bar. NA-H's uniform came into direct contact with R7's shoulder and arm as she assisted her. NA-H physically assisted R7 to a standing position and provided perineal cares along with pulling up her undergarments and clothing. NA-H transferred R7 to her wheelchair. NA-H assisted R7 to use hand sanitizer. NA-H removed the cloth gait belt from around R7's waist and placed the cloth gait belt around her neck. NA-H performed hand hygiene and exited the room. During observation on 11/19/20, at 4:05 p.m. the DON was hanging purple flower signs on several resident doors on the west COVID-19 wing. The DON was overheard, explaining to staff working on the COVID-19 wing, the purple flower signs were to identify residents that were under quarantine and the staff were to wear isolation gowns to care for those residents. Further, if the resident door had a yellow flowered sign, the resident was under isolation and full PPE was needed when caring for the resident. The DON did not hang a purple or yellow flower sign on R7's door, despite R7's potential exposure to COVID-19 positive residents. During interview on 11/19/20, at 4:30 p.m. registered nurse (RN)-A stated there were five positive residents on the COVID-19 wing and the other residents on the wing were there due to a potential exposure to a positive resident. RN-A stated the purple flower signs indicated the resident had a possible exposure to a COVID-19 positive resident and needed to be quarantined. The yellow flower signs indicated a COVID-19 positive residents that were under isolation. RN-A stated the residents on the COVID-19 wing that did not have a purple or yellow flower sign on their door were not under any type of quarantine and only gloves, masks and eye protection was needed to care for those residents. RN-A indicated R7 had frequently come out of her room to leave the COVID-19 wing to play cards with other residents. RN-A indicated R7's activities would have exposed her to a COVID-19 positive residents because of this. RN-A stated R7's door did not have a purple or yellow flowered sign on her door. Further, R7's door should have a purple flowered sign on the door to indicate to staff she was under quarantine, and to don an isolation gown when providing cares. RN-A indicated the purple and yellow signs could be confusing for staff. During interview on 11/20/20, at 8:50 a.m. LPN-C stated R7 was leaving the west wing to play cards until 11/16/20, and had potential exposure to COVID-19 positive residents during that time. All the residents residing on the COVID-19 wing were there because they all had a potential exposure to the COVID-19 positive residents. Staff were not putting on isolation gowns to care for some of the residents on the COVID-19 wing because they were not a potential risk and then stated, but I guess they are a potential risk. LPN-C stated she did not know why some of the residents were not considered to have had a potential exposure and things were changing every day. On 11/20/20, at 8:53 NA-J stated R7's roommate, R6 was moved to another room the previous night after she had tested positive for COVID-19. There was no purple flower sign or precaution sign to indicate to staff that R7 had a high risk exposure to her roommate, a positive COVID-19 resident, and would need to be quarantined to her room and staff would need to use gowns while providing direct resident care. During interview on 11/19/20, at 3:45 p.m. NA-E stated staff only wore isolation gowns for the COVID-19 positive residents. NA-E stated they did not wear isolation gowns for the quarantined resident as it made the residents nervous and fearful that they were ill with COVID-19. R5's annual MDS dated [DATE], identified R5 was [AGE] years of age and had intact cognition. R5 required limited assistance with dressing, toileting and grooming. The MDS included a [DIAGNOSES REDACTED]. R5's progress note(s) from 11/1/20 through 11/20/20, identified the following: -11/19/20, R5 was put into quarantine due to contact exposure from a COVID-19 positive resident with whom she shared a bathroom. Options were discussed with R5 regarding room changes. R5 was offered to remain in her room or to move to a room on the east non-COVID-19 wing. R5 opted to move to the east, non-quarantine wing as she was worried about contracting [MEDICAL CONDITION]. On 11/20/20, at 8:05 a.m. R5 was observed seated in a chair, in her new room on the east wing. R5's door had a purple flower sign hanging on it. There was no PPE station setup near R5's room or door but a red bag garbage can was located just inside the door to her room, which was open. R5 stated she had just moved to the east wing room the previous night. On 11/20/20, at 8:10 a.m. LPN-B stated R5 had been moved to the room from the west COVID-19 wing. LPN-B stated she thought the purple flower signs were from an activity project the residents had done. On 11/20/20, at 8:15 a.m. NA-I stated the signs posted on resident doors looked like purple flowers but she did not know why they were hanging on some of the resident doors. During interview on 11/20/20, at 8:35 a.m. LPN-B stated she had seen a red bag garbage in R5's room but there was not a transmission based precaution sign on R5's door. LPN-B stated she asked another nurse if R5 needed use of PPE for care. A resident on quarantine usually had yellow PPE drapes hanging on their doors to indicate they were quarantined. Some of the residents on the east wing were residents who had an exposure to COVID-19 positive residents but had tested negative. Further, LPN-B did not know which of the residents on the east wing had exposure but stated she thought it was the residents who had PPE drapes hanging on their doors. After checking with another nurse, it was clarified the purple flower sign on resident doors was to identify the residents under quarantine. LPN-B was unsure if all the staff knew what the purple flower signs meant. Following the interview, LPN-B went down the hall to instruct the two NAs working on the unit on the purple flower signs. During interview on 11/20/20, at 8:40 a.m. LPN-C stated the purple flower signs on some of the resident doors on both the east and the west COVID-19 wings were to indicate the resident was under quarantine and the yellow signs on some of the resident doors on the west COVID-19 wing indicated the resident was positive for COVID-19 and under isolation. The facility was not using the standard CDC precaution signs because they were trying to protect the resident's dignity and had chosen to use the purple and yellow signs instead. On 11/20/20, at 8:47 a.m. the DON stated R5 had been moved to the east wing where there were no COVID-19 positive residents because the room she occupied on the west COVID-19 wing had a shared bathroom. The resident who shared the bathroom with R5 had tested positive for COVID-19 and could not use a commode so they moved R5 to a new room on the east wing and did not move R5 to another open room on the west COVID-19 wing even though R5 had potential exposure. R4's quarterly MDS dated [DATE], indicated R4 was [AGE] years of age and had moderate cognitive impairment. R4 required extensive assistance with all ADL's. R4's [DIAGNOSES REDACTED]. R4's progress note dated 11/16/20, indicated R4's rapid COVID [MEDICATION NAME] test was negative. During observation on 11/20/20, at 9:22 a.m. R4 was seated in a chair in her room. R4 demonstrated an active, loose sounding, productive cough. NA-J entered R4's room wearing goggles and a N95 face mask to assist her to the bathroom. NA-J did not don gloves or an isolation gown when entering R4's room. NA-J indicated R4 was very hard of hearing and put her hands on either side of R4's chair and leaned toward R4 to put her mouth close to R4's ear in order for R4 to hear her. R4 was not wearing a source control mask and continued to cough during this encounter. LPN-C entered room wearing a N95 mask and goggles, but did not don gloves or an isolation gown. NA-J and LPN-C assisted R4 into a stand lift and wheeled the lift into the bathroom. R4 continued to cough frequently during the transfer. NA-J stated R4 had a quick COVID-19 [MEDICATION NAME] test done the previous day that was negative. LPN-C lowered the lift to seat R4 onto the toilet. LPN-C left the bathroom to pull back the linens on the bed in preparation for R4 to lie down. LPN-C's scrub uniform pants came into direct contact with R4's bedding. LPN-C returned to the bathroom and using the stand lift, assisted R4 to stand. NA-J put on gloves and assisted R4 with perineal care and pulled up R4's brief and pants , NA-J's uniform brushed against R4 as she was assisting her with cares. R4 was assisted to her bed during which time NA-J and LPN-C's uniforms brushed against R4 and R4's bedding. R4's progress note dated 11/16/20, indicated R4's rapid COVID [MEDICATION NAME] test was negative. R4 exhibited COVID-19 symptoms of a loose productive cough, however, R4 was not placed under quarantine until a second, confirmatory RT-PCR test was done. R3's quarterly MDS dated [DATE], identified R3 was [AGE] years of age and had moderate cognitive impairment. R3 required extensive assistance with all ADL's. R3 [DIAGNOSES REDACTED]. R3's mandatory Resident Temperature/Heart Rate and Oxygen Saturation (O2) Tracking Log dated 11/1/20 through 11/19/20, identified R3's temperature, pulse and O2 were monitored two times per day 11/1/20 through 11/19/20. R3's temperature ranged 97 degrees (F) to 98.8 degrees (F) on a.m. and p.m. shifts from 11/1/20 through 11/28/20. On 11/19/20, R3's a.m. temperature was recorded at 100.3 degrees (F). R3's progress note dated 11/20/20, indicated rapid COVID-19 [MEDICATION NAME] test done due to R3 exhibiting symptoms of runny nose, headache and fever. Test results of the [MEDICATION NAME] test were negative. During observation on 11/20/20, at 9:44 a.m. NA-J and NA-K entered R3's room to assist her to the bathroom. There was a purple flower sign on R3's door, however no PPE station or PPE drape was located in the room. Both staff members were wearing N95 masks, goggles and faceshield's; however they did not put on isolation gowns or gloves prior to entering R3's room. Using the stand lift, NA-J and NA-K assisted R3 to a standing position and quickly wheeled the lift to the toilet. NA-J lowered R3's pants and NA-K lowered R3 onto the toilet. After toileting, NA-J assisted R3 to a standing position and NA-K donned gloves and assisted R3 with perineal care. R3 was then wheeled to her bed and lowered on to the bed. NA-K removed her gloves and assisted to lift R3's legs into the bed at which time NA-K's uniform came into contact with R3 and her bedding. NA-J covered R3 with her blankets and her uniform was observed to come into contact with R3's blankets. Both NA's entered R3's bathroom to wash their hands at the resident's sink. The front of their uniforms touched the sink while washing their hands. During interview with NA-J and NA-K, on 11/20/20, at 10:00 a.m. NA-J stated her uniform had the potential to brush against residents and their belongings when not wearing an isolation gown and stated she was sure they did. NA-J stated that was why the staff wore isolation gowns for the COVID-19 positive residents. NA-K indicated R3 was under quarantine but did not have [MEDICAL CONDITION]. R3's Covid-19 test results identified R3 had COVID-19 RT-PCR test on: 10/8/20, 10/12/20, 10/15/20, 10/19/20, 10/22/20, 10/26/20, 10/29/20, 11/2/20 and 11/17/20, all the tests negative. R3 was not tested for Covid-19 on 11/5/20, 11/9/20 and 11/20/20, however, R3 was not placed under quarantine until 11/19/20 due to a potential exposure to another COVID-19 positive resident. R3's RT-PCR Covid-19 test on 11/21/20, identified she tested positive for COVID-19. R2's annual MDS dated [DATE], indicated R2 was [AGE] years of age and had moderate cognitive impairment. R2 required extensive assistance with all ADL's. The MDS identified [DIAGNOSES REDACTED]. R2's mandatory Resident Temperature/Heart Rate and Oxygen Saturation (O2) Tracking Log dated 11/1/20 through 11/19/20, identified R2's temperature, pulse and O2 were monitored two times per day 11/1/20 through 11/19/20. R1's temperature ranged 97 degrees (F) to 98.8 degrees (F) on a.m. and p.m. checks 11/1/20 through 11/28/20. On 11/19/20 a.m. R2's temperature was recorded at 100.5 degrees (F). R2's progress note(s) from 11/1/20 through 11/20/20, identified the following: - 11/12/20, R2 received Tylenol (a pain reliever and fever reducer) daily, three times per day for pain. - 11/19/20, R2 had a slightly elevated temperature in the morning, however was normal by the afternoon. During observation on 11/20/20, at 9:57 a.m. R2 was lying in her bed, with the door open. There was a purple flower sign hanging on the front of R2's door. No PPE cart or drape was observed in the room and there were no PPE trash and/or laundry baskets in the room. NA-K entered R2's room. NA-K was wearing a N95 mask and a face shield. NA-K did not don an isolation gown or gloves. NA-K removed her cloth gait belt from around her waist and placed it around R2's waist. NA-K placed an arm around R2's shoulders and behind her knees to assist her to sit on the edge of the bed. Positioning R2's arms around her neck, NA-K braced her knees against R2's knees and hugged R2 around her waist to assist to stand and pivot transfer to her wheelchair. NA-K wheeled R2 into the bathroom and repeated the same hugging transfer onto the toilet. Toileting care was not observed as R2 requested the bathroom door stay shut. After assisting with toileting, NA-K wheeled R2 back to her bed and using the cloth gait, repeated the same hugging transfer back into bed. NA-K removed the cloth gait belt from around R2's waist and put the gait belt around her own waist. NA-K then placed an arm behind R2's shoulders and behind R2's knees and assisted R2 into a lying position on the bed, covered R2 with a blanket, completed hand hygiene and exited the room. R2's COVID-19 testing results identified R2 was tested on [DATE], with a rapid [MEDICATION NAME] test with a negative result, following an onset of a fever. R2 was tested on [DATE], with a RT-PCR test with a positive COVID-19 test result. During interview on 11/20/20, at 10:51 a.m. the DON and the facility infection preventionist (IP) were interviewed. The DON stated when they identified the COVID-19 positive residents they moved those residents to the very end of the west wing to create a west COVID-19 wing, with the exception of R11, who remained in the middle of the hall because of her mental and physical needs. The positive COVID-19 residents were placed in isolation with dedicated equipment and staff were to use full PPE, including gowns with resident cares. They attempted to identify residents that had high risk exposures with COVID-19 positive residents. They identified R1, R2 and R5 as residents with high risk exposures and placed them under quarantine. R5 was moved from the west COVID-19 wing to the east non- COVID-19 positive wing on 11/19/20, because R5 had been sharing a bathroom with a COVID-19 positive resident, R11, who needed the use of the bathroom. R7 was also placed into quarantine because her roommate, R6, had just tested positive. R6 was moved to the end of the hall with the other COVID-19 positive residents. Quarantined, non-COVID-19, residents were identified by a purple flower sign on their door so staff would understand the difference between quarantined residents and COVID-19 positive isolated residents. Full PPE was required when caring for the residents in the quarantined rooms, including gowns. Staff were not be able to go between the purple flowered rooms (quarantined) with other purple flowered rooms. Staff would need to disrobe upon exiting the purple flowered room and put on new gowns before entering another purple flowered room. COVID-19 positive residents were in isolation rooms and the staff were able to go between rooms of COVID-19 positive residents utilizing the same PPE, even though the west wing had a mixture of COVID-19 positive and negative residents. The facility had decided to use the colored flowered signs for resident dignity reasons and to keep the residents from worrying about it and what it meant. Some of the staff were not aware of the meaning of the colored flower signs as the facility had just started implementing the flowered sign system and had not yet educated all the staff on it. Education was planned to be done during report for the remaining staff. There were residents on the east non COVID wing that they had identified may have come into contact with COVID-19 positive residents, however, those residents had not been moved to the west COVID-19 wing. Those residents remained on the east non-COVID positive wing and had purple flowers (quarantine) on their doors and full PPE was required for their care. The facility policy Kittson Healthcare [MEDICAL CONDITION] Event (COVID-19) revised 11/20, indicated residents would be actively screened and symptomatic residents would be isolated as soon as possible. Signage on residents doors would identify transmission based precautions would be required prior to entering the room. Staff would be required to gown, glove, wear a face mask and eye protection to enter. Cohorting of residents would be done in the nursing home if there were two or more positive COVID-19 cases. Residents who were symptomatic of COVID-19 or refused to be tested would be isolated to their rooms, staff would monitor ill residents three times per day with dedicated medical equipment. 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. QUARANTINING OF SYMPTOMATIC STAFF: The CDC Interim Guidance for Rapid [MEDICATION NAME] Testing for [DIAGNOSES REDACTED]-CoV-2 dated 9/4/20, identified the sensitivity of current FDA-authorized [MEDICATION NAME] tests varies, and thus negative diagnostic testing results should be handled differently depending on the testing device and its stated performance characteristics. In most cases, negative [MEDICATION NAME] diagnostic test results are considered presumptive. CDC recommends confirming negative [MEDICATION NAME] test results with an RT-PCR test when the pretest probability is relatively high, especially if the patient is symptomatic or has a known exposure to a person confirmed to have COVID-19. Ideally, confirmatory RT-PCR testing should take place within two days of the initial [MEDICATION NAME] testing. The facility's staff symptom tracking log for October 2020, and November 2020, identified fifteen staff had complaints of COVID-19 signs and symptoms. The staff were given a quick [MEDICATION NAME] test the day of their complaints and twelve were determined to be negative for COVID-19. The twelve staff, while symptomatic, were allowed to work despite displaying potential signs and symptoms of COVID-19, without being quarantined to home pending a PCR COVID-19 confirmation test of the negative results. -LPN-A complained of a runny nose. and a rapid [MEDICATION NAME] test was done on 10/5/20, The [MEDICATION NAME] test was negative. LPN-A worked a shift on 10/5/20, and 10/7/20. On 10/8/20, a PCR COVID-19 test was administered during the facility's routine testing. -NA-K had a rapid [MEDICATION NAME] test done on 11/5/20, for complaints of symptoms which were not identified on the staff symptom tracking log. NA-K worked 11/10/20, 11/11/20 and 11/12/20. On 11/12/20, a PCR COVID-19 test was administered during the facility's routine testing. -NA-L complained of symptoms of a runny nose and a rapid [MEDICATION NAME] test was done on 11/5/20. NA-L worked 11/5/20, 11/6/20 (TRUNCATED)

Based on interview and document review, the facility failed to implement physician orders [REDACTED]. This failure resulted in an immediate jeopardy (IJ) situation for R1 due to the facility's failure to implement daily skin checks, which resulted in the development of a Stage 4 pressure ulcer. However, at the time of the investigation, it was determined the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance for R1. On 3/6/2020, at 1:15 p.m. the facility administrator and director of nursing were notified of the facilities failure to prevent the development of pressures ulcers resulting in an IJ situation related to the development of a Stage 4 pressure ulcer for R1. The past non-compliance IJ began on 1/30/20, when the provider had identified pressure related areas under R1's left splint, and ordered daily splint removal and skin assessments which were not implemented until 2/20/20, after R1 had been identified with a Stage 4 pressure ulcer. Findings include: A Nursing Home Incident Report (NHIR) submitted 2/25/20, indicated R1 had sustained a [MEDICAL CONDITION] fibula and tibia on 1/19/20, which was evaluated in the emergency department (ED). Treatment consisted of placement of a splint to the left lower leg. R1 had returned to the facility with a hospital verbal order to not remove the splint. On 1/27/20, R1 was seen by the physician, and an X-ray identified no change to fracture therefore, order was given to continue with the splint. On 1/30/20, the staff notified the physician assistant (PA) regarding swelling to R1's left foot. The PA removed the splint and Ace wrap (elastic wrap) and examined R1's foot and leg. A reddened area was noted behind R1's left leg. The PA added additional padding to the back of R1's knee, and no further orders were received. On 2/5/20, the Ace wrap was removed, and a clean Ace wrap was applied. On 2/19/20, an X-ray indicated the fracture was healing. During physician rounds on 2/20/20, the Ace wrap and splint were removed and a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer was discovered, and no impact on R1's quality of life was noted. Care plan and orders were followed. The facilty's 5 day investigation form indicted the splint was discontinued and a boot was applied. Nursing order was put into place were to check placement of the boot and skin condition every shift. R1's PA visit summary dated 1/30/20, indicated R1 exhibited severe puffiness with a fluid filled appearance at the top of the left foot from the toes to mid-foot, where the splint edge was. The edge of the splint was very tight on the foot and ankle bone. Ace wraps were removed times two, and the splint was released at the top of left leg and stretched back to loosen. Within two minutes, the swelling at the top of the foot started to decrease, and after five minutes there was minor puffiness noted. Pedal pulse (pulse noted on the top of the foot) was palpable, and the foot was warm and dry with good capillary refill. No open areas were noted. A one millimeter (mm) pink area was noted on the top of the left foot, medial side, without any sloughing of skin, and no raised area or indentation areas. A similar sized area was also noted on the posterior lower leg, lateral area at the bend of the knee. Cast padding was applied to the top of the foot and left lateral ankle. The splint was laid back over the leg and loosely wrapped with two Ace wraps to just below the knee, but not under where knee bends. The visit summary plan directed the nurses to check under R1's splint daily for skin exam, and then to rewrap. The swelling on the top of the left foot had gone down, and the physician had an order for [REDACTED]. R1's Physician Visit dated 2/20/20, indicated R1's splint was removed, and revealed a Stage 4 pressure ulcer with necrosis (death of cells or tissue) of muscle to left popliteal fossa (space behind the left knee). Dressing changes were implemented, and staff was to ensure R1 was seen by wound care staff. The splint was not to be reapplied, and a midcalf cushion boot was ordered to be worn for the left tibia/fibula fracture. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. R1 required total assistance of two staff for transfers, was unable to walk, and was at risk for pressure ulcers. R1's care plan dated 1/21/20, indicated R1 was at risk for developing pressure ulcers related to incontinence, immobility, and contractures to lower extremities. The care plan identified a superficial area on buttocks related to shearing, no other skin breakdown areas were identified. The care plan was revised on 2/20/20, identifying a pressure ulcer behind the left knee, and red area on top of left foot, with bi-weekly dressing change directives, and assessment of skin under boot every shift. However, the care plan lacked the directive related to the 1/30/20, PA order for the removal of the splint, and daily skin checks to be conducted under splint. R1's Medication Administration Record [REDACTED]. R1's Progress Notes reviewed from 1/30/20, through 2/20/20, lacked documentation reflecting daily skin monitoring had been conducted, as ordered. On 3/5/20, at 1:45 p.m. licensed practical nurse (LPN)-B confirmed R1's splint had not been removed, and skin assessments had not been completed prior to the identification of R1's pressure ulcer, because there were no orders to do so. -At 2:40 p.m. LPN-C stated following R1's fracture, she had been told the physician or NP would be following up on R1, and she was not to remove the splint. LPN-C stated R1's skin under the splint and behind the knee were not visible to assess without removing the splint. LPN-C stated removal of the splint and skin checks had not been implemented until after the physician had discovered the Stage 4 pressure ulcer. -At 3:12 p.m. during a telephone interview, PA-A confirmed she had visited R1 on 1/30/20, at which time the nursing staff had requested an evaluation of R1's left foot due to swelling. PA-A stated she had removed R1's splint, and noted two reddened areas on left lateral foot and behind the left knee which were approximately 1.0 mm in diameter, and were not open. PA-A stated she had written orders for the nurse to remove and check under R1's splint daily and to conduct a skin assessment, and then rewrap it. PA-A stated it was her expectation for nursing to implement the orders as written, as the ongoing monitoring of R1's skin would have identified the change in R1's skin condition thereby preventing R1's development of the Stage 4 pressure ulcer. -At 4:32 p.m. the director of nursing (DON) confirmed the physician identified R1 had developed a Stage 4 pressure ulcer on 2/20/20. The DON stated she reviewed R1's physician and PA visits and orders from the date of R1's fall resulting in fractures on 1/19/20, and on 2/20/20, she had discovered the order from the PA directing nursing staff to remove the splint and check R1's skin daily. The DON stated she discussed the order with the registered nurse (RN) unit coordinator, who confirmed she had not reviewed the summary and had missed the order. The DON stated the RN indicated the NP would add orders to her summaries that were not discussed during the NP visit, which resulted in the RN being unaware of the orders. The DON stated following a visit, the NP would dictate her visit, but verified the RN would have access to the dictated summary and any orders that same day. The DON confirmed the RN had neglected to review R1's PA visit summary, thereby missing the new order resulting in the daily skin assessments not being completed. The DON verified the daily skin checks had not been conducted from 1/30/20, until 2/20/20, when R1's Stage 4 pressure ulcer was identified by her physician. The DON stated it was her expectation for nursing to review provider summaries/orders, and implement changes as directed. The facility's Nurse Care Coordinator Job summary undated, indicated the care coordinator was responsible for transcribing and reviewing physician orders, and also assured that necessary arrangements were made, as ordered. The past non-compliance that began on 1/30/20, was reviewed to be corrected by 2/20/20, after the facility had implemented the following interventions: -Ensuring all residents had physician orders [REDACTED]. The floor nurses were assigned to obtain, monitor, review, and follow up on all resident skin assessments and follow up if needed. -R1's physician orders [REDACTED]. R1's Care plan revised to reflect skin monitoring and dressing changes. -The identification of all potentially affected residents and reviewed all physician orders [REDACTED].>-Nurse Unit Managers and MDS RN educated on physician order [REDACTED]. -Continued Quality Assurance: audits implemented to ensure enhanced system compliance. A risk management meeting was scheduled for 3/19/20. Weekly auditing in place and DON responsible for follow up. -Staff education was provided. Verification of corrective action was confirmed by observations, interviews with a variety of staff including administration, and document review. Training and education was completed by 2/20/20, and ongoing audits conducted verified interventions had been implemented. Nursing staff were educated to the facility policy and revisions were made to include the on-going monitoring of resident skin assessment and follow-up to physician orders [REDACTED]. The facility incorporated the action plan into the facility wide quality assurance program.

Based on interview and document review, the facility failed to implement physician orders [REDACTED]. This failure resulted in actual harm to R1 when the facility failed to conduct daily skin assessments as ordered resulting in the development of a stage 4 pressure ulcer. Although noncompliance was present at the time of the event, the facility implemented appropriate corrective action prior to the survey resulting in a finding of past-noncompliance for R1. Findings include: A Nursing Home Incident Report (NHIR) submitted 2/25/20, indicated R1 had sustained a [MEDICAL CONDITION] fibula and tibia on 1/19/20, which was evaluated in the emergency department (ED). Treatment consisted of placement of a splint to the left lower leg. R1 had returned to the facility with a hospital verbal order to not remove the splint. On 1/27/20, R1 was seen by the physician, and an X-ray identified no change to fracture therefore, order were given to continue with the splint. On 1/30/20, the staff notified the physician assistant (PA) regarding swelling to R1's left foot. The PA removed the splint and Ace wrap (elastic wrap) and examined R1's foot and leg. A reddened area was noted behind R1's left leg. The PA added additional padding to the back of R1's knee, and no further orders were received. On 2/5/20, the Ace wrap was removed, and a clean Ace wrap was applied. On 2/19/20, an X-ray indicated the fracture was healing. During physician rounds on 2/20/20, the Ace wrap and splint were removed and a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer was discovered, and no impact on R1's quality of life was noted. Care plan and orders were followed. The facilty's 5 day investigation form indicted the splint was discontinued and a boot was applied. Nursing order put into place were to check placement of the boot and skin condition every shift. R1's PA visit summary dated 1/30/20, indicated R1 exhibited severe puffiness with a fluid filled appearance at the top of the left foot from the toes to mid-foot, where the splint edge was. The edge of the splint was very tight on the foot and ankle bone. Ace wraps were removed times two, and the splint was released at the top of left leg and stretched back to loosen. Within two minutes, the swelling at the top of the foot started to decrease, and after five minutes there was minor puffiness noted. Pedal pulse (pulse noted on the top of the foot) was palpable, and the foot was warm and dry with good capillary refill. No open areas were noted. A one millimeter (mm) pink area was noted on the top of the left foot, medial side, without any sloughing of skin, and no raised area or indentation areas. A similar sized area was also noted on the posterior lower leg, lateral area at the bend of the knee. Cast padding was applied to the top of the foot and left lateral ankle. The splint was laid back over the leg and loosely wrapped with two Ace wraps to just below the knee, but not under where knee bends. The visit summary plan directed the nurses to check under R1's splint daily for skin exam, and then to rewrap. The swelling on the top of the left foot had gone down, and the physician had an order for [REDACTED]. R1's Physician Visit dated 2/20/20, indicated R1's splint was removed, and revealed a Stage 4 pressure ulcer with necrosis (death of cells or tissue) of muscle to left popliteal fossa (space behind the left knee). Dressing changes were implemented, and staff was to ensure R1 was seen by wound care staff. The splint was not to be reapplied, and a midcalf cushion boot was ordered to be worn for the left tibia/fibula fracture. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. R1 required total assistance of two staff for transfers, was unable to walk, and was at risk for pressure ulcers. R1's care plan dated 1/21/20, indicated R1 was at risk for developing pressure ulcers related to incontinence, immobility, and contractures to lower extremities. The care plan identified a superficial area on buttocks related to shearing, no other skin breakdown areas were identified. The care plan was revised on 2/20/20, identifying a pressure ulcer behind the left knee, and red area on top of left foot, with bi-weekly dressing change directives, and assessment of skin under boot every shift. However, the care plan lacked the directive related to the 1/30/20, PA order for the removal of the splint, and daily skin checks to be conducted under splint. R1's Medication Administration Record [REDACTED]. R1's Progress Notes reviewed from 1/30/20, through 2/20/20, lacked documentation reflecting daily skin monitoring had been conducted, as ordered. On 3/5/20, at 1:45 p.m. licensed practical nurse (LPN)-B confirmed R1's splint had not been removed, and skin assessments had not been completed prior to the identification of R1's pressure ulcer, because there were no orders to do so. -At 2:40 p.m. LPN-C stated following R1's fracture, she had been told the physician or NP would be following up on R1, and she was not to remove the splint. LPN-C stated R1's skin under the splint and behind the knee were not visible to assess without removing the splint. LPN-C stated removal of the splint and skin checks had not been implemented until after the physician had discovered the Stage 4 pressure ulcer. -At 3:12 p.m. during a telephone interview, PA-A confirmed she had visited R1 on 1/30/20, at which time the nursing staff had requested an evaluation of R1's left foot due to swelling. PA-A stated she had removed R1's splint, and noted two reddened areas on left lateral foot and behind the left knee which were approximately 1.0 mm in diameter, and were not open. PA-A stated she had written orders for the nurse to remove and check under R1's splint daily and to conduct a skin assessment, and then rewrap it. PA-A stated it was her expectation for nursing to implement the orders as written, as the ongoing monitoring of R1's skin would have identified the change in R1's skin condition thereby preventing R1's development of the Stage 4 pressure ulcer. -At 4:32 p.m. the director of nursing (DON) confirmed the physician identified R1 had developed a Stage 4 pressure ulcer on 2/20/20. The DON stated she reviewed R1's physician and PA visits and orders from the date of R1's fall resulting in fractures on 1/19/20, and on 2/20/20, she had discovered the order from the PA directing nursing staff to remove the splint and check R1's skin daily. The DON stated she discussed the order with the registered nurse (RN) unit coordinator, who confirmed she had not reviewed the summary and had missed the order. The DON stated the RN indicated the NP would add orders to her summaries that were not discussed during the NP visit, which resulted in the RN being unaware of the orders. The DON stated following a visit, the NP would dictate her visit, but verified the RN would have access to the dictated summary and any orders that same day. The DON confirmed the RN had neglected to review R1's PA visit summary, thereby missing the new order resulting in the daily skin assessments not being completed. The DON verified the daily skin checks had not been conducted from 1/30/20, until 2/20/20, when R1's Stage 4 pressure ulcer was identified by her physician. The DON stated it was her expectation for nursing to review provider summaries/orders, and implement changes as directed. The facility's Nurse Care Coordinator Job summary undated, indicated the care coordinator was responsible for transcribing and reviewing physician orders, and also assured that necessary arrangements were made, as ordered. The past non-compliance that began on 1/30/20, was reviewed to be corrected by 2/20/20, after the facility had implemented the following interventions: -Ensuring all residents had physician orders [REDACTED]. The Floor nurses were assigned to obtain, monitor, review, and follow up on all resident skin assessments and follow up if needed. -R1's physician orders [REDACTED]. R1's Care plan revised to reflect skin monitoring and dressing changes. -The identification of all potentially affected residents and reviewed all physician orders [REDACTED].>-Nurse Unit Managers and MDS RN educated on physician order [REDACTED]. -Continued Quality Assurance: audits implemented to ensure enhanced system compliance. A risk management meeting was scheduled for 3/19/20. Weekly auditing in place and DON responsible for follow up. -Staff education was provided. Verification of corrective action was confirmed by observations, interviews with a variety of staff including administration, and document review. Training and education was completed by 2/20/20, and ongoing audits conducted verified interventions had been implemented. Nursing staff were educated to the facility policy and revisions were made to include the on-going monitoring of resident skin assessment and follow-up to physician orders [REDACTED]. The facility incorporated the action plan into the facility wide quality assurance program.

Based on observation, interview and document review, the facility failed to identify, comprehensively assess, develop and/or implement appropriate interventions, and adequately monitor skin wounds in order to promote intact skin integrity and healing of an abrasion on the left great toe for 1 of 1 resident (R34) who had a history of [REDACTED]. This failure resulted in actual harm for R34 whose wound worsened and became infected. In addition, the facility failed to comprehensively assess, monitor and implement interventions for 1 of 1 resident (R52) who had increased [MEDICAL CONDITION] (swelling) of the legs without the application of compression stockings, as ordered. Findings include: R34's quarterly Minimum Data Set ((MDS) dated [DATE], identified R34 had severely impaired cognition, and [DIAGNOSES REDACTED]. The MDS indicated R34 was totally dependent on staff for all activities of daily living except was able to eat with supervision. R34's annual MDS dated [DATE], identified R34 had the same [DIAGNOSES REDACTED]. R34's Pressure Ulcer Care Area Assessment (CAA) dated 7/12/18, indicated R34 was at risk for pressure sores due to mobility deficits related to poor circulation, stroke, diabetes with insulin use, [MEDICAL CONDITION], bowel and bladder incontinence, and [MEDICAL CONDITION]. The CAA indicated R34 had a stasis ulcer to the left shin, but no pressure ulcers. R34's Care Plan dated 2/21/18, indicated R34 had a history of [REDACTED]. The last documentation indicated the wound was almost healed on 9/19/18. No further documentation was evident and R34 obtained a new abrasion to his toe on 11/21/18. R34's Care Plan dated 3/28/18, indicated staff were instructed to monitor the abrasion daily during cares and to notify the nurse if noted to be worsening. R34's Kittson Memorial Healthcare dated 9/6/17, indicated R34 had a personal history of circulatory system, probably venous stasis and combination of arterial for the non healing wound of his left shin. R34's physician indicated the wound was a chronic wound and the physician's goal was to prevent infection to the wound. R34's Progress Notes/ daily nurses notes dated 11/21/18, indicated the staff had identified a scrape on R34's left great toe, however, no further assessment as to how the scrape had been obtained, the size, depth and/or severity was noted. On 11/26/18, at 6:32 p.m. R34 was observed at the dining table, seated in a reclining wheelchair in a reclined position with feet slightly elevated. R34's left great toe was open to air and visible through the toe hole of a compression sock. An approximately 1-2 centimeters (cm) dark area was noted on the outer aspect of the toe with a reddened area on the outer portion. On 11/28/18, at 1:12 p.m. licensed practical nurse (LPN)- D was observed to perform R34's left shin wound care. At this time, LPN-D indicated R34's toe wound was from an abrasion which he received during a transfer. LPN-D stated the wound had progressed from a simple scratch/abrasion to a blackened area. LPN-D stated a note had been sent to R34's primary physician regarding the toe wound. At this time, an approximately 1-2 cm blackened colored scab was noted on the side of the left great toe and the entire rest of the toe was reddened. LPN-D confirmed the redness and stated the redness was noted on 11/27/18, however, the facility was not providing any type of treatment to the area, at this time. LPN-D stated R34 had a history of [REDACTED]. LPN-D applied the Prevalon boot (a pillow-like boot to help prevent pressure ulcers on the heels), elevated the foot on a pillow and exited the room. No assessment of the toe wound was completed. R34's Kittson Memorial Healthcare note (clinic office note) dated 11/28/18, indicated R34 was evaluated for a worsening toe abrasion. The nurse practitioner (NP) described the wound as an abrasion appearing like a skin tear in a circular pattern. The wound had dried crusted areas around the perimeter showing redness, warmth to the touch and swelling. NP diagnosed [MEDICAL CONDITION] (bacterial skin infection) of the left toe. The plan instructed staff to soak the foot three times a day with [MEDICATION NAME] (antibacterial solution) water and to keep the wound clean and dry. An antibiotic (Keflex) was also prescribed. R34's Resident Inadvertent Incident Report dated 11/28/18, indicated the scrape on R34's left great toe occurred on 11/21/18, during a transfer from chair to bed. Recommendations made were for occupational therapy to evaluate for protection of R34's toes, to monitor toes/feet closely with transfers and to follow up with the wound specialist during next rounds. On 11/29/18, at 9:30 a.m. registered nurse (RN)-B indicated a wound specialist followed R34 weekly for the stasis ulcer on his shin, but had not been aware of the toe wound until 11/27/18. RN-B stated she was unaware R34 had a wound on his left great toe until 11/27/18, when she was informed R34 had been refusing to wear the Prevalon boots and upon investigation of R34's refusals, RN-B noted the toe wound. RN-B stated R34 had a history of [REDACTED]. RN-B had directed the staff regarding the importance of immediately reporting skin concerns to either herself or to the charge nurse on duty due to the possibility of R34's wounds not healing. RN-B confirmed there was no documentation regarding the toe wound between 11/21/18, and 11/27/18, and stated R34's toe abrasion was currently an unstageable wound (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. RN-B stated a comprehensive skin assessment should have been completed on 11/21/18, at the time the wound was identified, however, a comprehensive skin assessment had not been completed. - 11/29/18, 12:58 p.m. the director of nursing (DON) stated she was unaware R34 had developed an unstageable wound to the left great toe. The DON confirmed a comprehensive skin assessment should have been completed at the time the toe wound was identified. R12's quarterly MDS dated [DATE], and annual MDS dated [DATE], identified R12 had moderately impaired cognition and [DIAGNOSES REDACTED]. The MDS indicated R12 required limited assistance with bed mobility and transfers, supervision/set up with walking with a front wheeled walker (FWW) in room/corridor/unit and extensive assistance with dressing, toileting, and personal hygiene. R12's CAA dated 3/7/18, indicated R12 had [DIAGNOSES REDACTED]. The CAA further indicated R12 usually made needs known and was usually understood by staff. R12's assessment identified the need for limited to extensive assist with ADLs, and R12's [MEDICAL CONDITION] (inflammation of the skin) would resolve with the current orders. R12's Care Plan last revised 11/15/18, indicated R12 had a history of [REDACTED]. Staff were instructed to apply [MEDICATION NAME] (steroid cream used to treat inflammation or itching of the skin) cream to itchy areas, apply [MEDICATION NAME] (a medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) lotion to irritated skin per doctor's orders. The staff were also instructed to report any skin breakdown. R34's Physician order [REDACTED]. The physician also directed the staff to ensure R12's skin was lotioned well and to ensure R12's fingernails were trimmed and cleaned at least twice daily. R12's Nursing Progress note dated 10/29/18, identified, old previous sores from scratching. On 11/26/18, at 6:26 p.m. scabbed abrasions were noted on the back of R12's left hand. At this time, R12 was observed to reach out with his right hand and scratch the back of the left hand and forefinger. Opened areas were not bleeding and the scabbed areas on the back of the left hand were approximately 1 cm in size. The left pointer finger also had an approximately 1 cm scabbed area and the finger was swollen and reddened. As R12 rubbed the left index finger, he stated his hands were sore and itched. The back of R12's right hand also had an approximately 1 cm scabbed abrasion. On 11/28/18, at 7:51 a.m. R12 was observed in the dining room. The left hand was noted to be swollen. -At 8:00 a.m. as R12 rubbed his hands, the left hand was noted to be pink colored and shiny. R12 stated his hands itched. -At 8:54 a.m. R12 observed to rub and scratch at his left hand. -At 11:31 a.m. R12 was observed seated at dining table in dining room, rubbing his hands together and scratch at the back of his hands. -At 12:52 p.m. NA-E offered R12 restorative exercises, however, R12 refused stating his fingers were sore, itched, were swollen and needed lotions. NA-E offered the exercises twice, however, R12 continued to refuse. NA-E did not provide/offer R12 any type of lotion for his hands. R34's medical record contained weekly skin checks which indicated: - 9/3/18, random open areas primarily on R12's legs, none draining and without much change from week prior. The skin check lacked location of the open areas along with a description including the size or if there had been drainage. Causal factors were not identified. - 9/10/18, scratches on legs (shins), behind right ear, right shoulder, and on right hand. The skin check lacked the size, color or possible drainage and/or causal factors. - 9/17/18, skin was about the same as the week prior skin assessment with scratches on legs (shins), behind right ear, right shoulder, and on the right hand healing. R12 continued to have other areas that needed lotion because they were dry and itchy. No measurements or descriptions were documented. - 9/24/18, scratches on R12's body were the same, most healing normally, with a new scratch on upper left thigh. No measurements or descriptions were documented. - 10/1/18, scabs and scars where R12 scratched skin. No new areas were noted. No measurements or descriptions documented. - 11/6/18, self inflicted scratch marks to both lower extremities and stomach. Random discolorations to different parts of body. No measurements were documented. - 11/12/18, old discolorations and bruising to both upper/lower extremities from scratching. Also had open area to the left hand where he has scratched it open. No measurement were documented. - 11/27/18, indicated random scratches, especially on R12's hands, ointment was applied. No measurements were documented. A Nursing Progress Note dated 11/28/18, at 8:33 p.m. indicated R12 utilized [MEDICATION NAME] cream as needed for itching. No further documentation or measurement of sores noted. R12's Medications Administration Record (MAR) dated 11/1/18 - 11/29/18, indicated [MEDICATION NAME] cream had been applied four times in (MONTH) (YEAR). On 11/29/18, 10:10 a.m. RN-B indicated R12 had a history of [REDACTED]. RN-B stated she was aware R12 had scratches and open areas on the left hand and that the nursing staff were to measure and document any concerns regarding his skin during the weekly skin checks. RN-B stated R12 also had a history of [REDACTED]. RN-B stated R12 had creams to be used as needed to help relieve any irritated skin concerns/itchy spots. RN-B reviewed R12's MAR and confirmed R12 had only utilized the [MEDICATION NAME] cream four times in (MONTH) (YEAR). RN-B stated she was not aware the creams had not been utilized when needed and that a comprehensive skin assessment had not been completed. -At 10:39 AM, RN-B and RN-C were observed to measure R12's open areas on his hands. The left pointer finger was open and bleeding while RN-C applied a Band-Aid for pressure. RN-C stated R34 had scratched open the right pointer finger wound that morning which required cleaning and a new dressing applied. R12 was noted to have the following wounds: - Left hand wound closest to the wrist had a pink open flesh wound which measured 0.5 x 0.7 cm. - Left hand wound closer to fingers had a pink open flesh wound which measured 1.1 x 0.3 cm. - Left index finger wound was open and actively bleeding and measured 0.3 x 0.3 cm. - Right hand pointer finger had a dry black scab/wound which measured 0.7 x 0.3 cm. - Right hand ring finger dry black scab wound measured 0.8 x 0.2 cm. -At 10:45 a.m. RN-C stated R12 continually picked at the wounds. R12 stated, They itch all the time. RN-B stated she was not aware R12 had wounds on the right hand and confirmed R12's wounds had gotten worse. RN-B also confirmed the staff had not been documenting the location, size, color or causal factors of the wounds. RN-B stated she would expect the staff to inform her of any additional wounds and complete a comprehensive skin assessment at the time new wounds were identified. - At 12:40 p.m. the DON stated she was not aware R12 had developed new open areas on his hands. The DON stated she was aware R12 had a history of [REDACTED]. A facility Skin Breakdown Prevention Protocol, undated, identified a system was in place for the prevention, identification, treatment and documentation of non-pressure wounds. The protocol stated nursing would do a weekly skin check for residents at least weekly, on the residents' bath day, and document any problems noted. The notes were to include a clear description of the ulcer and surrounding skin, a description of any drainage, what the treatment was with effectiveness, and verification the practitioner was notified of the status. R52's admission MDS dated [DATE], indicated R52 was cognitively intact and required limited assistance of one staff for dressing. R52's Occupational Therapy Treatment Encounter note dated 11/9/18, indicated [MEDICAL CONDITION] bilaterally in lower extremities. Size medium Tensoshape was provided and nursing was notified on communication log, to apply in AM remove at bedtime. R52's physician order [REDACTED]. Orders included compression stockings to bilateral lower extremities to be on during the day with a start date of 11/9/18. R52's care plan dated 11/21/18, directed staff to monitor weight daily and notify medical doctor (MD) and family of significant weight change. The care plan also directed staff to evaluate, record and report swelling of the ankles and feet. The care plan did not address use of Tensoshape stockings (compression stockings). R52's resident care sheet provided on 11/26/18, directed staff to apply Tensoshape stockings to lower extremities (on in AM, off at bedtime). On 11/28/18, at 7:13 a.m. NA-A was observed to provide R52 morning cares which included dressing. Gripper socks were applied and not the Tensoshape stockings, as directed. On 11/28/18, during observations from 8:02 p.m. until 12:53 p.m. licensed practical nurse (LPN)-B, LPN-A, and an unidentified occupational therapist had entered R52's room and interacted with R52. During the observation, none of the staff assessed R52 for [MEDICAL CONDITION] in lower legs or applied the Tensoshape stockings. -At 12:55 p.m. surveyor requested LPN-A to assess R52's [MEDICAL CONDITION] in the lower extremities. LPN-A assessed the [MEDICAL CONDITION] and stated the left extremity [MEDICAL CONDITION] measured 2+ (2 seconds to rebound when finger pressed into skin) and the right lower extremity measured 3+ (3 seconds to rebound) [MEDICAL CONDITION]. LPN-A stated R54 should have the Tensoshape stocking applied every morning by the NA. LPN-A proceeded to apply the stockings and reminded R52 to keep feet elevated as much as possible. -At 1:05 p.m. RN-A stated R52 should be wearing compression stockings daily and the NA's were responsible to apply them with morning cares. RN-A also stated R52 was to be weighed every morning, however, confirmed there were no parameters for when the MD should be notified of weight changes. -At 1:12 p.m. NA-A stated she was not sure if R52 was to wear compression stockings or if therapy applied leg wraps. NA-A acknowledged she had not applied compression stockings to R52 that morning with cares. On 11/29/18, at 8:07 a.m. the DON stated R52 was to have compression stockings applied each morning by the NA's and confirmed they did not have orders or specific instructions for when to notify the MD regarding any weight changes. The DON stated she would expect the nurse's to use their critical thinking skills as to when to notify the MD. Fallibility policy Weight and Height Measurement (undated), indicated to notify the charge nurse or physician of all weight changes of 5 pounds (or 5%) or more in a 30-day period or ten percent in a 180 day period or per state requirement.