Every finding on record at Lake Minnetonka Shores

Based on document review and interview the facility failed to ensure 1 of 5 residents (R13) was offered, educated and/or provided the pneumococcal vaccination series as recommended by the centers for disease control (CDC), who were reviewed for immunizations.Findings Include:A CDC Adult Immunization Schedule by age topic, dated 08/07/2025, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had not received the complete series of pneumococcal vaccination (i.e., PPSV23, PCV20 and PCV13) or their history is unknown, then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20), 1 dose of PCV-15, or PCV-21. R13's annual Minimum Data Set (MDS) dated [DATE], indicated R13 was admitted [DATE], was severely cognitively impaired and had the following diagnoses: hypertension (HTN) (high blood pressure), benign prostatic hypertrophy (BPH) (enlarged prostate), and non-Alzheimer's dementia.R13's Order summary report dated 7/22/26, indicated the following physician order:May receive pneumococcal vaccinations if not already received. Order date: 5/27/26.R13's Minnesota Immunization Information Connection report dated 7/22/26, indicated R13 had received the following vaccinations:Pneumo-PCV13 (Prevnar 13) administered 8/29/17Pneumo-PPSV23 (polysaccharide PSV23) administered 10/1/17R13's Pneumococcal Vaccinations Consent form signed 5/27/26, indicated R13 had given consent and requested to receive the pneumococcal vaccination.R13's medical record lacked any evidence a vaccination was provided.On 7/22/26 at 3:00p.m., the director of nursing, working as the infection preventionist, confirmed the vaccination had not been provided. The DON stated their expectation was the vaccinations should have been provided upon admission. The DON stated the family had wanted to wait until R13 was doing better to receive it; however, the facility should have followed up in 2-4 weeks after R13's admission. The DON stated the importance of providing vaccinations in a timely manner to prevent illness.The facilities Pneumococcal Vaccination Policy last revised 11-24, indicated each resident's pneumococcal immunizations status will be determined upon admission or soon thereafter if vaccination has occurred, the vaccination date will be documented in the resident's medical record.

Based on record review, and interview, the facility failed to update the provider of a weight change per physician order for 1 of 5 residents (R3) reviewed for unnecessary medications.Findings include:R3's quarterly minimum data set (MDS) dated [DATE], indicated R3 was severely cognitively impaired, admitted on [DATE], and had the following diagnoses: heart failure (inability of the heart to pump efficiently), non-Alzheimer's dementia, and anxiety. R3's clinical physician orders dated 7/22/26, indicated the following orders:Daily weight. Updated NP (nurse practitioner) if weight increases by 3 pounds (LBS) in one day or 5LBS in one week. Order start date: 4/29/26.R3's weights and vitals dated 7/22/26, indicated the following weight fluctuations:On 5/17/26, R3 weighed 171.2lbsOn 5/18/26, R3 weighed 174.2lbs, an increase of 5lbs.On 5/19/26, R3 weighed 170.6lbs, a decrease of 3.6lbsR3's medical record lacked any evidence the provider was ever updated per the provider order.On 7/22/26 at 7:43 a.m., the administrator confirmed the facility did not update the provider of the above noted weight changes per the order.On 7/22/26 at 3:00 p.m., the director of nursing (DON) confirmed the facility did not update the provider of the weight changes of R3 and stated they would have expected the staff to update the provider and document the communication in R3's chart. The DON stated the importance of updating the provider to prevent serious illness or harm to the resident.The facility Communication and Notification-Staff, Practitioners, and Resident Representatives last modified July 2024, indicated staff will notify the practitioner any time there is a:Significant change in clinical condition: including but not limited to a need to discontinue or change an existing form of treatment due to adverse consequences, or to initiate a new form of treatmentChange in mental, psychological or behavioral patternsAny other time there has been a significant change in status from the plan of careOccurrence involving a fall or other type of occurrence requiring more than nursing intervention to address.

Based on interview and document review, the facility failed to ensure resident advanced directives were accurately documented in the electronic medical record (EMR) and physician orders to ensure their wishes would be followed in the event of a cardiac arrest for 1 of 24 residents (R158) reviewed for advanced directives. The immediate jeopardy (IJ) began on [DATE] when R158 completed an updated Physician's Orders For Life Sustaining Treatment (POLST) to change code status to Do Not Resuscitate (DNR) and was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 12:18 p.m. on [DATE]. The immediate jeopardy was removed on [DATE] but noncompliance remained at the lower scope and severity level D, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: R158's EMR banner in Point Click Care (PCC) reviewed on [DATE] at 7:07 p.m., identified R158 was full code, meaning chest compressions would be started if the resident was found with no pulse and no respirations. On [DATE] at 7:07 p.m., R158's order summery report in the electronic medical record (EMR) included an order dated [DATE] for full code. R158's most current Physician's Orders For Life Sustaining Treatment (POLST) located in the scanned EMR, signed by R158 and nurse practitioner (NP)-A on [DATE], identified R158 wished to be do not resuscitate (DNR). R158's POLST located in hard chart dated [DATE], indicated a code status of DNR. Physician signed orders in hard chart dated [DATE], include notation to review new POLST. Orders were signed by LPN-C as reviewed. On [DATE] at 7:19 p.m., licensed practical nurse (LPN)-A stated she would look at the banner for code status. She stated if full code, she would start chest compressions. She stated staff were trained to look at the banner in the EMR for code status. On [DATE] at 7:20 p.m., LPN-B stated he would look at the EMR banner for code status. LPN-B looked at the banner for R158 and stated he would start chest compressions if he found the resident unresponsive. On [DATE] at 7:21 p.m., registered nurse (RN)-B stated he would look at the banner in the EMR for code status. RN-B stated if the banner indicated full code, chest compressions should be started. On [DATE] at 7:22 p.m., clinical coordinator (CC)-A stated code status was reviewed during admission, care conferences and with a change in condition. If a code status was changed during a provider visit, the new orders were entered into the EMR by the floor nurse. This included a change to code status/POLST. CC-A confirmed R158's banner indicated full code for code status. CC-A confirmed the most recent POLST dated [DATE], indicated R158 wished to be DNR. CC-A stated staff looked at the banner for guidance, however CC-A stated R158's documentation was inconsistent. On [DATE] at 7:31 p.m., director of nursing (DON) stated staff checked the EMR banner for code status. When a resident was listed as full code, chest compressions were started and another staff retrieved the POLST form for additional instructions. On [DATE] at 9:29 a.m., R158 stated she wished to be DNR and should not have CPR. The immediate jeopardy that began on [DATE], was removed when the facility developed and implemented a systematic removal plan. The removal plan was verified on [DATE] through interview and document review. The facility had corrected the code status for R158, completed a facility wide audit to ensure no other code status discrepancies, reviewed policies and procedures, implemented a double check practice for all new orders, and provided education for staff prior to start of shift.

Based on observation, interview and document review, the facility failed to follow food safety guidelines to thaw raw chicken to prevent the spread of cross-contamination. Furthermore, the facility failed to ensure appropriate hand hygiene was performed for 1 of 1 staff observed preparing food in the kitchen. These deficient practices had the potential to affect all 57 residents who ate in the facility. Findings include: During a kitchen observation on 4/25/24 at 11:55 a.m., cook-A stated chicken was being thawed for supper. Cook-A was working at a two-compartment stainless steel prep sink, and the right-side sink compartment was approximately 75% full of cloudy, pink-gray water, with cold water running from the faucet into the cloudy water, and the contents of the sink were not visible. A stainless draining pan, positioned over the left-side sink compartment, contained approximately 12 pieces of boneless, skinless chicken pieces. However, no water was running over the raw chicken in the left-side compartment. Cook-A submerged gloved hands passed the wristband of the gloves into the cloudy water, removed raw, frozen chicken pieces from the cloudy water, pulled the frozen pieces apart under the running water, and placed the separated pieces into the draining pan. After approximately five minutes, cook-A removed gloves, moved to the handwashing sink, applied liquid soap to hands, rubbed hands together for approximately 10 seconds, turned water on, rinsed hands, dried hands with paper towel, and used the same paper towel to turn off the faucet. Cook-A applied clean gloves, placed the chicken pieces from the draining pan onto two lined baking pans, and placed the pans on a rack located in the prep area. Cook-A then returned to the prep sink and continued to separate frozen chicken pieces in the same manner. After approximately another five minutes, cook-A removed her gloves, turned off prep sink faucet, turned the right-side drain lever, and moved to the handwashing sink. Cook-A applied liquid soap to hands, rubbed hands together for approximately 10 seconds, turned faucet on, rinsed hands, dried hands with paper towel, used the same paper towel to turn off the faucet, applied clean gloves, submerged gloved hands, past the wristband of the gloves, into the cloudy water, removed approximately 10-12 pieces of raw, frozen chicken pieces from the cloudy water, placed them into the draining pan, turned the cold water back on over the drain pan of chicken, separated the remaining frozen chicken pieces under the cold running water, and placed them on a lined baking pan. After approximately five minutes, cook-A removed gloves, placed the baking sheet on the rack, turned the right-side drain lever, ran the disposal until the water emptied, and moved to the handwashing sink. Cook-A applied liquid soap to hands, rubbed hands together for approximately 10 seconds, turned faucet on, rinsed hands, dried hands with paper towel, and used the same paper towel to turn off the faucet. The dietary manager (DM) told cook-A she needed to wash hands longer, for at least 20 seconds, needed to scrub with soap and water, and instructed cook-A to wash hands again the correct way. On 4/25/24 at 12:21 p.m., the DM stated raw chicken should never be thawed unwrapped in a filled sink of water. The chicken should have been pulled from the freezer the previous day, to thaw by the preferred method in the refrigerator overnight. If meat was not thawed by the preferred method, it needed to remain in leak-proof packaging, in a bin with cold water running continuously to prevent cross-contamination. Additionally, DM stated staff were expected to wash hands for at least 20 seconds, and staff needed to scrub with soap and water, not just soap and then rinse with water. DM stated proper handwashing had been reviewed multiple times and proper handwashing procedure signs were posted over all sinks. The facility's Proper Thawing of Frozen Foods policy, revised 7/19, indicated proper food handling procedures needed to be followed in regard to the thawing of all frozen foods. The facility's Handwashing Policy, updated 5/19, indicated hands and exposed portions of arms needed to be washed for at least 20 seconds by the following method: 1) rinse under warm, running water, 2) apply soap and rub all surfaces of hands and arms, 3) rinse thoroughly with warm, running water, 4) dry hands and exposed portions of arms with single-use paper towels, 5) use a clean barrier, such as a paper towel, to turn off faucet.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R1, R17) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Center for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R1's admission record printed 4/25/24, indicated an age of 90 and diagnoses of severe protein-calorie malnutrition, immunodeficiency, and type 2 diabetes. R1's electronic medical record (EMR) failed to include proof of offering of PVC20 vaccine. R1's care plan printed 4/25/24, included focus of potential for infection related to history of infection and use of immuno-suppressant medication. R17's admission report printed 4/25/24, indicated an age of 80 and diagnoses of morbid (severe) obesity, unspecified asthma, and type 2 diabetes. Facility document titled Pneumococcal Vaccination Consent, was signed as completed 2/18/24. Section on shared clinical decision making was not filled out. A notation was made appears to be up to date. R17's Order Summary Report, printed 4/25/24, included an order dated 2/17/24, resident may receive pneumococcal vaccinations if not already received. During interview on 4/24/24 at 2:42 p.m., director of nursing (DON) stated R1's EMR indicated eligibiltiy, however, lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. During interview on 4/24/24 at 2:42 p.m., director of nursing (DON) stated R17's EMR did include a document stating the resident appeared up to date on pneumococcal vaccinations, however, R17 was eligible for the PCV20 vaccine. R17's record lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. Facility policy Pneumococcal Vaccination Policy dated July 2023, included residents should be vaccinated in accordance with the CDC's pneumococcal vaccine recommendations and if a resident declined the vaccine, it should be documented in their medical record.

Based on observation, interview and record review, facility failed to follow proper use of personal protective equipment (PPE) for 1 of 1 residents (R1) reviewed for contact precautions. This had the potential to affect all 57 residents, staff and visitors. Findings include: R1's wound culture lab collected 4/2/24, indicated resident's right foot wound was infected with methicillin-reistant staphylococcus aureus (MRSA). Lab report included MRSA required contact precautions. R1's diagnosis report printed 4/25/24, included diagnoses of non-pressure chronic ulcer of other parts of left foot, non-pressure chronic ulcer of other parts of right foot, and dementia. R1's order summary report printed 4/25/24, included an order for wound care on right lateral foot. Clean with normal saline. Cover heel and medial wound with foam dressing. Observation on 4/24/24 at 7:13 a.m., license practical nurse (LPN)-C completed wound care on R1. LPN-C donned PPE outside of R1's room. PPE included a short sleeve, fabric gown tied around neck and disposable gloves. LPN-C cleansed wound by squirting normal saline onto wound bed and drying with gauze, which created an opportunity for splashing. During interview on 4/24/24 at 10:25 p.m., infection preventionist (IP) stated R1 had a wound culture that came back positive for MRSA and needed to be on contact precautions. She expected staff to wear a long sleeve gown with cuffs and gloves whenever coming in contact with the resident. IP confirmed short sleeved fabric gowns outside R1's room did not meet the criteria for contact precautions. During interview on 4/24/24 at 10:29 a.m., registered nurse (RN)-A stated he expected staff to wear long sleeve gowns with cuffs while providing wound care to a resident on contact precautions. RN-A stated it was important to protect clothing and skin that may come in contact with the wound during cares and could be spread to other residents. Undated facility policy titled Infection Prevention and Control Manual, included instructions on gown use. Policy indicated the gown should be a clean, non-sterile gown with long sleeves will be worn for direct care or when contact with secretions or excretions.

Based on observation, interview, and document review the facility failed to ensure all medications and biologicals were locked in compartments which only allowed authorized personnel to have access. This had the potential to affect all the residents residing on the third floor of the facility. Findings include: During continuous observation on 4/23/24 from 3:10 p.m. until 3:50 p.m. medication cart 1 on third floor remained unlocked. Registered nurse (RN)-C left the cart unlocked and out of eyesight at 3:10 p.m., 3:19 p.m., 3:28 p.m., 3:34 p.m., 3:41 p.m. to complete medication passes. During this time residents, visitors and unlicensed staff walked by the unattended cart. On 4/23/24 at 3:50 p.m., the clinical coordinator (RN)-A approached the medication cart, and locked the cart when RN-C was not present. On 4/24/24 at 4:12 p.m., RN-C stated the cart should have been locked when left unattended and out of eyesight. On 4/23/24 at 4:19 p.m., the clinical coordinator RN-A stated staff were expected to lock the medication cart when unattended and out of their view. RN-A stated this was an issue. On 4/25/24 at 12:07 p.m., the director of nursing (DON) stated staff were expected to lock the medication cart when not in range of sight of the cart. DON stated it was important to lock unattended medication carts to prevent diversion, and safety of the residents and staff. The facility's Medication Ordering and Receiving from Pharmacy Policy, undated, indicated only licensed nurses, pharmacy personal and those authorized to administer medications were permitted access to them. Medication rooms, carts, and medication supplies are to be locked when not in attendance by persons with authorized access.

Based on interview and document review, the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 57 residents residing in the facility, staff and visitors who may wish to view this information. Findings include: During review of the staff posting documentation from 3/24/24 through 4/25/24, the facility failed to provide evidence of staff postings for the following dates: 3/24/24, 3/30/24, 3/31/24, 4/3/24, 4/6/24, 4/7/24, 4/13/24, 4/14/24, 4/21/24. On 4/24/24 at 3:11 p.m., the administrator acknowledged the facility had not completed nor posted the staffing information daily. On 4/25/24 at 11:22 a.m., the staffing coordinator (O)-D stated staffing information needed to be posted and updated daily. On 4/25/24 at 12:07 p.m., the director of nursing (DON) and the administrator stated staff postings were expected to be completed every day and was important to have the information available to those who wished to view it, and to ensure enough staff were on site. The facility's Nurse Hours Posting Policy, last modified in October 2022, indicated the staff data would be posted on a daily basis.

Based on observation, interview, and documentation review the facility failed to provide assistance with facial hair removal for 1 of 1 residents (R26) with grooming needs who was dependent upon staff for assistance. Findings include: R26 Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of coronary artery disease, hypertension, osteoporosis, and spinal stenosis. R26's care plan indicated R26 was an assist of one staff with personal cares. On 8/22/23 at 3:14 p.m., R26 was observed in bed with one to one and half inch of neck hair to trachea area and down from his ears to the top of his shoulder area on both sides of neck. On 8/23/23 at 7:04 a.m., R26 was observed in bed, awake looking out the window. R26 had hair on the neck that was not shaved. On 8/23/23 at 7:10 a.m., nursing assistant (NA)-D was observed doing cares for R26 and did not shave his face or neck. On 8/23/23 at 10:01 a.m., NA-D stated R26 had one half inch to two inches in length on the sides of his neck. NA-D stated R26 needed to be shave. NA-D asked R26 if he wanted to be shaved because his neck hair was long, he agreed but it was to long for the shaver. NA-D stated he would need to go to the barber to have the long hair removed. On 8/23/23 at 10:14 a.m., registered nurse (RN)-B stated we encourage daily grooming for the residents. On 8/23/23 at 1:22 p.m., NA-E stated they shaved the male residents every day. NA-E stated R26's neck looked like a weeks' worth of growth or more on his neck. On 8/24/23 at 9:11 a.m., RN-C stated staff could shave residents on bath day or anytime they needed or wanted to be shaved. RN-C stated R26's neck hairs were one and a half to two inches in length and should not be that long. Further, if staff were shaving him, they were not doing it correctly. On 8/24/23, at 9:28 a.m. the director of nurses (DON) stated shaving should occur daily with grooming. The facility policy Resident Care Policy reviewed 2/2016, indicated to shave residents in am and apply makeup to female residents as requested.

Based on interview and document review the facility failed to ensure 1 of 1 residents (R5) and/or resident representative(s) were included in the comprehensive care planning reviewed for participation of care. Findings include: R(5)'s quarterly Minimal Data Set (MDS) dated [DATE], indicated fully intact cognition (able to fully understand), Diagnoses included medically complex conditions (more than one complicated medical diagnosis), hypertension (High blood pressure), Dementia (reduced brain function), depression (Feeling sad), and asthma (reduced airway function in lung tubes). On 8/23/23 at 12:40 p.m., R5 stated she did not recall having a care planning conference in the last year and would consider going if invited. R5 electronic health record (EHR) indicated MDS completed on 5/8/23. However, lacked documentation a care conference occurred which included R32 or his responsible representative for previous 4 quarters, since 5/4/22. On 8/23/23 at 12:45 p.m., Registered Nurse (RN)-B stated residents were offered care planning conferences but it was handled by the Home Care Coordinator (HCC) for the second floor. On 8/23/23 at 12:54 p.m., HCC stated she performed the social worker role for the second floor and organized the care conferences. HCC confirmed the record lacked documentation of care conferences being offered. She stated care conferences were important for resident outcomes. HCC stated care conferences were good for family and resident collaboration and would be beneficial for R5. On 8/24/23 at 11:14 a.m., Director of Nursing (DON) stated she was not sure why the care conferences had not been done. DON stated she felt care planning conferences were important for residents and families. DON stated that documentation of the care conferences needed to be done. Facility Care Plan policy requested, however, none provided.

Based on observation, interview and document review, the facility failed to ensure resident private care needs and therapy information was kept private for 3 of 3 residents (R354, R352, R302) who were receiving occupational therapy (OT) services. Findings include: R354's care plan dated 8/16/23 indicated R354 received OT services and required staff assistance with grooming and hygiene. R352's care plan dated 8/15/23 indicated R352 received OT services and required staff assistance with grooming, hygiene, and transfers. R302's care plan dated 8/17/23 indicated R302 received OT services and required staff assistance with grooming, hygiene, and transfers. On 8/21/23 at 3:12 p.m., a laminated, colorful, 8x10 sign was posted on the outside of R354's door. The sign indicated R354's name, room number, time and date of OT appointment, personal cares to be completed with OT and personal cares to be completed by nursing. On 8/21/23 at 3:12 pm p.m., an identical OT sign was posted on the outside of R352's door and was visible to anyone walking in the hallway. On 8/22/23 at 3:46 p.m., an OT sign was posted on the outside of R302's door and was visible to anyone walking in the hallway. On 8/23/23 at 8:00 a.m., OT-A stated signs are used for communication between OT and nursing. OT-A acknowledged the sign contained private resident information that was visible to the public. On 8/24/23 at 10:37 a.m., the administrator stated the OT posting contained private resident information and should not have been posted for the public to view. The facility's Notice of Privacy Practices, dated 7/21/21, defines the term health information as information that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

Based on interview, and document review, the facility failed to ensure complaints of worsening acute generalized pain were comprehensively assessed and treated in a timely manner to provide comfort and reduce risk of complications for 1 of 1 residents (R1) who voiced concerns about pain following a fall. This resulted in actual harm when after a fall R1 experienced increasing, ongoing pain with decreased mobility and was subsequently hosptialized for fractures. Findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R1 had intact cognition, was on scheduled and as needed pain medication and R1 reported frequent pain, however did not limit her from day to day activities and sleep at night. The facility did not provide evidence of pain assessment completed for R1 prior to or after the fall. R1's pain care plan dated 2/2/22, identified R1 had chronic managed pain related to [CONDITION(S)], [CONDITION(S)], decreased mobility, contractures, and history of left tibia fracture. The care plan directed staff nurses to monitor the effectiveness of pain interventions, notify the physician if interventions are unsuccessful or if current complaint was a significant change from R1's past experience of pain and nurses were to identify, record and treat R1's existing conditions which may increase pain and or discomfort. Incident Occurrence Report dated 7/28/22, at 10:30 a.m. revealed R1 while in the shower after having the shampoo rinsed out of her hair and was having conditioner put in her hair when R1 slipped off the shower chair and fell to the floor. During review of the Falls Huddle Review Form dated 7/28/22, revealed R1 had indicated I hurt allover however, staff wrote to the side commented prior to shower as well. During review of the interdisciplinary notes the following was revealed: -Fall description note dated 7/28/22, at 11:38 indicated at 10:30 a.m. while in the shower after having the shampoo rinsed out of her hair and having conditioner put in R1's hair R1 slipped off the shower chair. The note then indicated R1's pain was reported as unchanged from prior to the shower. R1 was examined for injury, none noted and then was assisted with four staff and with a full body lift into the manual wheelchair, was assisted to her room and into the bed. R1 complained of the right lower extremity (RLE) hurting. The note further indicated the nurse practitioner (NP) was notified of the fall and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . X-ray results noted negative results for fractures on the left foot and ankle, and right foot and ankle. -Fall follow up PN dated 7/28/22, at 8:55 p.m. indicated R1's range of motion (ROM) was limited at baseline, R1 complained of general pain with movement and both as needed (PRN) and scheduled pain medications were administered. The note did not indicate the level of pain assessed. -Fall follow up PN dated 7/29/22, at 12:52 a.m. indicated ROM limitation as her baseline related to contractures. Writer assessed resident's pain as follow up from evening report with [MEDICATION(S)] administration at 9:53 p.m., resident stated a little bit on my whole body when asked to rate current pain on a scale of 0-10, resident complained 1-2 pain med was effective. -Fall follow up PN dated 7/29/22, at 1:44 p.m. R1 complained of pain all over about 9:26 a.m. was given PRN [MEDICATION(S)] 10 mg. R1 stated she will get up at 10:30 a.m. and when staff went to get her up, she requested to get up at 12:00 p.m. then at 1:00 p.m. R1 requested 10 more minutes. Staff then assisted to get R1 up about 1:30 p.m. at which R1 had pain with movement and repositioning and the pain was general pain. -Fall follow up PN dated 7/30/22, at 5:10 a.m. nurse had administered PRN [MEDICATION(S)] per R1's request for pain rated 8 out of 10 with pending effect. -Fall follow up PN dated 7/30/22, at 11:49 a.m. indicated R1 did complain of nausea again, but no vomiting. Resident stated, My legs are killing me. [MEDICATION(S)] 10 mg given with relief and R1 noted to have dark purple bruises on both knees, right thigh had a larger bruise that was turning purple and deep purple bruise remained to left wrist. The noted did not indicated the physician/provider or on-call had been called for R1's expression of her legs killing her. -PN dated 7/31/22, at 4:30 a.m. indicated due to too much general body pain, PRN [MEDICATION(S)] was administered per resident request for pain rated 8 out of 10 after non-pharmacological intervention was ineffective. -Fall follow up PN dated 7/31/22, at 10:06 indicated R1 requested [MEDICATION(S)] for leg pain. My legs are killing me. Bruising on left leg was extending down to upper calf. R1 refused Ace wraps due to the pain, but it was not unusual for R1 to refuse ace wraps. R1 also would not allow the writer to elevate the head of bed (HOB) due to pain it caused. R1 continued to complain of pain to her legs from the fall. The note lacked documentation of the physician being notified for the resident expression of pain and continued complaints of pain including refusing the HOB to be elevated. -PN dated 8/1/22, at 1:49 p.m. R1 at 1:15 p.m. had requested to be assisted out of bed and prior to touching the covers on her bed R1 began to say, Ouch Ouch Ouch. The writer then asked R1 where she hurts and R1 responded all over. The writer then asked where exactly she was hurting, but R1 would not give details. The note indicated after the cares R1 transferred out of bed using a full body lift and R1 complained of pain during transfer but refused to offer specific details. The nurse indicated R1 did not have subjective signs of discomfort noted other than the verbal reports and she had called the NP and left message related to complaint of pain. -PN dated 8/5/22, at 10:01 a.m. indicated R1 had complained of pain during transfer in/out of bed to wheelchair and when the nurse offered pain medication R1 refused to take before she left for an appointment. -Late entry PN dated 8/7/22, at 7:00 p.m. indicated R1 had complained of generalized pain at approximately 5:30 p.m. R1 had rated the pain 5 out of 10 and did not identify specific origin of pain stating, I hurt everywhere. R1 and [MEDICATION(S)] 5 mg was given at 5:49 p.m. -Late entry PN dated 8/7/22, at 8:15 p.m. indicated the writer received notification from the trained medication aide (TMA) that R1's family requested a transfer to hospital at approximately 8:17 p.m. via phone call. Writer approached R1 who reported FM-A wanted her to go in. R1 further complained of having all over generalized pain rating it 12 out of 10. When questioned further on pain origin R1 indicated she was experiencing the pain in her legs. During assessment R1 was grunting. Records indicated R1 was transferred to the hospital at 10:22 p.m. per FM-A request. The hospital imaging report dated 8/7/22, revealed R1 was found to have the following fractures: -There are moderate compression fractures of indeterminate age involving the superior L4 and L5 vertebral bodies resulting in increased L3-4 and L4-5-disc height. - An impacted transverse fracture of the proximal tibial shaft, extending into the tibial plateaus, with mild varus angulation on the left knee. During review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -7/1/22 through 7/27/22, prior to the fall R1 had requested the PRN [MEDICATION(S)] 10 mg 15 times in 27 days -7/28/22 through 8/7/22, after the fall R1 had received PRN [MEDICATION(S)] 10 mg 25 times in 9 days of which resident rated her pain 7 to 10 Although staff nurses had contacted the NP on 7/29/22, and 8/1/22, the notes did not indicate specifics of what the NP had been updated on and the recommendation from the provider. In addition, the medical record lacked documentation of the nurses doing follow up with the NP and/or provider on-call about the complaints of pain and the increase in PRN pain medication. During interview on 8/15/22, at 4:34 p.m. FM-A stated after the fall, they had reached out to the facility and had been told R1 had been x-rayed and there were no results. FM-A stated they had received multiple messages from R1 indicating how she had pain and at some point when FM-A had spoken with R1 they had noticed R1 was experiencing a little [CONDITION(S)] and thought it may have been from all the pain medication R1 had been receiving following the fall. FM-A stated after 11 days of R1 being at the facility and feeling nothing was being done, they had requested to have R1 be evaluated at the hospital where she was found to have fractures as the hospital x-rays for the whole body were completed to rule out and identify the cause of the pain R1 was experiencing. During interview on 8/15/22, at 9:32 a.m. nursing assistant (NA)-A stated although R1 had chronic pain, after the fall she had noticed the pain had increased and R1 would tell them she was hurting all over and even before you touch her, she would complain of pain. NA-A stated, When she had the pain, we would let the nurses know and I think they were giving her Tylenol or something not sure what. During interview on 8/15/22, at 9:43 a.m. registered nurse (RN)-A stated the policy was when a resident had a change of condition and a new acute onset of pain she would administer the PRN pain medication, follow up with the provider, follow up with the resident if the medication was effective and then would follow up with the provider if she did not hear from them to make sure the issue was addressed. During interview on 8/15/22, at 12:50 p.m. the NP stated following the fall her colleague had taken the call regarding R1's fall. NP stated she had then received a call 7/28/22, requesting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP then stated she had subsequently received a call on 8/1/22, and was informed about the pain and that the pain medication [MEDICATION(S)] had been administered. NP also stated she was off from work on 8/2/22, through 8/7/22, however, during her absence she had her colleagues cover for her. The NP stated she had reviewed the calls which had been made to the colleagues and there was no documentation of staff nurses calling regarding the increased acute pain R1 was experiencing following the fall, the verbalization of pain and the increased use and need for PRN narcotics. The NP stated, It's hard to say if they should have called me because of her long history of chronic pain but I would have wanted them to call if she was using the PRN's more as there was someone covering for me while I was away. They should have called because she had increased PRN use, crying, moaning and at times not wanting to get out of bed. The NP further stated she had reviewed the notes from her colleagues and there had not been any calls until 8/7/22, night when she gave the order to send R1 to the hospital. During interview on 8/15/22, at 11:20 a.m. the clinical administrator (CA) reviewed the interdisciplinary and nursing notes and stated there was notes of the staff nurses updating the NP on 7/28/22, 7/29/22 and 8/1/22, about the pain. The CA stated the expectation was the nurses were to notify the provider if R1 had increased pain after being assessed and the nurses should have done a follow up with the provider when the pain continued, and they had not heard from the provider. During a follow up interview on 8/16/22, at 9:04 a.m. the CA stated the nurse should have called back the provider to notify the provider R1 was still experiencing the pain and was taking that many narcotics. The facility Pain Assessment and Management Policy Modified: November 2016, directed staff the following: 3. Notify MD of pain assessment findings if pain is indicated to start or change pain management program as necessary with on going evaluation of effectiveness of medications prescribed. 4. Follow prescribed orders for pain management-documenting results in the eMAR for PRN medications using provided pain scale of 0-10. For residents on scheduled pain medications, document effectiveness routinely and notify MD or Nurse Practitioner if/when change in medication regimen is needed .

Based on observation, interview, and document review, the facility failed to comprehensively assess resident equipment to ensure appropriateness and safety when using a shower chair for 1 of 1 resident (R1) who had a fall while receiving a shower. This resulted in actual harm for R1 who was hospitalized , and was diagnosed with compression fractures of L4-L5 and impacted transverse fracture of the proximal tibial shaft extending into the tibial plateaus reviewed for accidents. Findings include: R1's diagnoses included [CONDITION(S)] (RA), other chronic pain, contractures of the right and left knees, and arthritis obtained from the annual Minimum Data Set (MDS) dated [DATE]. In addition, the MDS identified R1 had intact cognition. R1's activities of daily living (ADL) care plan identified R1 had a self-care performance deficit related to limited range of motion (ROM), contractures, activity intolerance, RA and chronic pain. The care plan directed staff for bathing I require assist of two using the full lift for transfers and one assist staff participation with bathing. On 8/15/22, the shower chair which R1 was using at the time of the fall was observed stored in the Spa room. The rolling wheeled shower chair was constructed out of [MEDICATION(S)] chloride with a straight mesh covered backing and had a blue open front soft vinyl cushion seat with a donut cut out bottom. No safety belts were observed on the chair. The chair could also be used as a commode. Incident Occurrence Report dated 7/28/22, at 10:30 a.m. revealed while in the shower after having the shampoo rinsed out of her hair and was having conditioner put in her hair R1 slipped off the shower chair and fell to the floor. At the time of the fall R1 was being assisted by nursing assistant (NA)-A who witnessed the fall. The staff indicated Analysis as the cause of occurrence: Poor posture related to [R/T] co-morbidities. Action to Minimize Reoccurrence: Occupational [OT] to evaluate shower chair positioning. During review of the interdisciplinary notes the following was revealed: -Fall description note dated 7/28/22, at 11:38 indicated at 10:30 a.m. while in the shower after having the shampoo rinsed out of her hair and having conditioner put in R1's hair R1 slipped off the shower chair. R1 was being assisted, and the fall was witnessed and due to R1's size and body alignment, staff was unable to intervene as R1 slipped off the shower chair onto the right side. The note then indicated after the fall R1 rested on the shower room floor on the right side, both knees bent resting on the right shoulder with arm underneath R1. The note also indicated the witness believed R1 did not hit her head but was unable to say for sure. The note then indicated R1's pain was reported as unchanged from prior to the shower. R1 was examined for injury, none noted and then was assisted with four staff and a full body lift into the manual wheelchair, was assisted to her room and into the bed. R1 complained of the right lower extremity (RLE) hurting. The note further indicated the responsible parties, and the nurse practitioner (NP) were notified of the fall and an order was obtained for X-ray to be completed and R1 was noted to have bruising on both knees, left forearm and the left knee there was a 4.0 centimeter (cm) light bruise and skin was intact. The note did not indicate the level of pain R1 had prior to the fall. -PN dated 7/29/22, at 8:54 a.m. indicated the NP was updated on R1's current status and staff had obtained an order for OT to evaluate and treat, assess cognitive changes as well as shower chair positioning. -Interdisciplinary team (IDT) follow up analysis PN dated 7/29/22, at 12:34 p.m. indicated R1 had fallen on 7/28/22, at 10:30 a.m. in shower. The noted indicated R1's hair had been washed and rinsed but the body was soapy and was seated on the shower chair she prefers when showering. The nurse wrote WAS IT ASSESSED TO BE APPROPRIATE & DEEMED SAFE PRIOR TO FALL? She sat with her usual abnormal body alignment, head down and leaning to the right at the shoulders. It may be possible she fell asleep while having her hair washed, leaned forward, and went to the floor. Staff had hands on assist and care plan was followed. She landed on her right side; knees bent. She offered complaints of pain that compared to same pain reported prior to assist with shower per chronic pain noted. The note further indicated R1 had complained of feet hurting. X-ray was ordered. X-ray results noted negative results for fractures on the left foot and ankle, and right foot and ankle. The note did not address and/or respond if the shower chair had been assessed to be appropriate and safe for R1 to use despite R1's usual abnormal body alignment and no seat belt. Progress notes from 7/28/22-8/7/22 revealed documentation of R1 reporting consistent pain, refusing activity and receiving more than average amounts of PRN medication. The hospital imaging report dated 8/7/22, revealed R1 was found to have the following fractures: -There are moderate compression fractures of indeterminate age involving the superior L4 and L5 vertebral bodies resulting in increased L3-4 and L4-5-disc height. - An impacted transverse fracture of the proximal tibial shaft, extending into the tibial plateaus, with mild varus angulation on the left knee. On 8/15/22, at 1:35 p.m. NA-A stated prior to assisting R1 with the shower on the day R1 fell out of the shower chair, she and another staff had completed the shower the previous week with her observing and doing hands on care (training observation). NA-A stated she and NA-C had transferred R1 into the shower chair and then took R1 into the Spa room where they weighed R1 and then NA-C left her to assist with the shower. NA-A stated after washing and rinsing R1's hair between the shampoo and conditioner she had looked away from R1 to grab the conditioner for R1's hair and in that split second R1 fell out of the shower chair. NA-A stated the distance she had to travel in that split second was approximately a foot length. NA-A stated she was not sure what would have led to the fall to happen but thought it was a combination of R1's abnormal posture and the shower chair being slippery. NA-A stated following the fall she had not received any training but had been involved in discussions on using another shower chair for R1 and using two staff to assist with the bathing. NA-A further stated when R1 was seated on the regular wheelchair she felt R1 did not need help to stabilize, but when in the shower chair NA-A felt she had to hang on to R1 to provide to stabilize her because the chair had an upright back and was not fitted for her abnormal postured like her wheelchair. During interview on 8/15/22, at 12:50 p.m. the NP stated following the fall her colleague had taken the call regarding R1's fall. NP stated she had then received a call 7/28/22, requesting for an order for OT to evaluate the use of the shower chair and then she returned the call on 7/29/22. During interview on 8/15/22, at 11:20 a.m. the clinical administrator stated she had been notified about the fall. The CA then stated, I wish you could see [R1] the big part of this is her posture and she may have shifted. The CA stated since the fall she had been out of the building, however, with briefly discussing about the fall after it happened, the staff thought she could have been slippery from the shower and the shower chair may not be agreeable with her posture as resident had an abnormal posture issue. When asked if the shower chair had been assessed to be appropriate and safe for R1 to use during shower related to the progression in her disease and posture, the CA stated she could not speak about the chair and knew ??felt??the right size of chair was being used at the time of the fall. The CA directed surveyor to the director of therapy to provide information on when therapy had evaluated R1. During interview on 8/15/22, at 11:44 a.m. therapy director reviewed the therapy episodes R1 had attended since January 2021 and the medical record lacked documentation of the therapy department evaluating R1's shower chair appropriateness related to R1's postural abnormality. The director of therapy stated due to R1's abnormal posture they had evaluated R1's wheelchair to ensure it was working for R1. The therapy director stated there had not been an assessment done with OT as there was nothing that had been triggered to make them to look at it. The therapy director stated the preferred shower chair was something R1 liked and did not want to use the regular tub chair. During interview on 8/15/22, at 12:19 p.m. the OT stated she had not officially evaluated R1 before the fall in the shower chair but had seen R1 being transported in it in and out of shower, however, nursing had never reported concerns of R1 having positioning problems prior to the fall. OT stated not all residents were evaluated for the shower chairs and nursing would have to make the decision and assess if they had any questions they would seek out to therapy, who would get a referral and order to look into it. During interview on 8/15/22, at 12:33 p.m. the facility administrator stated following the incident the staff involved were given real time education, however, not sure if this was formal education. The administrator further stated no staff education had been implemented following the incident as they felt the staff was doing the correct thing and had followed the care plan. During a follow up interview with the clinical administrator, on 8/16/22, at 9:04 a.m. the CA stated for the shower chair if staff had brought the concern for positioning to management, it would have been assessed and addressed but this never happened and R1 never complained. The CA stated, Our plan after the fall was for [R1] to be assessed by therapy for safety. The CA acknowledged no assessment had been completed on R1 using the shower chair despite R1's posture changes over time which required other devices to be evaluated by therapy for safety and appropriateness. The CA stated staff education was needed, and she acknowledged R1 had changed, and the appropriateness of the shower chair should have been assessed as R1 was not even the same now in comparison to four months ago. The CA acknowledged R1's posture had changed over time however the shower chair had not been assessed to determine if the shower chair needed a safety belt to provide and secure R1 from falling during showers or to determine if a different shower chair would be appropriate.

Based on interview and document review, the facility failed to provide the resident or their representative, a bed hold notice for 1 of 1 residents (R1) reviewed for hospitalization s. Findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS identified R1 had intact cognition. During review of the medical record, it was revealed R1 on 8/7/22, was transferred to an acute hospital however, the interdisciplinary notes lacked documentation of a bed hold notice being provided to R1 or their representative. During review of a general late entry note dated 8/7/22, at 8:15 p.m. it was revealed the writer at 9:40 p.m. had spoken with family member (FM)-A to give an update however, there was no evidence FM-A was informed of the bed hold. The note further indicated at 10:22 p.m. left the facility with emergency medical services however, R1 was not provided the bed hold notice. During interview on 8/16/22, at 9:04 a.m. the director of nursing (DON) stated the social worker was responsible for letting residents and the responsible parties about the bed hold and this was supposed to be documented in the medical record. During interview with the clinical administrator (CA), on 8/16/22, at 9:04 a.m. the CA stated the social worker was responsible for providing bed holds and the social worker was supposed to document in the medical record. During interview on 8/16/22, at 11:14 a.m. the facility administrator acknowledged R1's medical record lacked documentation of a bed hold notice being provided. The administrator acknowledged all resident's regardless of their payment source. The facility Bed Hold policy modified April 2018, directed Before a resident leaves for hospitalization or therapeutic leave, the facility will attempt give the resident a copy of the bed hold policy. The Resident Services staff or designee will contact the resident/responsible party to inquire about bed hold. Discussion regarding bed hold will be documented in the progress notes .

Based on interview and document review, the facility failed to immediately report, no later than 2 hours, to the State Agency (SA) an allegation of staff to resident abuse for 1 of 1 resident (R1) who were reviewed for allegations of abuse. Findings include: R1 Admission Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairments and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that R1 required extensive assistance of one staff for personal hygiene, dressing, transfers, bed mobility, and bathing with independence in eating after set-up. The facility's Incident Report to the SA submitted on 3/2/2021, at 10:30 a.m. identified on 3/1/2021, at 11:30 p.m. Director of Nursing (DON) was notified of incident on 3/2/2021, at 8:30 a.m. R1 reported that someone had thrown his shirt/jacket next to him and was rough with providing his cares. R1 was assessed and interviewed on 3/2/2021, at 3:00 p.m. Facility policies and procedures were followed, and an investigation was initiated. The SA was notified of the alleged staff to resident rough cares approximately 9.5 hours after the alleged incident. On 3/9/2021, at 2:26 p.m. the RN Clinical Coordinator (RN)-A confirmed that the abuse needs to be reported immediately and should be entered into the MDH website within two hours. If it was after hours, they would need to call according to the calling tree, starting at the top. She confirmed that the calls should continue until someone is reached. RN-A confirmed that the incident with R1 would be reportable as possible abuse and was made aware of this incident on 3/2/21, at 8:45 a.m. via a text message from another staff member requesting she check her emails. She had received an email at 11:20 p.m. on 3/1/21, that contained information regarding a call with the son that the care on the AM shift the day prior was rough. She confirmed that it was not common or expected that this information be passed an in an email format. On 3/9/21, at 2:53 p.m. RN-B stated that on 3/1/21, the nursing assistant (not identified) had called her to let her know that the son had wanted to talk with her between 9:00 p.m. and 10:00 p.m. The son reported that R1 had told him that he felt like he was in a military camp. The son stated that R1 had complained that the morning nursing assistant on 3/1/21, was rough with him but didn't know who the aid was. The son stated he wanted to settle the matter because it may be some type of miscommunication due to R1's current ability and being hard of hearing. RN-B believed that she did not think of it as possible abuse because R1 is sometimes confused. On 3/9/2021, at 3:40 p.m. DON confirmed the above findings and indicated she had been notified on 3/2/2021, at approximately 8:30 a.m. of the alleged incident of rough cares. The DON indicated the facility used a facility document, a decision tree as a reference to decide whether an allegation of abuse needed to be reported to the SA. The DON indicated R1 had no injury at the time of the allegation and confirmed that the incident should have been reported to the SA within two hours. The DON confirmed the facility abuse policy and indicated she would expect staff to follow the facility abuse policy as written. The DON verified all allegations of abuse were required to be reported to her and the admissions counselor immediately. A facility policy Vulnerable Adult Abuse Prevention Plan, modified 9/20, identified allegations of abuse were to be reported to the SA no later than 2 hours after the allegation of abuse was made.

Based on observation, interview, and document review, the facility failed to ensure potentially unsafe, escalating wandering behaviors were comprehensively assessed and interventions were developed to provide adequate supervision for 1 of 1 male resident (R39) identified to wander into female resident rooms. This had potential to affect 7 of 7 female residents identified on the Lafayette Bay Unit. In addition, the facility failed to assess and ensure adequate supervision with cleaning supplies, medications, heating pad and alcohol consumption for 2 of 2 residents (R4, R7) reviewed who had these items accessible. Findings include: R39's significant change Minimum data Set (MDS), dated [DATE], identified R39 had severe cognitive impairment and required only supervision to complete locomotion on the unit. R39 displayed other behavioral symptoms (e.g., disrobing, rummaging, scratching or hitting self), however, these behaviors did not interfere or place others at risk. Further, the MDS identified R39 demonstrated wandering during the look-back period. R39's care plan, dated 1/13/20, identified R39 had potential to demonstrate physical behaviors evidence by a history of striking out and shouting at others. The care plan also identified R39 was at risk of elopement and had history of wandering off the unit. A series of interventions were listed for these concerns including documenting wandering behavior(s) and attempting diversional interventions, turning on a movie in the evening, and, Observe for patterns of behavior. The care plan lacked any recorded problem statements of interventions prior to 2/22/21, which outlined R39 as wandering or potentially harming female residents. R39's progress notes identified the following recorded entries: On 5/13/20, at 6:52 p.m. R39 was found in a female resident' room with the door closed. The note outlined, Writer entered into [room] and observed this res. to haveturned [sic] out the lights and was slowly self-propelling towards [female resident] bed where she was lying. R39 was then directed out of the room and was recorded as becoming belligerent. On 9/19/20, at 7:07 p.m. R39 was found in the supper room holding a female resident's hands. R39 stated her hands are so cold someone needs to warm them. The nursing assistant (NA) then removed the female resident and took her back to her room. On 10/3/20, at 5:46 p.m. R39 was in the hallway with another female resident. The note outlined, [female resident] said that [R39] touched her buttock are with his hand [sic]. He was laughing. The nurse voiced that was inappropriate and the female resident voiced she was not harmed. On 10/4/20, at 9:41 a.m. R39 was recorded as being inappropriate and trying to touch or grab other females staff buttocks along with name badges on their chest. The note outlined, Staff emphasize [sic] how that is inappropriate and to not do it again. On 1/20/21, at 10:39 p.m. R39 was found in a female resident' room. The note recorded, Per [NA] res[ident] was attempting to take off his pants. Res was escorted back to room. R39's medical record was reviewed and lacked evidence these escalating, potentially unsafe behaviors had been comprehensively assessed to help determine interventions to ensure R39 and other residents were appropriately supervised to prevent potential resident-to-resident altercations. Despite nearly all of these incidents and behaviors being recorded in the evening hours, there was no evidence the facility had assessed this pattern to determine if increased supervision or interventions were needed. During an interview on 2/23/21, at 2:53 p.m. NA-I stated R39 was able to transfer himself from his bed to his wheelchair and self-propel throughout the unit without assistance. NA-I voiced she recalled hearing R39 had been found in another female resident's room a few weeks ago which she expressed the nurses were aware of. NA-I expressed R39 was not on any formal monitoring or safety checks, to her knowledge, despite these incidents. A provided Resident List Report, printed 2/22/21, identified seven female residents resided on R39's unit. On 2/24/21, at 12:59 p.m. registered nurse unit manager (RN)-C was interviewed. RN-C explained R39 had a history of wandering and had a wanderguard bracelet (device which alarms when passed through set doors) in place as a result. RN-C stated if a resident displays wandering behaviors they need to come up with interventions to help reduce or eliminate them. RN-C verified R39 was able to self-transfer from bed to wheelchair and vice versa and expressed she was aware R39 had wandering behaviors during the evening, however, had not ever hurt anyone. When questioned on actions the facility had taken to reduce these behaviors, RN-C voiced multiple meetings had been held and they kind of just came up with thoughts for interventions to try out. RN-C stated she was unaware of the early progress note(s) for R39 which outlined potential sexual behaviors, however, expressed she did recall the note recorded on 1/20/21, which outlined R39 had been found in a female residents room attempting to remove his pants. RN-C stated the note was concerning and was brought to their IDT (interdisciplinary team) where they didn't feel it was a big deal. RN-C stated R39 had been seen in October 2020 by ACP (Associated Clinic of Psychology) for similar behaviors where recommendations were made, however, these had not been added to the care plan. RN-C stated R39 was on formal behavior monitoring, however, verified there had been no comprehensive assessment of the data collected to ensure all interventions were identified, including safety checks or increased direct supervision on the evenings. RN-C added, I did not do that. A provided Behavioral Health Services policy, dated 2/2019, indicated mood and behavior tracking documentation will be completed by front line staff, based upon comprehensive assessment outcomes, to identify any mod and behavior patterns, interventions attempted, and outcome of approaches. Mood behavior tracking will be reviewed by the IDT on a quarterly basis or more often as needed to determine trends and effectiveness of care plan interventions. R4's Admission record included diagnoses of chronic diastolic [CONDITION(S)] (progressive disease affecting the pumping power of the heart), [CONDITION(S)] (irregular, rapid heart rate), repeated falls, dementia, major depressive disorder, and anxiety. R4's quarterly minimum data set (MDS) dated [DATE], indicated severe cognitive impairment, able to communicate her needs, and understood by staff. She required assist of one for ambulation, transfer, toileting, bathing, bed mobility, grooming, dressing, and set up with eating. R4's care plan dated 8/26/20, indicated R4 was not able to self administer medication. R4's physician orders lacked evidence of an order for alcohol consumption or self administration of medications. During an observation on 02/22/21, at 6:26 p.m. there was a box of [MEDICATION(S)], a bottle of Tito's vodka, and bottle of Windex in R4's bathroom. During a subsequent observation on 02/23/21, at 1:49 p.m. the [MEDICATION(S)], vodka and Windex remained in R4's bathroom. During observation and interview on 02/24/21, at 7:57 a.m. nursing assistant (NA)-H confirmed [MEDICATION(S)], vodka, and Windex in R4's bathroom. NA-H stated daughter completes most cares for R4. NA-H stated it was very dangerous to have these items in a resident bathroom. During observation and interview on 02/24/21, at 7:59 a.m. registered nurse (RN)-F confirmed [MEDICATION(S)], vodka, and Windex in R4's bathroom. RN-F was not aware of these items. RN-F stated residents needed orders for self administration of medication and alcohol. Further, cleaning supplies cannot be kept in resident rooms. All items were removed immediately. During an interview on 02/24/21, at 8:35 a.m. clinical manager (RN)-B stated alcohol was not allowed in resident rooms, required physician's order and was kept in the medication room. Further, cleaning supplies were kept in staff areas to be used by staff. During a subsequent interview on 02/24/21, at 10:47 a.m. RN-B stated oral medication storage was not allowed in resident rooms, required a physician's order and kept in the medication room. During an interview on 02/24/21, at 10:20 a.m. nursing assistant (NA)-E stated alcohol, medications and cleaning supplies were not allowed in a resident room. If he saw any of those items, the expectation was to report to a nurse manager immediately. During an interview on 02/25/21, at 10:40 a.m. nursing assistant (NA)-G stated alcohol, medications and cleaning supplies were not allowed in a resident room. If she saw any of those items, the expectation was to report to a nurse manager immediately. During an interview on 02/25/21, at 11:17 a.m. director of nursing (DON) stated her expectation was when a resident requested alcohol it was kept at nurse's station and a physician order was required. When a resident requested to self administer medications, a physician order was required. Further, cleaning supplies were kept in staff areas to be used by staff. The facility policy Self Administration of Medication Policy, dated November 2016, indicated each resident had a right to self administer drugs unless the interdisciplinary team has determined for each resident that the practice is clinically inappropriate. Further, it indicated The resident care plan must be updated to reflect self administration of medications. The facility policy Alcohol Consumption, dated September 2015, indicated residents are allowed limited amounts of alcohol consumption on special occasions unless contraindicated. Further, it indicated a resident's physician may order limited amounts of alcohol as requested. The policy indicated, 1. Obtain physician's order. R7's admission record included diagnoses of acute on chronic diastolic (congestive) heart failure (progressive disease affecting the pumping power of the heart), morbid (severe) obesity, low back pain, cervicalgia (neck pain), migraine (severe, throbbing headache), [CONDITION(S)] (chronic widespread pain, tiredness), chronic pain syndrome. R7's quarterly minimum data set (MDS) dated [DATE], indicated moderate cognitive impairment, able to communicate her needs and understood by staff. She required one assist to transfer with walker, assist to toilet, bed mobility, and bathing, set up with meals, and steady ambulation with walker once set up. R7's care plan dated 2/19/21, indicated she was at risk for pain related to [CONDITION(S)], gout, migraine, low back pain, restless leg syndrome, right foot pain and left shoulder pain. R7 verbalized chronic headaches/migraines, and neck pain. R7 could verbalize and describe symptoms as they arose. During observation and interview on 02/22/21, at 06:30 p.m. R7 had an uncovered aqua k pad (heating pad) on her bed, it was turned on. The pump was on the floor, set at 100 degrees Fahrenheit. She stated she mainly used it for migraines that affect neck and shoulders. R7 stated at times it can get too hot for her, and stated she was not sure how it worked. Sometimes she puts a pillow case or towel over it. R7 stated the facility provided it to her without any instruction. During observation and interview on 02/23/21, at 1:59 p.m. The pump was on he floor. Temperature was set at 100 degrees Fahrenheit. There is no covering on the pad itself. R7 was in her bed using her aqua k pad and stated there was no on or off button. R7 did not know how to control it and stated it was just on all the time. She stated she moved the aqua k pad to the recliner when needed. During an interview on 02/24/21, at 10:20 a.m. NA-E did not have any residents that use aqua k pads. He stated he would check with nurse to get instruction if he saw one for one of his residents. During observation on 02/24/21, at 11:06 a.m. aqua-k pad was on head of R7's bed with no covering on it. Pump was turned on and located on the floor. R7 was not in her room. During observation and interview on 02/25/21, at 09:41 a.m. aqua k pad set at 100 degrees Fahrenheit, and no covering on it. R7 stated it was supplied by facility, she said she does use it on her knee sometimes. She had picked up the machine before and moved it herself to use it in her recliner. During an interview on 02/25/21, 10:51 a.m. RN-B stated he had an order for the aqua k pad for R7. He stated aqua-k pad typically goes on the treatment sheet. During an interview on 02/25/21, at 11:17 a.m. DON stated her expectations would be that an order be obtained for an aqua k pad and it should be on the treatment sheet. On 2/25/21, at 12:10 p.m. facility provided order for aqua k pad with order date of 10/19/20 at 14:49 to apply aqua k pad to left shoulder scheduled three times daily times seven days. Update nurse practitioner after seven days. Apply for a maximum of 20 minutes for left shoulder pain until 10/26/20, 23:59. Also provided was the treatment administration record for 10/1/20-10/31/20, indicating the administration of the aqua k pad to R7's left shoulder three times day times seven days, then discontinuing. The physician orders and treatment administration record lacked orders, assessment, and evaluation for further use of the aqua k pad for R7. The facility policy, Hot-Cold Water Therapy Pump Policy modified September 2019, indicated physician order for use of the device including temperature setting. Further, the policy indicated to monitor the resident's skin every 30 minutes during therapy or more often if directed by physician. The service manual for the Stryker T/Pump (aqua k pad) 2014/06 E.3, provided by the facility, indicated to position the pump at or above the level of the pad (pg. 16). If the pump is placed below the pads, water will drain into the pump when it is shut off. If the pump has been overfilled or if multiple pads are connected, excess water can leak.

Based on interview and document review, the facility failed to ensure the care plan was updated with psychology-recommended interventions to reduce behaviors and mitigate risk to others for 1 of 1 resident (R39) reviewed who wandered into female resident rooms and displayed sexual behaviors. Findings include: R39's significant change Minimum data Set (MDS), dated [DATE], identified R39 had severe cognitive impairment and required only supervision to complete locomotion on the unit. R39 displayed other behavioral symptoms (e.g., disrobing, rummaging, scratching or hitting self), however, these behaviors did not interfere or place others at risk. Further, the MDS identified R39 demonstrated wandering during the look-back period. R39's Associated Clinic of Psychology (ACP) Progress Note, dated 10/7/20, identified R39 had been seen for potential sexual behaviors including grabbing at female staff. The note outlined several recommendations which were to be implemented, including keeping greater distance(s) when he appears to be excited, reminding him to deep breath to help regulate his mood, and addressing behaviors, if displayed, in a friendly manner instead of shaming him for them. R39's subsequent progress note, dated 1/20/21, identified R39 had been found in a female resident' room. The note recorded, Per [NA] res[ident] was attempting to take off his pants. Res was escorted back to room. R39's care plan, dated 1/13/20, identified R39 had potential to demonstrate physical behaviors evidence by a history of striking out and shouting at others. The care plan also identified R39 was at risk of elopement and had history of wandering off the unit. A series of interventions were listed for these concerns including documenting wandering behavior(s) and attempting diversional interventions, turning on a movie in the evening, and, Observe for patterns of behavior. However, the care plan lacked any of the recommendations listed on the 10/7/20 ACP Progress Note. On 2/24/21, at 12:59 p.m. registered nurse unit manager (RN)-C was interviewed. RN-C explained R39 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-C verified R39 was able to self-transfer from bed to wheelchair and vice versa and expressed she was aware R39 had wandering behaviors during the evening, however, had not ever hurt anyone. RN-C stated she was unaware of the early progress note(s) for R39 which outlined potential sexual behaviors, however, expressed she did recall the note recorded on 1/20/21, which outlined R39 had been found in a female residents room attempting to remove his pants. RN-C verified R39 had been seen in October 2020 by ACP for similar behaviors where recommendations were made, however, none of the recommendations had been added to the care plan. RN-C expressed she was unsure why they had not been care planned, however, voiced they should have been. A policy on care planning was not provided.

Based on observation, interview and document review, the facility failed to identify, implement interventions to prevent further injury to bilateral lower extremities for 1 of 1 resident (R30) reviewed for skin concerns, not pressure related. Findings include: R30's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated R30's cognition was moderately impaired, R30 was able to make herself understood and was usually able to understand others. R30 was independent, after set up, with bed mobility, transfers, walking in room and walking outside of room. During observation and interview on 2/22/21, at 2:14 p.m. R30 was noted to have four to five bruises, ranging from deep purple to faded yellow, on each of R30's lower extremities. Bruising placement was consistent with R30's reports that she is hitting her legs on her walker during transfers and walking. R30's Body Audit assessment dated [DATE], identified a bruise on R30's left calf. Cause of the bruise was identified as the resident bumping her legs into her walker. Bruising on left calf again noted on Body Audit dated 12/28/20. Body Audit dated 1/4/21, identified bruising on R30's right lower calf. Cause of bruising noted as R30 bumping her leg on her walker. Body Audit dated 1/11/21, identified faded bruising on right and left lower extremities with cause of bruising identified as R30 bumping her legs on her walker. Body Audits dated 1/18/21, 1/25/21, 2/8/21 and 2/15/21 noted bruising to right and left lower extremities from legs bumping R30's walker. Each of these assessments failed to identify intervention in place to prevent further occurrences of bruising. R30's care plan failed to identify current bruising or interventions in place to prevent ongoing and future bruising in relation to R30 using her walker. During interview on 2/24/21, at 2:05 p.m. registered nurse (RN)-A confirmed bruising on R30's right and left lower extremities. RN-A stated she was aware of the bruising before this day and confirmed attempts to wrap or otherwise adjust R30's walker had not been attempted. During interview on 2/24/21, at 2:24 p.m. Clinical Manager (RN)-B indicated he was not aware of R30's bruises on her lower legs. RN-B stated, given R30's independent ability, R30 would be able to request changes necessary in regards to R30's walker or bruising. The bruises were known, where they came from. The nursing staff monitored the bruising on bath day. The bruises had not changed much, so were being monitored properly. RN-B stated physical therapy should be involved in making changes to R30's walker or assistive devices, to prevent further bruising. During interview on 2/25/21, at 10:15 a.m. Clinical Coordinator (DON) indicated physical therapy should be involved when an assistive device, such as a walker, is used and the resident has possibly received bruises when that device was used. DON stated she expected the Clinical Manger was made aware of the bruising so follow up was possible. Facility policy on managing skin conditions, not related to pressure, was requested but was not received.

Based on observation, interview and document review, the facility failed to provide assistance with facial hair removal for 1 of 4 residents (R30) with grooming needs who was dependent upon staff for assistance. Findings include: R30's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated R30's cognition was moderately impaired, R30 was able to make herself understood and was usually able to understand others. R30 required physical assistance from staff for personal hygiene. Behaviors, such as refusal of cares, were not noted on R30's MDS. R30's care plan, revised on 7/22/19, indicated R30 required assistance from one staff member for personal hygiene as needed. R30's care plan indicated staff were supposed to check with R30 for all cares to ensure her needs were met and assistance was provided as needed. During observation and interview on 2/22/21, at 1:52 p.m. R30 was noted to have several, long, white, coarse hairs on her chin and three-four long, white, coarse hairs on her upper lip. R30 stated, I wish I could have somebody pull some of them. I try, but I can't see in the mirror anymore. I've asked them, but they don't come. R30 indicated she did not like the facial hair and felt bad when others noticed it. R30 then reached for a cup on the table next to her chair and offered tweezers to the surveyor and asked for assistance to remove the facial hair. R30 stated she received assistance from staff this morning with her bath, staff did not offer to assist with removal of the facial hair. During observation and interview on 2/23/21, at 1:07 p.m. R30 was again noted to have long, white, coarse hairs on her chin and five or more long, white, coarse hairs on her upper lip. R30 stated no one had offered her assistance with her chin hairs. On 2/24/21, at 11:21 a.m. nursing assistant (NA)-D stated R30 required staff to check on her daily, to make sure she is safe and help her if something is needed. NA-D indicated R30 did not receive assistance with grooming unless R30 asked for it, that help with grooming was not offered. NA-D did not know if R30 had her own razor, but stated the nurse had access to a facility razor that could be used. On 2/24/21, at 2:05 p.m. registered nurse (RN)-A confirmed staff were supposed to check on R30, to ask if she wanted assistance with ADLs, including shaving facial hair. RN-A confirmed R30's scheduled bath day was on Monday, and R30 received a bath on 2/22/21. RN-A indicated staff should have offered to assist R30 with shaving her facial hair on her bath day. On 2/24/21, at 2:24 p.m. RN-B indicated staff are not required to ask residents if assistance is needed with grooming, if they were able to complete this task on their own. RN-B stated R30 has been independently able to request assistance with grooming, RN-B did not expect staff to offer assist with grooming. On 2/25/21, at 10:15 a.m. Clinical Coordinator (DON) stated R30's facial hair should have been noticed on her bath day and R30 should have received assistance to remove the facial hair. Facility policy on staff offering assistance with ADLs, including removal of facial hair, was requested but was not received.

Based on observation, interview and document review, the facility failed to ensure residents were treated in a dignified manner when providing assistance or neglecting to provide needed assistance for 3 of 3 residents (R9, R30 and R36) reviewed for dignity. Findings include: R9's Admission Record indicated R9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9's cognition was severely impaired, his vision was severely impaired, his speech was clear, he was usually able to make himself understood and sometimes understood others. R9 required physical assistance from one staff with eating. R9's care plan revision date 11/16/20, indicated staff need to assist R9 with his feeding needs. During observation on 2/22/21, at 5:53 p.m. R9 was in the dining room, in his wheelchair. A tray table was in front of him. There was a sitting stool next to R9. Nursing assistant (NA)-C placed a covered plate on the tray table in front of R9, then walked away. NA-C did not tell R9 the plate was on the tray table. NA-C returned 30 seconds later, stood next to R9, removed the cover from the plate and told R9 his food was in front of him and told R9 what was on the plate. NA-C put food on R9's fork and brought it to his mouth whiling stating, Here. R9 opened his mouth for the food. NA-C put the fork on the tray table and walked away from R9. NA-C returned to R9 after approximately 30 seconds. While standing next to R9, NA-C put potatoes on R9's fork, told him it was potatoes and brought the fork to R9's mouth. NA-C put the fork on the tray table and walked away from R9. NA-C returned with R9's beverages, juice and water. NA-C brought the cup of water to R9's mouth and stated, Here. NA-C put the cup on the tray table, then sat down next to R9 to continue assisting him with his meal. On 2/22/21, at 6:25 p.m. NA-C stated the process when a resident requires assistance with eating included: bring their food and beverages to the resident, sitting down by the resident, explaining what is on their plate and what they have to drink. The resident would then be assisted with their clothing protector, if they want one. The resident should be offered something to drink, then asked what they would like to eat first. NA-C stated that is the process she followed when she assisted R9 with his evening meal on 2/22/21. When NA-C was asked about what the surveyor observed when NA-C was providing assistance to R9, including standing and walked away from NA-C multiple times, giving R9 food on his fork without telling him what was on the fork and provided R9 with fluids without telling him what was in the glass. NA-C stated she was feeling overwhelmed and possibly forgot what the full process was. On 2/24/21, at 2:24 p.m. Clinical Manager (RN)-B stated he expected staff to sit with residents when assistance with eating was required. That staff should explain what food and drink items were provided for the resident and to make the resident aware of what is being given to them. RN-B expected the resident was provided with options regarding what they wanted to eat or drink next. On 2/25/21, at 10:30 a.m. Clinical Coordinator (DON) stated she expected staff to sit by the resident when they assisted with eating, not stand next to or over the resident. The DON expected the assisting staff would get up if the resident requested or required something additional, otherwise would remain seated next to the resident until the meal was finished. If the resident was cognitively impaired or had poor eye sight, the assisting staff should explain what each items was before it was provided to the resident, this included food and drink. R30's Admission Record indicated R30's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's quarterly MDS dated [DATE], indicated R30's cognition was moderately impaired, R30 was able to make herself understood and was usually able to understand others. R30 required physical assistance from staff for personal hygiene. Behaviors, such as refusal of cares, were not noted on R30's MDS. R30's care plan, revised on 7/22/19, indicated R30 required assistance from one staff member for personal hygiene as needed. R30's care plan further indicated staff were supposed to check with R30 for all cares to ensure her needs were met and assistance was provided as needed. During observation and interview on 2/22/21, at 1:52 p.m. R30 was noted to have several, long, white, coarse hairs on her chin and three-four long, white, coarse hairs on her upper lip. R30 stated, I wish I could have somebody pull some of them. I try, but I can't see in the mirror anymore. I've asked them, but they don't come. R30 indicated she did not like the facial hair and felt bad when others noticed it. R30 then reached for a cup on the table next to her chair and offered tweezers to the surveyor and asked for assistance to remove the facial hair. R30 stated she received assistance from staff this morning with her bath, staff did not offer to assist with removal of the facial hair. During observation and interview on 2/23/21, at 1:07 p.m. R30 noted to have long, white, coarse hairs on her chin and five or more long, white, coarse hairs on her upper lip. R30 stated no one had offered her assistance with her chin hairs. As R30 was rubbing the hairs on her chin, she indicated she had tried to remove as many hairs as possible the previous day, without assistance from staff. On 2/24/21, at 11:21 a.m. nursing assistant (NA)-D stated the care provided to R30 included looking in on her to make sure she was safe and if something was not right, they would make it right. NA-D indicated R30 does not receive assistance with dressing or grooming unless she asks for it, that assistance was not offered because R30 would tell staff what she needed help with, when she needed help. On 2/24/21, at 1:57 p.m. NA-E stated he had not noticed R30 had facial hair, R30 has not asked for assistance with her facial hair and that R30 prefers to do things herself. During interview on 2/24/21, at 2:05 p.m. registered nurse (RN)-A stated she had observed and confirmed the long, white, coarse hairs on R30's chin and upper lip. R30 told RN-A the facial hair bothered her. RN-A stated unlicensed staff had not told her that R30 had facial hair. On 2/24/21, at 2:24 p.m. Clinical Manager (RN)-B indicated R30 likes to complete certain tasks on her own, but if the staff have the opportunity to offer additional assistance to R30, they should. RN-B stated he was not aware of R30 making comments about her facial hair or how it makes her feel when walking in the hallway to activities or to get her hair done. On 2/25/21, at 10:14 a.m. Clinical Coordinator (DON) acknowledged that R30's facial hair was likely to make R30 feel uncomfortable when walking in the hallway, when other residents and staff are present. DON stated staff should have noticed R30's facial hair and offered assistance to remove it. R36's Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's quarterly MDS dated [DATE], indicated R36's cognition was moderately impaired. R36 was able to communicate needs and able to understand others, required extensive assistance with bed mobility, eating, and personal hygiene. R36 required total dependence with transferring, dressing, toileting and was unable to ambulate. R36's Care Plan intervention dated 2/18/21, indicated that R36 was able to sit on the Broda (specialized) commode for bathing, or to attempt a bowel movement. R36 was not always able to have a bowel movement on this specialized chair and has a history of needing to transfer to bed to complete a bowel movement episode. R36 was able to request the Broda commode per his preference. During an interview on 02/23/21, at 2:16 p.m. R36 stated in order to have a bowel movement, it takes about the same time as it does to get on bed pan as it does to get on a commode. R36 further stated if his tailbone isn't real sore, he can handle the bedpan. He stated he had been on the commode this past weekend and that staff gave him the option to use the bed pan or the commode. R36 stated approximately two weeks ago had been told to go in his brief by a nursing assistant. He stated is made him feel bad and embarrassed. and that he does not want that to happen again. During an interview 02/24/21, at 2:33 p.m. nursing assistant (NA)-H stated if she heard another staff member tell a resident to go in their brief, she would report that to a nurse right away. On 02/25/21, at 10:37 a.m. NA-G had put R36 in full lift onto shower chair, to have a bowel movement, it had been successful. If she heard a staff member say you should just have a BM in your pad or bed she would report that to the charge nurse and to clinical manager (RN)-B right away.